A randomized trial of nurse-administered behavioral interventions to manage anticipatory nausea and vomiting in chemotherapy.

PURPOSE: Chemotherapy side effects diminish quality of life and can lead to treatment delay. Nausea and vomiting can occur prior to chemotherapy because of classical conditioning. We studied the effects of 20-minute behavioral interventions, administered by oncology nurses, of higher intensity (mindfulness relaxation-MR) or lower intensity (relaxing music-RM), on anticipatory nausea and vomiting (ANV). PATIENTS AND METHODS: Patients undergoing chemotherapy for solid tumors were randomized to MR (N = 160), RM (N = 159), or standard care SC (N = 155). Subjects were mostly female (91.8%) and white (86.1%) with breast cancer (85%). Most patients had early stage disease (Stage I: 26%; II: 52.9%; III: 19%; IV: 0.1%). Anticipatory nausea and vomiting were assessed at the midpoint and end of the chemotherapy course using the Morrow Assessment of Nausea and Emesis (MANE). RESULTS: Compared to SC, there was reduced anticipatory nausea at the midpoint of chemotherapy in those receiving MR (OR 0.44, 95% CI 0.20-0.93) and RM (OR 0.40, 95% CI 0.20-0.93), controlling for age, sex, cancer stage, and emetogenic level of chemotherapy. There was no difference between treatment groups in anticipatory nausea at the end of chemotherapy or in anticipatory vomiting and postchemotherapy nausea and vomiting at either time point. CONCLUSION: A brief nurse-delivered behavioral intervention can reduce midpoint ANV associated with chemotherapy.

Anticipatory nausea and vomiting due to chemotherapy.

As a specific variation of chemotherapy-induced nausea and vomiting, anticipatory nausea and vomiting (ANV) appears particularly linked to psychological processes. The three predominant factors related to ANV are classical conditioning; demographic and treatment-related factors; and anxiety or negative expectancies. Laboratory models have provided some support for these underlying mechanisms for ANV. ANV may be treated with medical or pharmacological interventions, including benzodiazepines and other psychotropic medications. However, behavioral treatments, including systematic desensitization, remain first line options for addressing ANV. Some complementary treatment approaches have shown promise in reducing ANV symptoms. Additional research into these approaches is needed. This review will address the underlying models of ANV and provide a discussion of these various treatment options.

Risk factors at pretreatment predicting treatment-induced nausea and vomiting in Australian cancer patients: a prospective, longitudinal, observational study.

PURPOSE: Despite significant advances in antiemetic management, almost 50% of cancer patients still experience nausea and vomiting during treatment. The goal of antiemetic therapy is complete prevention of treatment-induced nausea and/or vomiting (TINV); however, realisation of this goal remains elusive, thus supplementary strategies identifying patients at high risk must be employed in the interim. Consequently, we examined TINV incidence and its risk factors, including patient, clinical and pretreatment quality of life (QOL)/psychological factors. METHODS: Two hundred newly diagnosed cancer patients beginning combined treatment participated in this prospective, longitudinal, observational study. QOL (including TINV), psychological adjustment, and patient/clinical characteristics were examined at pretreatment, on-treatment (8 weeks ± 1 week) and post-treatment. RESULTS: Overall, 62% of patients experienced TINV, with TIN incidence (60%) doubling that of TIV (27%). Eight independent risk factors predicted 73% of TIN incidence: high premorbid/anticipatory NV, moderately/highly emetogenic chemotherapy (M/HEC), longer treatment (>3 months), female gender, surgery prior to adjuvant chemotherapy ± radiotherapy, private health insurance and low emotional functioning (pretreatment). Six independent risk factors predicted 77% of TIV incidence: premorbid/anticipatory vomiting, M/HEC, female gender, cancer resection and low role functioning (pretreatment). CONCLUSIONS: TINV still represents a very major concern for patients. Several pretreatment risk factors for the development of TIN and TIV, respectively, were identified. Patients about to undergo cancer treatment, particularly combined treatment involving emetogenic chemotherapy and surgery, should be screened for these factors with a view to modifying standard pretreatment/maintenance antiemetic therapy. Furthermore, and consistent with recent research, it is recommended that more comprehensive interventions combining antiemetics with other effective pharmacological (e.g. anxiolytics) and non-pharmacological approaches (e.g. acupuncture, relaxation techniques) be considered by clinicians in attempts to improve control of TIN and TIV (and overall QOL) for their patients. In this way, optimal holistic care will be ensured for cancer patients by clinicians providing conventional oncology treatment.

Preoperative hypnotherapy in the management of a child with anticipatory nausea and vomiting.

A six-year-old boy with oesophageal strictures secondary to neonatal repair of oesophageal atresia and requiring six to eight weekly oesophageal dilatations by bouginage developed anticipatory nausea and vomiting. This was effectively managed by a course of preoperative hypnotherapy over four sessions. Resolution of anticipatory nausea and vomiting occurred along with cessation of postoperative nausea and vomiting. This case supports early intervention with preoperative hypnotherapy in children with anticipatory nausea and vomiting that has not responded to other measures.

Anticipatory nausea: the role of individual differences related to sensory perception and autonomic reactivity.

BACKGROUND: Anticipatory nausea (AN) during chemotherapy has been difficult to control with conventional antiemetics. AN can lead cancer patients to delay or discontinue chemotherapy, possibly compromising the treatment. PURPOSE: The aim is to investigate the possible influence on the development of AN of individual differences in absorption, somato-sensory amplification, and autonomic perception-measures theorized to be related to sensory perception and autonomic reactivity. METHODS: Prior to treatment, 125 women (M age = 48.5 years) undergoing adjuvant chemotherapy for breast cancer rated their expected severity of side effects and completed the Tellegen Absorption Scale, the Somato-Sensory Amplification Scale, and the Autonomic Perception Questionnaire. AN, as well as anticipatory vomiting (AV), distress, and worry/anxiety, were measured prior to the fourth, sixth, and last cycle of chemotherapy. Posttreatment nausea (PN), vomiting, and fatigue were measured after the first, fourth, sixth, and last cycle. RESULTS: 34% of the women reported AN before 1 or more cycles. When controlling for treatment characteristics and other known predictors, AN was significantly associated with high absorption in addition to severity of PN, pretreatment worry/anxiety, and not receiving radiotherapy between chemotherapy sessions. AV was not associated with any of the variables investigated. Our data suggest that the association is strongest in the early phases of treatment. CONCLUSIONS: Our results partly confirm the results of a previous study showing absorption and autonomic perception as predictors of anticipatory side effects in cancer patients receiving chemotherapy. Individuals high in absorption may be more autonomically reactive to aversive stimuli and, subsequently, more conditionable. Additional radiotherapy could be a competing stimulus, reducing the conditioning of chemotherapy-related nausea. Further studies investigating possible psycho-physiological mechanisms in the development of AN are needed.

Behavioral interventions in treating anticipatory nausea and vomiting.

Anticipatory nausea and vomiting (ANV) is associated with a significant reduction in the quality of life for many chemotherapy patients. The use of 5-hydroxytryptamine type 3 receptor antagonists provides some relief for chemotherapy-induced nausea and vomiting, but does not seem to control ANV. Nonpharmacologic approaches, which include behavioral interventions, may provide the greatest promise in relieving symptoms. Little evidence supports the use of complementary and alternative methods, such as acupuncture and acupressure, in relieving ANV. Behavioral interventions, especially progressive muscle relaxation training and systematic desensitization, should be considered important methods for preventing and treating ANV.

The efficacy of behavioral interventions for cancer treatment-related side effects.

The use of increasingly aggressive methods of cancer treatment (e.g., cytotoxic doses of chemotherapy and total body irradiation) has resulted in the need for more effective management of pain, nausea, and other aversive side effects. One of the most promising approaches is nonpharmacologic intervention based on behavioral research and theory. The purpose of this article is to review the efficacy of behavioral intervention methods in controlling aversive side effects of cancer treatments. Sixty-seven published studies were identified for review. Results indicated that: (1) behavioral intervention can effectively control anticipatory nausea and vomiting in adult and pediatric patients undergoing cancer chemotherapy. However, evidence for the efficacy of behavioral intervention to control post-chemotherapy nausea and vomiting is mixed; (2) behavioral intervention integrating several behavioral techniques can decrease levels of anxiety and distress associated with invasive treatments and cancer diagnosis; and (3) although a variety of behavioral methods have been shown to reduce acute treatment-related pain, not all behavioral techniques are equally effective. Hypnotic-like methods involving relaxation, suggestion, and imagery appear to have the greatest impact on cancer-related pain management. The use of behavioral theory and techniques has an important place in the care of patients undergoing invasive cancer treatments.

The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: a randomised controlled trial.

This study was a randomised controlled trial designed to assess the effectiveness of progressive muscle relaxation training (PMRT) in the clinical management of chemotherapy-related nausea and vomiting as an adjuvant intervention to accompany pharmacological antiemetic treatment (metoclopramide and dexamethasone i.v.). Seventy-one chemotherapy-naive breast cancer patients of an outpatient oncology unit of a university hospital in Hong Kong participated, with 38 subjects randomised to the experimental group and 33 to the control group. The intervention included the use of PMRT 1 h before chemotherapy was administered and daily thereafter for another 5 days (for a total of six PMRT sessions). Each session lasted for 25 min and was followed by 5 min of imagery techniques. The instruments used for data collection included the Chinese versions of the Profile of Mood States and the State-Trait Anxiety Inventory (measured before chemotherapy and then at day 7 and day 14 after chemotherapy), and the Morrow Assessment of Nausea and Vomiting Scale, which was used daily for the first 7 post-chemotherapy days. The use of PMRT considerably decreased the duration of nausea and vomiting in the experimental group compared with the control group ( P<0.05), whereas there were trends toward a lower frequency of nausea and vomiting ( P=0.07 and P=0.08 respectively). Neither nausea nor vomiting differed in intensity between the two groups. The significant effects were mainly evident on the first 4 post-chemotherapy days, when differences were statistically significant. Although there was a significantly less severe overall mood disturbance in the experimental group over time ( P<0.05), this did not apply in the case of anxiety. Such findings suggest that PMRT is a useful adjuvant technique to complement antiemetics for chemotherapy-induced nausea and vomiting and that incorporation of such interventions in the care plan can enhance the standards of care of cancer patients who experience side effects of chemotherapy.

Understanding anticipatory nausea.

PURPOSE/OBJECTIVES: To address the concept of anticipatory nausea within the theoretical framework of classical conditioning. DATA SOURCES: Published articles, book chapters. DATA SYNTHESIS: Although classical conditioning explains much in the development of anticipatory nausea, other factors also are at work. Preventing this phenomenon is necessary because it is difficult to treat and control once it develops. CONCLUSIONS: Nurses are in a position to identify patients at highest risk for developing anticipatory nausea and implement interventional strategies to prevent/minimize it. IMPLICATIONS FOR NURSING PRACTICE: Many aspects of anticipatory nausea have not yet been researched well. Nurses must study how anticipatory nausea develops and interventions that can be used to reduce its prevalence.

Cognitive distraction and relaxation training for the control of side effects due to cancer chemotherapy.

Sixty cancer chemotherapy patients were randomly assigned to one of six conditions formed by a 3(cognitive distraction, relaxation training, no intervention) x 2(high anxiety, low anxiety) factorial design. All patients were followed for five consecutive chemotherapy sessions. Outcome measures included patient reports, nurse observations, and physiological indices. Results indicated that distraction patients reported less nausea prior to chemotherapy and lower systolic blood pressures after chemotherapy than controls. Relaxation training patients reported less nausea prior to chemotherapy and exhibited lower systolic and diastolic blood pressures after chemotherapy than control patients. There were no significant differences between distraction and relaxation training patients on any measure. Patients with high initial levels of anxiety exhibited continually elevated levels of distress throughout the chemotherapy experience; however, anxiety level did not interact with the effectiveness of the treatment interventions. Overall, the data support the use of both cognitive distraction and relaxation training for reducing the distress of chemotherapy with both high and low-anxiety patients and suggest that at least some of the effects of relaxation training can be achieved with distraction alone.

An experimental analysis of classically conditioned nausea during cancer chemotherapy.

This study investigated classical conditioning in women undergoing outpatient adjuvant chemotherapy for breast cancer. Breast cancer chemotherapy outpatients were randomly assigned either to an Experimental Group (exposed to a distinctive stimulus before each infusion of chemotherapy) or to a Control Group. After repeated infusions of chemotherapy, patients' responses to the experimental stimulus were assessed in a location not associated with chemotherapy. Experimental Group patients had increased nausea (self-reported on a visual analog scale) following the presentation of the experimental stimulus at this test trial, whereas Control Group patients did not. Two other measures of nausea corroborated these results. Post hoc statistical analyses confirmed predictions based on conditioning theory. This conditioning model of anticipatory nausea bears witness to the relevance of classical conditioning in clinical medicine.

Effectiveness of biofeedback and relaxation training in reducing the side effects of cancer chemotherapy.

Assessed the effectiveness of electromyographic (EMG) and skin-temperature (ST) biofeedback and relaxation training (RT) in reducing the aversiveness of cancer chemotherapy. Eighty-one cancer patients, equated on several individual-difference variables, were randomized to one of six groups formed by a 3 (EMG Biofeedback, ST Biofeedback, No Biofeedback) x 2 (RT, No RT) factorial design. Outcome was assessed with physiological, patient-reported, and nurse-reported indices taken over five consecutive chemotherapy treatments. RT patients showed decreases in nausea and anxiety during chemotherapy and physiological arousal after chemotherapy. EMG and ST biofeedback reduced some indices of physiological arousal but had no other effects on chemotherapy side effects. These findings suggest that RT can be effective in reducing the adverse consequences of chemotherapy and that the positive effects found for biofeedback in prior research were due to the RT that was given with the biofeedback, not to the biofeedback alone.

Distraction and relaxation training in the treatment of anticipatory vomiting: a single subject intervention.

A within-series phase change design (ABABC) was used to evaluate the effect of video distraction and relaxation in the treatment of a 29-year-old male with anticipatory vomiting associated with cancer chemotherapy. Heart rate, blood pressure, nausea ratings, and the occurrence of emesis were recorded during 18 chemotherapy treatments over a 9 month period. Video distraction initially inhibited vomiting but the treatment effects were not maintained. Subsequent relaxation training inhibited vomiting after two sessions. These effects were maintained for the remainder of the patient's chemotherapy protocol.