Radiotherapy-induced Nausea and Vomiting

Table 1.  Antiemetic guidelines for management of radiotherapy-induced nausea and vomiting.

Emetic risk level	Site/radiotherapy	Recommendation
MASCC/ESMO
High	TBI	Prophylaxis with a 5-HT3RA + Dex
Moderate	Upper abdomen, HBI, UBI	Prophylaxis with a 5-HT3RA ± Dex (Dex for days 1–5)
Low	Cranium (all), craniospinal, head and neck, lower thorax, pelvis	Prophylaxis or rescue with a 5-HT3RA
Minimal	Extremities, breast	Rescue with a dopamine RA or a 5-HT3RA
ASCO
High	TBI	Prophylaxis with a 5-HT3RA ± Dex. Give prior to each fraction and for at least 24 h after
Moderate	Upper abdomen, HBI, abdomen/pelvis, mantle, craniospinal, cranial radiosurgery	Prophylaxis with a 5-HT3RA prior to each fraction
Low	Lower thorax, cranial radiosurgery, craniospinal	Prophylaxis or rescue with a 5-HT3RA. Once initiated, administer prior to each fraction
Minimal	Breast, head and neck, cranium, extremities	Rescue with a dopamine RA or a 5-HT3RA. Once initiated, administer prior to each remaining fraction
NCCN
High	TBI	Granisetron 2 mg p.o. OD ± Dex 4 mg p.o. OD prior to each fraction or Ondansetron 8 mg p.o. b.i.d.–t.i.d. ± Dex 4 mg p.o. OD prior to each fraction
Moderate	Upper abdomen/localized sites	Granisetron 2 mg p.o. OD ± Dex 4 mg p.o. OD prior to each fraction or Ondansetron 8 mg p.o. b.i.d. ± Dex 4 mg p.o. OD prior to each fraction

5-HT₃RA: 5-hydroxytryptamine-3 (serotonin) receptor antagonist; ASCO: American Society of Clinical Oncology; b.i.d.: Twice daily; Dex: Dexamethasone; Dopamine RA: Dopamine receptor antagonist; HBI: Hemi-body irradiation; MASCC/ESMO: Multinational Association for Supportive Care in Cancer/European Society of Medical Oncology; NCCN: National Comprehensive Cancer Network; OD: Once daily; p.o.: Per os (by mouth); TBI: Total body irradiation, t.i.d.: Three-times daily; UBI: Upper body irradiation.

Authors and Disclosures

Kristopher Dennis¹, Ernesto Maranzano², Carlo De Angelis¹, Lori Holden¹, Shun Wong¹ and Edward Chow*<sup>1

1</sup>Radiation Oncology and Pharmacy Departments, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada
²Department of Oncology and Radiation Oncology Centre, 'S. Maria' Hospital, Terni, Italy

*Author for correspondence
Tel.: +1 416 480 4998 Fax: +1 416 480 6002 edward.chow@sunnybrook.ca

Sidebar

Key Issues

• The overall cumulative incidence of radiotherapy-induced nausea and vomiting (RINV) among patients undergoing radiotherapy is estimated at 50–80%.

• Patients suffering from RINV have a decreased quality of life and are more likely to interrupt or cancel radiotherapy treatments, which may compromise the chances of cure or effective symptom palliation.

• RINV have garnered significantly less interest and investigation when compared with chemotherapy-induced nausea and vomiting.

• Evidence-based antiemetic guidelines for the prevention of RINV exist, but they are underutilized by radiation oncologists.

• Barriers to implementing antiemetic guidelines include an underappreciation of the prevalence of RINV, a perceived lack of applicability of guidelines to one's own unique practice setting, a lack of knowledge on the current patterns of practice for the management of RINV and the diffusion of responsibility for antiemetic management among radiation oncologists, medical oncologists, palliative care specialists and family physicians.

• Future research needs to focus on defining the true incidence of RINV during irradiation of all common treatment sites (e.g., brain, thorax, abdomen, pelvis and so on). Patient- and radiotherapy-related risk factors beyond the site of irradiation need be clarified.

• Translational studies need to explore the mechanisms underlying RINV for all common treatment sites.

• New patient-reported scales for nausea and vomiting are needed to better capture the nuances of the symptom experience, and standardized efficacy end points for future studies in RINV will allow comparisons of antiemetic regimens across studies.

• Cooperation among small groups of interested investigators is critical to progress, as the field of radiation oncology is dominated by research into technology rather than supportive care and symptom control.