Summary of the Best Evidence for the Evaluation and Management of Chemotherapy-Related Nausea and Vomiting in Cancer Patients ()
1. Introduction
Cancer is one of the most important health problems facing mankind. Treatment methods mainly include surgical resection, chemotherapy and radiotherapy. At present, chemotherapy is one of the important means of tumor treatment, 70% - 80% of tumor patients need to receive chemotherapy. However, over 90% of chemotherapy drugs will destroy other normal tissue cells while killing tumor cells, resulting in a series of adverse reactions [1] . Among them, nausea and vomiting are the most common adverse reactions of digestive tract. According to statistics, about 70% - 80% of patients receiving chemotherapy are at risk of chemotherapy-related nausea and vomiting [2] . Chemotherapy-induced nausea and vomiting (CINV) refers to nausea (a state characterized by nausea and/or imminent vomiting) and vomiting (a reflex action of vomiting of stomach contents through the mouth) caused by or associated with chemotherapy drugs. CINV can lead to dehydration, metabolic disorders, self-care ability decline, malnutrition, anorexia, physical decline, wound dehysis and esophageal mucosa tear and other adverse consequences, on the emotional, social and physical functions of patients will have significant negative effects, reduce the quality of life and treatment compliance of patients, and may cause metabolic disorders, nutritional disorders, weight loss. All of these situations can increase patients’ fear of treatment. According to statistics, CINV can cause about 20% of patients to delay chemotherapy, 30% of patients refuse further chemotherapy, and have to terminate anti-tumor therapy in severe cases, which affects the effect of chemotherapy [3] [4] . Therefore, a positive, reasonable and standardized assessment of chemotherapy related nausea and vomiting in cancer patients is very important to ensure the successful treatment of cancer patients. However, there is still a lack of systematic and standardized nursing guidelines for the evaluation and management of CINV. In view of this, this study conducted systematic retrieval, quality evaluation, evidence extraction and synthesis of domestic and foreign studies on CINV evaluation and management, in order to provide references for clinical medical personnel to implement CINV evaluation and management.
2. Methods
2.1. Deterministic Problem
PIPOST problem development tool of JBI Evidence-Based Center was adopted to determine evidence-based problems in this study [5] . P (Population) Adult cancer patients receiving chemotherapy; I (Intervention) Targeted patient interventions: a series of interventions for the prevention and treatment of chemotherapy-related nausea and vomiting; P (Professional) Practitioners or executors of evidence application: medical staff, patients and their caregivers; O (Outcome) Outcome measures: incidence and degree of nausea and vomiting in chemotherapy patients; S (Setting) Place for evidence application: oncology ward; T(Type of evidence) Types of evidence resources: clinical decision, best practice, clinical guidelines, evidence summary, systematic review.
2.2. Retrieval Strategy
“Drugtherapy” OR “Chemotherapy” OR “Chemical therapy” OR “Chemicaldrug”) AND (“Nausea” OR “Naupathia” OR “Emesis” OR “Vomiting” OR “Chemotherapy induced nausea and vomiting “OR” CINV”) AND (“Neoplasms” OR “Cancer” OR “Tumor”) AND (“Nursing” OR “Assessment” OR “Management” OR “Prevention” OR “Intervention”) are English keywords; According to the 6S pyramid basis [6] , evidence retrieval starts from the top down. Search Cochrane Library, BMJ Best Practice, JBI Center for International Collaboration in Evidence-Based Health Care Library, Up to Date, Embase, CINAHL, PubMed, Database of Evidence-Based Health Care Centers (JBI), US Guidelines Network, US National Guidelines Database, US National Comprehensive Cancer Network, UK National Institute of Clinical Medicine Guidelines Library, International Guidelines Collaborative Group, Scottish College Guidelines Network, Registered Nurses Association of Ontario, CNKI, Wanfang Database, China Biomedical Literature Database. The search period was from December 31, 2022. Literature inclusion criteria: Study subjects were cancer chemotherapy patients; Studies involving chemotherapy-related nausea and vomiting; The outcome included nausea and vomiting and nausea and vomiting related indicators; Literature types: guidelines, expert consensus, best clinical practice information booklet, recommended practice, evidence summary, systematic review, study inclusion guidelines, expert consensus using the latest version; Language: Chinese and English literature. Exclusion criteria: the document type was only abstract or research proposal; Repeated publication, incomplete literature content, unable to obtain the full text or literature quality evaluation results are low.
2.3. Criteria for Evaluation of Literature Quality
According to the type of the included literature, the corresponding evaluation tools were selected for quality evaluation. 1) Guidelines: Evaluation was carried out using Appraisal of Guidelines for Research and EvaluationⅡ(AGREEⅡ) (2010 edition), which includes 6 areas [7] . There are 23 entries and 2 overall evaluation entries for the guidelines. Each item will be evaluated according to Likert 7-level scoring method (1 is strongly disagree, 7 is strongly agree), the minimum possible score of a single field = 1 point × number of items × number of evaluators, the maximum possible score of a single field = 7 points × number of items × number of evaluators, each field score is the normalized percentage of the sum of the entries’ scores in that field = (actual score-lowest possible score)/(highest possible score-lowest possible score) × 100%. According to the guidelines for standardized percentage evaluation in 6 fields recommended levels: Level A: Standardized percentage of most dimensions > 60%; Level B: The standardized percentage of most dimensions is 30% - 60%; Level C: Standardized percentage of most dimensions < 30%. 2) System evaluation: Quality evaluation was conducted according to JBI evidence-based health care center system evaluation tool [8] . The tool consists of 11 evaluation items, and the evaluator was asked to make a “yes”, “no”, “unclear” or “not applicable” judgment on each evaluation item. 3) Clinical decision: Trace the original literature based on each piece of evidence in the literature, and use corresponding evaluation tools for evaluation [9] . 4) Consensus evidence: The expert consensus evaluation standard (2016 edition) of JBI evidence-based Health Care Center in Australia was used for evaluation [10] .
2.4. Document Quality Evaluation Process
Three nursing graduate students who had undergone systematic evidence-based training and study participated in the literature quality evaluation, and two of them conducted the literature quality evaluation independently. In case of disagreement, the third researcher was invited to conduct the evaluation. When evidence from different sources contradicts each other, this study follows the principle of high-quality evidence, high-level evidence and newly published authoritative literature.
2.5. Classification of Evidence and Recommendation Level
The included evidence adopts the JBI evidence pre-grading and evidence recommendation level system (2014 edition) [11] . According to the type of research design, the evidence level is divided into level 1 - 5. According to the four attributes of evidence: clinical significance, suitability, effectiveness and feasibility, the JBI recommendation strength grading principle was applied to divide the evidence recommendation level into A recommendation and B recommendation. The original literature of evidence summary, clinical decision and guidelines tracing evidence was graded according to this system [12] .
2.6. Extraction of Data
Two researchers extracted and cross-checked the relevant contents of the included literature, including author, source, nature of the literature, title, publication period, relevant recommendations, conclusions.
3. Description of Evidence
3.1. General Information about the Included Literature
16 literatures were finally included in this study, including 9 guidelines, 2 expert consensus papers, and 5 systematic reviews, as shown in Table 1.
3.2. Quality Evaluation Results of the Included Literature
3.2.1. Quality Evaluation Results of the Guidelines
A total of 9 guidelines were included in this study. The results of standardization
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Table 1. General information of the included literature.
and quality evaluation in various fields of the guidelines are shown in Table 2.
3.2.2. Quality Evaluation Results of Systematic Evaluation
A total of five systematic reviews were included in this study from the Cochrane Library, CNKI and Web of Science. Among them, the evaluation results of 11 items in Tan JY et al. [19] , Toniolo J et al. [23] and Ezzo J et al. [26] were all “Yes”, and the overall quality was high, so they were allowed to be included. Chen F et al. [22] and Wei T T [24] et al. studied 11 items except item 10, “Is the possibility of publication bias assessed? Except for item 11, “Whether it indicates the relevant conflict of interest”, which is evaluated as “unclear”, the evaluation results of other items are all “Yes”. The overall quality of the study is high, so it is allowed to be included.
3.3. Evidence Description and Summary
The best evidence eventually included in this study came from 9 guidelines, 5 systematic reviews, and 2 expert consensus papers. Through evidence extraction and summary, based on FAME evaluation, 46 best evidence summaries on assessment and management of chemotherapy-related nausea and vomiting from six aspects, including risk assessment and management, non-drug management, drug management, multidisciplinary cooperation, education and training, and health education, were finally formed from the feasibility, suitability, clinical significance and effectiveness of evidence. The specific results are shown in Table 3.
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Table 2. Methodological quality evaluation of the guidelines included in this study.
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Table 3. Summary of the best evidence for the assessment and management of chemotherapy-associated nausea and vomiting.
4. Results
4.1. Risk Assessment and Management
The occurrence and severity of CINV are affected by a variety of factors, the mechanism of which is complex and there are large individual differences. In recent years, it has been clear that, in addition to the type of chemotherapy drugs or administration plan, individual risk factors such as patient’s gender, age and history of morning sickness also affect the occurrence of CINV in high-risk patients. The likelihood of CINV in high-risk patients is 3 - 4 times that of low-risk patients. Therefore, early prediction, rapid identification of CINV risk, and effective control of CINV is extremely critical. Comprehensive collection of individual CINV influencing factors and accurate symptom assessment are the basis of treatment decision-making and adjustment. History assessment included patient age, psychological expectations, sleep status, morning sickness history, whether patients had received chemotherapy with platinum-based or anthracyclines, whether they had taken over-the-counter antiemetic drugs at home, and whether CINV had occurred during previous chemotherapy. The Dranitsaris scoring system and online tool (http://www.riskcinv.org/) can be used to individually predict the risk of CINV in patients, which can easily identify high-risk patients before each chemotherapy cycle, so as to optimize patients’ CINV management and adjust medication in subsequent courses [29] . A comprehensive assessment of symptoms can lead to more interventionable information and individualized interventions to reduce the patient’s experience of discomfort. Due to the subjectivity of CINV, patients can get the best symptom management only after they accurately self-report their symptoms [30] . It is recommended that clinicians provide patient-appropriate tools for measuring nausea and vomiting to help patients accurately self-report CINV, inform patients how to monitor CINV and note the severity of symptoms, and encourage patients to freely discuss their thoughts, fears, and experiences with CINV. At present, visual simulation scale MASCC antiemesis Evaluation tool (MAT) is clinically recommended as a self-measuring tool for patients to measure nausea and vomiting. It is a self-reporting CINV evaluation tool, which can be used by printing forms or smart phone applications [31] . At the same time, attention should be paid to the reassessment of CINV risk, and the treatment plan should be reassessed and adjusted before the next cycle of treatment. Antiemetic efficacy should be evaluated at every visit for outpatients and within 24 hours after chemotherapy for inpatients. The antiemetic effect and adverse drug reactions should be timely evaluated after each application of antiemetic drugs, and generally reported by the patient to the medical staff within 24 hours after medication. For discharged patients should pay attention to the continuity of care outside the hospital, do a good job of follow-up work, follow-up time recommended from the beginning of chemotherapy to the 5th day after chemotherapy, can use mobile technology to monitor patients at home medication, the recommended follow-up content includes nausea and vomiting frequency and degree, physical condition, medication, etc.
4.2. Non-Drug Management
Non-drug intervention plays an important role in alleviating CINV in patients. Non-drug intervention has low risk and low cost, so it has been widely concerned at present. At present, CINV treatment is mainly prevention, the whole risk period should be protected against CINV, and the program recommended by the guidelines should be used to standardize treatment. In the whole CINV management, it is very important to establish the system of multiple follow-up visits, complete records and dynamic evaluation. The whole-course management of CINV before, during and after treatment can effectively reduce and control the occurrence of CINV in patients. At present, the nursing technique of traditional Chinese medicine has been widely concerned because of its less trauma and better curative effect. Acupressure and acupuncture of traditional Chinese medicine can be used as effective auxiliary treatment measures to improve CINV, and aromatherapy also has a certain effect on CINV. There is insufficient evidence for the use of ginger and other complementary or alternative therapies to prevent nausea and vomiting in cancer patients, and ginger and other Chinese herbs are not recommended for the prevention of CINV. Pleasant and comfortable environment is particularly important for patients. Studies have pointed out that creating a good environment can alleviate the discomfort brought by CINV to patients. Therefore, medical staff should do a good job of ward environment sorting and maintenance work. In addition, for patients with CINV, dietary care is indispensable, should be a reasonable collocation of diet, light diet, eat less and more meals, eat 5 - 6 meals a day, and eat more properly in the morning, before and after eating less water. During chemotherapy, juice with sour flavor, broth, vegetable soup instead of plain water to replenish moisture and nutrition, to relieve nausea and vomiting. Ensure adequate liquid supply, maintain water and electrolyte balance, and correct acid-base imbalance. Avoid eating within 1 to 2 hours before and after chemotherapy, and lie down half an hour after eating to avoid gastroesophageal reflux and vomiting symptoms. Avoid exposure to irritating, odorous or smelly gases during chemotherapy to avoid exacerbating nausea and vomiting. Therefore, medical staff should strengthen the health education of patients and their families, in order to alleviate the discomfort caused by CINV through education and guidance. According to the emetic risk of chemotherapy drugs and programs, the patients were managed by grades, and follow-up files were established to record and dynamically evaluate the nausea and vomiting of patients, conduct whole-process management, and summarize regularly, so as to dynamically adjust the management strategy, so as to conduct early intervention, reduce the nausea and vomiting symptoms of patients, and improve the quality of life of patients.
4.3. Drug Management
Nausea and vomiting caused by chemotherapy can be divided into three categories: acute, delayed and antiemetic. It is suggested that the selection of antiemetic drugs should be based on the emetic risk of chemotherapy regimen and previous experience in using antiemetic drugs, and the relevant risk factors of patients should be fully considered. Risk factors include being female, having a history of motion sickness or morning sickness, being younger than 50, drinking alcohol, anxiety, and a history of chemotherapy-related nausea and vomiting. These risk factors can increase the probability of its occurrence. CINV antiemetic drugs can be administered orally, percutaneous, intravenously, or rectum or intravenously if the vomiting patient is unable to swallow and digest the tablets due to vomiting; When necessary, multiple drug combination therapy can be selected, and different schemes or different routes can be selected. The usage, dosage and time of different routes of administration should be mastered, and the adverse reactions of drugs should be observed. Oral or topical dosage forms can be used for patients at home to increase convenience of administration and patient comfort. Long-acting or combination antiemetics may be used before chemotherapy to reduce the need for home administration. Prevention of CINV should be initiated before chemotherapy and should last long enough to cover the duration of the risk of vomiting. For patients without a history of nausea and vomiting, it is not necessary to routinely administer antiemetic drugs before chemotherapy. For patients with a history of vomiting, motion sickness, anxiety and other high-risk factors for nausea and vomiting, strengthen antiemesis. For breakthrough nausea and vomiting, 24 hours of fixed administration should be considered, depending on the patient’s symptoms.
4.4. Multidisciplinary Cooperation
The implementation of multidisciplinary management, medical work process has both division of labor and cooperation, mutual assistance and different focus. The establishment of MDT teams including oncologists, gastroenterologists, nurses, clinical pharmacists and dietitians is conducive to standardizing CINV management, reducing the incidence of CINV, improving patients’ compliance, improving patients’ quality of life, and improving patients’ treatment satisfaction.
4.5. Education and Training
Although the use of antiemetic drugs can reduce the incidence of CINV, the improvement effect of CINV is not good due to the underestimation of CINV problems by patients or medical staff and the non-standard use of clinical practice guidelines in the control and management of CINV. Oncology nurses play an important role in nursing patients with chemotherapy, and their influence and status become more and more prominent. The core position of nurses in CINV management can effectively control the occurrence of CINV and play a positive role in improving patients’ symptoms. Strengthen training of CINV nurses, including awareness of highly emetic chemotherapy (HEC) and moderate emetic chemotherapy (MEC) regiments, the role of patient-related factors, and the importance of optimal preventive care.
4.6. Health Education
Life and psychological education for patients and their caregivers, such as wearing loose clothes, resting when tired, avoiding eating that causes stomach upset, paying attention to the amount of food, etc., can help patients relieve the discomfort of nausea and vomiting, and help reduce the occurrence of CINV. Explain the knowledge about CINV, so that they have a comprehensive understanding of what may happen in the course of treatment and corresponding measures can be given. For patients with excessive anxiety, psychological guidance and, if necessary, antianxiety medication should be given the night before medication. For patients discharged from hospital or at home with oral chemotherapy drugs, attention should be paid to strengthening education, informing adverse drug reactions and precautions, treating symptoms appropriately when symptoms are serious, and making corresponding adjustments to the next cycle of chemotherapy prevention and antiemetic program.
5. Conclusion
This study summarized the best evidence from 6 aspects in the assessment and management of chemotherapy-related nausea and vomiting in cancer patients, providing evidence-based evidence for medical staff. However, it cannot be directly replicated in the clinic. Therefore, it is necessary to analyze the promoting factors and impediments to the application of evidence by medical staff in combination with the existing environment of the undergraduate room and the will of patients, consider the suitability and feasibility of each piece of evidence, and extract local evidence and apply it in clinical practice to reduce the incidence of chemotherapy related nausea and vomiting in cancer patients and improve the quality of care. Although the evidence summary of this study was formulated in strict accordance with evidence-based methodology, there were still recommendations based on expert consensus or lower-level evidence, so it is necessary to carry out high-quality original research to enrich the evidence.
Acknowledgements
This study was supported by Nursing elite talent pool of Shanghai Pulmonary Hospital (HL-C3) and Nursing elite talent pool of Shanghai Pulmonary Hospital (HL-C4).
NOTES
*Co-first authors.
#Corresponding author.