Chemotherapy-induced nausea and vomiting (CINV) and adherence to antiemetic guidelines: results of a survey of oncology nurses.

PURPOSE: Chemotherapy-induced nausea and vomiting (CINV) can be prevented in most patients with use of guideline-recommended antiemetic regimens. However, studies have suggested that adherence to antiemetic guidelines is suboptimal. Oncology nurses, as part of a multidisciplinary team, can help promote appropriate antiemetic prophylaxis. Therefore, nurses were surveyed to assess antiemetic guideline awareness and practice patterns of antiemetic use, determine adherence to guideline recommendations, and query barriers to adherence. METHODS: In September 2015, 531 US-based oncology nurses participated in an online survey administered and analyzed by ONS:Edge. RESULTS: Nurses were most familiar with National Comprehensive Cancer Network (73%) and American Society of Clinical Oncology (48%) antiemetic guidelines. While most (77%) felt that antiemetics prescribed were consistent with guideline recommendations, practice patterns of antiemetic use revealed low adherence to those guidelines, particularly during the delayed (25-120 h) phase following highly emetogenic chemotherapy, where only 25% of nurses reported administration of guideline-recommended agents. Overutilization of phenothiazines and benzodiazepines was common. Only 17% of respondents reported that most (> 75%) of their patients have CINV optimally controlled; 39% reported between 6 and 20% of patients have an alteration in their chemotherapy due to CINV, and reports of emergency department/hospital visits due to poorly controlled CINV were high. The predominant barrier interfering guideline-recommended antiemetic prophylaxis was reported as physician preference (71%). CONCLUSIONS: This survey revealed an opportunity to increase awareness of antiemetic guidelines and a critical need to address barriers interfering with utilization of guideline-recommended antiemetic agents in order to optimize CINV control for patients undergoing emetogenic chemotherapy.

2016 Updated MASCC/ESMO Consensus Recommendations: Controlling nausea and vomiting with chemotherapy of low or minimal emetic potential.

PURPOSE: The purpose of this review is to update the MASCC (Multinational Association of Supportive Care in Cancer) guidelines for controlling nausea and vomiting with chemotherapy of low or minimal emetic potential. METHODS: The antiemetic study group of MASCC met in Copenhagen in 2015 to review the MASCC antiemetic guidelines. A subgroup performed a systematic literature review on antiemetics for low emetogenic chemotherapy (LEC) and chemotherapy of minimal emetic potential and the chair presented the update recommendation to the whole group for discussion. They then voted with an aim of achieving 67 % or greater consensus. RESULTS: For patients receiving low emetogenic chemotherapy, a single antiemetic such as dexamethasone, a 5HT3 receptor antagonist, or a dopamine receptor antagonist may be considered for prophylaxis of acute emesis. For patients receiving chemotherapy of minimal emetogenicity, no antiemetic should be routinely administered. If patients vomit, they should be treated as for chemotherapy of low emetic potential. No antiemetic should be administered for prevention of delayed nausea and vomiting induced by low or minimally emetogenic chemotherapy. CONCLUSIONS: More research is needed to determine the incidence of emesis, particularly delayed emesis, in the LEC group. Prospective studies are required to evaluate antiemetic strategies. The risk of emesis within LEC may be more accurately determined by adding the patient risk factors for emesis to those of the chemotherapy drugs. Improved strategies for promoting adherence to guidelines are required.

Left behind: cancer disparities in the developed world.

Huge advances have been made in cancer treatments over recent decades; however, significant disparities still exist in the developed world on the basis of race, socioeconomic status, education level, geographical location, and immigration status and in the United States, insurance status. Cancer disparities persist in the continuum of cancer care from risk factors, screening, diagnosis, treatment, survivorship, and end-of-life care. The causes of disparities are complex and multifactorial. The MASCC (Multinational Association of Supportive Care in Cancer) Education Study Group would like to propose a framework of cancer disparities from a social perspective utilizing "social determinants of health" as delineated by the World Health Organization and highlight an unmet need for research and policy innovations to address cancer disparities in developed world.

Assessment and measurement of medication adherence: oral agents for cancer.

BACKGROUND: Clinicians are challenged to find ways to assess and measure adherence to oral agents for cancer (OACs). OBJECTIVES: The purpose of this article is to report on available ways to assess and measure medication adherence by patients with cancer. METHODS: Tools examined include the Morisky Medication Adherence Scale (MMAS) and the Adherence Estimator, which are able to predict risk of nonadherence. Adherence Starts With Knowledge (ASK®)-12 and the Brief Adherence Rating Scale (BARS) are likely to be effective for predicting nonadherence and measuring adherence rates. FINDINGS: Additional research needs to focus on the testing of reliable and valid tools that are sensitive and specific to patients with cancer who are prescribed OACs. The authors found that the MMAS and Adherence Estimator tools may be useful at predicting risk of medication nonadherence, and the ASK-12 and BARS may be useful for measuring rates of adherence. Tools could be modified to a specific clinical setting and used in a standardized format so that nurses can assess risk of medication nonadherence and measure adherence rates of OACs.

Analysis of aprepitant for prevention of chemotherapy-induced nausea and vomiting with moderately and highly emetogenic chemotherapy.

AIM: This study aimed to determine how aprepitant affects the impact of chemotherapy-induced nausea and vomiting (CINV) on daily activities during highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). PATIENTS & METHODS: Patients received aprepitant plus standard antiemetic therapy (ondansetron plus dexamethasone) or standard antiemetic therapy alone. Data were analyzed from pooled data of two Phase III randomized, double-blind HEC trials and one MEC trial. Patients completed the Functional Living Index-Emesis questionnaire. RESULTS: A significantly greater percentage of patients receiving aprepitant reported no or minimal CINV impact on daily life (overall total Functional Living Index-Emesis score >6) compared with those receiving standard therapy alone (HEC: 74.4 vs 63.9%, respectively; p < 0.01; MEC: 73.4 vs 66.3%; p < 0.05). In HEC, favorable responses to aprepitant treatment persisted in nausea (70.2 vs 60.9%) and vomiting domains (84.6 vs 68.7%; both p < 0.01). Similar results were seen in MEC. CONCLUSION: Addition of aprepitant reduced CINV impact on daily life compared with standard antiemetic therapy.

Consensus recommendations for the prevention of vomiting and nausea following high-emetic-risk chemotherapy.

In this update of our 2005 document, we used an evidence-based approach whenever possible to formulate recommendations, emphasizing the results of controlled trials concerning the best use of antiemetic agents for the prevention of emesis and nausea following anticancer chemotherapies of high emetic risk. A three-drug combination of a 5-hydroxytryptamine type 3 receptor (5-HT(3)) receptor antagonist, dexamethasone, and aprepitant beginning before chemotherapy and continuing for up to 4 days remains the standard of care. We address issues of dose, schedule, and route of administration of five selective 5-HT(3) receptor antagonists. We conclude that, for each of these five drugs, there is a plateau in therapeutic efficacy above which further dose escalation does not improve outcome. In trials designed to prove the equivalence of palonosetron to ondansetron and granisetron, palonosetron proved superior in emesis prevention, while adverse effects were comparable. Furthermore, for all classes of antiemetic agents, a single dose is as effective as multiple doses or a continuous infusion. The oral route is as efficacious as the intravenous route of administration.

Acute emesis: moderately emetogenic chemotherapy.

This paper is a review of the recommendations for the prophylaxis of acute emesis induced by moderately emetogenic chemotherapy as concluded at the third Perugia Consensus Conference, which took place in June 2009. The review will focus on new studies appearing since the Second consensus conference in April 2004. The following issues will be addressed: dose and schedule of antiemetics, different groups of antiemetics such as corticosteroids, serotonin(3) receptor antagonists, dopamine(2) receptor antagonists, and neurokinin(1) receptor antagonists. Furthermore, antiemetic prophylaxis in patients receiving multiple cycles of moderately emetogenic chemotherapy will be reviewed. Consensus statements are given, including optimal dose and schedule of serotonin(3) receptor antagonists, dexamethasone, and neurokinin(1) receptor antagonists. The most significant recommendations (and changes since the 2004 version of the guidelines) are as follows: the best prophylaxis in patients receiving moderately emetogenic chemotherapy (not including a combination of an anthracycline plus cyclophosphamide) is the combination of palonosetron and dexamethasone on the day of chemotherapy, followed by dexamethasone on days 2-3. In patients receiving a combination of an anthracycline plus cyclophosphamide, a combination of a serotonin(3) receptor antagonist plus dexamethasone, plus the neurokinin(1) receptor antagonist aprepitant on the day of chemotherapy, followed by aprepitant days 2-3, is recommended.

Antiemetic therapy for multiple-day chemotherapy and additional topics consisting of rescue antiemetics and high-dose chemotherapy with stem cell transplant: review and consensus statement.

This paper will evaluate various topics related to chemotherapy-induced nausea and vomiting. The results published reflect a consensus conference convened in Perugia, Italy. The topics discussed include antiemetic therapy of multiple-day chemotherapy, high-dose chemotherapy, and rescue antiemetics.

An oral history of MASCC, its origin and development from MASCC's beginnings to 2009.

INTRODUCTION: This paper presents an oral history from the mid-1980s to 2009 of the start and evolution of the Multinational Association of Supportive Care in Cancer (MASCC) as seen through the recollections of the founders and early leaders. The growth of the supportive cancer care movement and MASCC's contribution to oncology supportive care is described. DISCUSSION: As science was making progress towards better cancer treatment, a group of professionals began to research ways to prevent or mitigate the symptoms and side effects that accompany the disease and its treatments. Joining forces, they created an international, multidisciplinary organization to address and promulgate evidence-based practices of cancer supportive care. Through annual international scientific symposia, a peer-reviewed journal, an accessible website, and study group projects such as guidelines and tools, MASCC is accomplishing its mission.

Development of the MASCC Teaching Tool for Patients Receiving Oral Agents for Cancer.

BACKGROUND: Oral agents for cancer treatment commonly are prescribed throughout the world. Since oral agents usually are self-administered or administered by lay caregivers, patient education is vital to help ensure that the oral agents are being stored, handled, and taken correctly. When oral agents are taken as prescribed and patients are well informed about signs and symptoms to report, patient outcomes are optimized. Patient education varies globally; consequently, there is a need for a consistent and comprehensive approach to educate patients about oral cancer treatment. GOAL OF WORK: To create a teaching tool to be used with patients receiving oral cancer agents for worldwide use. MATERIALS AND METHODS: Six oncology nurse experts conducted a literature review and convened as an expert panel to draft a teaching tool for patients receiving oral cancer agents. The tool includes key assessment questions, generic education discussion points, drug-specific education, and evaluation questions to help ensure that patients/caregivers understand the information provided. Eighteen healthcare providers from 15 countries reviewed the tool for clarity and usefulness in practice by scoring each item in the teaching tool on a 0-10 scale ("0 = not at all to "10" = most clear/useful"). Items that scored 5 or below required comments. At the Multinational Association for Supportive Care in Cancer (MASCC) Symposium in 2008, the healthcare providers who reviewed the teaching tool met with the oncology nurse experts who had developed the tool to review the item scores and revise the tool as necessary. RESULTS: All items on the teaching tool received high scores, with the exception of items on refilling prescriptions and insurance issues, which vary from country to country. There was consensus that the MASCC Teaching Tool for Patients Receiving Oral Agents for Cancer was ready to be used and further evaluated in clinical practice. CONCLUSIONS: The MASCC Teaching Tool for Patients Receiving Oral Agents for Cancer is an available resource to assist healthcare providers assess and teach patients about oral cancer treatment.

Psychosocial care for patients and their families is integral to supportive care in cancer: MASCC position statement.

This position paper, written on behalf of the MASCC Psychosocial Study Group, reviews the most common psychosocial concerns and needs of cancer patients during all phases of the cancer continuum, from diagnosis to death or survivorship. Developments in psychosocial care at both individual and systems levels are surveyed and summarized, along with gaps in knowledge and research and needed improvements in the dissemination and application of acquired knowledge and expertise. The roles of culture, spirituality, and religion as part of psychosocial care are reviewed, along with families' and caregivers' specific psychosocial concerns and needs, and areas of needed psychosocial interventions in supportive cancer care. Deficits in recognizing and meeting patients' psychosocial needs at the system level are examined, and international guidelines and models of psychosocial care are reviewed, including their potential applications to local contexts. The paper calls for a shift to a new paradigm of care through adoption of an integrated approach to identify and meet the psychosocial needs of cancer patients and survivors as part of supportive care worldwide.

Role of the nurse in patient education and follow-up of people receiving oral chemotherapy treatment: an international survey.

PURPOSE: The aim of this study was to explore the nursing role in education and follow-up of patients who were taking oral chemotherapy (CT) and to identify the worldwide gap in patient education about oral CT. MATERIALS AND METHODS: Multinational Association of Supportive Care in Cancer members were invited to participate in a survey on oral CT. Nurse coordinators collected data via a 16-item questionnaire. Respondents totaled 1115 oncology nurses from 15 countries. RESULTS: Findings showed that about half of subjects work in outpatient/ambulatory clinics and had given at least two or more oral CT drugs. Although 52% had some type of guidelines/protocols, 47% reported not having received any education about oral CT drugs. While 64% report being involved in patient education, 58% of subjects indicated lack of patient education materials that are specific for oral CT agents. Only 27% stated that they gave all necessary information such as when and how to take the drugs, drug safety and storage, side effects, and symptom management. Reasons for not being involved in oral CT education and follow-up included beliefs that the physician plans the oral CT and gives patients necessary instructions (34%), that nurses only see patients who receive intravenous chemotherapy (16%), that nurses have lack of knowledge about oral agents (15%), and belief that physicians are responsible for patient follow-up. The nurses suggested better education and follow-up of patients to include the written patient education materials (33%) and professional education for nurses (30%). CONCLUSIONS: Findings revealed the need for professional education for nurses to ensure comprehensive, consistent patient education and development of written materials for patients receiving oral CT treatment.

Validation and psychometric assessment of a short clinical scale to measure chemotherapy-induced nausea and vomiting: the MASCC antiemesis tool.

There is a lack of clinical tools to facilitate communication between clinicians and patients about chemotherapy-induced nausea and vomiting (CINV). The Multinational Association of Supportive Care in Cancer (MASCC) has developed such a tool, which is an eight-item scale for the assessment of acute and delayed nausea and vomiting, and is completed once per cycle of chemotherapy. The aim of the current study was to assess its psychometric properties, specifically reliability and validity, cultural transferability and equivalence, and congruence with proxy assessments, as well as to determine if accuracy of recall of CINV events using the MASCC Antiemesis Tool (MAT) differed over time from chemotherapy. A prospective study was carried out with adult cancer patients and their informal carers from two hospitals, one each in the United Kingdom (UK) and United States of America (U.S.). Patients completed the Rhodes Index for nausea, vomiting and retching (INVR) daily for the first five days after chemotherapy and were then asked to complete the MAT at one week, two weeks, or three weeks after chemotherapy. Carers completed an adapted MAT concurrently with patients. The sample consisted of 87 patients and 22 informal carers. The internal consistency reliability of the scale was high, with Cronbach alphas of 0.77 (patient sample) and 0.82 (carer sample). Responses were similar between the UK and U.S. samples in terms of nausea and vomiting, and both samples found the scale easy to use. Contrasted-groups validity (using age as a grouping variable) and concurrent validity (MAT compared with INVR) suggested that the scale is sensitive to detect the different dimensions of CINV and performed well against a daily assessment of nausea/vomiting (total score correlation r=0.86, P<0.001). Recall of events was high even three weeks after chemotherapy (correlations with INVR of 0.44-0.99, all P<0.01). Factor analysis clearly identified three factors, namely vomiting, acute nausea, and delayed nausea. Proxy assessments by carers were congruent with the patients' responses, especially in relation to vomiting. The MAT is a reliable, valid, clear, and easy-to-use clinical tool that could facilitate discussion between clinicians and patients about their nausea and vomiting experience, thereby potentially aiding treatment decisions. Regular assessment of nausea and vomiting after chemotherapy has the potential to significantly improve CINV management.

Antiemetic therapy for multiple-day chemotherapy and high-dose chemotherapy with stem cell transplant: review and consensus statement.

The objective of this paper is to evaluate the efficacy of modern antiemetic therapy for chemotherapy-induced nausea and vomiting for patients receiving multiple-day or high-dose chemotherapy. Published phase II and phase III studies as well as their personal experiences were evaluated by the authors to develop this consensus statement. The largest published experience with multiple-day chemotherapy is with 5-day cisplatin combination chemotherapy. The introduction of 5-HT3 antagonists greatly improved emetic control. However, day 4-5 nausea as well as delayed nausea and vomiting remains a clinical problem despite the inclusion of dexamethasone. A 5-HT3 antagonist plus dexamethasone is the preferred current option for patients receiving high-dose chemotherapy with stem cell transplant. However, the results do not appear as successful as for highly emetic standard-dose chemotherapy.