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Chemotherapy-Induced Vomiting
in Women Treated for Breast Cancer
Suzanne L. Dibble, RN, DNSc, Karen Casey, MS, RN, ANP, Brenda Nussey, BA,
Jill Israel, BSN, RN, and Judith Luce, MD
Key Points . . .
Purpose/Objectives: To describe the incidence and intensity of vom-
iting in women receiving chemotherapy treatment for breast cancer since
the advent of 5-HT3 antagonists.
Chemotherapy-induced acute vomiting continues to be a prob-
Design: Longitudinal, descriptive.
lem for approximately 15% of women treated for breast cancer
Setting: 7 outpatient oncology clinics situated in hospitals, 5 outpa-
despite the advent of 5-HT3 antagonists.
tient oncology clinics associated with major teaching universities, 27
private outpatient oncology practices, and 1 outpatient clinic located in
Medications rarely are changed between cycles of chemo-
a county hospital.
therapy even though better antiemetic control is needed.
Sample: Typical participants (N = 303) were 51.9 years, Caucasian
Delayed chemotherapy-induced vomiting affects more than a
(79%), married or partnered (65%), born U.S. citizens (93%), heterosexual
third of women undergoing treatment for breast cancer.
(96%), living with someone (84%), and high school graduates (82%).
Methods: Baseline and poststudy questionnaires and a daily diary of
Minority women experience delayed chemotherapy-induced
vomiting through two cycles of chemotherapy (approximately two
vomiting significantly more frequently than Caucasian women.
months) were used to collect data.
Main Research Variable: Vomiting experience.
Findings: The worst vomiting occurs three days after having chemo-
motherapy treatments because of fears about nausea and vom-
therapy for breast cancer. The types of oral antiemetics ordered for home
iting (Pendergrass, 1998).
use were changed between the two cycles of the study only 8% (n = 24)
Vomiting is a physical protective reaction to the ingestion
of the time. No demographic factors were associated with acute vomit-
of toxins resulting in the expulsion of gastric contents through
ing at times 1 or 2; younger age (r = 0.16; p = 0.012) was associated
the mouth. Vomiting during chemotherapy is distinguished as
with more vomiting. Delayed vomiting was associated with age and body
mass index, and younger, heavier women experienced more vomiting.
either anticipatory and acute, occurring within 24 hours of
Minority women (n = 55) reported significantly more delayed vomiting
initial administration, or delayed, occurring after 24 hours.
--
than did Caucasian women (X = 6.56 versus 2.82; t = 2.02; p < 0.05).
Researchers have theorized that the physiologic causes of
Conclusions: Vomiting continues to be a significant problem for some
acute and delayed vomiting differ because the pharmacologic
women receiving chemotherapy for breast cancer.
agents that are effective in acute vomiting are not as effective
Implications for Nursing: Oncology nurses can use the results from
with delayed vomiting (Kris, Roila, De Mulder, & Marty,
this study to provide anticipatory guidance for patients undergoing che-
1998; Maisano et al., 2000). Chemotherapy-induced vomiting
motherapy for breast cancer and to support efforts to provide appropri-
is an area that requires better understanding and treatment and,
ate symptom management for these women.
therefore, was the focus of this study.
Chemotherapy for breast cancer consists of the following
n estimated 211,300 women were diagnosed with
s t a n d a r d chemotherapy regimens: cyclophosphamide,
A
breast cancer in 2003, 32% of all new female cancer
methotrexate, and 5-fluorouracil and cyclophosphamide and
cases in that year (American Cancer Society, 2003).
Many of these women received chemotherapy. Two of the
Suzanne L. Dibble, RN, DNSc, is a professor, Karen Casey, MS, RN,
side effects of chemotherapy, nausea and vomiting, remain a
ANP, is a research associate, Brenda Nussey, BA, is a programmer
major worry for patients who are undergoing treatment for
analyst, and Jill Israel, BSN, RN, is a research associate, all in the In-
breast cancer. The positive relationship between breast cancer
stitute for Health and Aging at the University of California, San Fran-
survival and the completion of a full course of chemotherapy
cisco (UCSF). Judith Luce, MD, is a professor in the School of Medi-
demonstrates the necessity for adherence to the treatment
cine at UCSF. This study was funded by the Delta Alpha Beta Chapter
of Phi Beta Psi and the ONS Foundation Center for Leadership, Infor-
plan. Research has documented that some patients experienc-
mation and Research through a grant from GlaxoSmithKline. (Submit-
ing postchemotherapy nausea and vomiting have withdrawn
ted March 2003. Accepted for publication September 1, 2003.)
from seemingly beneficial treatment (Fessele, 1996; Osoba et
al., 1997), and 10%50% of patients may refuse or delay che-
Digital Object Identifier: 10.1188/04.ONF.E1-E8
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E1
doxorubicin, with or without 5-fluorouracil and with or without
Soukop, & Greenstreet, 1993; Oettle & Reiss; Stewart, 1996).
paclitaxel. Although these are considered mildly to moderately
For patients receiving moderately emetogenic regimens, the 5-
emetogenic regimens, they have been associated with a signifi-
HT3 receptor antagonists alone do not appear to be effective in
cant amount of nausea and vomiting (Goodman, 1997; Greene,
controlling delayed vomiting, leaving a 22%89% incidence of
Nail, Fieler, Dudgeon, & Jones, 1994; Stewart, 1996). Despite
delayed nausea and emesis (Italian Group for Antiemetic Re-
the advent of new medications, specifically 5-HT3 antagonists,
search, 2000; Uyl-de Groot et al., 2000).
acute vomiting appears to persist in 10%25% of women re-
The initial studies of the 5-HT3 receptor antagonists, their
interpretation by clinicians, and the observation of women as
ceiving chemotherapy treatment for breast cancer (Uyl-de
Groot, Wait, & Buijt, 2000). Delayed chemotherapy-induced
they undergo chemotherapy would suggest that acute vomit-
vomiting is associated particularly with cyclophosphamide and
ing almost has been eliminated from the acute side affects as-
sociated with chemotherapy administration with control rates
doxorubicin, with an incidence of 33%67% (American Can-
cer Society & National Comprehensive Care Network, 2001;
of 75%90% (Uyl-de Groot et al., 2000). Unfortunately, the
Kris et al., 1998). Nausea and vomiting are a symptom cluster
concerns of 33%67% of women receiving moderately
emetogenic chemotherapy who continue to experience vom-
that has been studied together for decades. The current study's
authors have chosen to deconstruct them to better understand
iting after this acute period are not being addressed effectively
(Kris et al., 1998). Therefore, the purpose of the current study
each as a separate side effect, both in their acute and delayed
was to describe the acute and delayed vomiting experience
phases (see Dibble, Israel, Nussey, Casey, & Luce, 2003).
Seventy-five percent of patients who experience vomiting
and intensity in women undergoing chemotherapy for breast
cancer since the advent of the 5-HT3 receptor antagonists.
within the first 24 hours after receiving chemotherapy are
likely to experience delayed vomiting as well (Italian Group
Methods
for Antiemetic Research, 1999). Twenty-five percent of those
who do escape nausea and vomiting within the first 24 hours
Design
also will develop delayed vomiting (Italian Group for Anti-
The design for this multisite research was a longitudinal
emetic Research, 2000). Treating acute vomiting therefore is
seen as an important component in preventing delayed vom-
descriptive study over two cycles of chemotherapy. A cycle of
chemotherapy for women with breast cancer usually ranges
iting. Chemotherapy induces acute vomiting through direct or
from 2128 days.
indirect stimulation of the chemoreceptor trigger zone (CTZ)
and vomiting center. The CTZ is located outside of the blood-
Sample and Setting
brain barrier and, therefore, can be stimulated directly by cy-
totoxic agents in the bloodstream or cerebrospinal fluid
The settings for this study conducted from July 1999
(Pendergrass, 1998). The CTZ stimulates the vomiting center
through December 2000 consisted of 40 sites throughout the
through key receptors: serotonin (5-HT3), dopamine, and neu-
United States, including 7 outpatient oncology clinics situated
in hospitals, 5 outpatient oncology clinics associated with
rokinin (Oettle & Riess, 2001). The CTZ also can be stimu-
lated by enterochromaffin cells on the gastrointestinal mucosa
major teaching universities, 27 private outpatient oncology
practices, and 1 outpatient clinic located in a county hospital.
that, when assaulted by cytotoxic agents, release 5-HT3, which
binds to 5-HT3 receptors along the gastrointestinal tract, va-
The sites were located in the western, eastern, and midwest-
gus nerve, and, ultimately, the CTZ, which then sends a sig-
ern United States and one site in Virginia. The sites were a
nal to the vomiting center (American Cancer Society & Na-
combination of urban and rural. The eligibility criteria in-
tional Comprehensive Care Network, 2001; Dicato, 1996).
cluded (a) receiving any vomiting-inducing chemotherapy
The stimulation of enterochromaffin cells and resultant release
regimen in the treatment of breast cancer, (b) the ability to
of 5-HT3 largely is responsible for acute chemotherapy-in-
communicate (verbally and in writing) in English, and (c) the
duced nausea and vomiting (Maisano et al., 2000). Under-
willingness to participate in the study. Of the 353 eligible
standing this chain of events and role of neurotransmitters is
women who were approached to participate, 50 women re-
important in choosing a medication to treat acute vomiting.
fused. The most common reason patients gave for refusal to
Because the pathways mediating delayed vomiting are be-
participate was feeling overwhelmed.
lieved to be different from acute vomiting and are not well
Instruments
understood, an effective medication regimen that targets de-
layed vomiting has not been found.
Patient information questionnaire: Demographic informa-
The most effective medications used to treat chemotherapy-
tion collected included age, education, partnership status, eth-
induced acute vomiting are aimed at blocking the neurotrans-
nicity, employment status, and income. This tool has been used
mitters mentioned that ultimately stimulate the vomiting center:
successfully to collect demographic data in previous work.
5-HT3, dopamine, and neurokinin. These medications include
Disease and treatment questionnaire: Information gath-
5-HT3 receptor antagonists, such as ondansetron, granisetron,
ered from the medical record included diagnostic information,
and tropisetron, and dopamine-receptor antagonists, such as
treatment regimen, chemotherapy dosages, and antiemetics
metoclopramide and alizapride, and are most effective if given
ordered. This tool has been used successfully to collect treat-
prior to initiation of treatment. They can be used alone or in
ment data in previous work.
combination with a corticosteroid such as dexamethasone
A daily log consisted of the three-item vomiting experience
(Oettle & Reiss, 2001; Pendergrass, 1998). The combination of
subscale from Rhodes Index of Nausea, Vomiting, and
a 5-HT3 receptor antagonist and a corticosteroid, especially
Retching (INVR). This scale has established reliability and
dexamethasone, is considered the "gold standard" in treating
validity (Rhodes, Watson, & Johnson, 1984; Rhodes, Watson,
acute vomiting with moderately to highly emetogenic doses of
Johnson, Madsen, & Beck, 1987). Items from this subscale
cyclophosphamide (Bartlett & Koczwara, 2002; Clavel,
were summed. Subscale scores could range from 012 with a
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E2
higher number reflecting a more severe vomiting experience.
age body mass index (BMI = a ratio of weight to height) for
these women was 28.3 kg/m2 (SD = 6.1 kg/m2); 30% of the
In addition, the log also provided a place for each person to
women had a BMI from 2530, which reflects being over-
record any interventions used for nausea and vomiting control.
Ratings were done on a daily basis, before bedtime.
weight; and 35% of the women had a BMI of greater than 30,
The exit questionnaire packet included a series of ques-
which indicates obesity. Most (60%) of the women had expe-
rienced morning sickness with a pregnancy, 24% had a history
tions about other things (besides medication) that the partici-
pant may have tried to alleviate chemotherapy-induced vom-
of seasickness, 20% had a history of car sickness, and 22%
iting, and three evaluation questions.
had a history of nausea with stress (see Table 1).
Procedures
Institutional review board approval of the protocol was
Table 1. Demographic Characteristics
obtained for each institution participating in this study. Poten-
tial participants were approached about the study by the re-
n
%
Characteristic
search assistants in the waiting room, by their physician, or by
Age (years)
their nurse. After consenting to take part in the study, partici-
--
X (SD) = 51.9 (11.0)
pants completed the baseline data collection and were taught
Range = 2886
how to complete the daily logs. All women received their
Education (years)
usual antiemetics as prescribed by their physicians and re-
--
X (SD) = 13.9 (2.9)
corded their usage on a daily basis. The participants recorded
Range = 723
in their daily log for two cycles of chemotherapy. Women
Body mass index (kg/m2)
--
receiving chemotherapy on a weekly basis were asked to com-
X (SD) = 28.3 (6.1)
Range = 15.5 40.4
plete their logs for three weeks per log.
Ethnicity
To exit the study, participants were scheduled to arrive 30
239
79
Caucasian
minutes early on the first day of their next chemotherapy cycle
062
21
Other
(after completing data for two cycles of chemotherapy) to com-
Sexual orientation
plete the exit questionnaire. In addition, nurses reviewed the
272
96
Heterosexual
patients' medical records to obtain information about their can-
012
04
Other
cer diagnosis, antiemetic prescription, and current, previous,
Employed
and known future treatment modalities. All participants who
145
48
Yes
completed the study were paid $10 to thank them for their time.
155
52
No
Born a U.S. citizen
Data Analysis
281
93
Yes
022
07
No
SPSS statistical software package (SPSS Inc., Chicago, IL)
Retired
and SAS (SAS Institute Inc., Cary, NC) were used for data
066
22
Yes
analysis. Data were double entered into SPSS, and discrepan-
234
78
No
cies between the files were resolved to ensure the accuracy of
Disabled
the data entered. Descriptive statistics were generated related
041
14
Yes
to sample characteristics and other variables of interest. Re-
259
86
No
peated measures analysis of variance (ANOVA) was used to
Income
answer the research questions. With this analysis strategy,
106
42
< $20,000
participants serve as their own controls, so that the variabil-
079
32
$20,000$39,999
065
26
> $40,000
ity caused by the individual differences is eliminated from the
Relationship status
error term (Dawson-Saunders & Trapp, 1994). This analysis
196
65
Married or partnered
technique is quite robust with small sample sizes and statisti-
105
35
Other
cal assumption violations. In addition, a Delayed Vomiting
Lives alone
Scale (DVS) was created by adding the three-item vomiting
048
16
Yes
subscale of the INVR for days 110 after chemotherapy ad-
253
84
No
ministration (day 0). Scores on the DVS could range from 0
History of car sickness
120. Because of the small sample size, the researchers did not
062
20
Yes
attempt to explore differences resulting from setting or types
240
80
No
of treatment. Other statistical tests used were t tests, paired t
History of seasickness
072
24
Yes
tests, chi square, McNemar, and ANOVA.
229
76
No
History of nausea with stress
Results
067
22
Yes
235
78
No
Typical participants (N = 303) were 51.9 years old (SD =
History of morning sickness
11.0), Caucasian (79%), married or partnered (65%), not on
Yes
181
60
disability (86%), unemployed (52%), born U.S. citizens
No
121
40
(93%), heterosexual (96%), not living alone (84%), and had
an annual personal income of more than $20,000 (58%). The
N = 303
average education for these participants was 13.9 years (SD =
Note. Because some data are missing for some variables, the n values may not
2.9); 56% had more than a high school education. The aver-
equal the total N.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E3
trolling acute or delayed vomiting. The types of IV antiemet-
The average time since diagnosis for these women was 2.64
months (SD = 9.28 months, range = 0.07139.6 months). In-
ics were changed between the two cycles of the study only 6%
(n = 18) of the time. The most common antiemetic ordered for
cluded in these statistics are two women who had recurrent
home use was prochlorperazine (70%). The types of oral an-
disease. Excluding those two women resulted in an average
t i m e since diagnosis for the sample of 1.93 months
tiemetics ordered for home use were changed between the two
cycles of the study only 8% (n = 24) of the time (see Table 3).
(SD = 1.87) or approximately two months. Most participants
The pattern of acute and delayed vomiting as measured by
had a surgical biopsy (64%) to determine that they had infil-
trating ductal breast cancer (80%). Most (62%) of the women
the INVR vomiting subscale can be observed in Figure 1. The
worst vomiting occurs the day of chemotherapy and for the
did not have a mastectomy. Multiple lymph nodes were exam-
next three days as measured by the INVR. Included in those
ined in 241 women (80%), and 12% of the women had a sen-
tinel node biopsy. Positive nodes were reported in 46% (n =
statistics are those who did not experience vomiting on a par-
ticular day. Figure 2 details the percentage of participants who
123) of the participants. Radiation therapy had been com-
described any vomiting as measured by the vomiting subscale
pleted or was concurrent with their chemotherapy in 7% of the
sample, and 61% (n = 171) were planning radiation therapy
after finishing their chemotherapy (see Table 2).
Table 3. Chemotherapy Treatments Used
Most (76%) of the women were receiving doxorubicin and
cyclophosphamide as their chemotherapy regimen. The aver-
Treatment
n
%
age dose of doxorubicin was 102.7 mg and the average dose
of cyclophosphamide was 993.2 mg. The dosages of chemo-
Chemotherapy regimen
therapy were reduced between the two cycles of the study
Cyclophosphamide, methotrexate, and 5-fluorouracil
034
11
only 5% (n = 14) of the time. The most common IV antiemet-
Cyclophosphamide and doxorubicin
228
76
Cyclophosphamide, doxorubicin, and 5-fluorouracil
005
02
ics given during the administration of chemotherapy were
Cyclophosphamide, doxorubicin, and paclitaxel
007
02
dexamethazone (80%), ondansetron (49%), granisetron
Other
028
09
(24%), and dolasetron (17%). Numerous combinations and
Weekly chemotherapy
dosages were given pre- and postchemotherapy. No one com-
Yes
023
07
bination or dosage emerged as the "right" treatment for con-
No
277
93
Dosage of cyclophosphamide (mg) (n = 273)
Table 2. Diagnostics and Surgical Treatments Used
--
X (SD) = 993.2 (267.7)
Range = 90 1,888
Characteristic
%
n
Dosage of 5-fluorouracil (mg) (n = 41)
--
X (SD) = 920.6 (232.2)
a
Time since diagnosis (months)
Range = 60 1,200
--
X (SD) = 1.93 (1.87)
Dosage of doxorubicin (mg) (n = 258)
Range = 0.0719.4
--
X (SD) = 102.7 (16.9)
Surgical biopsy
Range = 30 145
64
Yes
193
Dosage of chemotherapy decreased with next cycle
36
No
108
Yes
014
05
Lumpectomy
No
285
95
48
Yes
145
IV antiemetics given
52
No
156
Dexamethazone
241
80
Mastectomy
Ondansetron
148
49
38
Yes
113
Granisetron
072
24
62
No
188
Dolasetron
051
17
Lymph node dissection
Lorazepam
020
07
80
Yes
241
Diphenhydramine
007
02
20
No
060
Prochlorperazine
012
04
Sentinel node biopsy
IV antiemetics changed with subsequent chemotherapy
12
Yes
037
Yes
018
06
88
No
264
No
282
94
Positive nodes
Oral antiemetics ordered
46
Yes
123
Prochlorperazine
211
70
54
No
142
Ondansetron
113
38
Type of breast cancer
Dexamethazone
068
23
80
238
Infiltrating ductal
Lorazepam
059
20
08
Infiltrating lobular
025
Granisetron
036
12
12
Other
035
Phenergan
015
05
Radiation therapy
Diphenhydramine
015
05
07
Yes
019
Oral antiemetics changed with subsequent chemotherapy
0
33
No
092
Yes
024
08
61
171
Planned after chemotherapy
No
273
92
N = 303
N = 303
a
Does not include two patients who had recurrence
Note. Because some data are missing for some variables and some patients
Note. Because some data are missing for some variables, the n values may not
received more than one antiemetic treatment, the n values may not equal the
equal the total N. Because of rounding, percentages may not total 100.
total N and percentages may not total 100.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E4
5.5
1
5
4.5
0.5
4
3.5
0
3
0
1
2
3
4
5
6
7
8
9
10
2.5
Days After Chemotherapy
2
Time 1
Time 2
N = 241
1.5
Figure 1. Vomiting Over Time
1
0.5
of the INVR on a particular day for this sample. This figure
0
reveals that less than one-fifth of the women undergoing treat-
0
1
2
3
4
5
6
7
8
9
10
ment for breast cancer on any given day actually experienced
Days After Chemotherapy
vomiting after receiving chemotherapy, with the worst day
Time 1
Time 2
being two days after the administration of chemotherapy.
When the women who did not experience vomiting on a par-
N = 241
ticular day are eliminated from the analyses, vomiting clearly
Note. Includes only those reporting vomiting
is a significant problem for those who have it (see Figure 3).
Figure 3. Intensity of Vomiting Over Time
The average Acute Vomiting Score (AVS) was 0.82 (SD =
2.2) during the first data collection period and 0.55 (SD = 1.7)
for the second data collection period. This difference was not
layed vomiting during the second data collection period. In
statistically significant (t = 1.66, p = 0.099; n = 255). Using a
comparing delayed vomiting at both time periods using a
McNemar test, significant (p < 0.0001) differences existed in
McNemar test, no significant differences existed in the per-
the percentage of women with acute vomiting from the first to
centage of women with delayed vomiting from the first to
second data collection periods. Eighty-two percent (n = 216)
second data collection periods. Forty-eight percent (n = 116)
of the sample had absolutely no acute vomiting during both
of the sample had absolutely no delayed vomiting during both
time periods and 0.4% (n = 1) had acute vomiting during both
time periods, and 19% (n = 45) had delayed vomiting during
time periods. Of the 223 women without acute vomiting at the
both time periods. Of the 155 women without delayed vom-
first data collection period, seven (3%) developed acute vom-
iting at the first data collection period, 39 (25%) developed
iting with their next cycle. Of the 42 women with acute vom-
delayed vomiting with their next cycle. Of the 87 women with
iting at the first data collection period, 41 (98%) did not have
delayed vomiting during the first data collection period, 42
acute vomiting with their next cycle.
(48%) did not have delayed vomiting with their next cycle.
The mean DVS score for the women during the first data
These differences were not statistically significant (p = 0.824).
collection period was 2.8 (SD = 6.0), and the mean DVS score
No demographic factors were associated with AVS scores
during the second data collection period was 3.5 (SD = 9.2).
at time 1. At time 2, age was associated with AVS (r = 0.16;
Again, these values were compared using a paired t test, and
p = 0.012); younger women had more acute vomiting. Educa-
no significant differences existed in delayed vomiting be-
tion and BMI were not associated with AVS scores at either
tween the two time periods (t = 1.623; p = 0.106; n = 242). In
time period. No significant differences in AVS existed by eth-
exploring the percentage of women who had absolutely no
nicity, relationship status, or living arrangement. No signifi-
delayed vomiting, the authors found that 63% (n = 165) of the
cant differences in AVS existed by history of nausea with
women did not have any delayed vomiting during the first
stress, seasickness, or morning sickness. Women with a his-
data collection period and 64% (n = 161) did not have any de-
tory of car sickness (n = 62) had more acute vomiting during
the second time period (t = 2.1; p < 0.04) than those who did
not get carsick. Significantly less acute vomiting was reported
20
by women receiving 5-fluorouracil (t = 2.84; p = 0.005) dur-
ing the second time period, whereas those receiving doxoru-
15
bicin had more acute vomiting (t = 4.07; p < 0.0001) during
the second time period. Those having their chemotherapy on
10
a weekly basis reported less acute vomiting during the second
5
time period than those on a more traditional 21- or 28-day
cycle (t = 4.95; p < 0.0001). The women who received IV
0
ondansetron with their chemotherapy had higher AVS scores
0
1
2
3
4
5
6
7
8
9
10
during the second time period (t = 1.98; p < 0.05). No signifi-
Days After Chemotherapy
cant differences in AVS scores existed by any other IV an-
Time 1
Time 2
tiemetic usage. Those who had their IV antiemetic changed
N = 241
did not have significantly higher AVS scores during either
Figure 2. Percentage of Sample With Vomiting Over Time
time period.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E5
At time 1, age was associated with DVS (r = 0.15; p =
the medication differently than some minorities. Recent re-
0.014) and at time 2, BMI was associated with DVS (r = 0.125,
search into the liver enzyme cytochrome P450 2D6, which var-
p = 0.05); younger, heavier women had more delayed vomiting.
ies somewhat by ethnicity, suggests that the metabolism of
Education was not associated with DVS at either time period.
many drugs can be affected (Kaiser et al., 2002). In addition, by
No significant differences existed in DVS by relationship sta-
examining effectiveness of an intervention on one group--Cau-
tus or living alone. During the first time period, minority
casians--a researcher ignores the potential effect that different
women (n = 55) reported significantly more delayed vomiting
food and lifestyle habits have on the manifestation of a symp-
--
than did Caucasian women (X = 6.56 versus 2.82; t = 2.02; p
tom and interventions used to treat it. However, the current
< 0.05). For those with a history of seasickness, car sickness,
study's finding was not similar to that of African American and
morning sickness, or nausea under stress, no significant differ-
Caucasian patients with colon cancer. In a large, randomized,
ences in delayed vomiting existed during either time period.
phase III trial of adjuvant chemotherapy for resected colon can-
Significantly more delayed vomiting was reported by women
cer, African Americans appeared to experience fewer side ef-
receiving cyclophosphamide (t = 3.11; p < 0.002) during the
fects related to chemotherapy, including significantly lower
second time period. Those receiving chemotherapy on a weekly
rates of nausea and vomiting (McCollum et al., 2002). More
basis did not report any less delayed vomiting than those on a
studies need to be conducted to examine the effectiveness of an-
more traditional 21- or 28-day cycle during either time period
tiemetics with diverse populations.
(p = 0.194; p = 0.285). No significant differences in DVS scores
Research has documented that some patients experiencing
existed by any use of IV antiemetics. However, those who did
postchemotherapy vomiting withdraw from seemingly benefi-
not receive oral granisetron (n = 218) or dexamethazone (n =
cial treatment (Fessele, 1996; Osoba et al., 1997). This suggests
184) for home use at time 2 had significantly more delayed
a need for increased vigilance by clinicians who treat chemo-
vomiting than those who used granisetron (n = 29; t = 3.13; p
therapy-induced vomiting. In addition to determining the inci-
= 0.002) or dexamethazone (n = 63, t = 2.01; p < 0.046). No sig-
dence of vomiting in people currently receiving treatment,
nificant differences in DVS scores existed in those who had
nurses may be able to anticipate those who are more likely to
their IV antiemetics changed during either time period. Other
experience this symptom in the future by looking at available
comparisons can be found in Table 4.
data. For instance, younger women had significantly more acute
vomiting in their first cycle of chemotherapy and significantly
Discussion
more delayed vomiting in their second cycle. In addition, as with
nausea (Dibble et al., 2003), women with a higher BMI had sig-
nificantly more delayed vomiting than their smaller counter-
The results of this study indicate that, in spite of the emer-
parts. Women with a history of carsickness had significantly
gence of 5-HT3 receptor antagonists that are considered the
more vomiting than those who did not experience motion sick-
"gold standard" for chemotherapy-induced vomiting, acute and
ness. Each of these factors could assist nurses in their approach
delayed vomiting continue to be a significant problem for some
to educating clients about what to expect regarding vomiting
patients with breast cancer. Of particular interest is the indica-
with the administration of chemotherapy to those diagnosed
tion that despite the clinical need for different antiemetic treat-
with breast cancer. In addition, oncology nurses can work with
ment between chemotherapy cycles, with specific IV and oral
patients to plan the intensity of postchemotherapy antiemetic
medications being more effective, few medication changes are
prophylaxis and treatment as well as surveillance strategies.
made from one cycle to the next. This could be related to the
false belief by patients that vomiting is a symptom that they
Limitations
must endure if they wish to seek treatment for their breast can-
cer or that clinicians are not aware of the prevalence of vomit-
This study has a number of limitations. First, the sites used
ing among their clients. In the second case, these data reaffirm
in the study may have been those where vomiting was a par-
ticular problem. The physicians who told the authors that their
that clinicians may believe the myth that nausea and vomiting
are no longer a problem for chemotherapy recipients, a state-
patients did not experience any vomiting may have been cor-
ment heard many times from oncology practices that were
rect and what is demonstrated in this article is the experience
asked to participate in the authors' studies.
of women who are not properly treated for this side effect.
This study showed that a significantly greater number of
Second, the women were not followed for their entire chemo-
minority women were affected by delayed vomiting than their
therapy experience, so the researchers do not know how many
Caucasian counterparts. Disparity in health care by ethnicity has
women eventually stopped treatment or whether the vomiting
received national attention for a number of years, resulting in
increased or decreased with subsequent cycles. The study did
the development of standards of culturally and linguistically
not have large enough samples of women in the various eth-
competent care for healthcare workers in 2000 by the Office of
nic groups to perform the appropriate analyses to profile by
Minority Health of the U.S. Department of Health and Human
ethnicity the women who had the most vomiting.
Services. To eliminate language as a barrier, participants in this
Summary
study could read and write in English. In addition, no difference
existed in antiemetics ordered or taken by Caucasian and mi-
nority women. Currently, healthcare workers and researchers
This study clearly illustrates that chemotherapy-induced vom-
are trained to address the needs of the cultural majority, Cauca-
iting, especially delayed vomiting, continues to be a problem for
sians. This training presumes that African American, Asian, or
women undergoing moderately emetogenic treatment for breast
Hispanic or Latina clients will report symptoms and seek appro-
cancer. Nurses also must remember that this study was com-
priate medications or interventions. Pharmaceutical researchers
pleted before the aprepitant substance P/neurokinin 1 receptor
exploring the effectiveness of medications also may rely
antagonist was released. Although research into better medica-
heavily on results from Caucasian samples that may metabolize
tions is needed, so is research into the various complementary
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E6
Table 4. Comparison of Differences in Delayed Vomiting by Various Factors
Time 1
Time 2
--
--
p
p
n
n
SD
Variable
SD
X
X
0.524
0.641
057
057
14.60
History of car sickness
03.28
07.20
04.60
192
203
07.04
No history of car sickness
02.84
05.97
03.32
0.591
0.677
062
067
07.62
History of seasickness
03.21
06.04
03.13
186
192
09.82
No history of seasickness
02.84
06.34
03.78
0.646
0.271
053
055
08.32
History of sickness under stress
03.76
06.92
04.13
196
205
09.55
No history of sickness under stress
02.72
06.05
03.47
0.552
0.872
146
151
06.85
History of morning sickness
02.99
05.68
03.29
103
109
12.00
No history of morning sickness
02.86
06.98
04.07
0.043
0.194
022
023
04.02
Weekly chemotherapy
01.35
04.81
01.59
226
235
09.66
No weekly chemotherapy
03.13
06.38
03.82
0.732
0.715
123
128
08.16
Ondansetron by IV
03.10
05.78
03.83
125
131
10.35
No ondansetron by IV
02.82
06.70
03.42
0.555
0.962
200
209
09.73
Dexamethazone by IV
02.97
06.28
03.77
048
07.35
050
No dexamethazone by IV
02.92
06.22
03.02
0.855
0.681
017
05.97
019
Lorazepam by IV
03.53
05.86
03.35
231
240
09.52
No lorazepam by IV
02.91
06.29
03.65
0.663
0.521
007
006
13.60
Diphenhydramine by IV
01.33
02.80
05.14
241
09.19
253
03.00
03.58
No diphenhydramine by IV
06.31
0.376
0.547
060
13.61
063
03.46
04.87
Granisetron by IV
08.14
188
196
07.44
No granisetron by IV
02.80
05.53
03.23
0.119
0.417
044
043
06.12
Dolasetron by IV
02.40
04.56
02.14
204
216
09.85
No dolasetron by IV
03.07
06.54
03.95
0.339
0.092
016
015
09.59
IV antiemetic change
05.60
05.26
05.69
231
243
09.23
No IV antiemetic change
06.30
02.79
03.40
0.340
0.889
179
188
07.22
Prochlorperazine orally
06.00
02.92
03.10
068
070
13.20
No prochlorperazine orally
06.99
03.04
04.72
0.265
0.927
047
050
05.79
Lorazepam orally
05.55
02.88
02.55
200
208
09.88
No lorazepam orally
06.44
02.97
03.78
0.000
0.132
010
011
01.49
Promethazine orally
02.33
01.73
00.70
237
247
09.42
No promethazine orally
06.38
03.01
03.67
0.643
013
0.842
013
06.08
Diphenhydramine orally
04.57
02.62
02.38
234
245
09.40
No diphenhydramine orally
06.35
02.97
03.61
0.002
029
0.540
030
02.63
Granisetron orally
04.67
02.43
01.28
218
228
09.76
No granisetron orally
06.45
03.02
03.85
0.321
099
0.612
097
08.25
Ondansetron orally
05.41
03.20
04.26
148
161
09.86
No ondansetron orally
06.74
02.81
03.07
0.046
063
0.965
063
04.96
Dexamethazone orally
05.61
01.57
00.83
184
195
10.30
No dexamethazone orally
02.03
06.48
02.55
225
0.002
236
0.069
09.70
Cyclophosphamide
03.11
06.41
03.86
025
025
02.81
No cyclophosphamide
01.44
03.94
01.20
033
0.713
037
0.629
07.02
5-fluorouracil
05.60
02.49
03.15
217
224
09.59
No 5-fluorouracil
03.02
06.34
03.66
216
0.725
223
09.59
0.449
Doxorubicin
06.35
03.07
03.66
034
038
07.06
No doxorubicin
05.49
02.24
03.18
186
0.183
195
21.51
0.262
Cyclophosphamide and doxorubicin
17.68
18.84
20.25
030
034
18.37
Cyclophosphamide, methotrexate, and 5-fluorouracil
15.21
15.38
14.70
N = 303
Note. Because some data are missing for some variables, the n values may not equal the total N.
and without nausea and specific antiemetic regimens, as well as
therapies. This descriptive study demonstrates that existing
age, BMI, ethnicity, and history of car sickness.
medications are not being used as effectively as they could. On-
cology nurses play an active role in the prevention and treat-
ment of this unpleasant symptom of chemotherapy. Further re-
Author Contact: Suzanne L. Dibble, RN, DNSc, can be reached at
search should evaluate the relationships among vomiting with
sdibble@itsa.ucsf.edu, with copy to editor at rose_mary@earthlink.net.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E7
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