Clinical, neuropsychological factors influence chemotherapy-induced nausea severity
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Chemotherapy-induced nausea remains a significant clinical problem, but severity varies based on multiple factors, according to results presented during the virtual Oncology Nursing Society Congress.
These factors included demographic, clinical, neuropsychological and stress characteristics.
“Research focused on evaluating biological mechanisms that contribute to interindividual variability in chemotherapy-induced nausea occurrence may help with designing targeted interventions to alleviate nausea, especially among patients in the high [severity] subgroup,” Komal Singh, PhD, RN, assistant professor in Edson College of Nursing and Health Innovation at Arizona State University, said during a presentation.
Between 30% and 60% of patients with cancer experience chemotherapy-induced nausea. Most available interventions offer limited or no relief.
Limited evidence is available regarding the characteristics associated with risk for severe cases, and little is known about the interindividual variability of chemotherapy-induced nausea.
Singh and colleagues used latent variable modeling and a patient-centered analytic approach to identify subgroups of patients with distinct chemotherapy-induced nausea profiles. They also evaluated differences in demographic and clinical factors, as well as stress characteristics and neuropsychological symptoms, among subgroups.
The analysis — part of a larger, longitudinal study — included 1,343 adults recruited from one VA hospital, two comprehensive cancer centers and four community-based oncology programs.
All study participants had breast, lung, gastrointestinal or gynecologic cancer. They received chemotherapy within the 4 weeks prior to evaluation and were scheduled to receive at least two more chemotherapy cycles.
Investigators administered questionnaires to obtain demographic information, and they used several assessment tools to measure clinical factors, neuropsychological symptom severity and stress.
Researchers used the Memorial Symptom Assessment Scale to assess chemotherapy-induced nausea in this cohort six times over two cycles of chemotherapy — prior to administration of each cycle, and approximately 1 week and 2 weeks after each cycle. The assessment scale measured nausea occurrence, frequency, severity and distress.
Singh and colleagues identified four distinct nausea profiles:
- 40.8% had no nausea.
- 21.5% were classified as increasing-decreasing. In this group, nausea increased from the first to second assessment and decreased at the third assessment. This pattern repeated in the second chemotherapy cycle.
- 8.9% were classified as decreasing. In this group, nausea increased slightly from the first to second assessment and gradually decreased over the remaining four assessments.
- 28.8% were classified as high. In this group, occurrence of nausea remained consistently high on all six assessments.
Compared with patients with no nausea (n = 548), those in the high group (n = 387) tended to be younger, have a higher comorbidity burden and have lower functional status. They were less likely to receive a targeted therapy, more likely to receive chemotherapy on a 14-day cycle and more likely to receive highly emetogenic chemotherapy. They also were more likely to have child care responsibilities and more likely to report ulcer/stomach disease or anemia/blood disease.
An analysis of neuropsychological symptoms showed that — compared with patients with no nausea — those in the high nausea group had significantly higher scores for depression (F = 27.81), trait anxiety (F = 17.21), general sleep disturbance (F = 37.49), morning fatigue (F = 26.35), evening fatigue (F = 21.06), pain intensity (F = 5.41) and pain interference (F = 15.61; P < .001 for all).
Compared with patients who had no nausea, those in the high group also had significantly higher levels of perceived stress (F = 16.32; P < .001), avoidance of feelings (F = 6.04; P < .001), intrusion (F = 18.17; P = .002) and hyperarousal (F = 20.75; P < .001).
Because results showed co-occurrence of high levels of neuropsychological symptoms and stress among patients who developed chemotherapy-induced nausea, it is possible that common underlying biological mechanisms — such as alterations in the hypothalamic-pituitary adrenal axis or microbiome-gut-brain axis — may contribute to variability in nausea occurrence between individuals, researchers concluded.
The findings emphasize the importance that clinicians assess patients for chemotherapy-induced nausea, as well as for neuropsychological symptoms and stress, Singh said.
“Patients who receive chemotherapy on a 14-day cycle and who receive highly emetogenic chemotherapy warrant additional assessments,” Singh said. “Pharmacological and nonpharmacological interventions warrant consideration for modifiable risk factors associated with nausea.”
For example, patients’ child care needs should be assessed so referrals to social services can be made as appropriate, and patients with depressive symptoms should receive referrals for mental health services.
Singh acknowledged study limitations. Researchers did not assess participants’ adherence to antiemetic regimens or additional risk factors, such as motion sickness, morning sickness or chemotherapy-induced nausea occurrence in their first cycle of chemotherapy. In addition, the majority of patients were women, white and college educated and had metastatic disease, suggesting the findings may not be generalizable to all patients receiving chemotherapy.
Future research can focus on several areas, Singh said.
“We need to evaluate additional risk factors for nausea and we need to assess patients’ adherence to antiemetic regimens in their first cycle of chemotherapy,” she said. “We need to investigate additional underlying mechanisms for nausea, so patients in the high subgroup potentially can receive targeted interventions to alleviate this devastating symptom.”
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Singh K, et al. Differences in neuropsychological symptoms and stress among oncology patients with distinct nausea profiles. Presented at: Oncology Nursing Society Congress (virtual meeting); April 20-29, 2021.
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