Editors note: One of a series of articles on managing cancer-related symptoms from the

Oncology Nursing Society.

Chemotherapy-induced nausea and vomiting (CINV) is one of the most feared side effects of
cancer treatment for patients with cancer (de Boer-Dennert et al., 1997; Hickok et al., 2003).
However, healthcare providers may underestimate the impact CINV has on their patients
(Grunberg et al., 2004). Approximately 50% to 60% of patients with cancer receive highly
emetogenic chemotherapy, and about 70% to 80% of that population may experience CINV if
not properly treated (Grunberg et al., 2004). Uncontrolled CINV with administration of
chemotherapy can lead to anticipatory nausea and vomiting (a learned response to an earlier,
uncontrolled episode of CINV) with the next treatment. This, in turn, can create significant
quality-of-life and treatment adherence issues for patients.

Nausea is a subjective sensation associated with the will or desire to vomit. Vomiting is
described as the oral expulsion of stomach or intestinal contents with a person having signs and
symptoms such as a rapid or irregular heartbeat, dizziness, sweating, pallor, pupil dilation, and
retching (de Carvalho, Martins, and dos Santos, 2007). CINV can be acute (taking place minutes
or hours after treatment), delayed (taking place 24 hours or longer after treatment), anticipatory,
breakthrough (occurring even after preventative medications have been taken), or refractory
(antinausea medications that worked in the past no longer control the symptoms) (National
Comprehensive Cancer Network [NCCN], 2008) and can lead to dehydration, electrolyte
imbalance, malnutrition, decreased self-care, decrease functioning, depression, and fatigue (Lohr,
2008; NCCN, 2008).
Oncology nurses are in a key position to monitor and assess patients CINV. Ongoing assessment
(see Table 1) also can lead to treatment changes or new management strategies (Friend &
Johnston, 2009). A thorough assessment can help oncology nurses and the healthcare team to
fully understand the impact of CINV on patients.

Table 1. Assessment for the impact of CINV

Assess the number of episodes of retching.

Document the timing of the CINV (acute phase within the first 24 hours, delayed phase
after initial 24 hours)

Assess the patients ability to eat after chemotherapy.

Note the patients oral intake.

Document antiemetics taken by the patient.

Track other related symptoms or problems affecting the patient.

Several clinical measurement tools are available to augment the assessment steps. The Common
Terminology Criteria for Adverse Events (CTCAE) from the National Cancer Institute (2006) is
one of the more common tools. The Index of Nausea, Vomiting, and Retching (INVR) and the
Functional Living IndexEmesis (Friend & Johnston, 2009) also are useful forms of measure.
Finally, the Multinational Association of Supportive Care in Cancer ([MASCC], 2004)
developed an antiemesis tool (MAT) that measures the frequency and intensity of acute and
delayed nausea and vomiting.

Putting evidence into practice

To promote nursing practice that is based on evidence, ONS launched the Putting Evidence Into
Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff
nurses, and a nurse scientist were charged with reviewing the literature to determine what
treatments and interventions are proven to alleviate many cancer-related problems that are
sensitive to nursing interventions. Each team classified interventions under the following
categories: recommended for practice, likely to be effective, benefits balanced with harms,
effectiveness not established, effectiveness unlikely, and not recommended for practice.

Recommended for practice

The following are recommended for practice based on effectiveness established through
rigorously designed studies, meta-analysis, systemic reviews, or professional guidelines.

Anticipatory nausea and vomiting:

Several treatments exist for this learned response to an earlier, uncontrolled episode of CINV.
Among the nonpharmacologic methods are behavior therapies such as relaxation, hypnosis,
guided imagery, and acupuncture. Benzodiazepines are used for pharmacologic treatment, with
alprazolam (0.5-2 mg orally three times per day) and lorazepam (0.5-2 mg orally the night before
and the morning of treatment) as being recommended for practice (American Society of HealthSystem Pharmacists [ASHP], 1999; Gralla et al., 1999; NCCN, 2008; Plovich, White, &
Kelleher, 2005).

Acute or delayed nausea and vomiting:

Certain regimens have shown great effectiveness in controlling acute and delayed CINV. Table 2
contains of list of these agents based on emetogenic properties (Oncology Nursing Society,
2008).

Table 2. Medications recommended for

controlling CINV based on emetogenic
properties of chemotherapeutic agents
Highly and moderately emetogenic

5-HT3 receptor antagonists

o Palonosetron
o

Granisetron

Ondansetron

DolasetronM

Tropisetron

Neurokinin 1 (NK1) receptor antagonist

o

Aprepitant

Fosaprepitant

Corticosteroid
o

Dexamethasone

Benzodiazepine
o

Lorazepam

Low emetogenic

Corticosteroid
o Dexamethasone

Metoclopramide with or without diphenhydramine

Phenothiazine
o

Prochlorperazine

Benzodiazepine
o

Lorazepam

Minimal emetogenic

No routine antiemesis prophylaxis is recommended

Note. Effective dosage, timing, and combinations of medications may vary according to the
emetogenic properties of the chemotherapy regimen and onset of CINV. More information about
dosage and schedule information can be found in Friend and Johnston (2009).
Note. Based on information from ASHP, 1999; Gralla et al., 1999; MASCC, 2008; NCCN, 2008;
Polovich et al., 2005).

Breakthrough or refractory nausea and

vomiting:
According to NCCN (2008), prevention of breakthrough or refractory CINV is much easier than
treatment. The general principle is to give an agent from a different drug class than was
previously used, to consider around-the-clock dosing instead of PRN, and to use parenteral or
rectal routes since oral would be contraindicated (Friend & Johnston, 2009). Treatment options
would be similar to those shown in Figure 2 with the exception of an NK1 receptor antagonist.

Likely to be effective
The ONS PEP team found several avenues that were likely to be effective when treating patients
with cancer suffering from CINV. In order to be classified as likely to be effective in the PEP
program, an intervention must have effectiveness demonstrated by strong evidence from
rigorously designed studies, meta-analyses, or systemic reviews. Also, expectation of harm must
be small compared with benefits (Eaton & Tipton, 2009).

Acupressure:

Three randomized, controlled trials (Dibble, Chapman, Mack, & Smith, 2000; Klein & Griffiths,
2004; Shin, Kim, Shin, & Juon, 2004) found some evidence that acupressure reduced CINV
compared to no intervention at all. The noted benefits were decreased severity, frequency, and
duration and were seen in a patient population of mixed cancers. A study by Molassiotis, Helin,
Dabbour, and Hummerston (2007) found significant decreases in occurrence and distress among
patients with breast cancer. Finally, Dibble et al. (2007) concluded that acupressure significantly
reduced the frequency of CINV over time when compared to placebo or usual care.

Acupuncture:
Collins and Thomas (2004) and Mayer (2000) found that acupuncture provided a clinically
significant reduction in CINV. Shen et al. (2000) came to a similar conclusion when comparing
acupuncture and pharmacotherapy to pharmacotherapy alone. However, in a systematic review
by Klein & Griffiths (2004), acupuncture reduced vomiting but not nausea.

Guided imagery, music therapy, and muscle

relaxation:
A collection of studies found that these three strategies reduced nausea, vomiting, and/or retching
for anticipatory CINV (Arakawa, 1997; Ezzone, Baker, Rosselet, & Terepka, 1998; King, 1997;
Luebbert, Dahme, & Hasenbring, 2001; Miller & Kearney, 2004; Molassiotis Yung, Yam, Chan,
& Mok, 2002; Sahler, Hunter, & Liesveld, 2003; Troesch, Rodehaver, Delaney, & Yanes, 1993).
In addition, these strategies can be used together (i.e., guided imagery with music) or separately.

Psychoeducational support and information:

Two studies documented that a reduction in nausea and an improvement in well-being occurred
after oncology nurses provided increased support and education (coupled with standard
antiemetics) (Borjeson, Hursti, Tishelman, Peterson, & Steineck, 2002; Williams & Schreier,
2004). Both studies provided verbal, written, and audiotaped information to a population of
women with ovarian or breast cancer. Friend and Johnston (2009) suggest that this is an area for
additional study.

Effectiveness not established

The following interventions contain insufficient data or data or inadequate quality; however, no
clear indication of harm has been noted. Further in-depth research should be considered for the
following methods:

Acustimulation with a wristband device

Chinese herbal medicine

Exercise

Ginger

Hypnosis (for the presence of nausea)

Massage and aromatherapy

Yoga

Progressive muscle relaxation (for the presence of nausea).

Nurses are in a unique position to support patients suffering from CINV by using evidence-based
interventions. In addition to initiating treatments, nurses should assess the impact of CINV on
patients and their families, provide instruction and information about potential management
options, and help patients maintain treatment adherence.