Treatment of Nausea and Vomiting Caused by Chemotherapy and Radiotherapy in Advanced Cancer Patients

About the Study

Despite significant progress over the last 30 years, nausea and vomiting remain two of the most distressing side effects of cancer chemotherapy. Several professional organisations issued recommendations on the best antiemetic prophylaxis for patients undergoing chemotherapy and/or radiotherapy in the late 1990s. The results of the third Consensus Conference on Antiemetics, held in Perugia in June 2009, were published in Annals of Oncology in 2010 by the European Society of Medical Oncology (ESMO) and the Multinational Association for Cancer Supportive Care (MASCC). This paper contains an update to these recommendations, which were discussed in Copenhagen in June 2015. The methodology for developing guidelines is detailed in the 2010 publication. A consensus of at least 67% of the expert panellists was required to change a 2010 recommendation or to accept a new guideline recommendation. In general, the panel considered changes of 10% or more to be significant enough to warrant changing a recommendation. The ESMO evidence levels [I-V] and recommendation grades [A-D] are based on the ESMO-adapted version of the Infectious Diseases Society of America grading.

High

Repeated, randomised trials that were appropriately sized and well conducted, according to the MASCC levels of scientific confidence.

Moderate

At least one randomised controlled trial supported by well-conducted phase II trials, or possibly several well-conducted phase II studies.

Low

Formal clinical trials with a lower level of confidence than stated above.

Very low

Clinical impression only; no confidence possible. The MASCC Levels of consensus are classified as either high, moderate, or low.

The 2016 MASCC/ESMO antiemetics guidelines updated the classification of antineoplastic agents' emetogenic potential, adding 42 new drugs, many of which are orally administered.

Given the lack of antiemetic trials with orally administered antineoplastics and the considerable uncertainty in defining the emetogenic risk of oral agents, the MASCC antiemetic guideline recommendations can currently only be applied to intravenously administered antineoplastic agents. The recommendations for the prevention of nausea and vomiting caused by various chemotherapeutic agents have been updated.

Two new NK1 RAs have been approved by the FDA (netupitant and rolapitant) and the European medicines agency (netupitant), and their role in the prevention of acute and delayed nausea and vomiting caused by cisplatin, AC, or carboplatin is discussed. In the future, it would be interesting to plan randomised double-blind comparative studies among the three NK1 RAs to determine whether the two new drugs outperform the more established aprepitant or if they produce the same results. In addition, the new NK1 RAs should be studied in settings other than cisplatin and AC chemotherapy.

Two studies found that aprepitant and metoclopramide were equally effective in preventing cisplatin-induced delayed nausea and vomiting, and that dexamethasone was as effective as aprepitant in women with breast cancer receiving an AC combination, despite the fact that aprepitant was administered on day 1. In multiple-day cisplatin-based chemotherapy and high-dose chemotherapy, adding an NK1 RA to the previous standard regimen of a 5-HT3 RA plus dexamethasone has been addressed.

Nausea and vomiting are common side effects of cancer treatment and affect the majority of patients who receive chemotherapy. Nausea and vomiting are also side effects of radiation therapy to the brain, gastrointestinal tract, or liver also this sensation typically felt in the back of the throat and/or stomach causing discomfort and unease.