Cancer Related Nausea and Vomiting

Nausea is an unpleasant feeling or urge to vomit. Nausea is a symptom, which is experienced by a person and not visible to other. 

Vomiting can be described as “throwing up” the content of the stomach due to abrupt contraction of stomach muscles that push the stomach contents out through mouth via esophagus (food pipe). Vomiting is a sign, that is it is visible to others. Vomiting may or may not preceded by nausea. 
Nausea and/or vomiting are 2 of the most common and distressing side effects associated with cancer or its treatment. These mostly occur simultaneously, but these are considered as 2 different problems in medical science. It is important to control it in cancer patients so that they can remain compliant with their cancer treatment. Thus, cancer patients generally receive medicines that help in controlling nausea and vomiting also known as anti-emetics.

What are the different types of Nausea and Vomiting in Cancer patients?

Nausea and vomiting are side effects that are subjective in nature and each individual’s experience is unique. With the same type and severity of disease, and with the same treatment, it may occur in an individual while it may not for the others due to different threshold levels of activation for vomiting center among different individuals. Also, it can vary in intensity, duration, pattern, and response to treatment with anti-emetics. 

Based on such characteristics, nausea and vomiting can be divided into the following types:

Acute Emesis

It is usually intense and short-lived. Treatment-related acute emesis generally happens within a few minutes to hours after cancer treatment is administered or during the treatment administration. 

Delayed Emesis

It happens more than 24 hours to few days after cancer treatment administration. This type of emesis is usually mild to moderate in intensity and take more time than acute to resolve. 

Anticipatory Emesis

It occurs prior to a cancer-treatment administration. Patients usually experience this due to prior experience with the same kind of treatment. Experts believe that the brain pairs the cancer treatment’s taste, smell, sight, sound, or pain with the emesis. It is more common among children.

Breakthrough Emesis

This type of emesis is usually intense and short-lived. It happens even when a patient is receiving anti-emetic treatment to prevent it. Higher dose or a different type of anti-emetic is generally required for the management of this type of emesis.

Refractory Emesis

This is the most severe type that does not respond to anti-emetics being used for preventing it. It is usually intense and long-lived. Higher dose or a different type of anti-emetic is generally required for a longer duration of time for the management of this type of emesis.

What causes Nausea and/or Vomiting in people with cancer?

Vomiting is a reflex action that is triggered upon activation of the vomiting center, a part of the brain. It may occur as a result of many unpleasant things related to the disease or its treatment, for example, foul smell or taste of the drug used, patient experiencing anxiety or pain due to disease or treatment administration, disease/treatment-related inflammation, poor blood flow, or irritation in the upper GIT. 

Following are the factors that can induce nausea or vomiting in cancer patients: 

Cancer

The disease (cancer) itself can cause it if it involves the brain, upper GIT, or liver, and pancreas. Large tumors that are present in nearby organs but press on the brain or GIT organs may also cause vomiting. Also, cancer affecting the liver or pancreas can cause N/V.

Surgery

Patients who undergo surgery, depending upon the extent of the procedure, may report emesis due to the tissue damage caused by the surgery or due to the side effects of anesthesia or other intervention during the surgery. The risk of developing further increases if surgery is carried out on the brain or on organs directly linked with the brain. 

Chemotherapy

Chemotherapy is frequently employed as a primary treatment in cancer patients with advanced-stage disease. It involves treatment with cytotoxic agents that kill the cancer cells. Many chemotherapeutic agents are emetogenic. 

Radiation therapy

Radiotherapy is another common treatment modality employed for cancer treatment. Radiations also cause tissue damage and have the potential to cause nausea and vomiting. 

Concomitant medicines/procedure

Sometimes, the supportive treatment used beside the primary treatment may cause emesis. For example, biopsy procedure or pain medicines may cause it in cancer patients.

Constipation

Cancer patients who have the problem of constipation are prone to emesis. Constipation may occur due to a side-effect of a medicine or may occur naturally. To avoid nausea vomiting in such patients, constipation must be treated.

Electrolytes Imbalance

An imbalance of electrolytes (minerals and salts) in the blood may cause emesis in cancer patients.

Anxiety

Some cancer patients have severe anxiety due to the disease they have or due to other disease-related factors. The anxiety increases the probability of cancer treatment causing emesis. Thus, cancer patients with severe anxiety should receive supportive care for anxiety besides the primary cancer treatment. 

Intense pain

Cancer patients usually deal with the pain that may couple with emesis if not controlled properly. Thus, it is recommended that such patients should also receive pain treatment along with cancer therapy.

Past experience

Some patients may have an experience of nausea and vomiting with certain chemotherapy drug(s). Such patients are prone to have it when they undergo similar treatment in future. In such cases, pre-treatment with anti-emetic medicine is usually recommended.

What are the factors that make an individual more prone to Nausea and Vomiting?

The likelihood that a patient will have cancer-related nausea and vomiting depends on many factors as detailed below:

• Type of disease: Cancer involving brain or associated structures or those that affect upper GIT usually cause emesis more commonly.
• The severity of disease: The advanced disease is more likely to cause emesis compared to the less advanced disease. Also, the disease that has spread to brain or GIT organs usually cause emesis.
• Type of treatment: Certain type of surgery, chemotherapy, and/or radiotherapy are more likely to cause emesis.
• Treatment regimen: Higher dose or higher dosing frequency of chemotherapy is more likely to cause emesis.
• Age of patient: Younger patients are more likely to have emesis compared to old-age individuals.
• Gender of the patient: Females are more prone to emesis compared to male counterparts.
• Anxiety or Depression: Patients who have anxiety or depression are at higher risk of developing emesis.
• Motion sickness: Patients with motion sickness usually have a lower threshold for emesis.
• Prior Treatment: Patients who have received chemotherapy in past are usually more prone to emesis.
• Drinking habit: It has been reported that patients who have never drunk are more prone to emesis.

How to treat nausea and vomiting in cancer patients?

Although cancer-related N/V is difficult to be relieved completely, in most cases, it can be reduced to a level that does not bother. Medicines that are used to control N/V are called as anti-emetics. 
Cancer-related N/V can be best managed by preventing it rather than after it has happened. This is why anti-emetics are usually given on a regular schedule rather than after the occurrence of N/V. The anti-emetic treatment continues for the time cancer-treatment is expected to cause N/V. 

Appropriate anti-emetic drug or combination of drugs for a patient is selected based on many factors, as described below:

Treatment related factors

For example, the likelihood of primary treatment for causing N/V should be considered for selecting the appropriate anti-emetics. Some chemotherapeutic drugs are more likely to trigger N/V compared to the other drugs. Thus, various chemotherapeutic drugs have been classified according to their emetogenic potential into the following four categories: high, moderate, low, or minimal risk. And the antiemetic drug combination used for each category is different.

Patient Related factors

For example, prior history of N/V with the same kind of treatment, anti-emetics that have been effective in past; side effects associated with the anti-emetics; the efficacy of ongoing anti-emetic medicine, etc are some of the patient related factors.

Based on the above-listed factors, an appropriate anti-emetic is selected.

Serotonin (5-hydroxytryptamine or 5-HT3) receptor antagonists

These drugs block the effects of serotonin on its receptor (a mechanism that commonly causes nausea and vomiting). Examples of drugs included in this category are ondansetron, granisetron, dolasetron, azasetron, ramosetron, tropisetron etc. These are very effective anti-emetics that are usually given before cancer-treatment administration and then continued until few days after cancer-treatment cessation. They have a favorable side-effect profile with common side effects including a low-grade headache, malaise, and constipation.

Neurokinin-1 (NK-1) receptor antagonists

These drugs block the action of neurokinin via its binding to the NK-1 receptor. These can delay or prevent the occurrence of both acute and delayed N/V in cancer patients. Example of such medicines includes aprepitant, rolapitant, netupitant, casopitant etc. 

Glucocorticoids

These drugs can be used alone or in combination with other anti-emetic drugs. These are also very effective anti-emetics with favorable side-effect profile. Examples of glucocorticoids that are commonly employed as anti-emetics include dexamethasone and prednisone.

Dopamine antagonists

These block the action of dopamine, a neurotransmitter generally released in response to noxious stimuli, on its receptor present in vomiting center of the brain. This prevents N/V cancer patients. Examples of such drugs include prochlorperazine and metoclopramide. These are now rarely used for the management of N/V in cancer patients.

Antipsychotic Drugs

For example, olanzapine blockS the action of serotonin on 5-hydroxytryptamine (5-HT2) receptors and dopamine on D2 receptors. This dual action of olanzapine makes it a very effective antiemetic medicine. It can be used alone or in combination with other drugs.

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