This site is intended for healthcare professionals
Doctor holding patient
Supportive care in oncology Learning Zone

Transcript: Nausea and vomiting

Last updated:20th May 2024
Published:20th May 2024

Dr Gary Lyman

All transcripts are created from interview footage and directly reflect the content of the interview at the time. The content is that of the speaker and is not adjusted by Medthority.


So, nausea and vomiting associated with cancer chemotherapy has emerged as another very important complication of cancer treatment, and one that clinical practise guidelines have tried to address in recent years. And, it has been recognised as one of the most distressing adverse effects of cancer chemotherapy, impact on quality of life, and the willingness of patients to continue with their chemotherapy. And, we also recognise that while the, perhaps the greatest fear, is the early occurrence of chemotherapy-induced nausea and vomiting shortly after receipt of chemotherapy
That it also may be more delayed or continuing beyond the chemotherapy. And, it turns out that the mechanisms involved with early versus delayed are somewhat different, different signals within the body, and there may require, or be better treated with somewhat different agents as a result. So, the first step in managing these is to recognise who's at high risk, intermediate risk, low risk, and so forth. And, the guidelines have pretty much consistently identified the risk-strata established originally by the Multinational Association of Supportive Care in Cancer, or MASCC.
Classifying patients as high risk, if they have more than a 90% risk, with the regimen they're receiving for nausea and vomiting; intermediate risk, somewhere between 30 and 90% risk; and low risk, if they're between 10 and 30% risk of chemotherapy-induced nausea and vomiting. And, those less than 10% are considered minimal risk. Of course, fortunately, again, many new antiemetic agents and combinations have emerged in recent years, and these have led to improved results, and reducing the need for compromising cancer treatment, reducing doses or stopping treatment early, and have been integrated into clinical practise guidelines. I have been privileged to co-chair and senior lead on the initial antiemetic guideline for the American Society of Clinical Oncology. But, at this point, virtually all the guidelines that I mentioned have, are in alignment, and recognised the need for both initial appraisal of risk, and then the recommendation for a risk-stratified approach to patients based on their level of risk.
The acute chemotherapy-induced nausea and vomiting, by guideline recommendations, is best managed with a 5-HT3 antagonist, such as ondansetron or granisetron. And, these are very effective in the majority of patients. Unfortunately, not 100%. But, the majority of patients will have reasonable control of their acute event. But, they may also experience that delayed nausea and vomiting; again, via different mechanism. And, this may lead to nausea and vomiting later in the course, or even after chemotherapy is delivered. And, the NK1 antagonist, such as fosaprepitant, have been shown to be most effective at reducing the risk of these delayed effects. The introduction of the antipsychotic olanzapine, in the last few years, has also further improved control of patients at particularly high risk for nausea and vomiting from chemotherapy.
So, this is often added to those patients who are high or even intermediate risk of nausea and vomiting. And, we generally add a corticosteroid, specifically dexamethasone, due to the impact of inflammation on the risk of severe chemotherapy-induced nausea and vomiting. And, this is generally done at all levels of risk in patients getting cancer chemotherapy. It's important to emphasise the need for prevention as opposed to treating these events after they've occurred, both to reduce the future risk of an anticipatory nausea and vomiting, as patients prepare to come in for their next treatment. Having experienced previous nausea and vomiting with their chemotherapy, they may have symptoms that emerge even before coming in for treatment. And, also to improve compliance or adherence to the chemotherapy regimen in patients with particularly responsive and and potentially curative cancers. So, prevention is the key factor here. Although, we can sometimes control it once it's occurred; it's far more difficult to control than it is to prevent in these settings. So, but again, I'd emphasise the progress that's occurred. While we're always looking for better and safer agents, we can prevent or minimise the risk of this complication in the majority of patients getting modern cancer therapy.

View the video