Lee S. Schwartzberg, MD, FACP
Although many targeted anticancer therapies have become available over the past several decades, chemotherapy remains the cornerstone of treatment for many types of cancer. Despite the widespread availability of antiemetic regimens, between 30% and 50% of patients receiving chemotherapy experience treatment-related nausea and/or vomiting.1
Poorly controlled chemotherapy-induced nausea and vomiting (CINV) increases the risk of treatment delays, treatment discontinuation, and hospitalization.2,3
It is also one of patients’ biggest concerns during chemotherapy and significantly affects their quality of life.3
, Lee S. Schwartzberg, MD, FACP, moderated a Peer Exchange panel on the management of CINV. All the panelists have substantial knowledge of and experience with CINV; Schwartzberg, Dawn Dolan, PharmD, BCOP, and Eric Roeland, MD, were members of the National Comprehensive Cancer Network (NCCN) panel that updated the NCCN antiemesis guidelines in March 2017. The panelists discussed how to ensure that more patients undergoing chemotherapy receive optimal antiemetic regimens, their own approaches to managing CINV, and some of the more recently approved antiemetics.
Antiemetic Guidelines and Barriers to Care
The American Society of Clinical Oncology (ASCO), NCCN, and the Multinational Association of Supportive Care in Cancer/European Society of Medical Oncology have all published evidencebased antiemetic guidelines, which they routinely update (Table). “We have great guidelines now,” said Schwartzberg, who noted that they are all similar. The guidelines identify which drugs are highly emetogenic chemotherapy (HEC) or moderately emetogenic (MEC). “HEC is typically considered to induce nausea in more than 90% of the population if you were not to give any prophylactic antiemetics...MEC induces emesis in 30% to 90% if you were not to give antiemetics,” Dolan said. She praised the reclassification of carboplatin and cisplatin from MEC to HEC in the guidelines.
Table. Emetic Risk Levels for Antineoplastic Agents
“I have a little bit of a problem with the way the categories are laid out; 90% or more is highly emetogenic but 89% is not,” said panelist Howard Levine, PharmD. The risk of emetogenicity is used to guide choice of prophylaxis. The panel agreed that since many antiemetics are available, the goal should be to prevent CINV in all patients by using the most effective agent first—even if the chemotherapy agent has a low risk of emesis.
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