Association Between Serotonin Transport Polymorphisms and Postdischarge Nausea and Vomiting in Women Following Breast Cancer Surgery

Nausea and vomiting are two of the most common and debilitating side effects following surgery. About half of all patients experience postoperative nausea and vomiting (PONV) during the 24 hours following surgery, or postdischarge nausea and vomiting (PDNV) when they return home following surgery (Cruthirds, Sims, & Louis, 2013). About 80% of patients are considered high-risk, particularly women nonsmokers with a positive history of PONV and who use opioids for relief of pain (Apfel, Korttila, et al., 2004). Opioids given for postoperative pain often are considered the primary cause of PONV (Watcha & White, 1992). Women with breast cancer undergoing mastectomy are particularly high-risk for PONV, with a reported incidence rate of 60%–80% in patients receiving no antiemetic medications (Lee et al., 2008). PONV and PDNV can lead to aspiration; wound dehiscence; bleeding; hematoma; dehydration; electrolyte imbalance; exhaustion; and delayed mobilization, recovery, and ability to begin oral medications (Jolley, 2001; Miaskowski, 2009). PONV is one of the strongest predictors of prolonged hospital stays and unanticipated admission for outpatients following breast cancer surgery (Marla & Stallard, 2009), accounting for millions of dollars of healthcare costs annually (Apfel, Kranke, & Eberhart, 2004). For some women with breast cancer, PONV and PDNV can be more problematic than pain. In scenario studies, when surgical patients were given limited amounts of money to hypothetically “buy away” potential postoperative complications, nausea and vomiting were chosen before pain (Kerger et al., 2007; Macario, Weinger, Carney, & Kim, 1999). Patients with nausea also reported greater impairment in quality of life and psychological distress (Pirri et al., 2013). The American Society of Clinical Oncology indicated that the goal for managing treatment-induced nausea and vomiting (from surgery, chemotherapy, or radiation) should be complete antiemetic response (Basch et al., 2011). However, even when the best available antiemetic medications are applied correctly, that goal has remained elusive (Gan et al., 2007). Documented risk factors for PDNV differ slightly than those for PONV, and include younger age, history of PONV in the postanesthesia care unit, female gender, and use of opioids for pain (Apfel, Philip, et al., 2012). However, female gender is a better independent predictor than history of PONV (Lee et al., 2008), and nonsmoking has not been found to influence PDNV (Apfel, Philip, et al., 2012). The increased risk for PDNV in female patients is not yet understood, but this increased risk persists throughout life, even following menopause (Apfel, Kranke, et al., 2004). In addition, patients scheduled for breast cancer surgery frequently experience high levels of distress, which also may contribute to PONV and PDNV (Montgomery, Schnur, Erblich, Diefenbach, & Bovbjerg, 2010). The significant impact of post-treatment nausea on quality of life in patients with cancer has been reported both as a single symptom and as a symptom cluster with vomiting and appetite loss. Patients with nausea had significantly higher quality-of-life impairment and psychological distress, as well as greater cancer distress (Pirri et al., 2013). To develop effective strategies for the prevention and management of PONV and PDNV in women following breast cancer, understanding the physiologic basis of these problems is important.