Running Head: CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

Controlling Chemotherapy Induced Nausea and Vomiting Through Guideline Adherence
Jennifer Barbosa, BSN, RN, OCN
Arizona State University

1

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

2

Abstract
Background
Thirty to fifty percent of cancer patients undergoing chemotherapy will experience
chemotherapy induced nausea and or vomiting (CINV) despite the use of antiemetic prophylaxis
Uncontrollable CINV can lead to complications that add extra stress to patients, increase in
healthcare costs, and utilization of resources. CINV can lead to chemotherapy dose reductions,
treatment delays, chemotherapy changes, or discontinuation of treatment. Guidelines exist to
better prevent and treat CINV. Evidence supports the use of guidelines to prevent CINV,
however patients still suffer from CINV often due to a lack of guideline adherence.
Objectives
The purpose of this project was to increase CINV guideline adherence by increasing
knowledge of antiemetic guidelines utilizing an educational intervention for providers and nurses
at an outpatient oncology office.
Methods
A brief educational intervention on CINV and recommended NCCN guidelines was
conducted with providers and nurse (n=6) at an oncology practice in Southwestern United States.
An evaluation to assess change in knowledge was performed using a pre and post test format.
Statistical analysis was performed using descriptive statistics, McNemar tests and Wicoxan
Signed Rank Test.
Findings
There was a significant effect on knowledge of NCCN antiemetic guidelines (Z=-1.89,
p=0.059, mean 2.5) post intervention. There also was a significant impact on likelihood to use
guidelines in practice (Z=-1.89, p=0.059, mean 2.5). Increasing awareness and likelihood to

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
follow recommended guidelines may improve CINV symptoms in patients undergoing
chemotherapy and improve the treatment outcomes for these patients.

Keywords: CINV, Chemotherapy, Symptoms management, guideline adherence

3

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

4

Chemotherapy Induced Nausea and Vomiting Guideline Adherence
One of the most distressing side effects of cancer treatment is chemotherapy induced
nausea and vomiting (CINV). CINV is difficult to assess and treat because it is subjective and
often underreported by patients and its impact is often under estimated by providers.
Problem Statement
Chemotherapy induced nausea and vomiting adds extra stress to patients and causes an
increase in healthcare costs and utilization of resources. CINV can lead to chemotherapy dose
reductions, treatment delays, chemotherapy changes, or discontinuation of treatment. Van Lear,
Desai, and Jatoi (2015) found 32% of oncologists surveyed needed to delay or dose reduce
chemotherapy due to CINV. Guidelines exist to better prevent and treat CINV (American
Society of Clinical Oncology [ASCO], 2017; National Comprehensive Cancer Network
[NCCN], 2017). Evidence supports the use of guidelines to prevent CINV, however patients still
suffer CINV often due to a lack of guideline adherence (Caracuel, Munoz, Banos, & Ramirez,
2015).
Purpose and Rationale
Chemotherapy induced nausea and vomiting is one of the most distressing and severe
side effects of chemotherapy for patients (Hernandez Torrez et al., 2015; Inoue et al., 2015).
Uncontrolled CINV negatively impacts patients’ lives and can lead to decreased quality of life,
dehydration, and poor treatment outcomes. There is an extensive body of evidence to guide
providers in effectively preventing and managing CINV. The purpose of this project is to create
more knowledge and awareness of these guidelines in an effort to increase their use in practice.
Background and Significance

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

5

The National Cancer Institute (NCI) (2016) estimates one million people are diagnosed
with cancer each year and for many of these people chemotherapy is a treatment option. It is
estimated 30-50% of patients undergoing chemotherapy experience CINV (Hu et al., 2016;
Moradian & Howell, 2015). It is a major concern because if left uncontrolled it can lead to dose
reductions, treatment delays, and unanticipated stoppage of treatments which can affect overall
treatment outcomes. Improving treatment outcomes and improving supportive and palliative
therapy are major initiatives of the NCI (National Cancer Institute [NCI], 2016).
CINV is a major area of concern for both patients and providers. Hernandez Torres et al.
(2015) suggest many providers consider adequate treatment of CINV to be the absence of
emesis. However, patients report nausea just as distressing as vomiting (Hernandez Torres et al.,
2015; Vidall et al., 2015). Patients have also suggested providers underestimated the impact
nausea has on daily life (Vidall et al., 2015). Van Lear et al. (2015) found 88%-92% of providers
felt they could adequately control CINV but 38% of providers admitted to delaying, stopping, or
changing chemotherapy due to uncontrolled CINV. This gap in patient provider perception of the
impact of CINV suggests room for improvement in understanding and managing symptoms.
Treating CINV can be a difficult undertaking as there are many risk factors and multiple
mechanisms of actions. CINV usually occurs in the first 5 days following chemotherapy
administration and poorly controlled nausea and vomiting during this time can cause anticipatory
nausea and vomiting in following cycles of chemotherapy (Hopkins &Donovan, 2014; NCCN,
2017; Tegeja &Groning, 2016).
Another complexity in the management of CINV is the emetogenic potential of certain
chemotherapies meaning the likelihood of a chemotherapy to cause nausea and vomiting.
Different chemotherapies and regimens have different emetogenic potentials which creates the

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

6

need for varying medications to control CINV. Tageja and Groninger (2016) as well as Boccia
(2013) indicate multiday regimens for IV chemotherapy and oral chemotherapy agents further
add to the emetogenic potential of medications.
The different types of CINV, multiple mechanisms of action, individual risk factors and
the different emetogenic potential of chemotherapeutic agents require a complex assessment and
multipronged approach to successfully manage CINV. This complexity has led to the importance
of guidelines for the management CINV.
To help manage the effects of CINV, professional organizations have created guidelines
to help providers to adequately prescribe the correct prophylaxis and treatment needed. Three
main organizations – the Multinational Association for Supportive Care in Cancer/ European
Society for Medical Oncology (MASCC/ESMO), ASCO, and NCCN have all issued guidelines
for the management of CINV. These guidelines were based on research and evidence in
antiemetic agents, as well as consensus of experts. The Oncology Nursing Society (ONS), the
major certifying agency for chemotherapy administration, recommends the utilization of
guidelines.
Despite the evidence and consensus behind the guidelines, there is a lack of adherence to
guideline recommendations. Guideline adherence is the responsibility of providers and patients.
Providers must be aware of guideline recommendations to prescribe and educate the patients.
Gilmore et al. (2014) found patients were less likely to experience CINV when guidelines were
followed.
Guideline nonadherence can take many shapes and forms such as prescribing incorrect
classes of medications, not prescribing corticosteroids in the delayed phase, and the over dosing
of some medications. All of the guidelines take into account the emetogenic potential of the

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

7

chemotherapy agents used. The emetogenic potential of chemotherapy agents are classified as
highly emetogenic (HEC), moderately emetogenic (MEC), low emetogenic (LEC), and
minimally emetogenic. Some providers are less likely to adhere to guidelines with LEC, mostly
by over prescribing medications with LEC regimens (Franca et al., 2015; Vidall et al., 2015).
Other studies have found that guideline nonadherence was due to the lack of prescribing
corticosteroids during the delayed phase of CINV (Burmeister, Aebi, Studer, Fey, & Gautschi,
(2012).
Another aspect of guideline adherence is patient compliance with medications. Patients
must comply with the guideline recommendations and take medications as prescribed to achieve
optimal results. Patient compliance is easier to manage in the hospital setting as nurses are often
administering medications, however this is difficult to control in the outpatient setting when the
patient must take medications independently at home in the days following chemotherapy
administration. Caracuel et al. (2015) found only 61% of patients were compliant with their oral
antiemetics. In another survey, only 38% of patients remembered taking their antiemetics as
instructed (Vidall et al., 2015). Reasons patients did not want to take medications included not
wanting to taking medications when not feeling nauseous, not wanting to take any additional
medications, and being afraid taking medications may lead to vomiting (Vidall et al., 2015).
Educating both providers and patients may be a way to help improve guideline adherence and
better control CINV.
In an oncology practice in the Southwestern United States, patients are usually given their
chemotherapy education on a day prior to starting chemotherapy. On this day, the patient often
receives all the information needed for their entire chemotherapy course, including information
for managing CINV. This amount of information is overwhelming and often forgotten. There is

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

8

no system currently set up to track the incidence of CINV or dehydration related to CINV in this
practice.
Providers will often follow some of the NCCN guideline recommendations to insure
insurance approval; however, there are often inappropriate exceptions or omissions. For
example, patients receiving HEC will often be written for a prescription for an NK-1 receptor
antagonist (NK-1RA), 5-HT3RA, and corticosteroids per NCCN guidelines. Some patients are
not able to afford the high cost associated with the NK-1RA and often this gets removed from
the treatment plan. NCCN also recommends the use of olanzapine, an atypical antipsychotic, and
corticosteroids orally as antiemetic prophylaxis prior to HEC but this option is rarely utilized.
The severity of CINV experienced by patients and the lack of guideline adherence raise
the following PICO question: In adults undergoing chemotherapy, how does guideline adherence
compare to nonadherence affect CINV?
Search Process
A search of the literature was done using 3 databases - CINHAL, PubMed, and the
Cochrane library. Search terms included chemotherapy, antiemesis, nausea, vomiting, guidelines,
protocols, adherence, and compliance. Variations of these terms were also searched. The results
were limited to the last 5 years to make sure current evidence was being used. All of the studies
considered needed to include the use of chemotherapy guidelines. The results were also limited
to adults over the age of 18. Ancestry was also used during the literature search (Appendix A).
Critical Appraisal and Synthesis
Following the literature search, 10 high quality studies were used for critical appraisal
and analysis. Most of the studies were level three cohort studies but two of the studies were level
2 randomized control trials (RCTs) according to the hierarchy of evidence (Melnyk &Fineout-

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

9

Overholt, 2015). The eight other studies reviewed were observational studies, retrospective and
prospective studies (Appendix B). There was homogeneity as all the studies showed better
CINV outcomes with guideline adherence as a result, but only one study looked at patient
adherence to prescription medication (Caracuel, et al., 2015). The samples all included cancer
patients undergoing chemotherapy. Three studies looked at breast cancer patients and one study
looked at glioma patients. There was some heterogeneity in the guidelines. Some studies used a
combination of guidelines and some used independent institutional protocols.
The studies took place all over the world, Europe, Japan, Singapore, Canada, and the
United States. Most of the studies followed international guidelines except for two studies which
followed institutional guidelines. The most common guideline used was MASCC/ESMO
guideline (Appendix C).
The consensus of results from the critical analysis shows guideline adherence when
prescribing antiemetics has better outcomes. Antiemetic guidelines are evidenced based and have
been shown to decrease CINV incidence. Decreased incidence of CINV improves the overall
treatment experience and treatment outcomes of patients. Improving guideline adherence in both
patients and providers can reduce the overall incidence of CINV. Controlling CINV in early
chemotherapy cycles also improves the rates of anticipatory CINV in following cycles.
Guideline consistent prescribing leads to less office and emergency room visits for dehydration
secondary to CINV, lowering health care costs. Ensuring guideline adherence can reduce health
care costs and decrease the incidences of CINV.
Conceptual/Theoretical Model and Evidence Based Practice Model
The theory of symptom management depicts the three main components, symptom
experience, the components of symptoms management, and the outcome, as being interrelated

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

10

and affecting each other (Linder, 2010). The symptoms experience and symptom management
strategies are encompassed in the outcomes (Appendix D). The symptom experience, CINV,
includes the perception, evaluation, and response to symptoms; symptoms management
strategies includes the providers who deliver care, what is being done to improve the symptoms,
how much and when the intervention is being delivered (Linder, 2010). The symptoms
management strategy utilized for the intervention is CINV guideline adherence. The symptom
may or may not be present but may be a threat to the individual’s overall outcome. Adherence
also plays a role in maintaining the balance of wellbeing and has the power to disrupt the
outcome. Adherence or nonadherence to symptom management strategies may cause a
worsening of symptoms and put an individual at risk for poor outcomes (Linder, 2010).
The evidence based practice model that drove this project was the Ottawa Model for
Research Use (OMRU) (Graham & Logan, 2004). This model is a dynamic and fluid model for
evidenced based practice. OMRU identifies who is responsible for making change decisions and
key stakeholders for change (Appendix E). After key individuals are assessed, it is important to
clearly state and know the intervention being implemented. The next step is to identify potential
barriers and potential adopters and facilitators to the change. After implementation, evaluation
of knowledge translation and situational assessment are important to monitor the change.
Another key aspect of monitoring change is the evaluation of the change and the impact it has on
key stakeholders. Due to the dynamic nature of this model, there is a constant evaluation,
assessment and monitoring of change and adaptations needed (Graham & Logan, 2004). The
dynamic nature of this model allows for post intervention changes, which may be important to
any change. The fluid nature of the OMRU allows for constant adaptation and change during the
implementation process and helps to aid with sustainability.

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

11

Using OMRU, the practice environment was assessed first. The patient flow and
education were noted, and key individuals were identified. Potential adopters were also
identified, as were those who could be resistant to change. Also, the evidence was analyzed and
synthesized during the initial stages. The evidence transfer strategy chosen was dissemination,
and an evidence based educational intervention was the tool used to disseminate the evidence.
Following the interview, the staff chose to adopt the change and outcomes were assessed for
providers.
Project Methods
Protections of human subjects was approved through the Institutional Review Board at
Arizona State University. Recruitment was done by a team member familiar with the practice.
Participants were provided with information of the intervention, including risks and benefits;
consent was implied by participation in the educational intervention. Providers and nurses were
asked to participate in a brief educational intervention. A pretest and posttest assessment was
conducted before and immediately after the intervention (Appendix F). Unique identification
numbers were assigned to the participants to maintain confidentiality. Content validity for the pre
and posttest was assessed by review by content experts.
The educational session on CINV was prepared for both providers and nurses in the
office using the evidence gathered from the literature search. The educational session discussed
the underlying pathophysiology of CINV and risk factors for CINV; the educational session also
included the 2017 NCCN guideline recommendations for HEC and MEC, patient education for
CINV, and information the MASCC Antiemesis Tool (MAT) for objective CINV assessment.
Patient education material was created utilizing NCCN guidelines, ONS
recommendations, and evidence gathered during the literature search and given to the

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

12

participants as part of the intervention. The educational sheets where written using plain
language and clearly listed steps for patients to take to manage their CINV at home. Also
included in the educational material was a blank calendar week for the patient to list when they
needed to take their home corticosteroids and information on how to manage breakthrough
medications as needed. Lastly, the patient education sheet listed who to call for questions or
uncontrolled CINV.
Outcomes and Impact
Data gathered through the pretest and posttest was analyzed utilizing SPSS (IBM Corp,
2016) for statistical analysis. Demographic information was analyzed using descriptive statistics.
The sample consisted of two doctors and four nurses who cared for patients undergoing
chemotherapy (n=6). The years of oncology experience ranged from 3 years to 17 years with a
mean of 9.08 years (SD= 5.43). The level of education of the participants included associate’s
degrees, bachelor’s degrees, and MDs.
Pretest and posttest data were compared using the McNemar test and Wilcoxan Signed
Rank test. Due to the pre-existing knowledge level of the participants about CINV, the McNemar
test indicated this intervention failed to change the knowledge level and there was no change in
the knowledge of CINV when comparing the pretest and the posttest.
Participants were asked to rate their familiarity with NCCN guidelines for antiemesis on
a scale of zero to five before and after the intervention. Using the Wilcoxan Signed Rank test and
a 90% confidence interval (a=0.1), there was a significant change in familiarity of the guidelines
(Z= -1.89, p=0.059). Similar results were found when participants were asked to rate their
likelihood to use the guidelines in practice (Z= -1.89, p=0.059). These results indicate the

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

13

intervention was effective in increasing knowledge of the guidelines and increasing the
likelihood the participants would use them in practice.
Discussion
CINV is very distressing for many patients undergoing chemotherapy and is a side effect
that most patients are concerned about. Recommended guidelines are consensus and evidence
based, making them the standard of practice. The results for both familiarity of NCCN guidelines
and likelihood to use these guidelines in practice showed significant change following the
educational intervention (Z= -1.89, p=0.059). The significance of these results indicates the
educational intervention was effective at increasing familiarity and awareness of the guidelines.
Improving the awareness of the guidelines and the options offered for treating CINV may
improve patient symptoms and outcomes if applied to practice.
The intervention also caused a significant result in participants’ likelihood to use
guidelines in practice (Z= -1.89, p=0.059). Increasing awareness of the recommended guidelines
may increase provider adherence when writing antiemetic prophylaxis. Properly medicating
patients before chemotherapy will have a positive effect on overall treatment outcomes because
there will be an expected decrease in the treatment changes, stoppages, and delays. It may also
decrease the cost to the healthcare system in general as there will likely to be less costs for
additional medications and hydration treatments.
Strengths and Limitations
One of the biggest strengths was this project did increase providers knowledge of the
guidelines and providers reported an increase in likelihood to utilize the guidelines in practice.
Another strength of this project was that it gave providers resources to use in future practice.
This helps to aid in the sustainability as it creates a simpler way for assessing and educating

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

14

patient on CINV. Participants were able to keep the patient education designed from current
evidence and a copy of the MAT tool for assessing CINV. Another strength of this intervention
was it worked with the current practice environment and strengthened it with the current
evidence.
This intervention did have some weaknesses as well as strengths. The first limitation was
the timeframe for the intervention. Due to the limited time to perform the intervention, the
original plan needed to be changed and excluded implementing the MAT tool and performing
chart audits for outcome measures addressing compliance with guidelines and assessing whether
there was an improvement in the management of CINV. Also, all of the educational sessions
were held in one day and one participant did not finish the post test, making it difficult to
compare the data. The condensed timeframe also did not allow for the measurement of long
term outcomes associated with the educational intervention.
Another limitation was the small sample size (n=6). While the sample was a sample of
convenience by including participants who were in the office on that day, the small sample size
may have affected the validity of the results and limited the transferability of the intervention.
Conclusion
The purpose of this project was to increase knowledge regarding CINV guideline
recommendations in an effort to increase guideline adherence. The educational intervention was
designed specifically for the practice environment in which the project took place, limiting its
transferability. The timeframe was also a large limitation of this intervention. Despite its
limitations, this intervention demonstrated a significant change on familiarity with NCCN
recommended guidelines for CINV. Participants also indicated a significantly higher likelihood
to use the guidelines in future practice. This project provided the practice with additional patient

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
education tools which may help to improve patient adherence to prescribed treatment for the
management of CINV.

15

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

16

References
Aapro, M., Molassiotis, A., Dicato, M., Pelaez, I., Rodriguez-Lescure, A., Pastorelli, D., … &
Roila, F. (2012). The effect of guideline consistent antiemetic therapy on chemotherapyinduced nausea and vomiting (CINV): The pan European emesis registry (PEER).
Annals of Oncology, 23, 1986-1992. doi: 10.1093/annonc/mds021
Affronti, M., Schneider, S. M., Herndon, J. E., Schlundt, S., & Friedman, H. S. (2014).
Adherence to antiemetic guidelines in patients with malignant glioma: A quality
improvement project to translate evidence into practice. Support Care Cancer, 22(7),
1897-1905. doi: 10.1007/s00520-014-2136-0
American Society of Clincial Oncology. (2017). Supportive care and treatment related issues:
Antiemetics. Retrieved from https://www.asco.org/practice-guidelines/qualityguidelines/guidelines/supportive-care-and-treatment-related-issues#/9796
Boccia, R.V. (2013). Chemotherapy-induced nausea and vomiting: Identifying and addressing
unmet needs. Journal of Clinical Outcomes Management, 20(8), 377-384.
Burmeister, H., Aebi, S., Studer, C., Fey, M., & Gautschi, O. (2012). Adherence to ESMO
clinical recommendations for prohylaxis of chemotherapy-induced nausea and vomiting.
Support Care Cancer, 20, 141-147. doi: 10.1007/s00520-010-1079-3
Caracuel, F., Munoz, N., Banos, U., & Ramirez, G. (2015). Adherence to antiemetic guidelines
and control of chemotherapy-induced nausea and vomiting (CINV) in a large hospital.
Journal of Oncology Pharmacy Practice, 23(3), 163-169.
doi:10.1177/1078155214524809

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

17

Chan, A., Low, X. H., & Yap, K. Y. (2012). Assessment of the relationship between adherence
with antiemetic drug therapy and control of nausea and vomiting in breast cancer patients
receiving anthracycline-based chemotherapy. Journal of Managed Care Pharmacy,
18(5), 385-394.
Clemons, M., Bouganim, N., Smith, S., Mazzerello, S., Vandermeer, L., Segal, R., … &
Dranitsaris, G. (2016). Risk model-guided antiemetic prophylaxis vs. physician’s choice
in patients receiving chemotherapy for early-stage breast cancer: A randomized clinical
trial. Journal of the American Medical Association, 2(2), 225-231. doi:
10.1001/jamaoncol.2015.3730
Dransitsaris, G., Mazzarello, S., Smith, S., Vandermeer, L., Bouganim, N., Clemons, M. (2016).
Measuring the impact of guideline-based antiemetic therapy on nausea and vomiting
control in breast cancer patients with multiple risks. Support Care Cancer, 24, 15631569. doi 10.1007/s00520-015-2944-x
Franca, M. S., Uson, P. L. S., Antunes, Y. P. P. V., Prado, B. L., Donnarumma, C. D., Mutao, T.
S., … & del Giglio, A. (2015). Assessment of adherence to the guidelines for the
management of nausea and vomiting induced by chemotherapy. Einstein, 13(2), 221-225.
doi: 10.1590/s1679-45082015AO3097
Gilmore, J.W., Peacock, N.W., Gu, A., Szabo, S., Rammage, M., Sharpe, J., … & Burke, T.
(2014). Antiemetic guideline consistency and incidence of chemotherapy-induced nausea
and vomiting in US community practice: INSPIRE study. Journal of Oncology Practice,
10(1), 68-74. doi: 10.1200/JOP.2012.000816
Graham, I. D., & Logan, J. (2004). Ottawa model of research use: A framework for adopting
innovations. Canadian Journal of Nursing Research, 36(2), 89-103.

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

18

Hernandez Torres, C., Mazzarello, S., Ng, T., Dranitsaris, G., Hutton, B., Smith, S., . . .
Clemons, M. (2015). Defining optimal control of chemotherapy-induced nausea and
vomiting-based on patients' experience. Supportive Care in Cancer, 23(11), 3341-3359.
doi:10.1007/s00520-015-2801-y
Hopkins, U.T., & Donovan, D. (2014). Using guideline adherence to manage CINV effectively.
Oncology Nurse Advisor, 21-25.
Hogan, D. & Logan, J. (2004). The Ottawa modelof research use: A guide to clinical innovation
in the NICU. Clinical Nurse Specialist, 18(5), 255-261. (image).
Hu, Z., Liang, W., Yang, Y., Keefe, D., Ma, Y., Zhao, Y., . . . Zhao, H. (2016). Personalized
estimate of chemotherapy-induced nausea and vomiting: Development and external
validation of a nomogram in cancer patients receiving Highly/Moderately emetogenic
chemotherapy. Medicine, 95(2), 1-6. doi:10.1097/MD.0000000000002476
IBM Corp. Released 2016. IBM SPSS Statistics for Macintosh, Version 24.0. Armonk, NY: IBM
Corp.
Inoue, M., Shoji, M., Shindo, N., Otsuka, K., Miura, M., & Shibata, H. (2015). Cohort study of
consistence between the compliance with guidelines for chemotherapy-induced nausea
and vomiting and patient outcome. BioMed Central Pharmacology and Technology,
16(5), 1-6. doi:10.1186/s40360-015-0005-1
Linder, L. (2010). Analysis of the UCSF symptom management theory: Implications for
pediatric oncology nurses. Journal of Pediatric Oncology, 27(6), 316-324. doi:
10.1177/1043454210368532
Melnyk, B.M., & Fineout-Overholt, E. (2015). Evidence-based Practice in Nursing and
Healthcare: A Guide to Best Practice (3rd ed.). Lippincott, Williams & Wilkins.

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

19

Molassiotis, A., Aapro, M., Dicato, M., Gascon, P., Novoa, S. A., Isambert, N., … & Roila, F.
(2014). Evaluation of risk factors predicting chemotherapy-induced nausea and vomiting:
Results from a European prospective observational study. Journal of Pain and Symptom
Management, 47(5), 839-848. doi: 10.1016/j.jpainsymman.2013.06.012
Moradian, S., & Howell, D. (2015). Prevention and management of chemotherapy-induced
nausea and vomiting. International Journal of Palliative Nursing, 21(5), 216-224.
National Cancer Institute. (2016). About Cancer. Retrieved from: https://www.cancer.gov/aboutcancer/understanding/statistics
National Comprehensive Cancer Network. (2017). NCCN clinical practice guidelines in
oncology: Antiemesis. Retrieved from
https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf
Tageja, N., & Groninger, H. (2016). Chemotherapy-induced nausea and vomiting: An overview
and comparison of three consensus guidelines. Post Graduate Medical Journal, 92, 3440. doi: 10.1136/postgradmedj-2014-132969
Van Laar, E.,S., Desai, J. M., & Jatoi, A. (2015). Professional educational needs for
chemotherapy-induced nausea and vomiting (CINV): Multinational survey results from
2388 health care providers. Supportive Care in Cancer, 23(1), 151-157.
doi:10.1007/s00520-014-2325-x
Vidall, C., Fernandez-Ortega, P., Cortinovis, D., Jahn, P., Amlani, B., & Scotte, F. (2015).
Impact and management of chemotherapy/radiotherapy-induced nausea and vomiting and
the perceptual gap between oncologists/oncology nurses and patients: A cross-sectional
multinational survey. Supportive Care in Cancer : Official Journal of the Multinational

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

20

Association of Supportive Care in Cancer, 23(11), 3297-3305. doi:10.1007/s00520-0152750-5

Appendix A
CINHAL Search Strategy

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
PubMed Search Strategy

Cochrane Library Search Strategy

21

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

22

Appendix B
Evaluation Table

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Aapro et al.,
(2012). The
effect of
guidelineconsistent
antemetic
therapy on
chemotherapyinduced nausea
and vomiting.

Physiological
framework

Prospective
Observational
Multicenter
Study

n=1128
Pt initiating
HEC or MEC

Major
Variables
&
Definitions

Measurement/
Data
Instrumentation Analysis
(stats
used)

IV- GCP
DV-GIP

Daily Diary
Rx information
VAS

Pearson X2
Student ttest

g/l: MASCC
C1=991
C2=888
C3=769
Setting: 8
European
Countries,
Infn clinic

Multivariate
logistic
regression

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Adh
increased in
MEC.
g/l Rx
higher in AP
MEC or
HEC.
CR higher in
GCP.
Desired
outcomes
higher GCP.

Lvl of Evidence:
Lvl 3
Decision for
Practice: GCP
improves CINV
for pts and
decreases HCC.
Application to
Practice:

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
Country: 8
European
Countries

23
GCP grp
had less OV
and ER visit
follow tx

Encourage GCP
to decrease HCC
and improve Pt
outcomes.

Funding:
Merck Sharp &
Dohme Corp.
Bias: None
Stated. ESMO
guideline study.

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

Affronti et al.
(2014).
Adherence to
antiemetic
guideline in
patients with
malignant
glioma: A quality
improvement
project to
translate
evidence into
practice.

Change
Theory

Single arm
quasi
experimental
study

n= 61 pt
order sets for
MEC
n= 32 pts
surveyed for
QOL

Pts of
providers
who received
intervention

24
Chart Review of
Rx
Osoba Survey
FACT-BR
FACIT-fatigue

DS
Cronbach’s
Alpha
Wilcoxan
Sign Rank
test

Post
intervention
adh
increased
from 58% to
92% with
edu and
EMR;

Lvl of evidence:
Lvl 3

CR 75%
with adh

Application to
practice:
Provider edu
increase adh.

Decision for
Practice:
g/l adh increases
CR of CINV.

Limitations:
One center
Specialty
practice.

Country: US
(Duke
University)
Bias: None
Stated.
Burmeister et al.
(2012).
Adherence to
ESMO clinical
recommendations

Retrospective
observational

n= 299 charts

New CT pts

Chart Review of
Regimen

DS
Logistic
Regression

61% g/l adh

Lvl of Evidence:
Lvl 3

Overuse of
triple AE

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

25

for prophylaxis
of chemotherapyinduced nausea
and vomiting

11% g/l adh
in LEC
No Dex DR
with NK-1

Country:
Switzerland

Decision for
Practice:
Over use of
antiemetics
reason for low g/l
adh.
Application to
Practice:
Provider edu on
g/l…

Bias: None
stated

Limitations:
Does not look at
CINV CR
outcomes.
Does not include
personal risk
factors for low
adh.

Caracuel et al.
(2015).
Adherence to
antiemetic
guidelines and

Medication
adherence?

Observational
Study

n= 102 Rx
n= 10 Rx
providers

New CT pts

Chart Review
Daily Diary

DS
X2

No sig
between g/l
adh and CR

Lvl of Evidence:
Lvl 3
Decision for
practice:

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

26

control of
chemotherapyinduced nausea
and vomiting
(CINV) in a large
hospital.

Adh to HP
which was
different the
g/l

Application for
Practice:
Need intervention
to increase pt
adherence.

Country: Spain
Bias:
None Stated
Chan et al.
(2012).
Assessment
between
adherence with
antiemetic drug
therapy and
control of nausea
and vomiting in
breast cancer
patients receiving
anthracyclinebased
chemotherapy.

Pt adh plays role
in CINV and g/l
adh

Physiological

Prospective
Observational
study

n=519
123 excluded
d/t loss of f/u
or refused
participation
outpt clinic

Cohort:
Adult Breast
Ca pts
receiving
anthracycline
CT

Diary
Likert Scale for
n/v
f/u phone call

DS
X2
Fisher’s
exact test
Linear
association

62% took b/t
med
57.9% adh
to outpt med
Low adh to
dex Rx
58.6% adh
had CR in
DP

Limitations:
Follow HP not std
g/l.
Lvl of Evidence:
Lvl 3
Decision for
practice: g/l adh
increases CR or
CINV
Application:
Better adh
decreases CINV.
Limitations:

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

27

Country:
Singapore
Bias: None
stated.
Clemons et al.
(2016). Risk
Model guided
antiemetic
prophylaxis vs
physcians choice
in patients
receiving
chemotherapy for
early-stage breast
cancer: A
randomized trial
Country:
Canada
Funding:
Canadian Breast
Cancer Research
Foundation

NK-1 not used d/t
cost. Used
Independent g/l.
Physiological

RCT

n= 324
newly dx
breast ca

IV- RMG
n=154
DV- PC
n=170
RMG grp AE
adjusted after
each cycle

FLIE index
Likert scale
f/u phone call

DS
Repeated
measures

6% in each
grp An/v;
4.1% in PC
grp used
NK-1; More
med to inc
control
added to
RMG grp
than PC grp;
Fewer pt in
RMG
required b/t
med

Lvl of Evidence:
Lvl 2
Decision for
practice:
Triple AE
improve HEC
CINV (g/l
recommendation)
Application:
AE should be eval
with each cycle of
CT.
Limitations:
Did not use g/l
but followed
some
recommendations.
At one facility.

Bias: None
stated.

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
Dranitsaris et al.
(2016).
Measuring the
impact of
guideline-based
antiemetic
therapy on
nausea and
vomiting control
in breast cancer
patients with
multiple risk
factors.
Country:
Canada
Funding:
Canadian Breast
Cancer Research
Foundation
Bias: None
Stated. Same
sample from
Clemons et al.

Exploratory
analysis

n=152
Newly dx
breast Ca pt.
(same sample
as clemons et
al.)

Newly dx
breast Ca pt
in RMG
utilizing
personal RF

28
FLIE index
Diary
Telephone call f/u

Repeated
Measures

Pts with inc
RF for
CINV had
higher
instances of
CINV
despite
prophylaxis.
RMG
decreased
CINV from
C1 to C4.

Lvl of Evidence:
Lvl 3
Decision For
Practice:
Personal RF
needs to be
considered
despite adequate
prophylaxis.
Application for
practice:
Consider personal
RF for CINV
when Rx for AE.
Limitations:
Missing data on
3-6% of
participants.
Sample used in
previous study.
Don’t clearly
identify g/l
following.

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
Gilmore et al.
(2014).
Antiemetic
guideline
consistency and
incidence of
chemotherapyinduced nausea
and vomiting in
US community
practice:
INSPIRE study.

Physiological

Prospective
Observational
Study

n= 1295
C1 new
chemo for
HEC or MEC
per NCCN g/l

IV- GCP
n= 742
DV-GIP
n= 553

29
MAT
f/u phone call

DS
X2
t-test
Multivariate
logistical
regression

Main reason
for lack of
g/l adh no
dex Rx for
DP. GCP
had less
CINV than
GIP.

Decision for
Practice:
GCP inc CR in
CINV
Application: g/l
Rx to decrease
CINV.

Country: US
Funding:
Merck Sharp &
Dohme Corp

Inoue et al.
(2015). Cohort
study of
consistency
between the
compliance with
guidelines for

Lvl of Evidence:
Lvl 3

Physiological
Retrospective
design

n=73
Outpt CT
clinic

CT pts in
outpt setting
monitored for
g/l adh.

MAT
Chart Review

DS
Relative risk

Inc g/l adh
in AP, less
g/l adh HEC
in DP,
CINV not
prevented in
22.2% in AP

Limitation:
Assumed pts adh
to home AE med.
Research funded
by pharmaceutical
company. Data
collected in one
f/u phone call 5-8
days after CT
Lvl of Evidence:
Lvl 3
Decision for
Practice:
Evaluation of
CINV and g/l adh

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

30

chemotherapyinduced nausea
and vomiting and
patient outcome.

Application:
Encourages use of
g/l adherence in
practice.

Country:
Japan

Limitations:
Used 3 g/l in
practice, used
HEC, MEC, and
LEC pts.

Bias: None
stated
Molassiotis et al.
(2014).
Evaluation of
risk factors
predicting
chemotherapy
related nausea
and vomiting:
Results from a
European
Prospective
observational
study.

Physiological

Prospective
Observational
Study

n=1128
137 excluded
for no diary
or CT change
MASCC g/l

n=991 CT
naïve pts
receiving
HEC or MEC
with GCP

Diary
VAS

DS
Multivariate
Logistic
Regression
GEE

Lack of CR
from C1 to
C2
increased
risk for
CINV 6.6
time; lack of
CR in C2
caused 8
times inc in
RF for
CINV in C3.

Lvl of Evidence:
Lvl 3
Decision for
practice:
g/l adh shows
decreased rates of
CINV but
personal RF need
to be considered
Applications for
Practice:
An/v plays large
role in CINV
management.

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

31

Country: 8
European
Countries

Limitations:
Does not consider
outpt adh as part
of study.

Funding:
Merck Sharp &
Dohme Corp
Bias:
Authors speakers
and have
received
compensation
from Merck
Sharp & Dohme
Corp.

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
&
Definitions

N=
n=

IVDV-

Measurement/
Data
Instrumentation Analysis
(stats
used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Key: AE-Antiemetic; Adh- Adherence; An/v- Anticipatory nausea and vomiting; AP- Acute Phase; b/t- breakthrough; C1-Cycle one;
C2- Cycle 2; C3-Cycle 3; C4-Cycle 4; Ca-Cancer; CINV- Chemotherapy induced nausea and vomiting; CR- Complete response;
CT- Chemotherapy; d/t- due to; dex-dexamethasone; DP- delayed phase; DS- Descriptive Statistics; DV-dependent variable; EREmergency Room; FACIT-Functional Assessment of Chronic Illness Therapy Fatigue; FACT-BR- Functional assessment of cancer
therapy-brain; FLIE- Functional living index-emesis; f/u- follow up; g/l-guideline; GCP- guideline consistent prescribing; GEEgeneralized equation estimates; GIC-guideline inconsistent prescribing; grp-group; HCC-Health Care Costs; HEC- Highly
Emetogenic Chemotherapy; HP- Hospital Protocol; IG- Intervention group; inc-increase; Infn- Infusion; IV- independent variable;
LEC- Low emetogenic chemotherapy; Lvl- level; MASCC- Multinational Association of Supportive Care in Cancer; MAT-MASCC
Antiemetic Tool; MEC- Moderately emetogenic chemotherapy; med- medication; N-number of studies; n- number of participants;
n/v- nausea and/or vomiting; NCCN-National Comprehensive Cancer Network; NK-1- Neurokinin receptor antagonist; outptoutpatient; OV- Office visit; PC- physicians choice; Pt- Patient; Pts- Patients; QOL- quality of life; RF-Risk Factors; RMG-Risk
model guided; Rx- Prescribing/prescription; std- Standard; VAS- visual analog scale; X2- Chi Squared

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

32

Appendix C
Synthesis Table

Citation

Guideline

Tool

Diary

Aapro et al.
(2012)
Affronti et al.
(2014)
Burmeister et al.
(2012)
Caracuel et al.
(2015)
Chan et al. (2012).

MASCC

X

MASCC/ESMO,
NCCN, ASCO
MASCC/ESMO

VAS; Precribing
Inforomation
Chart Audit;
Osoba
Chart Audt

Indep/ASCO

Chart Audit

X

Independent

Likert Scale

X

ASCO

FLIE index

ASCO

FLIE index

NCCN

MAT

Independent

MAT/Chart Audit

MASCC

VAS

Clemons et al.
(2016)
Dranitsaris et al,
(2016).
Gilmore et al.
(2014)
Inoue et al. (2015)
Molasiotis et al.
(2014).

Phone

Emetogenic
Potential
HEC/MEC

Emesis w/ g/l
adherence
¯

MEC

¯

HEC/MEC/LEC

X

X

HEC/MEC/LEC/ Min

«

X

HEC/MEC

¯

X

HEC/MEC

¯

X

HEC/MEC

¯

X

HEC/MEC

¯

HEC/MEC/LEC/Min

¯

HEC/MEC

¯

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
Appendix D
Symptom Management Theory

(Linder, 2010)

33

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

Appendix E
Ottawa Model for Research Use

(Hogan & Logan, 2004)

34

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
Appendix F
Pretest

35

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

36

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

Appendix G
Posttest

37

CHEMOTHERAPY INDUCED NAUSEA AND VOMITING

38