ONLINE EXCLUSIVE This material is protected by U.S. copywright law. Uauthorized reproductio is prohibited. To purchase reprits or request permissio to reproduce, e-mail reprits@os.org. Dowloaded o 05 09 2018. Sigle-user licese oly. Copyright 2018 by the Ocology Nursig Society. For permissio to post olie, reprit, adapt, or reuse, please email pubpermissios@os.org Chemotherapy-Iduced Vomitig i Wome Treated for Breast Cacer Suzae L. Dibble, RN, DNSc, Kare Casey, MS, RN, ANP, Breda Nussey, BA, Jill Israel, BSN, RN, ad Judith Luce, MD Purpose/Objectives: To describe the icidece ad itesity of vomitig i wome receivig chemotherapy treatmet for breast cacer sice the advet of 5-HT 3 atagoists. Desig: Logitudial, descriptive. Settig: 7 outpatiet ocology cliics situated i hospitals, 5 outpatiet ocology cliics associated with major teachig uiversities, 27 private outpatiet ocology practices, ad 1 outpatiet cliic located i a couty hospital. Sample: Typical participats (N = 303) were 51.9 years, Caucasia (79%), married or partered (65%), bor U.S. citizes (93%), heterosexual (96%), livig with someoe (84%), ad high school graduates (82%). Methods: Baselie ad poststudy questioaires ad a daily diary of vomitig through two cycles of chemotherapy (approximately two moths) were used to collect data. Mai Research Variable: Vomitig experiece. Fidigs: The worst vomitig occurs three days after havig chemotherapy for breast cacer. The types of oral atiemetics ordered for home use were chaged betwee the two cycles of the study oly 8% ( = 24) of the time. demographic factors were associated with acute vomitig at times 1 or 2; youger age (r = 0.16; p = 0.012) was associated with more vomitig. Delayed vomitig was associated with age ad body mass idex, ad youger, heavier wome experieced more vomitig. Miority wome ( = 55) reported sigificatly more delayed vomitig tha did Caucasia wome ( X = 6.56 versus 2.82; t = 2.02; p < 0.05). Coclusios: Vomitig cotiues to be a sigificat problem for some wome receivig chemotherapy for breast cacer. Implicatios for Nursig: Ocology urses ca use the results from this study to provide aticipatory guidace for patiets udergoig chemotherapy for breast cacer ad to support efforts to provide appropriate symptom maagemet for these wome. Key Poits... Chemotherapy-iduced acute vomitig cotiues to be a problem for approximately 15% of wome treated for breast cacer despite the advet of 5-HT 3 atagoists. Medicatios rarely are chaged betwee cycles of chemotherapy eve though better atiemetic cotrol is eeded. Delayed chemotherapy-iduced vomitig affects more tha a third of wome udergoig treatmet for breast cacer. Miority wome experiece delayed chemotherapy-iduced vomitig sigificatly more frequetly tha Caucasia wome. A estimated 211,300 wome were diagosed with breast cacer i 2003, 32% of all ew female cacer cases i that year (America Cacer Society, 2003). May of these wome received chemotherapy. Two of the side effects of chemotherapy, ausea ad vomitig, remai a major worry for patiets who are udergoig treatmet for breast cacer. The positive relatioship betwee breast cacer survival ad the completio of a full course of chemotherapy demostrates the ecessity for adherece to the treatmet pla. Research has documeted that some patiets experiecig postchemotherapy ausea ad vomitig have withdraw from seemigly beeficial treatmet (Fessele, 1996; Osoba et al., 1997), ad 10%50% of patiets may refuse or delay chemotherapy treatmets because of fears about ausea ad vomitig (Pedergrass, 1998). Vomitig is a physical protective reactio to the igestio of toxis resultig i the expulsio of gastric cotets through the mouth. Vomitig durig chemotherapy is distiguished as either aticipatory ad acute, occurrig withi 24 hours of iitial admiistratio, or delayed, occurrig after 24 hours. Researchers have theorized that the physiologic causes of acute ad delayed vomitig differ because the pharmacologic agets that are effective i acute vomitig are ot as effective with delayed vomitig (Kris, Roila, De Mulder, & Marty, 1998; Maisao et al., 2000). Chemotherapy-iduced vomitig is a area that requires better uderstadig ad treatmet ad, therefore, was the focus of this study. Chemotherapy for breast cacer cosists of the followig stadard chemotherapy regimes: cyclophosphamide, methotrexate, ad 5-fluorouracil ad cyclophosphamide ad Suzae L. Dibble, RN, DNSc, is a professor, Kare Casey, MS, RN, ANP, is a research associate, Breda Nussey, BA, is a programmer aalyst, ad Jill Israel, BSN, RN, is a research associate, all i the Istitute for Health ad Agig at the Uiversity of Califoria, Sa Fracisco (UCSF). Judith Luce, MD, is a professor i the School of Medicie at UCSF. This study was fuded by the Delta Alpha Beta Chapter of Phi Beta Psi ad the ONS Foudatio Ceter for Leadership, Iformatio ad Research through a grat from GlaxoSmithKlie. (Submitted March 2003. Accepted for publicatio September 1, 2003.) Digital Object Idetifier: 10.1188/04.ONF.E1-E8 ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E1
doxorubici, with or without 5-fluorouracil ad with or without paclitaxel. Although these are cosidered mildly to moderately emetogeic regimes, they have bee associated with a sigificat amout of ausea ad vomitig (Goodma, 1997; Greee, Nail, Fieler, Dudgeo, & Joes, 1994; Stewart, 1996). Despite the advet of ew medicatios, specifically 5-HT 3 atagoists, acute vomitig appears to persist i 10%25% of wome receivig chemotherapy treatmet for breast cacer (Uyl-de Groot, Wait, & Buijt, 2000). Delayed chemotherapy-iduced vomitig is associated particularly with cyclophosphamide ad doxorubici, with a icidece of 33%67% (America Cacer Society & Natioal Comprehesive Care Network, 2001; Kris et al., 1998). Nausea ad vomitig are a symptom cluster that has bee studied together for decades. The curret study s authors have chose to decostruct them to better uderstad each as a separate side effect, both i their acute ad delayed phases (see Dibble, Israel, Nussey, Casey, & Luce, 2003). Sevety-five percet of patiets who experiece vomitig withi the first 24 hours after receivig chemotherapy are likely to experiece delayed vomitig as well (Italia Group for Atiemetic Research, 1999). Twety-five percet of those who do escape ausea ad vomitig withi the first 24 hours also will develop delayed vomitig (Italia Group for Atiemetic Research, 2000). Treatig acute vomitig therefore is see as a importat compoet i prevetig delayed vomitig. Chemotherapy iduces acute vomitig through direct or idirect stimulatio of the chemoreceptor trigger zoe (CTZ) ad vomitig ceter. The CTZ is located outside of the bloodbrai barrier ad, therefore, ca be stimulated directly by cytotoxic agets i the bloodstream or cerebrospial fluid (Pedergrass, 1998). The CTZ stimulates the vomitig ceter through key receptors: serotoi (5-HT 3 ), dopamie, ad eurokii (Oettle & Riess, 2001). The CTZ also ca be stimulated by eterochromaffi cells o the gastroitestial mucosa that, whe assaulted by cytotoxic agets, release 5-HT 3, which bids to 5-HT 3 receptors alog the gastroitestial tract, vagus erve, ad, ultimately, the CTZ, which the seds a sigal to the vomitig ceter (America Cacer Society & Natioal Comprehesive Care Network, 2001; Dicato, 1996). The stimulatio of eterochromaffi cells ad resultat release of 5-HT 3 largely is resposible for acute chemotherapy-iduced ausea ad vomitig (Maisao et al., 2000). Uderstadig this chai of evets ad role of eurotrasmitters is importat i choosig a medicatio to treat acute vomitig. Because the pathways mediatig delayed vomitig are believed to be differet from acute vomitig ad are ot well uderstood, a effective medicatio regime that targets delayed vomitig has ot bee foud. The most effective medicatios used to treat chemotherapyiduced acute vomitig are aimed at blockig the eurotrasmitters metioed that ultimately stimulate the vomitig ceter: 5-HT 3, dopamie, ad eurokii. These medicatios iclude 5-HT 3 receptor atagoists, such as odasetro, graisetro, ad tropisetro, ad dopamie-receptor atagoists, such as metoclopramide ad alizapride, ad are most effective if give prior to iitiatio of treatmet. They ca be used aloe or i combiatio with a corticosteroid such as dexamethasoe (Oettle & Reiss, 2001; Pedergrass, 1998). The combiatio of a 5-HT 3 receptor atagoist ad a corticosteroid, especially dexamethasoe, is cosidered the gold stadard i treatig acute vomitig with moderately to highly emetogeic doses of cyclophosphamide (Bartlett & Koczwara, 2002; Clavel, Soukop, & Greestreet, 1993; Oettle & Reiss; Stewart, 1996). For patiets receivig moderately emetogeic regimes, the 5- HT 3 receptor atagoists aloe do ot appear to be effective i cotrollig delayed vomitig, leavig a 22%89% icidece of delayed ausea ad emesis (Italia Group for Atiemetic Research, 2000; Uyl-de Groot et al., 2000). The iitial studies of the 5-HT 3 receptor atagoists, their iterpretatio by cliicias, ad the observatio of wome as they udergo chemotherapy would suggest that acute vomitig almost has bee elimiated from the acute side affects associated with chemotherapy admiistratio with cotrol rates of 75%90% (Uyl-de Groot et al., 2000). Ufortuately, the cocers of 33%67% of wome receivig moderately emetogeic chemotherapy who cotiue to experiece vomitig after this acute period are ot beig addressed effectively (Kris et al., 1998). Therefore, the purpose of the curret study was to describe the acute ad delayed vomitig experiece ad itesity i wome udergoig chemotherapy for breast cacer sice the advet of the 5-HT 3 receptor atagoists. Methods Desig The desig for this multisite research was a logitudial descriptive study over two cycles of chemotherapy. A cycle of chemotherapy for wome with breast cacer usually rages from 2128 days. Sample ad Settig The settigs for this study coducted from July 1999 through December 2000 cosisted of 40 sites throughout the Uited States, icludig 7 outpatiet ocology cliics situated i hospitals, 5 outpatiet ocology cliics associated with major teachig uiversities, 27 private outpatiet ocology practices, ad 1 outpatiet cliic located i a couty hospital. The sites were located i the wester, easter, ad midwester Uited States ad oe site i Virgiia. The sites were a combiatio of urba ad rural. The eligibility criteria icluded (a) receivig ay vomitig-iducig chemotherapy regime i the treatmet of breast cacer, (b) the ability to commuicate (verbally ad i writig) i Eglish, ad (c) the willigess to participate i the study. Of the 353 eligible wome who were approached to participate, 50 wome refused. The most commo reaso patiets gave for refusal to participate was feelig overwhelmed. Istrumets Patiet iformatio questioaire: Demographic iformatio collected icluded age, educatio, partership status, ethicity, employmet status, ad icome. This tool has bee used successfully to collect demographic data i previous work. Disease ad treatmet questioaire: Iformatio gathered from the medical record icluded diagostic iformatio, treatmet regime, chemotherapy dosages, ad atiemetics ordered. This tool has bee used successfully to collect treatmet data i previous work. A daily log cosisted of the three-item vomitig experiece subscale from Rhodes Idex of Nausea, Vomitig, ad Retchig (INVR). This scale has established reliability ad validity (Rhodes, Watso, & Johso, 1984; Rhodes, Watso, Johso, Madse, & Beck, 1987). Items from this subscale were summed. Subscale scores could rage from 012 with a ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E2
higher umber reflectig a more severe vomitig experiece. I additio, the log also provided a place for each perso to record ay itervetios used for ausea ad vomitig cotrol. Ratigs were doe o a daily basis, before bedtime. The exit questioaire packet icluded a series of questios about other thigs (besides medicatio) that the participat may have tried to alleviate chemotherapy-iduced vomitig, ad three evaluatio questios. Procedures Istitutioal review board approval of the protocol was obtaied for each istitutio participatig i this study. Potetial participats were approached about the study by the research assistats i the waitig room, by their physicia, or by their urse. After cosetig to take part i the study, participats completed the baselie data collectio ad were taught how to complete the daily logs. All wome received their usual atiemetics as prescribed by their physicias ad recorded their usage o a daily basis. The participats recorded i their daily log for two cycles of chemotherapy. Wome receivig chemotherapy o a weekly basis were asked to complete their logs for three weeks per log. To exit the study, participats were scheduled to arrive 30 miutes early o the first day of their ext chemotherapy cycle (after completig data for two cycles of chemotherapy) to complete the exit questioaire. I additio, urses reviewed the patiets medical records to obtai iformatio about their cacer diagosis, atiemetic prescriptio, ad curret, previous, ad kow future treatmet modalities. All participats who completed the study were paid $10 to thak them for their time. Data Aalysis SPSS statistical software package (SPSS Ic., Chicago, IL) ad SAS (SAS Istitute Ic., Cary, NC) were used for data aalysis. Data were double etered ito SPSS, ad discrepacies betwee the files were resolved to esure the accuracy of the data etered. Descriptive statistics were geerated related to sample characteristics ad other variables of iterest. Repeated measures aalysis of variace (ANOVA) was used to aswer the research questios. With this aalysis strategy, participats serve as their ow cotrols, so that the variability caused by the idividual differeces is elimiated from the error term (Dawso-Sauders & Trapp, 1994). This aalysis techique is quite robust with small sample sizes ad statistical assumptio violatios. I additio, a Delayed Vomitig Scale (DVS) was created by addig the three-item vomitig subscale of the INVR for days 110 after chemotherapy admiistratio (day 0). Scores o the DVS could rage from 0 120. Because of the small sample size, the researchers did ot attempt to explore differeces resultig from settig or types of treatmet. statistical tests used were t tests, paired t tests, chi square, McNemar, ad ANOVA. Results Typical participats (N = 303) were 51.9 years old (SD = 11.0), Caucasia (79%), married or partered (65%), ot o disability (86%), uemployed (52%), bor U.S. citizes (93%), heterosexual (96%), ot livig aloe (84%), ad had a aual persoal icome of more tha $20,000 (58%). The average educatio for these participats was 13.9 years (SD = 2.9); 56% had more tha a high school educatio. The average body mass idex (BMI = a ratio of weight to height) for these wome was 28.3 kg/m 2 (SD = 6.1 kg/m 2 ); 30% of the wome had a BMI from 2530, which reflects beig overweight; ad 35% of the wome had a BMI of greater tha 30, which idicates obesity. Most (60%) of the wome had experieced morig sickess with a pregacy, 24% had a history of seasickess, 20% had a history of car sickess, ad 22% had a history of ausea with stress (see Table 1). Table 1. Demographic Characteristics Characteristic Age (years) X (SD) = 51.9 (11.0) Rage = 2886 Educatio (years) X (SD) = 13.9 (2.9) Rage = 723 Body mass idex (kg/m 2 ) X (SD) = 28.3 (6.1) Rage = 15.540.4 Ethicity Caucasia Sexual orietatio Heterosexual Employed Bor a U.S. citize Retired Disabled Icome < $20,000 $20,000$39,999 > $40,000 Relatioship status Married or partered Lives aloe History of car sickess History of seasickess History of ausea with stress History of morig sickess 239 062 272 012 145 155 281 022 066 234 041 259 106 079 065 196 105 048 253 062 240 072 229 067 235 181 121 N = 303 te. Because some data are missig for some variables, the values may ot equal the total N. % 79 21 96 04 48 52 93 07 22 78 14 86 42 32 26 65 35 16 84 20 80 24 76 22 78 60 40 ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E3
Table 2. Diagostics ad Surgical Treatmets Used Characteristic Time sice diagosis (moths) a X (SD) = 1.93 (1.87) Rage = 0.0719.4 Surgical biopsy Lumpectomy Mastectomy Lymph ode dissectio Setiel ode biopsy Positive odes Type of breast cacer Ifiltratig ductal Ifiltratig lobular Radiatio therapy Plaed after chemotherapy 193 108 145 156 113 188 241 060 037 264 123 142 238 025 035 019 092 171 N = 303 a Does ot iclude two patiets who had recurrece te. Because some data are missig for some variables, the values may ot equal the total N. Because of roudig, percetages may ot total 100. % 64 36 48 52 38 62 80 20 12 88 46 54 80 08 12 07 33 61 The average time sice diagosis for these wome was 2.64 moths (SD = 9.28 moths, rage = 0.07139.6 moths). Icluded i these statistics are two wome who had recurret disease. Excludig those two wome resulted i a average time sice diagosis for the sample of 1.93 moths (SD = 1.87) or approximately two moths. Most participats had a surgical biopsy (64%) to determie that they had ifiltratig ductal breast cacer (80%). Most (62%) of the wome did ot have a mastectomy. Multiple lymph odes were examied i 241 wome (80%), ad 12% of the wome had a setiel ode biopsy. Positive odes were reported i 46% ( = 123) of the participats. Radiatio therapy had bee completed or was cocurret with their chemotherapy i 7% of the sample, ad 61% ( = 171) were plaig radiatio therapy after fiishig their chemotherapy (see Table 2). Most (76%) of the wome were receivig doxorubici ad cyclophosphamide as their chemotherapy regime. The average dose of doxorubici was 102.7 mg ad the average dose of cyclophosphamide was 993.2 mg. The dosages of chemotherapy were reduced betwee the two cycles of the study oly 5% ( = 14) of the time. The most commo IV atiemetics give durig the admiistratio of chemotherapy were dexamethazoe (80%), odasetro (49%), graisetro (24%), ad dolasetro (17%). Numerous combiatios ad dosages were give pre- ad postchemotherapy. oe combiatio or dosage emerged as the right treatmet for cotrollig acute or delayed vomitig. The types of IV atiemetics were chaged betwee the two cycles of the study oly 6% ( = 18) of the time. The most commo atiemetic ordered for home use was prochlorperazie (70%). The types of oral atiemetics ordered for home use were chaged betwee the two cycles of the study oly 8% ( = 24) of the time (see Table 3). The patter of acute ad delayed vomitig as measured by the INVR vomitig subscale ca be observed i Figure 1. The worst vomitig occurs the day of chemotherapy ad for the ext three days as measured by the INVR. Icluded i those statistics are those who did ot experiece vomitig o a particular day. Figure 2 details the percetage of participats who described ay vomitig as measured by the vomitig subscale Table 3. Chemotherapy Treatmets Used Treatmet Chemotherapy regime Cyclophosphamide, methotrexate, ad 5-fluorouracil Cyclophosphamide ad doxorubici Cyclophosphamide, doxorubici, ad 5-fluorouracil Cyclophosphamide, doxorubici, ad paclitaxel Weekly chemotherapy Dosage of cyclophosphamide (mg) ( = 273) X (SD) = 993.2 (267.7) Rage = 901,888 Dosage of 5-fluorouracil (mg) ( = 41) X (SD) = 920.6 (232.2) Rage = 601,200 Dosage of doxorubici (mg) ( = 258) X (SD) = 102.7 (16.9) Rage = 30145 Dosage of chemotherapy decreased with ext cycle IV atiemetics give Dexamethazoe Odasetro Graisetro Dolasetro Lorazepam Diphehydramie Prochlorperazie IV atiemetics chaged with subsequet chemotherapy Oral atiemetics ordered Prochlorperazie Odasetro Dexamethazoe Lorazepam Graisetro Pheerga Diphehydramie Oral atiemetics chaged with subsequet chemotherapy 034 228 005 007 028 023 277 014 285 241 148 072 051 020 007 012 018 282 211 113 068 059 036 015 015 0 024 273 N = 303 te. Because some data are missig for some variables ad some patiets received more tha oe atiemetic treatmet, the values may ot equal the total N ad percetages may ot total 100. % 11 76 02 02 09 07 93 05 95 80 49 24 17 07 02 04 06 94 70 38 23 20 12 05 05 08 92 ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E4
Idex of Nausea, Vomitig, ad Retchig Percetage 1 20 15 10 0.5 0 0 1 2 3 4 5 6 7 8 9 10 Days After Chemotherapy Time 1 Time 2 N = 241 Figure 1. Vomitig Over Time N = 241 5 0 0 1 2 3 4 5 6 7 8 9 10 Days After Chemotherapy Time 1 Time 2 Figure 2. Percetage of Sample With Vomitig Over Time Idex of Nausea, Vomitig, ad Retchig 5.5 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 N = 241 0 1 2 3 4 5 6 7 8 9 10 Days After Chemotherapy Time 1 Time 2 te. Icludes oly those reportig vomitig Figure 3. Itesity of Vomitig Over Time of the INVR o a particular day for this sample. This figure reveals that less tha oe-fifth of the wome udergoig treatmet for breast cacer o ay give day actually experieced vomitig after receivig chemotherapy, with the worst day beig two days after the admiistratio of chemotherapy. Whe the wome who did ot experiece vomitig o a particular day are elimiated from the aalyses, vomitig clearly is a sigificat problem for those who have it (see Figure 3). The average Acute Vomitig Score (AVS) was 0.82 (SD = 2.2) durig the first data collectio period ad 0.55 (SD = 1.7) for the secod data collectio period. This differece was ot statistically sigificat (t = 1.66, p = 0.099; = 255). Usig a McNemar test, sigificat (p < 0.0001) differeces existed i the percetage of wome with acute vomitig from the first to secod data collectio periods. Eighty-two percet ( = 216) of the sample had absolutely o acute vomitig durig both time periods ad 0.4% ( = 1) had acute vomitig durig both time periods. Of the 223 wome without acute vomitig at the first data collectio period, seve (3%) developed acute vomitig with their ext cycle. Of the 42 wome with acute vomitig at the first data collectio period, 41 (98%) did ot have acute vomitig with their ext cycle. The mea DVS score for the wome durig the first data collectio period was 2.8 (SD = 6.0), ad the mea DVS score durig the secod data collectio period was 3.5 (SD = 9.2). Agai, these values were compared usig a paired t test, ad o sigificat differeces existed i delayed vomitig betwee the two time periods (t = 1.623; p = 0.106; = 242). I explorig the percetage of wome who had absolutely o delayed vomitig, the authors foud that 63% ( = 165) of the wome did ot have ay delayed vomitig durig the first data collectio period ad 64% ( = 161) did ot have ay delayed vomitig durig the secod data collectio period. I comparig delayed vomitig at both time periods usig a McNemar test, o sigificat differeces existed i the percetage of wome with delayed vomitig from the first to secod data collectio periods. Forty-eight percet ( = 116) of the sample had absolutely o delayed vomitig durig both time periods, ad 19% ( = 45) had delayed vomitig durig both time periods. Of the 155 wome without delayed vomitig at the first data collectio period, 39 (25%) developed delayed vomitig with their ext cycle. Of the 87 wome with delayed vomitig durig the first data collectio period, 42 (48%) did ot have delayed vomitig with their ext cycle. These differeces were ot statistically sigificat (p = 0.824). demographic factors were associated with AVS scores at time 1. At time 2, age was associated with AVS (r = 0.16; p = 0.012); youger wome had more acute vomitig. Educatio ad BMI were ot associated with AVS scores at either time period. sigificat differeces i AVS existed by ethicity, relatioship status, or livig arragemet. sigificat differeces i AVS existed by history of ausea with stress, seasickess, or morig sickess. Wome with a history of car sickess ( = 62) had more acute vomitig durig the secod time period (t = 2.1; p < 0.04) tha those who did ot get carsick. Sigificatly less acute vomitig was reported by wome receivig 5-fluorouracil (t = 2.84; p = 0.005) durig the secod time period, whereas those receivig doxorubici had more acute vomitig (t = 4.07; p < 0.0001) durig the secod time period. Those havig their chemotherapy o a weekly basis reported less acute vomitig durig the secod time period tha those o a more traditioal 21- or 28-day cycle (t = 4.95; p < 0.0001). The wome who received IV odasetro with their chemotherapy had higher AVS scores durig the secod time period (t = 1.98; p < 0.05). sigificat differeces i AVS scores existed by ay other IV atiemetic usage. Those who had their IV atiemetic chaged did ot have sigificatly higher AVS scores durig either time period. ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E5
At time 1, age was associated with DVS (r = 0.15; p = 0.014) ad at time 2, BMI was associated with DVS (r = 0.125, p = 0.05); youger, heavier wome had more delayed vomitig. Educatio was ot associated with DVS at either time period. sigificat differeces existed i DVS by relatioship status or livig aloe. Durig the first time period, miority wome ( = 55) reported sigificatly more delayed vomitig tha did Caucasia wome ( X = 6.56 versus 2.82; t = 2.02; p < 0.05). For those with a history of seasickess, car sickess, morig sickess, or ausea uder stress, o sigificat differeces i delayed vomitig existed durig either time period. Sigificatly more delayed vomitig was reported by wome receivig cyclophosphamide (t = 3.11; p < 0.002) durig the secod time period. Those receivig chemotherapy o a weekly basis did ot report ay less delayed vomitig tha those o a more traditioal 21- or 28-day cycle durig either time period (p = 0.194; p = 0.285). sigificat differeces i DVS scores existed by ay use of IV atiemetics. However, those who did ot receive oral graisetro ( = 218) or dexamethazoe ( = 184) for home use at time 2 had sigificatly more delayed vomitig tha those who used graisetro ( = 29; t = 3.13; p = 0.002) or dexamethazoe ( = 63, t = 2.01; p < 0.046). sigificat differeces i DVS scores existed i those who had their IV atiemetics chaged durig either time period. comparisos ca be foud i Table 4. Discussio The results of this study idicate that, i spite of the emergece of 5-HT 3 receptor atagoists that are cosidered the gold stadard for chemotherapy-iduced vomitig, acute ad delayed vomitig cotiue to be a sigificat problem for some patiets with breast cacer. Of particular iterest is the idicatio that despite the cliical eed for differet atiemetic treatmet betwee chemotherapy cycles, with specific IV ad oral medicatios beig more effective, few medicatio chages are made from oe cycle to the ext. This could be related to the false belief by patiets that vomitig is a symptom that they must edure if they wish to seek treatmet for their breast cacer or that cliicias are ot aware of the prevalece of vomitig amog their cliets. I the secod case, these data reaffirm that cliicias may believe the myth that ausea ad vomitig are o loger a problem for chemotherapy recipiets, a statemet heard may times from ocology practices that were asked to participate i the authors studies. This study showed that a sigificatly greater umber of miority wome were affected by delayed vomitig tha their Caucasia couterparts. Disparity i health care by ethicity has received atioal attetio for a umber of years, resultig i the developmet of stadards of culturally ad liguistically competet care for healthcare workers i 2000 by the Office of Miority Health of the U.S. Departmet of Health ad Huma Services. To elimiate laguage as a barrier, participats i this study could read ad write i Eglish. I additio, o differece existed i atiemetics ordered or take by Caucasia ad miority wome. Curretly, healthcare workers ad researchers are traied to address the eeds of the cultural majority, Caucasias. This traiig presumes that Africa America, Asia, or Hispaic or Latia cliets will report symptoms ad seek appropriate medicatios or itervetios. Pharmaceutical researchers explorig the effectiveess of medicatios also may rely heavily o results from Caucasia samples that may metabolize the medicatio differetly tha some miorities. Recet research ito the liver ezyme cytochrome P450 2D6, which varies somewhat by ethicity, suggests that the metabolism of may drugs ca be affected (Kaiser et al., 2002). I additio, by examiig effectiveess of a itervetio o oe groupcaucasiasa researcher igores the potetial effect that differet food ad lifestyle habits have o the maifestatio of a symptom ad itervetios used to treat it. However, the curret study s fidig was ot similar to that of Africa America ad Caucasia patiets with colo cacer. I a large, radomized, phase III trial of adjuvat chemotherapy for resected colo cacer, Africa Americas appeared to experiece fewer side effects related to chemotherapy, icludig sigificatly lower rates of ausea ad vomitig (McCollum et al., 2002). More studies eed to be coducted to examie the effectiveess of atiemetics with diverse populatios. Research has documeted that some patiets experiecig postchemotherapy vomitig withdraw from seemigly beeficial treatmet (Fessele, 1996; Osoba et al., 1997). This suggests a eed for icreased vigilace by cliicias who treat chemotherapy-iduced vomitig. I additio to determiig the icidece of vomitig i people curretly receivig treatmet, urses may be able to aticipate those who are more likely to experiece this symptom i the future by lookig at available data. For istace, youger wome had sigificatly more acute vomitig i their first cycle of chemotherapy ad sigificatly more delayed vomitig i their secod cycle. I additio, as with ausea (Dibble et al., 2003), wome with a higher BMI had sigificatly more delayed vomitig tha their smaller couterparts. Wome with a history of carsickess had sigificatly more vomitig tha those who did ot experiece motio sickess. Each of these factors could assist urses i their approach to educatig cliets about what to expect regardig vomitig with the admiistratio of chemotherapy to those diagosed with breast cacer. I additio, ocology urses ca work with patiets to pla the itesity of postchemotherapy atiemetic prophylaxis ad treatmet as well as surveillace strategies. Limitatios This study has a umber of limitatios. First, the sites used i the study may have bee those where vomitig was a particular problem. The physicias who told the authors that their patiets did ot experiece ay vomitig may have bee correct ad what is demostrated i this article is the experiece of wome who are ot properly treated for this side effect. Secod, the wome were ot followed for their etire chemotherapy experiece, so the researchers do ot kow how may wome evetually stopped treatmet or whether the vomitig icreased or decreased with subsequet cycles. The study did ot have large eough samples of wome i the various ethic groups to perform the appropriate aalyses to profile by ethicity the wome who had the most vomitig. Summary This study clearly illustrates that chemotherapy-iduced vomitig, especially delayed vomitig, cotiues to be a problem for wome udergoig moderately emetogeic treatmet for breast cacer. Nurses also must remember that this study was completed before the aprepitat substace P/eurokii 1 receptor atagoist was released. Although research ito better medicatios is eeded, so is research ito the various complemetary ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E6
Table 4. Compariso of Differeces i Delayed Vomitig by Various Factors Time 1 Time 2 Variable X SD p X SD p History of car sickess history of car sickess 03.28 02.84 07.20 05.97 057 203 0.641 04.60 03.32 14.60 07.04 057 192 0.524 History of seasickess history of seasickess 03.21 02.84 06.04 06.34 067 192 0.677 03.13 03.78 07.62 09.82 062 186 0.591 History of sickess uder stress history of sickess uder stress 03.76 02.72 06.92 06.05 055 205 0.271 04.13 03.47 08.32 09.55 053 196 0.646 History of morig sickess history of morig sickess 02.99 02.86 05.68 06.98 151 109 0.872 03.29 04.07 06.85 12.00 146 103 0.552 Weekly chemotherapy weekly chemotherapy 01.35 03.13 04.81 06.38 023 235 0.194 01.59 03.82 04.02 09.66 022 226 0.043 Odasetro by IV odasetro by IV 03.10 02.82 05.78 06.70 128 131 0.715 03.83 03.42 08.16 10.35 123 125 0.732 Dexamethazoe by IV dexamethazoe by IV 02.97 02.92 06.28 06.22 209 050 0.962 03.77 03.02 09.73 07.35 200 048 0.555 Lorazepam by IV lorazepam by IV 03.53 02.91 05.86 06.29 019 240 0.681 03.35 03.65 05.97 09.52 017 231 0.855 Diphehydramie by IV diphehydramie by IV 01.33 03.00 02.80 06.31 006 253 0.521 05.14 03.58 13.60 09.19 007 241 0.663 Graisetro by IV graisetro by IV 03.46 02.80 08.14 05.53 063 196 0.547 04.87 03.23 13.61 07.44 060 188 0.376 Dolasetro by IV dolasetro by IV 02.40 03.07 04.56 06.54 043 216 0.417 02.14 03.95 06.12 09.85 044 204 0.119 IV atiemetic chage IV atiemetic chage 05.60 02.79 05.26 06.30 015 243 0.092 05.69 03.40 09.59 09.23 016 231 0.339 Prochlorperazie orally prochlorperazie orally 02.92 03.04 06.00 06.99 188 070 0.889 03.10 04.72 07.22 13.20 179 068 0.340 Lorazepam orally lorazepam orally 02.88 02.97 05.55 06.44 050 208 0.927 02.55 03.78 05.79 09.88 047 200 0.265 Promethazie orally promethazie orally 01.73 03.01 02.33 06.38 011 247 0.132 00.70 03.67 01.49 09.42 010 237 0.000 Diphehydramie orally diphehydramie orally 02.62 02.97 04.57 06.35 013 245 0.842 02.38 03.61 06.08 09.40 013 234 0.643 Graisetro orally graisetro orally 02.43 03.02 04.67 06.45 030 228 0.540 01.28 03.85 02.63 09.76 029 218 0.002 Odasetro orally odasetro orally 03.20 02.81 05.41 06.74 097 161 0.612 04.26 03.07 08.25 09.86 099 148 0.321 Dexamethazoe orally dexamethazoe orally 01.57 02.03 05.61 06.48 063 195 0.965 00.83 02.55 04.96 10.30 063 184 0.046 Cyclophosphamide cyclophosphamide 03.11 01.44 06.41 03.94 236 025 0.069 03.86 01.20 09.70 02.81 225 025 0.002 5-fluorouracil 5-fluorouracil 02.49 03.02 05.60 06.34 037 224 0.629 03.15 03.66 07.02 09.59 033 217 0.713 Doxorubici doxorubici 03.07 02.24 06.35 05.49 223 038 0.449 03.66 03.18 09.59 07.06 216 034 0.725 Cyclophosphamide ad doxorubici Cyclophosphamide, methotrexate, ad 5-fluorouracil 18.84 15.21 17.68 15.38 195 034 0.262 20.25 14.70 21.51 18.37 186 030 0.183 N = 303 te. Because some data are missig for some variables, the values may ot equal the total N. therapies. This descriptive study demostrates that existig medicatios are ot beig used as effectively as they could. Ocology urses play a active role i the prevetio ad treatmet of this upleasat symptom of chemotherapy. Further research should evaluate the relatioships amog vomitig with ad without ausea ad specific atiemetic regimes, as well as age, BMI, ethicity, ad history of car sickess. Author Cotact: Suzae L. Dibble, RN, DNSc, ca be reached at sdibble@itsa.ucsf.edu, with copy to editor at rose_mary@earthlik.et. ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004 E7
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