Effect of chemotherapy-induced nausea on patients quality of life

Transcription

1 Art & science literature review Effect of chemotherapy-induced nausea on patients quality of life Melissa Fitzgerald and Siobhan Murphy discuss ways to manage treatment side effects including non pharmacological approaches, such as yoga Correspondence Melissa Fitzgerald is staff nurse, Health Service Executive South, Ireland Siobhan Murphy is lecturer, School of Nursing and Midwifery, University College Cork, Ireland Date of submission June Date of acceptance September Peer review This article has been subject to double-blind review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ cnp-author-guidelines Abstract The aim of this review was to synthesise and critique the evidence on patients experiencing chemotherapy-induced nausea and vomiting (CINV) and how it affects quality of life (QoL). CINV has been recognised internationally as a life-limiting side effect. The needs of patients are recognised but poorly managed, which has an adverse effect on their QoL. Patients are potentially vulnerable and may require ongoing nursing advocacy and support. Databases were searched during September 2014, after which limitations and inclusion criteria were applied. Outcomes were clustered into four main themes: effect of acute and delayed nausea and vomiting on QoL; effect of highly CHEMOTHERAPY IS the use of cytotoxic drugs to kill cancer cells with curative or palliative intent (Lewis et al 2014). Long-term survival from cancer has increased in the past decade, with more than 100,000 survivors in Ireland. The five-year survival rate between 2005 and 2009 in Ireland was 60% for men (prostate cancer) and 62% for women (breast cancer), with survival rates of less than 22% observed for patients with cancers of the pancreas, liver, lung, oesophagus and brain. During this period, 31% of patients chose chemotherapy as a treatment to stimulate a systemic response to cancer cells with the goal of reducing cell replication and preventing metastases (National Cancer Registry 2013). However, chemotherapy, unable to distinguish malignant from healthy cells, affects fast-dividing cells, with significant implications for patients (Lewis et al 2014). emetogenic chemotherapy in comparison with moderately emetogenic chemotherapy; effect of non-pharmacological approaches in reducing the effects of CINV; and psychosocial effects of CINV on QoL. The review exposed inconsistencies in symptom management during chemotherapy. CINV is prevalent despite use of antiemetic treatments. Further qualitative research is recommended to understand the effect CINV has on QoL and non-pharmacological approaches are presented to be considered as additions to care. Keywords antiemetics, cancer, chemotherapy-induced nausea and vomiting, quality of life, side effects, symptom control Chemotherapy-related side effects can be detrimental and include gastrointestinal disturbances, fatigue, alopecia and malnutrition (Bergkvist and Wengström 2006). Nevertheless, the experience of chemotherapy-induced nausea and vomiting (CINV) has been recognised internationally as a life-limiting side effect and most frightening for patients (Hawkins and Grunberg 2009). CINV is often associated with physiological complications such as fatigue, muscle strain and metabolic imbalance. Distressing complications may contribute to inadequate caloric and fluid intake, which can aggravate lethargy and fatigue. CINV that is insufficiently managed adversely affects quality of life (QoL) and can affect how treatment is perceived (Hawkins and Grunberg 2009). Two main types of CINV are identified in the literature that have the potential to have a negative effect on QoL if uncontrolled. Nausea and vomiting 34 November 2015 Volume 14 Number 9 CANCER NURSING PRACTICE

2 that occurs within 24 hours of chemotherapy is referred to as acute, whereas emesis that develops 24 hours post-administration is known as delayed (Hesketh 2008). Antiemetics are the first choice of treatment. Antiemetic guidelines were published in 2013 by the Multinational Association of Supportive Care in Cancer (MASCC) and in 2015 by the National Comprehensive Cancer Network (NCCN). Guidelines are based on the emetogenic potential of chemotherapy agents and it is difficult to recommend specific antiemetic regimens. Regimens with the highest therapeutic index include corticosteroids, serotonin (5HT3) receptor antagonists, and neurokinin 1 (NK1) receptor antagonists (Table 1). These medications are effective in reducing the risk of emesis and can be administered in combination (MASCC 2013, NCCN 2015). In addition, non-pharmacological interventions such as yoga and supportive therapies aim to complement antiemetics and improve QoL (Cho 2013). In Ireland, the National Cancer Control Programme (2014) reported that most nurses are involved regularly or for brief, rigorous periods of time in the care of people affected by cancer. Nurses are at the front line of services and potentially the most significant members of the healthcare team from patients perspective. Nursing presence to provide patient advocacy and support is essential for this potentially vulnerable group. Literature search An extensive search was conducted on CINV and its effect on QoL. CINAHL and PubMed databases were searched during September Search terms used were chemotherapy-induced nausea and vomiting and quality of life, which yielded 520 hits: CINAHL (n=61) and PubMed (n=459). Limitations used on CINAHL (n=61) were publication date ( ); English language; peer reviewed; human and adult, which resulted in 11 hits. Limitations in using PubMed (n=459) were last ten years; English language; nursing journals; and above 19 years, which resulted in eight hits. Removal of non-accessible and duplicated papers resulted in 11 abstracts being scrutinised. Papers outside the scope of nursing were excluded, for example pharmacological comparison trials, socioeconomicbased research, instrument research and tools for data assessment. Three further papers arose from hand-searching of reference lists, bringing the total to 14 international studies. Irrespective of study methodology or setting, parallel findings were uncovered relating to four main themes: Effect of acute and delayed nausea and vomiting on QoL. Effect of highly emetogenic chemotherapy (HEC) in comparison with moderately emetogenic chemotherapy (MEC) on QoL. Effect of non-pharmacological approaches in reducing the effects of CINV. Psychosocial effects of CINV on QoL. Results Effect of acute and delayed nausea and vomiting on QoL Incidence and severity of acute and delayed CINV vary according to the particular drug and dose as well as individual patient variables. The incidence of delayed CINV is usually higher than acute. This can be linked to the neuropharmacologic Table 1 Chemotherapy-induced emesis: emetic risk levels and guidelines Specific guidelines depend on patient and drug administered. The table offers general guidelines of drugs to be administered with highest therapeutic index Risk level Chemotherapy Multinational Association of Supportive Care in Cancer (MASCC) antiemetic guidelines National Comprehensive Cancer Network (NCCN) antiemetic guidelines High (>90%) Example = cisplatin and mechlorethamine Acute nausea and vomiting: 5HT3 + DEX + APR or FOS Acute and delayed nausea and vomiting: 5HT3 + DEX + APR or FOS Delayed nausea and vomiting: DEX* + APR* Moderate (30%-90%) Example = doxorubicin and carboplatin Acute nausea and vomiting:palo + DEX Delayed nausea and vomiting: DEX Acute nausea and vomiting: 5HT3 + DEX Delayed nausea and vomiting: depends on previous antiemetics administered 5HT3= serotonin receptor antagonist; DEX = dexamethasone; APR = aprepitant; FOS= fosaprepitant; PALO = palonosetron; DEX only if fosaprepitant used on day 1 * if fosaprepitant used on day 1 (MASCC 2013, NCCN 2015) CANCER NURSING PRACTICE November 2015 Volume 14 Number 9 35

3 Art & science acute literature carereview Table 2 Main drug groups recommended to treat chemotherapy-induced nausea and vomiting (CINV) and mechanism of action Drugs Serotonin 5HT3 receptor antagonist, for example, palonosetron Neurokinin 1 (NK1) receptor antagonist, for example, aprepitant Corticosteroid, for example, dexamethasone (National Comprehensive Cancer Network 2015) Mechanism of action An antiemetic that acts at inhibiting receptor antagonists at the 5HT3 receptor areas of the brain. It is considered mainly effective in controlling acute nausea and vomiting in patients receiving high and moderate emetogenic chemotherapy An antiemetic that actively acts to block the binding of substances at the NK1 area found in the central nervous system. Aprepitant especially is considered to enhance the effectiveness of the 5HT3 receptor antagonist and corticosteroid dexamethasone providing protection against cisplatin-induced nausea and vomiting Mechanism of action is not fully understood. However, the addition of dexametasone is used to increase the efficiency of antiemetics. It particularly improves the effectiveness of the 5HT3 receptor antagonist mechanism of delayed CINV, which is a well-researched topic although inadequately understood (Grunberg et al 2004). However, despite research and improvements in management, both types still affect patients QoL (Hawkins and Grunberg 2009). Haiderali et al (2011) observed a sample of patients (n=198) experiencing either acute or delayed CINV irrespective of receiving antiemetics. The Functional Living Index-Emesis (FLIE) questionnaire was used to evaluate the influence of CINV on QoL. The most frequently prescribed antiemetics included the corticosteroid dexamethasone, the 5HT3 receptor antagonist palonosetron, and the NK1 receptor antagonist aprepitant. These medications are considered of highest therapeutic index when administered in combination (Tables 1 and 2), yet up to 61% of study participants experienced acute and delayed CINV. Nausea affected 60% and vomiting affected 17%. Delayed CINV was more common (58%) than acute CINV and had a negative effect on QoL. A decline in daily functioning due to CINV was reported by 37% of participants. They reported being less productive in daily life and were subjected to financial stressors as CINV affected work productivity and ability to attend work. Using the FLIE questionnaire, Hilarius et al (2012) examined incidence of acute and delayed CINV affecting patients functional status. Study participants (n=173) indicated that acute and delayed CINV affected QoL, but did not state how. Similar findings were established by Ballatori et al (2007) who used the FLIE questionnaire to estimate frequency of patients reporting CINV affecting QoL. More than 90% of those with acute and delayed nausea and vomiting reported an effect on QoL. Delayed emesis was perceived to have a negative effect on QoL, with a significant influence on the ability to carry out everyday activities. Fernández-Ortega et al (2012) used the FLIE questionnaire to analyse the effect of CINV on patients (n=160) receiving HEC and MEC and how this influenced QoL. Results indicated that despite using antiemetics, patients experienced significant nausea and vomiting during chemotherapy. Delayed CINV was most life-limiting, with the intensity and duration of CINV associated with a greater effect on QoL. Fernández-Ortega et al (2012) emphasised that nausea was more life-limiting than vomiting (75%). Nausea is an ongoing experience that can potentially affect QoL and its duration poses many challenges for chemotherapy patients. Acute and delayed CINV have a negative effect on patients QoL, with duration of emesis rather than intensity influencing how QoL is perceived. However, although quantitative methods such as the FLIE questionnaire describe the incidence and severity of CINV, actual effects on QoL are under-explored. This is despite the literature suggesting that the psychosocial needs of patients undergoing chemotherapy are paramount (Molassiotis et al 2008a). Effect of HEC in comparison with MEC on QoL A range of chemotherapy agents can be administered to cancer patients. Emetogenic properties that have the potential to induce nausea and vomiting vary depending on the type of drug given. The most established regimens in the literature are classified as either highly (HEC) or moderately (MEC) emetogenic. The most commonly used HEC agent is cisplatin and doxorubicin is an example of a MEC drug. The effect of these agents on QoL was examined. Hilarius et al (2012) explored how QoL was affected in patients treated with HEC, MEC or MEC containing anthracycline. Despite the use of antiemetics, the presence of CINV had a profound effect on patients (n=173) QoL. During the first treatment cycle where CINV is considered a great risk, 33% of patients indicated a substantial negative effect on QoL. 36 November 2015 Volume 14 Number 9 CANCER NURSING PRACTICE

4 Patients receiving treatment with MEC containing anthracycline reported experiencing more acute nausea than those receiving HEC or MEC. However, Bloechl-Daum et al (2006) revealed that patients receiving HEC experienced the greatest effect on QoL. Physical abilities, social interaction, emotional function and ability to enjoy meals were greatly affected. In addition, Bloechl-Daum et al (2006) suggested that those in receipt of HEC reported an increased number of emetic occurrences daily. There was no difference noted in the rate of acute and delayed nausea between patients receiving HEC and MEC, yet those treated with HEC reported greater nausea severity during the first five days post-chemotherapy. The study was not restricted to specific cancer type and included a wide range of chemotherapy regimens. Molassiotis et al (2008b) found that patients receiving HEC and MEC experienced interference with daily life. HEC patients reported greater incidence of delayed nausea during chemotherapy that was difficult to control. Haiderali et al (2011) had similar findings, suggesting patients treated with HEC were more likely to experience CINV with adverse effects on QoL. Uncontrolled CINV was a burden for patients, as it resulted in increased costs due to healthcare use, reduced work productivity and decreased functional ability in daily life (Haiderali et al 2011), with potential to affect QoL when uncontrolled. Effect of non-pharmacological approaches in reducing the effects of CINV Non-pharmacological approaches to prevent CINV and improve health-related QoL were explored in several studies (Raghavendra et al 2007, Kearney et al 2008, Jahn et al 2009, Jordan et al 2010, Genç et al 2013, Mollaoǧlu and Erdoǧan 2014). Yoga, acupressure, education and supportive/coping therapies have been examined as alternatives to manage CINV independently or to complement antiemetics (Cho 2013). The concept evolved from western countries where CINV may not be managed pharmacologically due to affordability of new-generation antiemetics (Raghavendra et al 2007). In a randomised controlled study, Raghavendra et al (2007) evaluated the effects of yoga (n=28) versus supportive therapies/coping interventions (n=34) on QoL. Findings revealed that practising yoga significantly reduced frequency and severity of post-chemotherapy nausea; however, it was not as successful in reducing the frequency or intensity of vomiting. Similarly, supportive therapies (patient education) and coping interventions (counselling sessions) were beneficial in reducing side effects of chemotherapy. Patients who received supportive therapies/coping interventions experienced a decrease in duration of CINV, thus improving QoL. Conversely, patients practising yoga displayed greater reduction in distressing symptoms associated with CINV, such as anxiety and depression, when compared with those receiving supportive therapies. Jordan et al (2010) stated that neither active (problem solving) nor passive (denial) coping strategies influenced whether patients (n=43) would or would not develop nausea and vomiting post-chemotherapy. Thus, coping strategies and non-pharmacological approaches are ineffective in reducing the effect CINV has on QoL. Genç et al (2013) investigated the effect of acupressure in prevention of CINV with patients in experimental (real acupressure wrist band) and control groups (placebo). No meaningful differences were found between the two groups, suggesting real acupressure was ineffective in reducing the occurrence or experience of CINV among patients, or improving QoL. Mollaoǧlu and Erdoǧan (2014) investigated the effect of planned, structured patient education on how to manage the chemotherapy symptom experience, using control (n=60) and experimental groups (n=60). Patients receiving planned education and support before chemotherapy experienced lower frequency of effects such as nausea, vomiting, appetite changes and weight loss post-chemotherapy. Significant results were observed, as the frequency of vomiting for patients in the control group was 67% compared with 27% in the experimental group. Severity and distress associated with symptoms post-chemotherapy dramatically decreased for the experimental group. Thus, planning for side effects allows patients to take control of the symptom experience and ultimately improve QoL. The aim of Jahn et al s (2009) cluster-randomised trial of a self-care improvement programme was to reduce the side effects of CINV/anorexia through nurse-led education sessions on relaxation, counselling and supportive therapies. The intent was to increase patients self-care behaviours in conjunction with antiemetics. No significant difference was found between patients receiving antiemetics and supportive therapies compared with those who received standard antiemetic care. However, Jahn et al (2009) suggested that physicians may not have been aggressive enough in prescribing prophylaxis during this trial. CANCER NURSING PRACTICE November 2015 Volume 14 Number 9 37

5 Art & science acute literature carereview Alternatively, Kearney et al (2008) focused on planned assessment and management of chemotherapy-related symptoms by use of an electronic symptom management tool. In-depth patient assessment allowed nurses to understand the pattern of symptoms emerging post-chemotherapy for each patient and offer suggestions on appropriate interventions to improve QoL. Nausea and vomiting dramatically decreased for participants (n=249) and QoL improved. Psychosocial effects of CINV on QoL The psychosocial wellbeing of patients undergoing chemotherapy is affected. Nausea and vomiting affects physical and psychosocial aspects of life. The influence this symptom has on QoL is determined by its intensity, whether it is intermittent or constant and its duration (Lewis et al 2014). For some, the distress of being physically sick and having a constant feeling of nausea can dramatically affect daily functional ability (Yarbro et al 2004). Many symptoms are associated with CINV, such as loss of appetite and inability to enjoy meals and time spent with family and friends, as well as fatigue, which influence perception of daily life and ability to enjoy it. Molassiotis et al (2008a) explored the experiences of patients undergoing chemotherapy and the most distressing symptoms associated with nausea from their perspective. Sweating, dizziness, lethargy and fever were considered life-limiting side effects that interfered with QoL. Bergkvist and Wengström (2006) also aimed to understand patients chemotherapy symptom experiences (n=9). They found emesis had a profound effect on how the treatment process was perceived. Patients descriptions of CINV confirmed it as an ongoing problem that affected their daily lives regardless of antiemetics. One described nausea as an ongoing, stressful experience throughout the body (Bergkvist and Wengström 2006). The findings provide insight into how nausea and vomiting continually affect QoL of chemotherapy patients. However, these qualitative findings were generated from an all-female sample and may not be generalisable to other groups. Nurses spend great amounts of time with patients and are often the first to identify psychosocial needs (Yarbro et al 2004). Further research is required into strategies that nurses could use to enrich their advocate/supporting roles in caring for chemotherapy patients. Conclusion Studies examining patients experiences of CINV and how it affects QoL were reviewed. Overall, References Ballatori E, Roila F, Ruggeri B et al (2007) The impact of chemotherapy-induced nausea and vomiting on health-related quality of life. Supportive Care in Cancer. 15, 2, Bergkvist K, Wengström Y (2006) Symptom experiences during chemotherapy treatment with focus on nausea and vomiting. European Journal of Oncology Nursing. 10, 1, Bloechl-Daum B, Bloechl-Daum B, Deuson R, Mavros P et al (2006) Delayed nausea and vomiting continue to reduce patients quality of life after highly and moderately emetogenic chemotherapy despite antiemetic treatment. Journal of Clinical Oncology. 24, 27, Cho W (Ed) (2013) Evidence-based Nonpharmacological Therapies for Palliative Cancer Care. Springer, Netherlands, Dordrecht. Fernández-Ortega P, Caloto M, Chirveches E et al (2012) Chemotherapy-induced nausea and vomiting in clinical practice: impact on patients quality of life. Supportive Care in Cancer. 20, 12, Genç A, Can G, Aydiner A (2013) The efficiency of the acupressure in prevention of the chemotherapy-induced nausea and vomiting. Supportive Care in Cancer. 21, 1, Grunberg S, Deuson R, Mavros P et al (2004) Incidence of chemotherapy-induced nausea and emesis after modern antiemetics. Cancer. 100, 10, Haiderali A, Menditto L, Good M et al (2011) Impact on daily functioning and indirect/direct costs associated with chemotherapy-induced nausea and vomiting (CINV) in a US population. Supportive Care in Cancer. 19, 6, Hawkins R, Grunberg S (2009) Chemotherapyinduced nausea and vomiting: challenges and opportunities for improved patient outcomes. Clinical Journal of Oncology Nursing. 13, 1, Hesketh P (2008) Chemotherapy-induced nausea and vomiting. New England Journal of Medicine. 358, 23, Hilarius D, Kloeg P, van der Wall E et al (2012) Chemotherapy-induced nausea and vomiting in daily clinical practice: a community hospitalbased study. Supportive Care in Cancer. 20, 1, Jahn P, Renz P, Stukenkemper J et al (2009) Reduction of chemotherapy-induced anorexia, nausea, and emesis through a structured nursing intervention: a cluster-randomized multicenter trial. Supportive Care in Cancer. 17, 12, November 2015 Volume 14 Number 9 CANCER NURSING PRACTICE

6 CINV continues to have a negative effect on QoL despite the introduction of new antiemetics (Hilarius et al 2012). Patients experiencing CINV endure side effects such as ongoing nausea, lethargy and flu-like symptoms among other adverse effects (Molassiotis et al 2008aa). Patients are less productive and suffer emotionally, socially and financially (Jahn et al 2009). Side effects continue to be experienced despite the use of antiemetics. Supportive therapies and non-pharmacological approaches to care were explored (Raghavendra et al 2007, Kearney et al 2008, Genç et al 2013, Jahn et al 2009, Jordan et al 2010, Mollaoǧlu and Erdoǧan 2014). Yoga reduced severity of nausea but did not reduce intensity of vomiting (Raghavendra et al 2007). Structured information given to patients before chemotherapy reduced the frequency of nausea and vomiting (Mollaoǧlu and Erdoǧann 2014). Therefore structured nursing assessment of symptoms and education aimed at symptom control have the potential to improve QoL and warrant further research. Antiemetics were not always successful in treating nausea but demonstrated success in managing vomiting. Hence, Genç et al 2013 suggested potential for non-pharmacological methods to be integrated into care as they are cost effective and have no adverse effects. Delayed CINV is most distressing for patients; however, it is also insufficiently controlled. Patients suffered greatly from the effects of nausea rather than vomiting and found this interfered with quality of life (Bergkvist and Wengström 2006). Fernández-Ortega et al (2012) emphasised that nausea was significantly more life-limiting than vomiting was. Delayed CINV and nausea are poorly understood and managed, indicating the need for further research to minimise detrimental effects. Psychosocial effects of CINV were addressed inadequately in the literature, so the genuine needs of patients are not known. Although quantitative studies outline the incidence and severity of this side effect, QoL complications are not addressed in depth. The literature offers nurses vague interpretations of how patients lives are affected by these side effects. A consideration for patients undergoing chemotherapy is to evaluate whether it outweighs the possible negative physical and psychosocial effects on QoL. Nurses need to generate more robust evidence to support nursing interventions aimed at alleviating CINV side effects. Antiemetics are available and can provide improvement in QoL for many patients, but whether they are sufficient for all patients or alternative approaches to care are needed to improve outcomes is questionable. Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared Jordan K, Grothey A, Pelz T et al (2010) Impact of quality of life parameters and coping strategies on postchemotherapy nausea and vomiting. European Journal of Cancer Care. 19, 5, Kearney N, Miller M, Maguire R et al (2008) WISECARE+: results of a European study of a nursing intervention for the management of chemotherapy-related symptoms. European Journal of Oncology Nursing. 12, 5, Lewis S, Dirksen S, Heitkemper M et al (2014) Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Ninth edition. Mosby, St Louis MO. Molassiotis A, Stricker C, Eaby B et al (2008a) Understanding the concept of chemotherapyrelated nausea: the patient experience. European Journal of Cancer Care. 17, 5, Molassiotis A, Saunders M, Valle J et al (2008b) A prospective observational study of chemotherapy-related nausea and vomiting in routine practice in a UK cancer centre. Supportive Care in Cancer. 16, 2, Mollaoǧlu M, Erdoǧan G (2014) Effect on symptom control of structured information given to patients receiving chemotherapy. European Journal of Oncology Nursing. 18, 1, Multinational Association of Supportive Care in Cancer (2013) MASCC/ESMO Antiemetic Guideline tinyurl.com/newqpwh (Last accessed: October ) National Cancer Control Programme (2014) Community Oncology Nursing Programme. tinyurl.com/ncy3jpm (Last accessed: October ) National Cancer Registry (2013) Cancer in Ireland 2013: Annual Report of the National Cancer Registry. tinyurl.com/newc6zx (Last accessed: October ) National Comprehensive Cancer Network (2015) NCCN Clinical Practice Guidelines in Oncology. Antiemesis Version tinyurl. com/qacbtop (Last accessed: October ) Raghavendra R, Nagarathna R, Nagendra H et al (2007) Effects of an integrated yoga programme on chemotherapyinduced nausea and emesis in breast cancer patients. European Journal of Cancer Care. 16, 6, Yarbro C, Frogge M, Goodman M (Eds) (2004) Cancer Symptom Management. Third edition. Jones and Bartlett, Sudbury MA. CANCER NURSING PRACTICE November 2015 Volume 14 Number 9 39