Antiemetic Guidelines: Not Just for the HEC of It
Authors: Kelsey A. Klute
Journal: Journal of the National Comprehensive Cancer Network (2020)

N ausea and vomiting are among the most feared complications of chemo- therapy. 1 Clinicians often reassure people starting chemotherapy that, "It's not like on TV.We have better medicines to manage nausea and vomiting now.We don't see many patients suffering with nausea and vomiting after chemotherapy these days."The first part of that assurance is true.We now have a variety of highly effective medications to prevent and manage nausea and vomiting today that we did not have a decade ago.Advances in the approach to prevention and management of chemotherapy-induced nausea and vomiting (CINV) allow patients to receive chemotherapy in the outpatient setting and minimize interruption of their daily lives.The impact of this advancement was recognized by both patients and physicians who voted the FDA's approval of ondansetron in 1991 and other antiemetics in subsequent years as one of the "Top 5 Advances in 50 Years of Modern Oncology" in ASCO's 50th anniversary poll in 2014. 2 The second half of the assurance, however, is misleading.We say it because we vastly underestimate the incidence of nausea in patients receiving chemotherapy. 3pproximately 50% of patients receiving highly emetogenic chemotherapy (HEC) experience some degree of nausea or vomiting, 3-5 and uncontrolled CINV has been associated with reduced quality of life, increased healthcare utilization, and missed work, with a significant impact on daily functioning. 4linical practice guidelines published by NCCN 6 and ASCO 7 have established standard approaches to the prevention of CINV.Each set of guidelines outlines antiemetic treatment according to the emetogenic potential of a given regimen.HEC, defined as chemotherapy that causes acute emesis in .90% of patients in the absence of adequate prophylaxis, includes regimens containing anthracycline and cyclophosphamide (AC), cisplatin, or carboplatin at an area under the curve of $4.Although certain elements of both guidelines are based on expert consensus, the prophylaxis guidelines for patients receiving HEC are largely evidence-based 5,8 and generally include a 3-drug regimen containing a neurokinin-1 receptor antagonist (NK1 RA), a serotonin type-3 receptor antagonist, and dexamethasone with or without olanzapine.In this issue of JNCCN, Roeland et al 9 used a large population database to query medical oncologists' rate of compliance with antiemetic prophylaxis guidelines for HEC.They found that only 35% and 58% of clinicians were .90%adherent to antiemetic guidelines when prescribing a patient's first cycle of cisplatin or AC.They observed significant variability in guidelines adherence among individual physicians and found that the most common reason for nonadherence was omission of an NK1 RA.Though understanding the reasons for deviating from a guideline-based approach to antiemesis is beyond the scope of their study, various factors were likely at play, including underestimation of the incidence of delayed chemotherapyinduced emesis, 3 lack of guideline awareness, toxicity concerns, and lack of reimbursement for antiemetic drugs.Physicians in this study possibly intentionally selected a nonadherent prophylactic regimen based on individual patient risk factors, which have been described in the literature.It has been well-established that female sex, age ,55 years, history of motion or morning sickness, and history of no alcohol use can increase an individual's See page 676 for related article.