CINV: Who Is at Risk?

Transcript:Lee S. Schwartzberg, MD: What kind of risk factors do we see for CINV, Becky?

Rebecca Clark-Snow, RN, BSN, OCN: So, we’ve identified several risk factors. There are patient-related risk factors and then there are treatment-related risk factors. For those patient-related risk factors, younger people, especially younger women, are more susceptible to having difficulty controlling CINV. Young women with breast cancer, in particular, definitely have more of a problem with not receiving adequate treatment. Motion sickness is also part of a history that we take with patients. And those patients who have a history of a high alcohol intake surprisingly have less of a risk of having emesis. Having said that, we still need to treat those patients with the most appropriate antiemetics, as well.

As far as treatment-related risk factors, definitely it includes those drugs that are likely to cause a good deal of nausea and vomiting, those highly emetogenic agents, as well as the moderately emetogenic agents. So, we do tend to look at antiemetic regimens, primarily based on the treatment-related factors. But we also need to look at patient-related factors, as well, and combine all of those.

Lee S. Schwartzberg, MD: Thinking about these different categories, Charles, can you tell us a little bit about which drugs that we commonly use that fall into the highly emetogenic category and which fall into the moderately emetogenic category?

Charles L. Loprinzi, MD: Yes, let me back up a little bit in terms of the risk factors. Morning sickness also fits in that category for some patients. And I have a hypothesis. It’s never been shown, but I suspect that if you get sickness from anesthesia, anesthesia-related nausea and vomiting, you’re probably going to get sickness from these agents. It’s mostly how you respond to toxins. The only time I had general anesthesia, I threw up for 12 hours. And I’ve never had chemotherapy, but I suspect I’m going to have a rough time. And I have motion sickness, too.

The other thing that I found interesting is alcoholics seem to have less nausea and vomiting. This came out in about 1982—and I know because in ’81 or ’82, I was a resident—in a New England Journal letter to the editor. And they actually hypothesized that the reason was because they thought the alcoholics had burned out their emetogenic center. I have a different hypothesis. I would never become an alcoholic because I can’t have more than a drink or two of wine before I get sickness from that hangover in the middle of the night. And so, I’m sensitive to that thing. I think that people who are sensitive will never become chronic alcoholics. That might be the rationale for it, but it’s never been proven.

In terms of highly emetogenic chemotherapy, the one we think about most is cisplatin, more than carboplatin. Carboplatin fits in the moderately emetogenic category. And more data recently show that it causes a little bit more nausea and vomiting than we like, even with our moderately emetogenic regimens that we give.

And then AC is an interesting group—adriamycin and cyclophosphamide. For a long time, that was considered moderately emetogenic. But it really is highly emetogenic because it’s used in young women with breast cancer oftentimes, and it does cause a lot of trouble. And for a while, some in the guideline committee said, “Well, let’s move it to the highly emetogenic.” Another committee said, “No, we called it moderately emetogenic. But for our highly emetogenic and the AC moderately-emetogenic agents, we’re going to treat with this.” But, I think it really is highly emetogenic.

Lee S. Schwartzberg, MD: And it’s really the one category where we have two drugs together as opposed to just listing them by individual drugs—because of that interaction, as you said. What other drugs are in the moderately emetogenic?

Eric Roeland, MD: So, just backing up a bit. Highly emetogenic is defined as greater than a 90% risk. And then moderately emetogenic is 30% to 90%, which is so broad. And those of us interested in the topic sit down and debate these things. But I think that’s a real area that we need to think about further and research. The other personal risk factor that I consider, and I’m seeing more and more in my practice, is just anxiety. For these patients that tend to be really anxious and are worried about nausea and vomiting, it almost becomes a self-fulfilling prophesy that they’re going to have that bad experience. I think that’s something that I’m pressed to think about. I describe them as my “nervous Nellies.” I know how they’re going to do, and I’m usually more aggressive about how I treat them.

Lee S. Schwartzberg, MD: And you might use different categories of drugs to treat anxiety, which is an overlay, in a sense, over the physiology.

Eric Roeland, MD: Yes. And then to Jim’s point about anticipatory nausea, everyone has these war stories about patients who just have this conditioned response, and it can actually be really disturbing, from a smell to driving by the cancer center. One of my favorite stories is one of my bosses is a breast oncologist, and she saw one of her patients in the supermarket. And just looking at her face, she vomited right there in the supermarket, which she doesn’t take personally; it’s just so conditioned. It’s really amazing that you’re so hardwired to have such a bad experience.

Transcript Edited for Clarity