Challenges in the Treatment of CINV

Lee S. Schwartzberg, MD: Hello. Thank you for joining us today for this OncLive^® Peer Exchange^® panel discussion on the management of chemotherapy-induced nausea and vomiting, or CINV. Nausea and vomiting are common in cancer, particularly for patients receiving emetogenic therapies. In this OncLive^® Peer Exchange^®, a panel of experts in oncology will discuss how to optimally manage CINV in practice, while focusing on the use of new agents, current guidelines, and individualized approaches.

My name is Dr. Lee Schwartzberg, and I am the executive director of the West Cancer Center, and a professor of medicine and chief of the Division of Hematology and Oncology at the University of Tennessee Health Science Center. Joining our distinguished panel to share their perspectives are Dr. Eric Roeland, assistant clinical professor at the University of California, San Diego, in La Jolla, California; Ms. Beth Eaby-Sandy, nurse practitioner at the University of Pennsylvania in Philadelphia, Pennsylvania; Dr. Dawn Dolan, Medical Oncology Clinical Pharmacy coordinator at the Moffitt Cancer Center in Tampa, Florida; and Dr. Howard Levine, pharmacy director of Queens Medical Associates in Fresh Meadows, New York.

Thank you, again, for joining us. Let’s begin. Let’s start by talking about challenges in the treatment of CINV. Eric, can you give us a high-level view of how big a problem CINV is in 2017?

Eric Roeland, MD: Chemotherapy-induced nausea and vomiting is still a major concern for our patients. In fact, despite all these new drugs that we have, or that are in development, there are 2 major concerns that patients have when starting therapy: losing their hair and having nausea and vomiting. I definitely think the 2 areas that we still have a lot of work to do are in the delayed phase and in considering individualizing the therapies for our patients.

Lee S. Schwartzberg, MD: Beth, why is there still an issue with CINV? We have had a lot of treatment options available for almost 30 years now. Why is this still an issue, and how do physicians think about this? How do you talk to your physicians about the problem of CINV?

Beth Eaby-Sandy, CRNP, OCN: I think there are a couple of things that we deal with. First of all, it’s hard for us to predict who is going to do poorly from a nausea and vomiting standpoint. I think another thing is that we’re still using a lot of chemotherapy drugs that cause nausea/vomiting, despite all of the new targeted therapies and immunotherapies. The cornerstone of many cancer therapies is still moderate and highly emetogenic chemotherapy. So, it’s still going to remain a problem.

We’ve come a long way with a lot of different medications, but still, patients are experiencing nausea/vomiting no matter what we’re doing sometimes. It’s hard to know who’s going to experience that and who’s not going to. I think as far as talking to the physicians that I work with about it, they’re very open to understanding which medications should go as a regimen together, and what might be right to tailor for each patient, individually.

Lee S. Schwartzberg, MD: Do you use specific order sets that include the types of antiemetics for each type of drug that you’re looking at?

Beth Eaby-Sandy, CRNP, OCN: We do. The EMR has been a godsend in that fact, because we’re able to have a preset order set for all of the chemotherapy regimens. Certainly, you can tailor it, and you can delete and add other medications, but we have a task force where I work for antiemetics. We routinely get together and update that as we need to, with updated guidelines and new medications that are approved.

Howard Levine, PharmD: One of the things that I’ve come across in practice—and years ago, we sat and talked about CINV with our physicians who gave it head service, “Yes, yes, yes,”—is that they are really more interested in treatments. We came to a decision in the practice to say, “Leave it to the professionals around you. Leave it to your PAs. Leave it to your nurses. Leave it to your pharmacist to help guide that,” which they’re more than happy to do.

This shifted the focus away from putting CINV into their thought process, where they were more concerned about treatment regimens or treatment options for the cancer. They let us, the professionals around them, deal with CINV. We were able to build those regimens, as you suggested, and put the options in the regimens. The physician doesn’t really have to think much about it. It’s already been preordained by the practice. And that seems to have helped dramatically.

Beth Eaby-Sandy, CRNP, OCN: Plus, I think that fosters adherence, then, with the guidelines. If they’re prebuilt, then you’re building them as part of the guidelines.

Dawn Dolan, PharmD, BCOP: That might be a little bit of a double-edged sword. We have these prebuilt order sets with what we think is the best antiemetic for a particular regimen, and that might make us a little bit more complacent in trying to hone in on specific patient risk factors and situations where we might need to tweak the regimen. We’re kind of just jumping. We fired off the order, everything is kind of already in there, and it doesn’t lend itself to having to think about the more individualized approach.

Howard Levine, PharmD: I agree. What we wound up doing was setting the standard as part of the order set, with the PRNs. It came to the point of the patients speaking to the nurse in the treatment area, and the nurse asking the questions that the patient didn’t want to bring up to the physician, which was, “How did you do last week? Did you tell the physician?” The patient’s response would be, “No, I didn’t tell him I was really ill last week.” The nurse would say, “Oh, we can help you with that.” And now, the PRN is there. “Let’s change it to this.”

Lee S. Schwartzberg, MD: If you give authority to the multidisciplinary team, then you get an opportunity to vary what’s going on. I do think it’s a double-edged sword as well because, as you say, physicians are really not that interested in that. This is a bit unfortunate because it’s such an important symptom for patients. It’s so top-of-mind that they kind of need to know about it. But, I agree with you. If you take the burden off them, and then you set those up, then you don’t miss patients—at least for the baseline of everything that you’re talking about. Now, what about education? How do you all address patient education at the time of starting chemotherapy?

Beth Eaby-Sandy, CRNP, OCN: We definitely tell them, “Please tell us.” When I go through my review of systems in the room, I always laugh because some patients will say, “No, I didn’t have nausea, but my stomach was really upset.” And I’m thinking, “Isn’t that the same thing?”

There’s communication barriers that we have to get past, and we need to educate them on when to take the proper medications. I’m a fan of writing things down. We type it down as a patient instruction. We give it to them. So, for instance, if they get a long-acting 5-HT3, we type out: “This is when you can take your PRN 5-HT3 at home. This is how you should take the steroids. They’re not a PRN. They’re supposed to be taken this way for 2 or 3 days after.” So, I’m a big fan of typing it out and giving to them to take home.

Eric Roeland, MD: I think another really important point is that we have to educate our patients and caregivers that they’re not to expect nausea. If they watch movies, or they watch the media, it’s almost an expectation that your chemotherapy is working. And, in today’s day and age, that is not the case. Emphasizing that, and advising that we have tools available for patients is important.

Lee S. Schwartzberg, MD: It’s such an important point. Our goal should be—and I think we all agree on this—that we should try to avoid all nausea and vomiting with every chemotherapy. We’re certainly not there yet, but we are getting closer and closer with some of the new agents that we’re talking about, today. So, the goal should not be, “You’re going to have this, and we’ll try to do the best we can.” Rather, it should be, “We’re going to try to prevent this. If it doesn’t work the first time, then we’ll include other agents the next time.”