According to Blows (2005), Systemic anti-cancer therapy (SACT) is one of the latest cancer treatments that fight against cancer cells preventing them from growing and multiplying. This essay will be exploring the significance of CINV for the patients as unpleasant consequences effects of the treatment, the pathophysiology and the psychological impact on patients’ quality of life as well as the nurse’s role in it. It is very important to observe how SACT impacts upon cell cycle. Involving five stages (Figure 1) (Gabriel, 2007), the cycle begins and ends with mitosis (cell division) including a interphase( the period between two divisions) as well.(Blows, 2005)
David Casalduero Cidón
Asunción Cuenca Sanchez
María Dolores Cuenca Sanchez
Tadman (2007) suggests that cytotoxic drugs have a greater impact on actively dividing cells. There are two types of these drugs: cell cycle-specific oriented towards precise phases of the cycle and cell cycle nonspecific oriented towards any phase of cell cycle. According to Gabriel (2007) understanding the importance of the phenomen that take place in the cell cycle and the cytotoxic drugs action upon the cell cycle is paramount for the further development of specific therapies against cancer.
Nausea and vomiting are often seen as a whole, but they are two different physiological states (Wickham, 2012). Nausea is an unpleasant sensation of the need to vomit. (Yarbro et al, 2006). Vomiting (emesis) is the strong expulsion of gastric contents through the oral cavity. (Navary, 2009)
Central nervous system is responsible for controlling nausea and vomiting. There are certain types of mechanism dealing with the side effects already mentioned. Nervous system deals with nausea while the vomiting center leads the vomiting process. It gets stimuli from chemoreceptor trigger zone (CTZ), vestibular- labyrinthine apparatus higher cortical centers and peripheral stimuli from visceral organs and vasculature. (Wickham, 2012) Stimulation of the vague nerve has a tremendous role in nausea and vomiting as a result of chemotherapy and radiotherapy. Impulses from the vestibular apparatus-motion and laberynthitis stimulate the vomiting center, this being the most common to produce nausea and vomiting. (Cefalo, 2007)
Both cancer and SACT can produce essential physical transformations in the patient‘s body: anxiety, pressure in the brain, constipation, liver damage. Nausea and vomiting manifest as consequence of these changes. (Mc Millan 2013)
I will highlight some specific drugs and regimes which may cause nausea and vomiting in up to 80% of the cases (Choi, 2015). Cisplatin is an antineoplastic chemotherapy agent. It can be classified as alkylating agent which is more active in the resting phase of cell cycle. Consider to be the first of a class of platinum-which contains anticancer drugs, carboplatin and oxaliplatin are now also parts of this class (Apps, 2015).Regarding this agents Wang (2006) suggest that they interfere with DNA, which will command to a cell to die in a programmed way.
Since 1978, cisplatin as a single preparation or combined with other chemotherapy (vinblastine, bleomycin, adriamycin, cyclophosphamide) was used in carcinom treatment of ovarian, lung, bladder and head-neck area The most common side effect occurring in cisplatin therapy area are impaired gastrointestinal (occurrence of nausea and vomiting) and kidney due to enzyme inhibition by platinum coordination to sulfhydryl groups of proteins.
A phenomenon commonly reported post-treatment in relationship to nausea and vomiting is anticipatory nausea and vomiting (ANV). In most studies is reported nausea that occurs before chemotherapy to be administered to “approximately 20% of patients in any cycle of chemotherapy and 25-30% of patients by their fourth chemotherapy cycle”. (A. Molassiotis 2010 p 72)
Assessement tools of CINV
Regarding the significance of assessment of CINV, Mantovani et.al (2010) suggests that it should involve all health professionals, the nurse role being very important In terms of the valid and practical ,assessment tools available can be subjective and objective, what patient tells you is very important, how is he feeling, any changes since started with the anti-sickness medication does his nausea eased after the treatment. The healthcare professionals needs to find out which drug is working better but in order to find out they need to liaise all the time with the patients and their careers .Physical assessment of the patient is important as well ”looks good “ feel good, UKONS-triage assessment tool is very effective being nationally used to asses acute symptoms Anti-emesis tool by Multinational Association of Supportive Care in Cancer(MASCC) offer’s possibility to be downloaded as a mobile phone application to be used by the cancer patient who are under the chemotherapy treatment which can be very helpful for the consultants for monitoring and evaluate closely the side effects of the drugs so they can improve patients quality of life.
According to Oshiro (2012) MAT proved to be very efficient in identifying “inappropriate antiemetic therapy “on 35 patients with breast cancer. Nakamura (2012) suggest that MAT is very important assessment tool of the antiemetic therapy. Analysing the results, Kamigaki (2012) considers that the different types of CINV like acute or delayed were identified with the same tool (MAT)
Alternative methods used to improve the SACT patient experience
I will discuss further about few alternative (non-pharmacological) methods which, according to Marrow (2010) can physically and mentally improve the wellbeing of a cancer patient who experienced post-chemotherapy symptoms like nausea and vomiting. These methods are acupuncture and acupressure.
According to Lao and Zhang (2010) acupuncture and acupressure are some the most well-known Chinese alternative treatments. Recent studies give us some information about acupuncture and acupressure as modalities of reducing N&V related to chemotherapy treatment. (Ch.Kamen, K. Chandwani, Gary R. Morrow, 2014). A study from 2007 realized in UK, Manchester on approximately 40 patients analysed if the sea bands (used in acupressure) could reduce after chemotherapy nausea and vomiting. A group of patients worn them for 5 consecutive days. Another group of patients did not wear these bands. Both groups of patients took their usual anti-cancer medication. The wearing bands group registered a significantly reduced nausea and vomiting symptoms. (J.O’Regan D,Filshi J.)
There is a strong relationship between nutrition and N&V in cancer patients in the sense that the process of eating can be influenced by the above mentioned symptoms. The patients will find it very difficult to enjoy their meals during chemotherapy treatment. That is why they are recommended to eat before the chemo session. According to Kamen (2014) The patients should as well avoid fatty foods (French fries, pizza, baked goods and burgers), Indian, Mexican or any other type of spicy food which will increase the possibility to experience nausea and vomiting. It is also recommended to eat a little amount of food slowly and frequently. The whole day of the treatment they should consume breadsticks, crackers, pretzels and soft foods.
As additional non pharmacologic methods many cancer patients use hypnosis and different types of relaxation techniques such as: meditation, yoga, guided imagery.
Nausea and vomiting and the quality of life in cancer patients
Nausea and vomiting have clear adverse effects on a cancer patient’s quality of life. It can have psychological impact and possible lead to depression. (Lis et al, 2006). Marin et al (2007) suggests that patients with a poor state of health need professional medical attention, therefore their quality of life will depend very much on the healthcare professionals. The negative effects of nausea and vomiting on cancer patients’ quality of life were evaluated by multiple studies.
One of them evaluates the effects of chemotherapy nausea and vomiting on quality of life before the 5-HT3 antagonists appeared. The study was done in1993 and was applied to 92 patients for 5 consecutive days. They used FLIE (Functional Living Index-Emesis) completed before chemotherapy for two specific days: 2 and 5 after chemotherapy. After 5 days, FLIE scores showed that 78% of the patients suffered a worsening of their functional status which was improved after the first day. The second day patients felt bad, especially because of vomiting (emesis) installed during some leisure activities. On the other hand, at some level, nausea affected more than vomiting.
The patients’ quality of life got improved once 5-HT3 antagonists began to be used. Their action is directed against CINV. There are some available effective agents (table 1).
Collecting important information about the mode of action of the major group of SACT agents enabled me to conclude that SACT side effects, like nausea and vomiting can‘t be avoided, but patients’ suffering could be eased through an intensive professional support of the health care staff.
Figure 1. Five stages of normal cell development. Within each stage there are checkpoints that are regulated by components within the cycle.
Table 1. Some useful antiemetic drugs: Table adapted from London Cancer Alliance (LCA, 2013)
Figures – SACT and CINV.pdf
Blows, W. (2005) The biological basis of nursing: Cancer. Oxfordshire: Taylor & Francis.
Cancer Research UK (2015) Steroids (dexamethasone, prednisolone, methylprednisolone) Available at: http://www.cancerresearchuk.org/about- cancer/cancers-in-general/treatment/cancer-drugs/steroids
Cefalo MG, Ruggiero A, Maurizi P, et al.: Pharmacological management of chemotherapy-induced nausea and vomiting in children with cancer, 2009
Farrell C, Beardly SG, Pilling M, et al : The impact of chemotherapy –related nausea on patients’ nutritional status, psychological distress and quality of life, 2013
Gill, Paula; Grothey, Axel; Loprinzi, Charles (2006). «Nausea and Vomiting in the Cancer Patient”. Oncology. pp.1482–96.doi:10.1007/0-387-31056-8_83
Gelling O, Escher H-G. Should 5-hy-droxytryptamine-3 receptor antagonists be administered beyond 24 hours after chemotherapy to prevent delayed emesis? Systematic re-evaluation of clinical evidence and drug cost implications. J Clin Oncol 2005;23: 1289-94.
Gabriel, J. (2007) ‘The Biology of Cancer. 2nd edition. My Library [Online]. Gan To Kagaku Ryoho. 2009 Oct;36(10):1691-6.
J O’Regan D, Fishier Acupuncture and cancer. Autos Neurosis 2010
Kelvin, JF, Tyson, LB. (2011) 100 Questions & Answers About Cancer Symptoms and Cancer Treatment Side Effects. 2nd edn. Jones and Bartlett Learning, LLC.
London Cancer Alliance (LCA). (2013) LCA Acute Oncology Clinical Guidelines. London: London Cancer Alliance.
Lin JG, ChenYH. The role of acupuncture in cancer supportive care: Am J Chin Med 2012; 40:219-29
Lao L, Zhang G, Wong RH, et al: The effect of electro acupuncture as an adjunct on cyclophosphamide-induced emesis in ferrets. Pharmacol Biochem Behan 74:691-9, 2003
Morrow GR, Roscoe, Kirshner JJ, Hynes HE, Rosenblatt RJ. Anticipatory nausea and vomiting in the era of 5-HT3 antiemetic. Support Care Cancer 1998; 244-7.
Miller AD. Central mechanisms of vomiting. Dig Dis Sci 1999;44:Suppl:39S-43S. Manage, and Treat Chemotherapy-Induced Nausea and Vomiting. Clinical Journal of Oncology Nursing, Volume 11, Number 1.
McMillan. (2013) Nausea and Vomiting [Online]. London. McMillan Cancer Support. Available from:
http://www.macmillan.org.uk/ information-and-support/coping/side- effects-and-symptoms/other-side-effects/nausea-and-vomiting.html[Accessed 15.10.16]
Navari RM : Antiemetic control: toward a new standard of care for emetogenic chemotherapy. Expert Opine Pharma other, 2009
National Cancer Institute: Common Terminology Criteria for Adverse Events: US National Institute of Health, 2010
Oncology Nursing Society, UKONS (2007). www.ukons.org
Oshiro C, Kamigaki S, Nakamura Y, Arai T, Kanai Y, Fujino M, Fujii C, Hamaguchi Y, Iseki C, Hachino Y, et al. Gan To Kagaku Ryoho. 2012 Feb; 39(2):241-4.
Perry, M. (2008). The Chemotherapy Sourcebook. 4th ed. Philadelphia: Lippincott Williams & Wilkins
Saller R, Hellen Brecht D. High doses of metoclopramide or droperidol in the prevention of cisplatin-induced emesis. Cancer Clin Oncol. 1986; 22:1199
SchwartzberL. S (2015). Challenges in management of chemotherapy induced nausea vomiting. Clinical advances in hematology & oncology, Volume 13, Issue 3, Supplemet3 March 2015.
Tadman, M., Roberts, D. (2007). Oxford Handbook of Cancer Nursing. 1st edh. New York: Oxford University Press
The New England Journal of medicine 358;23 www.nejm.org June 5,2008
The Index of Nausea, Vomiting, and Retching (INVR) and the Functional Living Index–Emesis (Friend & Johnston, 2009)
Wickham R: Evolving treatment paradigms for chemotherapy-induced nausea and vomiting. 2012