Anticipatory Nausea Research Articles

Prevalence and correlates of posttreatment and anticipatory nausea and vomiting in cancer chemotherapy

Prevalance and correlates of posttreatment and anticipatory nausea and vomiting (NV) were examined in 149 cancer patients receiving chemotherapy at four treatment centres. Results of multiple regression analyses indicated that posttreatment NV was associated with treatment centre, diagnosis, drug toxicity, and frequency of antiemetic premedication. Anticipatory NV was found to be associated with age, treatment centre, drug toxicity and frequency of posttreatment NV. Eight predictor variables accounted for 49% of the variance in anticipatory NV. Variables showing significant unique effects included age, treatment centre, posttreatment NV and the age by posttreatment NV interaction. Results suggest the importance of examining environmental, psychosocial, and treatment-related variables that may differentiate treatment centres and strongly support the role of classical conditioning in the development of anticipatory NV.

Prevalence and prediction of chemotherapy-related anxiety, nausea and vomiting in cancer patients

Anxiety, nausea and vomiting before, during and after chemotherapy administration were studied in 50 cancer patients. In addition, patient responses to the Autonomic Perception Questionnaire (APQ) and their relation to the anxiety, nausea and vomiting scores was studied. Anticipatory anxiety occurred in 66% and anticipatory nausea in 40% of the patients; 14% showed anticipatory vomiting. The number of patients reporting anxiety decreased to 38% after chemotherapy, whereas nausea and vomiting increased to 47 and 49%, respectively. APQ scores correlated significantly with anxiety and nausea reports during all time periods, but not with the frequency of vomiting.

Psychosocial aspects of cancer in adults: implications for teaching medical students.

This article addresses psychosocial aspects of cancer and the cancer patient that the authors feel are important to teach medical students. A section on understanding the cancer patient deals with patient psychosocial responses to a diagnosis of cancer. Loss of control, anger and guilt, fear of abandonment, fear of pain, psychiatric disorders, and psychosocial factors all need to be explored by the health care team. Interventions, such as education, support groups, environmental manipulation, or psychological counseling including imagery or relaxation have proved to be effective. Relaxation therapy can also help to counteract the side effects of chemotherapy such as anticipatory nausea and vomiting. An increasing openness about discussing dying and the development of hospices have resulted in improvements of the care of the dying patient and family. Family members should be involved in the care of the cancer patient and can support the patient by promoting autonomy and control and by encouraging communication and expression of feelings. The doctor-patient relationship is central, and is changing from a paternalistic model to one encouraging greater patient participation. In studying the behavior of physicians at Albany Medical College, the authors found that oncologists spend more time with patients with the poorest prognoses. Patient satisfaction with the relationship was found to be high. Students can be instructed in these psychosocial aspects of oncology by means of videotapes, role-playing, or patient presentations, and more importantly by using the physicians as a role model. Comprehensive care of the cancer patient necessitates the integration of psychosocial aspects of care into the overall assessment and management plan. This article reviews the psychosocial aspects of care of the adult cancer patient taught to second year medical students as part of a 42 hour course entitled "The Cellular Basis of Cancer Medicine" at Albany Medical College. The didactic material covered in this article is based on local clinical work and research endeavors with adult cancer patients and is included in the course syllabus given to the students. The students are divided into four small groups, each of which has one of four teaching experiences, each lasting for 2 hours. The psychosocial aspects of cancer is one of the small groups. This group, consisting of 32 students each, is taught by a medical oncologist and a behavioral scientist. Videotapes of interviews done with patients and/or live interviews with patients are used to highlight the material covered in the syllabus.(ABSTRACT TRUNCATED AT 400 WORDS)

Lorazepam in cancer patients treated with cisplatin: a drug having antiemetic, amnesic, and anxiolytic effects.

There currently is no pharmacologic approach to the problem of anticipatory nausea and vomiting (ANV). Lorazepam (Ativan, Wyeth Laboratories, Philadelphia) is an interesting candidate drug if it could block the recall of the unpleasant events associated with chemotherapy, especially if it also has antiemetic properties. Since ANV is a conditioned (learned) response, it may well depend on a memory imprint of the stimulus. This pilot study was designed to use intravenous lorazepam given before and after cisplatin infusion in 32 patients, and to make detailed measurements of nausea, vomiting, recent memory, anxiety, and sedation as well as toxicity. Satisfactory responses occurred in about 70%, as rated separately both by investigator and patient. Forty-six percent did not even recall receiving chemotherapy, regardless of whether or not they vomited; 80% had no significant anxiety after chemotherapy. Adverse reactions included some cases of perceptual disturbance, urinary incontinence, diarrhea, hypotension, and one case of severe transient amnesia. No long-term adverse effects were noted.

Concomitants of anticipatory nausea and emesis in cancer patients in chemotherapy.

125 cancer patients receiving chemotherapy were assessed for anticipatory nausea and anticipatory emesis, two side effects of chemotherapy for cancer. 32% and 12% of the patients reported experiencing anticipatory nausea and emesis, respectively. The prevalence and somatic concomitants of the anticipatory symptoms were assessed using the Cancer Chemotherapy Questionnaire and a standardized interview. Analysis of variance indicated that patients evidencing anticipatory nausea, emesis, and a combination of the two symptoms differed significantly from patients without these symptoms on six somatic side effects: vomiting, nausea, diarrhea, shortness of breath, muscle weakness, and fatigue. Results from the standardized interview indicated that patients with nausea or emesis had identified several cognitions and cues (visual, olfactory, but not gustatory) temporally contiguous with the anticipatory response. The possibility that this phenomenon is the result of a cognitive conditioning process was examined and the implications of such a process were discussed.

Personality factors associated with anticipatory nausea/vomiting in patients receiving cancer chemotherapy.

One hundred cancer chemotherapy patients rated the severity of pre- and posttreatment nausea and emesis and completed the State-Trait Anxiety Inventory. In addition, scores on the Millon Behavioral Health Inventory were obtained for 59 of those patients. Thirty-three percent of the patients reported having experienced anticipatory nausea and 11% reported having experienced anticipatory vomiting. Patients who experienced anticipatory nausea had more posttreatment nausea and vomiting, were more depressed, and were characteristically more anxious than other patients. A personality profile including the future despair, social alienation, and inhibited style (from the Millon Behavioral Health Inventory) identified patients with anticipatory nausea.

Development of anticipatory nausea: A prospective analysis.

Development of anticipatory nausea: A prospective analysis.

Lorazepam for Chemotherapy-Induced Emesis

To the Editor. —Stoudemire et al 1 eloquently described the difficult clinical problem of managing chemotherapy-induced emesis. Our experience with lorazepam suggests it is satisfactory for use even in regimens using cisplatin and in patients who previously suffered from anticipatory nausea and vomiting. 2 Lorazepam is a benzodiazepine with sedative, anxiolytic, and amnesic properties. We give it as a 4-mg dose, intramuscularly, two hours before treatment, then as 1 to 2 mg sublingually, hourly as needed, for up to six hours to maintain mild to moderate sedation, as defined by Gralla et al 3 ( mild : patient lethargic but aroused by verbal stimuli and completely oriented when awakened; moderate : patient aroused only by physical stimuli and completely oriented when awakened). Prochlorperazine is usually given rectally in a 25-mg dose at the beginning of treatment and four hours later if necessary. Our regimen resulted in adequate amnesia for emesis in 94% of

Control of cancer chemotherapy-induced nausea and vomiting.

With increasingly effective cancer chemotherapy, the control of chemotherapy-induced nausea and vomiting has become more important. These unpleasant side effects can be so severe that patients delay or stop potentially curative therapy. Phenothiazines and butyrophenones have been the mainstays of most antiemetic therapy but unfortunately have only partially controlled nausea and vomiting. Recently, renewed interest in the control of nausea and vomiting has led to the introduction of additional classes of agents. Cannabinoids appear to be superior to phenothiazines as antiemetics, but must be given in doses that also cause central nervous system side effects. Metoclopramide, given in high doses (1.0-3.0 mg/kg) has proven to be a major advance in the control of nausea and vomiting induced by cisplatin. Glucocorticoids may be useful, particularly when combined with other agents. There has been recent recognition of the importance of anticipatory nausea and vomiting, and attempts to control this through behavioral modification techniques have met with some success.

Lorazepam for Chemotherapy-Induced Emesis-Reply

In Reply. —We agree that the capacity to induce amnesia is a desirable attribute of lorazepam and that this drug may have unique advantages in preventing or reducing anticipatory nausea and vomiting. Our own studies1remarked on the amnestic effect, though it was documented less often than by Greenspoon et al. Recent publications are also supportive of a salutary role for lorazepam alone or in combination with other agents.2,3Our current studies are in the direction of documenting whether lorazepam and metoclopramide are particularly effective when given together in patients receiving aggressive emetogenic therapy. There probably is an important role for both agents.

Clinical characteristics associated with the development of anticipatory nausea and vomiting in cancer patients undergoing chemotherapy treatment.

Approximately one in four patients experiences nausea and/or vomiting in anticipation of a chemotherapy treatment by the time of their fourth treatment cycle. Anticipatory nausea and vomiting is a prevalent problem of clinical significance in the total management of chemotherapy side effects. While refractory to standard antiemetic treatment, anticipatory nausea and vomiting has been successfully treated with behavioral approaches such as systemic desensitization. The present study was designed to identify the characteristics of patients at high risk for developing anticipatory side effects. Early identification of cancer patients prone to developing anticipatory side effects could lead to preventive measures. One hundred seventy-six consecutive ambulatory patients with histologically confirmed cancer who were being treated at three geographically separate hospitals of the University of Rochester Cancer Center were studied at the time of their fourth chemotherapy treatment. Patients found to experience anticipatory nausea and vomiting were significantly more likely (P less than .001) to have four or more of the following characteristics than patients who did not report anticipatory side effects: (1) less than 50 years of age; (2) the experience of nausea and/or vomiting after their last chemotherapy treatment; (3) a description of nausea after the last treatment as "moderate, severe, or intolerable"; (4) a description of vomiting after the last treatment as "moderate, severe, or intolerable"; (5) the reporting of the side effect "warm or hot all over" after their last treatment; (6) a susceptibility to motion sickness; (7) the experience of "sweating after their last treatment"; (8) and the experience of "generalized weakness after their last chemotherapy treatment." Results support a view that anticipatory side effects are conditioned and point to practical interventions for their clinical control.

Anticipatory nausea and/or vomiting

Nausea and vomiting generally occur after the administration ofcancer chemotherapy as a direct response to the emetogenic effects of these agents. However, after a few courses of treatment some patients begin to develop nausea and vomiting prior to treatments. The incidence of anticipatory nausea or vomiting (ANV) understandably varies due to the heterogeneity of the patients and treatments. As regards anticipatory nausea (AN) alone, the percentage incidence ranges from 18.3% (24) to 44.4% (27). Table 1 summarizes the results. Morrow (22) subdivided the percentage figures of patients who reported AN as follows: 9% before every treatment session; 6% frequently; 4% before approximately 50% of the treatment sessions; and 5% rarely. The percentage incidence of anticipatory vomiting (AV) has also been examined. The percentages range from 9% (22) to 38% (16). Morrow (22) subdivided AV as follows: 2% experienced it before every treatment session; 3% frequently; 2% before approximately 50% of the treatment sessions; and 2% rarely. Redd

Advances in anti-emetic therapy

Evaluation of the activity of anti-emetic drugs in randomized controlled trials has, in most cases, demonstrated the superiority of treatment over placebo administration for the control of chemotherapy-induced emesis (see Table 15). The degree of control of emesis relates both to the intensity of the emetogenic stimulus and to the effectiveness of the antiemetic agent employed. Prochlorperazine is a relatively weak anti-emetic. The drug exhibits modest activity in the treatment of emesis produced by mild emetogenic stimuli, but is relatively ineffective in the treatment of patients on moderate to severely emetogenic drugs. Domperidone has demonstrated activity against moderately emetogenic stimuli but has not been evaluated in cisplatin-treated patients. The cannabinoids have proved efficacious in the treatment of emesis induced by more severe emetogenic stimuli. THC therapy, however, has been limited in some studies by toxicity. High-dose metoclopramide has demonstrated efficacy in small series of patients in the treatment of cisplatin-induced vomiting. Dexamethasone activity as a single agent is in doubt but the drug may improve the efficacy of metoclopramide when used in combination. For the future, the use of combinations of anti-emetics with differing sites of action and non-overlapping toxicities, may lead to further improvement in efficacy. Combinations of centrally-acting drugs such as the cannabinoids plus dopamine antagonists such as metoclopramide or domperidone, are worth evaluating. The control of anticipatory nausea and vomiting is another major area of interest which has, as yet, not been studied in any depth. A single comparative trial has been reported in the literature (50) and in this study, behavioural therapy rather than drug therapy was evaluated. There may be a place for the evaluation of behavioural therapy in combination with drugs exhibiting anxiolytic properties such as the benzodiazepines and the cannabinoids. Finally, new anti-emetic drugs with an improved therapeutic index will be welcomed by the patient.

The Assessment of Nausea and Vomiting

Given the diversity of assessment methodologies in previous studies, and given the increasing attention being shown in studies in which nausea and vomiting are used as outcome measures, it is reasonable to expect that there are more questions on the assessment of nausea and emesis than there are answers. There is little consensus on the efficacy of various approaches used to help control chemotherapy-induced nausea and emesis. There is also little consensus on the appropriate assessment techniques for their measurement. While there is room for much controlled experimentation and study of the ways to assess nausea and emesis, a review of past studies indicates several guidelines that should be kept in mind. The first of these is that nausea is a subjective phenomenon. It exists only insofar as it is defined by the patient. The clinical reality is that patients' decisions to delay or terminate chemotherapy are based on their subjective evaluations of the side effects, not on evaluations made by a clinician or others. With this in mind, a self-report approach to the assessment of nausea appears the most reasonable at this time. On the other hand, while vomiting does have subjective aspects, it represents a behavior that may be reliably observed by others. Thus, it is appropriate that observer ratings be obtained whenever feasible. The use of such indirect measures of nausea and vomiting as time to food intake, appetite change, and other measures of patient well-being should be considered whenever feasible. As with all measures, the cost in patient time needs to be balanced against the scientific needs of any study quantifying nausea and vomiting. While direct, physiologic measures would provide an important external reference to the assessment of nausea and vomiting, at the present time, these appear useful only in animal studies. The fact that nausea and vomiting can occur independently points to the validity of their assessment as separate behaviors. It is also important to note that their frequency, severity, and duration are separable phenomena. A complete assessment of nausea and vomiting responses should include separate measures of frequency, severity, and duration. Anticipatory nausea and vomiting are clinical phenomena that appear to occur with a reasonable enough frequency so that their measurement would be important in clinical studies.(ABSTRACT TRUNCATED AT 400 WORDS)

A pilot study of lorazepam-induced amnesia with cis-platinum-containing chemotherapy

Eighteen patients with advanced epithelial ovarian cancer were given 36 courses of cis-platinum-containing chemotherapy at Cedars-Sinai Medical Center. Patients were given lorazepam (Ativan) prior to chemotherapy. Amnesia for the day of chemotherapy was reported in 29 courses. Lack of recall for the chemotherapy infusion and the subsequent 8 hr or greater was reported in 33 of the 36 courses. In two courses, no amnesia effects were noted. No serious side effects of lorazepam therapy occurred and all patients believed that the amnesic effect was beneficial during chemotherapy. Lorazepam (Ativan) appears to be a safe medication to induce amnesia for cis-platinum chemotherapy and deserves further study to determine its effect on anticipatory vomiting, nausea and vomiting, and patient compliance with continued chemotherapy.

Anticipatory nausea and vomiting associated with cancer chemotherapy

Fifty adult oncology outpatients receiving chemotherapy were surveyed to assess their experiences with chemotherapy-associated nausea and vomiting. Of patients who noted post-chemotherapy nausea with or without vomiting, 46% reported anticipatory nausea. The anticipatory symptoms developed after the onset of post-chemotherapy neausea. Patients experiencing anticipatory symptoms had received chemotherapy over a significantly longer period of time than had the patients with post-treatment nausea only. Of these patients who had noted post-chemotherapy nausea with or without vomiting for two or more months, 50% reported pre-treatment nausea with or without vomiting. There was no tendency toward anticipatory symptoms according to age, sex, race, educational level, disease, or type of chemotherapy. Thoughts of chemotherapy, sights, specific odors and tastes evoked anticipatory symptoms. Pre-treatment or anticipatory nausea and vomiting are probably a manifestation of classical (Pavlovian) conditioning.

Appropriateness of taped versus live relaxation in the systematic densensitization of anticipatory nausea and vomiting in cancer patients.

Appropriateness of taped versus live relaxation in the systematic densensitization of anticipatory nausea and vomiting in cancer patients.

Prevalence of anticipatory nausea and emesis in cancer chemotherapy patients.

The prevalence of anticipatory nausea (AN) and anticipatory emesis (AE) in 71 cancer chemotherapy outpatients was measured by a self-report questionnaire. An 18.3% prevalence rate was found, with a mean onset of 5.12 hr prior to treatment. AN/AE most typically occurred at home or while traveling to the clinic and those who experienced it also reported a significantly higher frequency of posttreatment nausea, vomiting, constipation, and dry and itching skin.

Prevalence and Correlates of Anticipatory Nausea and Vomiting in Chemotherapy Patients<xref ref-type="fn" rid="fn2">2</xref><xref ref-type="fn" rid="fn3">3</xref>

Forty-seven of 225 (21%) consecutive cancer patients were found to experience nausea and/or vomiting prior to a chemotherapy treatment. Multivariate examination of demographic and clinical characteristics showed patients with anticipatory side effects to report more severe posttreatment emesis, to report their most severe posttreatment nausea as occurring later after treatment, and to be more likely to be taking cisplatin than patients without anticipatory side effects. Seventy percent of the patients with anticipatory nausea and/or vomiting attributed the side effects to a psychologic etiology.