Chemotherapy Induced Nausea & Vomiting

Chemotherapy Induced Nausea & Vomiting A Nurse s Perspective Michael Flynn MSc, PG Cert, RGN Chemotherapy Nurse Consultant Guy s and St Thomas NHS Foundation Trust

Guy s and St Thomas NHS Foundation Trust Two of London s oldest teaching hospitals St Thomas Hospital Waterloo Guy s Hospital London Bridge One of the largest Foundation Trusts in the UK Serving a culturally diverse population with high levels of socioeconomic deprivation. One of five Academic Health Sciences Centres King s Health Partners Guy s and St Thomas NHS Foundation Trust King s College London King s College Hospital NHS Foundation Trust South London and Maudsley NHS Foundation Trust

GSTFT Cancer Services Offers a full range of services for the diagnosis treatment and follow up of all adult cancers. 17000 chemotherapy attendances per annum 6 Linear Accelerators, 4 upgraded Accelerators, Tomotherapy, high dose brachytherapy & Stereotatic body, image guided and inverse planned image modulated radiotherapy Surgery (including laprascopic and robotic assisted surgery offered on day-case and inpatient basis at both hospitals) Hospital & Community Palliative care services A full range of support services including Dimbleby Cancer Care Underpinned by a comprehensive electronic Cancer Information Solution

A Quick recap of CINV Definitions Nausea The unpleasant, subjective feeling of the need to vomit Vomiting The forceful release of stomach contents through the mouth caused by strong contractions of the stomach muscles. Woodruff 1997

A Quick recap of CINV Physiological Rationale What function do nausea & vomiting perform in the body? Vomiting The physical expulsion of toxins from the stomach. Nausea Trigger for the vomiting reflex. Nausea deterrent from repeat exposure to the toxic substance.

Causes of Nausea & Vomiting in Cancer Patients Chemotherapy Uraemia Radiation Concomitant drug treatments Bowel obstruction Gastroparesis: chemo or disease Vestibular dysfunction Anxiety Brain metastases Anticipation Electrolyte imbalance

Vomiting pattern generator Also called the vomiting centre Activates the vomiting reflex Located in the medulla area of the brain. Is activated by one or a combination of neuronal pathways.

Neuronal Pathways Receptor Ach(M) Cholinergic muscarinic D Dopamine H Histamine NK neurokinin 5HT 5-hydroxytryptamine GABA Gamma-amino butyric acid

Factors influencing chemotherapy induced emesis Emetogenic risk of chemotherapeutic agent History of motion sickness Gender Performance status Age Other drugs History of alcohol Concomitant medical conditions History of morning sickness

Types of CINV Acute onset within 24hrs following chemo administration. Delayed onset after 24hrs following chemo administration. Anticipatory onset before chemo administration. Breakthrough responds to rescue. Refractory doesn t respond to rescue.

Emetogenic risk class

Principles of Emesis Control The goal is to prevent nausea and/or vomiting. The risk of emesis and nausea for persons receiving chemotherapy of high & moderate emetogenic potential lasts at least 4 days and 3 days respectively. Patients need to be protected throughout the full period of risk. Oral and IV antiemetic formulations have equivalent efficacy NCCN 2009

Principles of Emesis Control The toxicity of the specific antiemetic(s) should be considered. Antiemetic regimens should be chosen based on the drug with the highest emetic risk in the chemotherapy regimen, previous experience with antiemetics, and patient-specific risk factors. NCCN 2009

Present GSTFT Antiemetic Prophylaxis Emetogenic risk group High (>90%) Moderate (30-90%) Acute Nausea & vomiting prophylaxis (0 to 24 hours after chemotherapy) Aprepitant 125mg PO stat Ondansetron 16mg PO stat Dexamethasone 8mg PO stat Ondansetron 8mg PO stat Dexamethasone 8mg PO stat Delayed Nausea & Vomiting prophylaxis (24 or more hours after chemotherapy) Aprepitant 80mg PO days 2&3 Ondansetron 16mg PO stat day 2 Dexamethasone 8mg PO OD 3/7 Metoclopramide 20mg PO TDS 3/7 Dexamethasone 8mg PO OD 3/7 Metoclopramide 20mg PO TDS 3/7

Surely therefore since the development of 5HT3 receptor antagonists the problem is sorted. Just attach the correct antiemetic prophylaxis to the chemotherapy regime and the patient will be protected.

Not Quite

Chemotherapy induced nausea and vomiting Most feared side effect Hawkins (2009) Consistently list chemotherapy induced nausea and vomiting as one of their greatest fears...continues to have a great impact on the quality of life. Hesketh (2008) Rice (2011)

Current incidence of CINV Approximately 70 to 80% of all cancer patients receiving chemotherapy experience nausea and/or vomiting. 10 to 44% experience anticipatory nausea and/or vomiting.

Audit planning Plan to audit 50 patients Patients would be receiving Cisplatin based therapy. Cisplatin known to cause acute and delayed CINV. Audit would cover both nausea & vomiting. Although anecdotal reports of vomiting were the primary reason for auditing, it was expected that nausea would be the major issue. Questionnaire based on the MASCC designed tool. Vomiting objective number of times Acute Delayed Nausea subjective rating from 1 to 10 Pretreatment Acute Delayed

Audit Results n=73 Gender Age Diagnosis Male 30 <40 3 Upper GI 17 Female 29 40-49 9 Gynae 17 Undisclosed 14 50-59 19 Head & Neck 14 >59 38 Lung 4 Undisclosed 4 Melanoma 2 Liver 2 Colorectal 2 Undisclosed 15

Audit Results

Audit Results - 2009 Findings of note Acute Nausea (AN) n=37 Median onset 12 hours Median patient subjective rating 5 Delayed Nausea (DN) n= 38 Median onset Day 2 Median patient subjective rating 5 DN without experiencing AN n=8 Median onset Day 2 Median patient subjective rating 4.5

Audit Results - 2009 Diagnosis Number Pre% AV% AN% DV% DN% Upper GI 17 6 0 29 12 41 Gynae 17 12 0 53 18 53 Head & Neck 14 29 21 57 21 50 Age & Gender showed no significant differences in any reported field Presence of delayed vomiting without acute vomiting suggests duration of prophylaxis not adequate at present. Diagnosis may contribute to a disposition to nausea however treatment intensity and anatomical factors are more likely.

Audit findings interpretation - 2009 Patient Nausea is an expected and accepted side effect of treatment This has led to an underreporting of nausea to healthcare professionals during the treatment phase. Anticipatory nausea is a real threat to patients receiving treatment 2 nd line prophylaxis escalation is not consistent or sustained and unlikely to be successful Delayed vomiting suggests either under treatment or delay in prophylaxis commencement Delayed vomiting prophylaxis is not adequate and needs to be targeted to high risk groups

Audit findings interpretation - 2009 Organisational Process Assessment of Nausea & Vomiting Present lack of structure coordination and communication of proactive assessment between outpatient clinics and treatment units. Lack of consistent approach to 1 st line prophylaxis utilisation of out of date paper proformas and failure to adjust proformas to current guidelines suggest lack of knowledge of and access to current guidelines. Inconsistent approach to 2 nd line prophylaxis Suggestive of lack of knowledge of and access to current guidelines.

Recommendations based on Audit for HEC* Increase Dexamethasone dose to 12mg. Include PPI coverage in prophylaxis Use Aprepitant 1 st line in patients classified as high risk. Use Palonosetron as 5HT3 receptor antagonist of choice in patients receiving multiple day regimes

Re-evaluation of CINV - 2012 MASCC inspired questionnaire re-used Audit group all patients receiving HEC and MEC regimes Target to audit 100 patients

What changed between 2009 and 2012? All patients receiving HEC regimes receive Aprepitant first line. Complete e-prescribing and electronic medical record. Pre treatment consultations delivered in a clinic structure by competency assessed nurses. Pro-active telephone monitoring 24hrs after 1 st treatment episode. Tumour specific chemotherapy link nurses Nurse led Acute oncology assessment unit with telephone triage 0830 to 1830hrs (Oncall medical service out of hours)

CINV related calls to AOAU Month Calls Month Calls June 2012 19 October 2012 23 July 2012 29 November 2012 34 August 2012 20 December 2012 18 September 2012 15 January 2013 22

Audit was expected to show significant improvement in CINV occurrence and intensity

Not Quite

CINV Audit 2012 compared with 2009 Year Pre Nausea % Acute Vomiting % Acute Nausea % Delayed Vomiting % Delayed Nausea % Total Nausea % 2009 21 12 53 21 50 61 2012 9 9 33 9 45 51

CINV Audit 2012 compared with 2009 Median 5 Median 4.5 Year Pre Nausea % Acute Vomiting % Acute Nausea % Delayed Vomiting % Delayed Nausea % Total Nausea % 2009 21 12 53 21 50 61 2012 9 9 33 9 45 51 Median 4 Median 4.5

CINV Audit 2012 compared with 2009 Median 5 Median 4.5 Year Pre Nausea % Acute Vomiting % Acute Nausea % Delayed Vomiting % Delayed Nausea % Total Nausea % 2009 21 12 53 21 50 61 2012 9(13) 9(4) 33(39) 9(13) 45(48) 51(61) Median 4 (5) Median 4.5(6)

Pre-chemotherapy CINV Assessment 80 clinic entries for patients receiving HEC and MEC regimes week commencing 10 th of September 2012. 22 Entries CINV grading of previous cycle 10 Grade 0 6 Grade 1 1/6 prophylaxis adjusted 5 Grade 2 4/5 prophylaxis adjusted 1 Grade 3 1/1 prophylaxis adjusted 4 Entries document Nil other toxicity 54 Entries nausea assessment not documented

What does it all mean? Patients expect to feel nauseated? Is CINV really preventable in all patients? We expect patients to feel nauseated? There is an acceptable level of nausea for different regimens? We continue to underestimate the effect of CINV on patients? Patients don t or can t contact us when they feel nauseated? A blanket pharmacological solution is not the answer?

Way forward - GSTFT Joint working project with Pharma understanding the significance of other risk factors apart from agent emetogenic risk. Continue development of the pre-treatment consultation in regards to assessment of CINV risk. Continued development of pre-treatment consultation effectiveness in regards to access of acute oncology services. Expansion of proactive telephone monitoring for patients identified as high risk. Development of a prophylaxis kit for moderate emetogenic risk patients. Further development of multiprofessional chemotherapy on treat clinics.