Poor Adherence to Guidelines for Preventing Chemotherapy-Induced Nausea, Vomiting

Adherence to antiemetic regimens for patients undergoing emetogenic cancer chemotherapy is poor, according to an online survey of oncology nurses in the United States. That poor adherence has diverse causes and might be contributing to chemotherapy regimen modifications and emergency room visits, survey results suggested. Results of the survey were published in Supportive Care in Cancer.

Prophylactic antiemetic regimens described in the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) treatment guidelines are effective against chemotherapy-induced nausea and vomiting (CINV), preventing an estimated 85% and 65% of cases, respectively, the study authors noted.

But their survey of 531 oncology nurses found that fewer than half of respondents (48%) were familiar with the ASCO antiemetic guidelines; 73% were familiar with the NCCN guidelines.

That appears to be contributing to low rates of compliance with treatment recommendations, the study team found.

“While most (77%) felt that antiemetics prescribed were consistent with guideline recommendations, practice patterns of antiemetic use revealed low adherence to those guidelines, particularly during the delayed (25–120 hour) phase following highly emetogenic chemotherapy, where only 25% of nurses reported administration of guideline-recommended agents,” reported lead study author Rebecca Clark-Snow, RN, BSN, OCN, of the University of Kansas Cancer Center in Westwood, and coauthors.

Neuroleptic phenothiazines and benzodiazepines were commonly overused, the survey revealed.

“Only 17% of respondents reported that most (> 75%) of their patients have CINV optimally controlled; 39% reported between 6% and 20% of patients have an alteration in their chemotherapy due to CINV, and reports of emergency department [and] hospital visits due to poorly controlled CINV were high,” the study authors reported.

The “predominant barrier” underlying guidelines nonadherence, identified by 71% of respondents, was physician preference. Patient dissatisfaction with antiemetics during highly-emetogenic chemotherapy was another barrier (reported by 27% of nurse respondents). Insurance coverage and antiemetic treatment costs were also a barrier (reported by 26% of survey respondents). A quarter of respondents reported that guideline-recommended medications were not on their institutions’ formulary.

Respondents reported that challenges and unmet needs for managing CINV included control of delayed CINV, patient adherence, lack of access to effective antiemetics, and medications controlling only nausea.

“The survey revealed an opportunity to increase awareness of antiemetic guidelines and a critical need to address barriers interfering with utilization of guideline-recommended antiemetic agents in order to optimize CINV control for patients undergoing emetogenic chemotherapy,” the authors concluded.  “Oncology nurses, as part of a multidisciplinary team, are in a unique position to promote and reinforce guideline-recommended antiemetic prophylaxis and to improve health care providers’ adherence to evidence-based guideline recommendations.”

Study limitations include a low proportion of survey completion by invited oncology nurses (7%)-possibly a result of the short 2-week study period, the authors acknowledged. Because of the low survey response rate, it is unclear that respondents’ answers are representative of the general membership of the Oncology Nursing Society (ONS), they cautioned. Nor did the survey questions about emergency department visits and patient hospitalizations due to uncontrolled CINV include a time frame.

The survey was administered and analyzed by ONS:Edge and funded by Eisai Inc.