Many tools available to help APPs address nausea among children with cancer
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Nausea is among the most common and distressing symptoms experienced by children and adolescents with cancer.
Patients and their parents report that nausea interrupts daily life in all phases of the cancer trajectory, from new diagnosis to advanced cancer and even at the end of life.
Evidence is mixed, but data suggest that nausea worsens with age, as adolescents report nausea of greater severity and interference with daily activities compared with younger children, although younger children may not have the language to express the concept of nausea.
Management of symptoms such as nausea is a primary focus of advanced practice providers, who aim to prevent and minimize negative symptoms related to cancer and its treatment. The Children’s Oncology Group (COG) and Association of Pediatric Hematology/Oncology Nurses (APHON) collaborate closely to develop, share and deliver evidence-based guidance for APPs providing supportive care in the pediatric, adolescent and young adult clinical settings.
The symptom science of nausea
Nausea is a fundamental symptom requiring regular assessment among children and adolescents receiving cancer treatment. Gathering data directly from these young patients allows their voices to be heard, rather than relying on the perceptions of parents or caregivers.
Investigators are also examining the use of electronic or mobile health apps to facilitate symptom assessment from children and adolescents.
The NIH toolbox includes a newly published symptom assessment tool: Pediatric Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (Ped PRO-CTCAE). This resource was adapted from the adult-focused CTCAE and provides a valid and reliable approach to compare patient-reported symptoms before and after interventions, as well as across diverse populations, during the treatment continuum. Because nausea is a prevalent and distressing symptom, interventions can and should be tested to determine their impact on symptom control using standardized symptom assessments.
Types of nausea
Nausea often occurs in the absence of vomiting; therefore, vomiting is not a reliable indicator of nausea. Additionally, there are multiple types of nausea including chemotherapy-induced, anticipatory, disease related, and acute-onset or chronic, each of which requires different approaches to management. Uncontrolled nausea can result in anorexia, weight loss and malnutrition and negatively influences the patient experience. The developmental stage and subjective reporting of the child or adolescent add to the complexity of measuring nausea.
Reliable and valid tools to measure nausea, such as the Pediatric Nausea Assessment Tool (PeNAT), are available. Emerging evidence also supports that quality-of-life measures may capture nausea and its relationship to overall well-being. APPs should be aware of these clinical tools, which could help us recognize suffering related to nausea and optimize treatment plans.
Treatment recommendations
New evidence addressing optimal nausea management continues to emerge. Disseminating this information is a shared goal of APHON and COG.
APHON has an evidence-based practice committee that develops symptom management practices. APHON also endorses published clinical guidelines with links to them on their website.
Within COG, the supportive care guidelines committee includes APPs and reviews published clinical practice guidelines for endorsement.
Both APHON and COG have endorsed a published supportive care guideline for nausea and vomiting management (see references). Due to the complexity of nausea, the endorsed guideline addresses many facets, including prevention and treatment of acute, chronic and anticipatory nausea, as well as emetogenicity levels of chemotherapy regimens.
Cancer control and APPs
APPs may be confused by the term cancer control, which focuses on supportive care and involves preventing symptoms rather than curing the disease. This field is highly relevant to APPs who manage burdensome symptoms such as nausea. A unique opportunity exists for APPs to champion or even lead studies for nausea management through COG or APHON. APPs are well-suited to participate in all stages of the clinical research, including protocol design, participant recruitment and consent, data collection and data reporting. APPs can collaborate with physicians on cancer-directed therapeutic studies but may find working on cancer control studies more tailored to our clinical roles. In addition, with the shortage of clinical research coordinators, APPs can fill a gap by helping facilitate these studies during the routine daily care we provide.
APPs should keep in mind that patients with nausea may be eligible to participate in open cancer control research studies addressing antiemetic strategies. Treatments in these studies often have evidence of safety and efficacy in adults; however, additional evidence is needed before we can administer them to children and adolescents. This is the premise for clinical research, and APPs can help patients and their families understand the need for, and importance of, these studies — to ultimately improve cancer care and management of symptoms such as nausea for children and adolescents with cancer.
Conclusion
APPs will likely recognize the struggle to effectively prevent and manage nausea for patients. Even the experience of a brief viral gastrointestinal illness is a reminder of how terrible nausea feels.
When trying to ease this suffering for children and adolescents with cancer, APPs should turn to published guidelines for help. APPs can also promote research of new treatments through engagement with evidence-based practice, cancer control, and supportive care committees within APHON or COG. Other nonconventional strategies that APPs can explore with the support of the multidisciplinary team include acupuncture, aromatherapy and medical marijuana, which have preliminary evidence of safety and efficacy for nausea control in pediatrics.
APPs have a key clinical role: to help patients navigate symptom management. APPs can arm themselves with a toolchest of references, including creative and innovative ideas, to meet the needs and preferences of individual patients.
Healio | HemOnc Today collaborated with Association of Pediatric Hematology/Oncology Nurses (APHON) on the submission of this column.
References:
- Beauchemin M, et al. Appl Clin Inform. 2021;doi:10.1055/s-0041-1728698.
- Children’s Oncology Group. COG supportive care guidelines. Available at: childrensoncologygroup.org/index.php/cog-supportive-care guidelines.
- Dupuis LL, et al. Pharmacotherapy. 2006;doi:10.1592/phco.26.9.1221.
- Hinds PS, et al. Pediatr Blood Cancer. 2019;doi:10.1002/pbc.27606.
- Linder LA, et al. Semin Oncol Nurs. 2015;doi:10.1016/j.soncn.2015.05.002.
- Montgomery KE, et al. Cancer Nurs. 2020;doi:10.1097/NCC.0000000000000721.
- Montgomery KE, et al. Nurs Outlook. 2021;doi:10.1016/j.outlook.2021.06.013.
- Reeve BB, et al. J Natl Cancer Inst. 2020;doi:10.1093/jnci/djaa016.
- Seelisch J, et al. Pediatr Blood Cancer. 2019;doi:10.1002/pbc.27471.
- Withycombe JS, et al. J Pediatr Oncol Nurs. 2019;doi:10.1177/1043454219854983.
- Wolfe J, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2014.59.1222.
For more information:
Melissa Beauchemin, PhD, RN, CPNP, CPON, is an assistant professor of nursing at Columbia University School of Nursing. She can be reached at mmp2123@cumc.columbia.edu.
Lauri A. Linder, PhD, APRN, CPON, FAAN, FAPHON, is an associate professor University of Utah College of Nursing and clinical nurse specialist at Primary Children’s Hospital in Salt Lake City. She can be reached at lauri.linder@nurs.utah.edu.
Jennifer L. Raybin, PhD, RN, CPNP, is an associate professor of nursing and pediatric hematology oncology at Oregon Health & Science University and Doernbecher Children's Hospital. She can be reached at raybin@ohsu.edu.
Sue Zupanec, MN, NP, is a nurse practitioner in pediatrics at The Hospital for Sick Children in Toronto, Ontario, Canada, and chair of the nursing discipline for Children's Oncology Group. She can be reached at sue.zupanec@sickkids.ca.
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