General Information

KEY POINTS

• Nausea and vomiting are serious side effects of cancer therapy.
• It is important that nausea and vomiting are controlled so that the patient can continue treatment and have a better quality of life.
• Different types of nausea and vomiting are caused by chemotherapy, radiation therapy, and other conditions.

Nausea and vomiting are serious side effects of cancer therapy.

Nausea and vomiting are side effects of cancer therapy and affect most patients who have chemotherapy. Radiation therapy to the brain, gastrointestinal tract, or liver also cause nausea and vomiting.

Nausea is an unpleasant feeling in the back of the throat and/or stomach that may come and go in waves. It may occur before vomiting. Vomiting is throwing up the contents of the stomach through the mouth. Retching is the movement of the stomach and esophagus without vomiting and is also called dry heaves. Although treatments for nausea and vomiting have improved, nausea and vomiting are still serious side effects of cancer therapy because they cause the patient distress and may cause other health problems. Patients may have nausea more than vomiting.

Nausea is controlled by a part of the autonomic nervous system which controls involuntary body functions (such as breathing or digestion). Vomiting is a reflex controlled in part by a vomiting center in the brain. Vomiting can be triggered by smell, taste, anxiety, pain, motion, or changes in the body caused by inflammation, poor blood flow, or irritation to the stomach.

It is important that nausea and vomiting are controlled so that the patient can continue treatment and have a better quality of life.

It is very important to prevent and control nausea and vomiting in patients with cancer, so that they can continue treatment and perform activities of daily life. Nausea and vomiting that are not controlled can cause the following:

• Chemical changes in the body.
• Mental changes.
• Loss of appetite.
• Malnutrition.
• Dehydration.
• A torn esophagus.
• Broken bones.
• Reopening of surgical wounds.

Different types of nausea and vomiting are caused by chemotherapy, radiation therapy, and other conditions.

Nausea and vomiting can occur before, during, or after treatment.

The types of nausea and vomiting include:

• Acute: Nausea and vomiting that happen within 24 hours after treatment starts.
• Delayed: Nausea and vomiting that happen more than 24 hours after chemotherapy. This is also called late nausea and vomiting.
• Anticipatory: Nausea and vomiting that happen before a chemotherapy treatment begins. If a patient has had nausea and vomiting after an earlier chemotherapy session, he or she may have anticipatory nausea and vomiting before the next treatment. This usually begins after the third or fourth treatment. The smells, sights, and sounds of the treatment room may remind the patient of previous times and may trigger nausea and vomiting before the chemotherapy session has even begun.
• Breakthrough: Nausea and vomiting that happen within 5 days after getting antinausea treatment. Different drugs or doses are needed to prevent more nausea and vomiting.
• Refractory: Nausea and vomiting that does not respond to drugs.
• Chronic: Nausea and vomiting that lasts for a period of time after treatment ends.

Many factors increase the risk of nausea and vomiting with chemotherapy.

Nausea and vomiting with chemotherapy are more likely if the patient:

• Is treated with certain chemotherapy drugs.
• Had severe or frequent periods of nausea and vomiting after past chemotherapy treatments.
• Is female.
• Is younger than 50 years.
• Had morning sickness or vomiting with a past pregnancy.
• Has a fluid and/or electrolyte imbalance (dehydration, too much calcium in the blood, or too much fluid in the body's tissues).
• Has a tumor in the gastrointestinal tract, liver, or brain.
• Has constipation.
• Is receiving certain drugs, such as opioids (pain medicine).
• Has an infection, including an infection in the blood.
• Has kidney disease.

Patients who drank large amounts of alcohol over time have a lower risk of nausea and vomiting after being treated with chemotherapy.

Radiation therapy may also cause nausea and vomiting.

The following treatment factors may affect the risk of nausea and vomiting:

• The part of the body where the radiation therapy is given. Radiation therapy to the gastrointestinal tract, liver, or brain, or whole body is likely to cause nausea and vomiting.
• The size of the area being treated.
• The dose of radiation.
• Receiving chemotherapy and radiation therapy at the same time.

The following patient factors may cause nausea and vomiting with radiation therapy if the patient:

• Is younger than 55 years.
• Is female.
• Has anxiety.
• Had severe or frequent periods of nausea and vomiting after past chemotherapy or radiation therapy treatments.

Patients who drank large amounts of alcohol over time have a lower risk of nausea and vomiting after being treated with radiation therapy.

Other conditions may also increase the risk of nausea and vomiting in patients with advanced cancer.

Nausea and vomiting may also be caused by other conditions. In patients with advanced cancer, chronic nausea and vomiting may be caused by the following:

• Brain tumors or pressure on the brain.
• Tumors of the gastrointestinal tract.
• High or low levels of certain substances in the blood.
• Medicines such as opioids.

KEY POINTS

• Anticipatory nausea and vomiting may occur after several chemotherapy treatments.
• The earlier that anticipatory nausea and vomiting is identified, the more effective treatment may be.

Anticipatory nausea and vomiting may occur after several chemotherapy treatments.

In some patients, after they have had several courses of treatment, nausea and vomiting may occur before a treatment session. This is called anticipatory nausea and vomiting. It is caused by triggers, such as odors in the therapy room. For example, a person who begins chemotherapy and smells an alcohol swab at the same time may later have nausea and vomiting at the smell of an alcohol swab. The more chemotherapy sessions a patient has, the more likely it is that anticipatory nausea and vomiting will occur.

Having three or more of the following may make anticipatory nausea and vomiting more likely:

• Having nausea and vomiting, or feeling warm or hot after the last chemotherapy session.
• Being younger than 50 years.
• Being female.
• A history of motion sickness.
• Having a high level of anxiety in certain situations.

Other factors that may make anticipatory nausea and vomiting more likely include:

• Expecting to have nausea and vomiting before a chemotherapy treatment begins.
• Doses and types of chemotherapy (some are more likely to cause nausea and vomiting).
• Feeling dizzy or lightheaded after chemotherapy.
• How often chemotherapy is followed by nausea.
• Having delayed nausea and vomiting after chemotherapy.
• A history of morning sickness during pregnancy.

The earlier that anticipatory nausea and vomiting is identified, the more effective treatment may be.

When symptoms of anticipatory nausea and vomiting are diagnosed early, treatment is more likely to work.

Psychologists and other mental health professionals with special training can often help patients with anticipatory nausea and vomiting. The following types of treatment may be used:

• Muscle relaxation with guided imagery.
• Hypnosis.
• Behavior changing methods.
• Biofeedback.
• Distraction (such as playing video games).

Antinausea drugs given for anticipatory nausea and vomiting do not seem to help.

KEY POINTS

• Acute and delayed nausea and vomiting are common in patients being treated with chemotherapy.
• Acute and delayed nausea and vomiting with chemotherapy or radiation therapy are usually treated with drugs.

Acute and delayed nausea and vomiting are common in patients being treated with chemotherapy.

Chemotherapy is the most common cause of nausea and vomiting that is related to cancer treatment.

How often nausea and vomiting occur and how severe they are may be affected by the following:

• The specific drug being given.
• The dose of the drug or if it is given with other drugs.
• How often the drug is given.
• The way the drug is given.
• The individual patient.

The following may make acute or delayed nausea and vomiting with chemotherapy more likely if the patient:

• Had chemotherapy in the past.
• Had nausea and vomiting after previous chemotherapy sessions.
• Is dehydrated.
• Is malnourished.
• Had recent surgery.
• Received radiation therapy.
• Is female.
• Is younger than 50 years.
• Has a history of motion sickness.
• Has a history of morning sickness during pregnancy.

Patients who have acute nausea and vomiting with chemotherapy are more likely to have delayed nausea and vomiting as well.

Acute and delayed nausea and vomiting with chemotherapy or radiation therapy are usually treated with drugs.

Drugs may be given before each treatment, to prevent nausea and vomiting. After chemotherapy, drugs may be given to prevent delayed vomiting. Patients who are given chemotherapy several days in a row may need treatment for both acute and delayed nausea and vomiting. Some drugs last only a short time in the body and need to be given more often. Others last a long time and are given less often.

The following table shows drugs that are commonly used to prevent nausea and vomiting caused by chemotherapy and the type of drug.

Drugs Used to Prevent Nausea and Vomiting Caused by Chemotherapy

The following table shows drugs that are commonly used to prevent nausea and vomiting caused by radiation therapy and the type of drug:

Drugs Used to Prevent Nausea and Vomiting Caused by Radiation Therapy

It is not known whether it is best to give antinausea medicine for the first 5 days of radiation treatment or for the full treatment course. Talk with your doctor about the treatment plan that is best for you.

KEY POINTS

• Treatment without drugs is sometimes used to control nausea and vomiting.

Treatment without drugs is sometimes used to control nausea and vomiting.

Non-drug treatments may help relieve nausea and vomiting, and may help antinausea drugs work better. These treatments include:

• Diet changes.
• Acupuncture and acupressure.
• Relaxation methods such as guided imagery and hypnosis.
• Behavior therapy.

Nausea and vomiting are the most distressing side effects of chemotherapy and are experienced by up to three-fourths of patients receiving chemotherapy. They can interfere with the ability to perform normal household tasks, enjoy meals, and maintain daily function and activities, thereby reducing their quality of life. The severity of these symptoms can also reduce adherence to chemotherapy regimens and lead to malnutrition. In addition to the numerous antiemetics that are available, several integrative therapies also significantly reduce chemotherapy-induced nausea and vomiting (CINV).

Acupuncture

Several acupressure points, when stimulated by needles, electricity, or pressure, reduce CINV. Acupressure reduces the severity of acute and delayed nausea, however, it has no benefit on the incidence and severity of vomiting. For the prevention of nausea, needles should be placed at least 30 minutes before the chemotherapy session and continued for as long as required. Acupuncture can also be done the day before and day after chemotherapy, and should be administered by acupuncturists specially trained in oncology who will have knowledge of contraindications. Some specific acupuncture points are described below. For general information, refer to Passport to Whole Health Chapter 18, Whole Systems: Chinese Medicine and Acupuncture.

The PC6 (P6) acupressure point alleviates nausea and is easy to find:[5]

1. Take your index finger and middle finger and place them on your wrist at the base of your palm to measure where your nausea acupressure point is.
2. Two or three finger widths down from the top crease in the wrist, centered in the groove between the two large tendons is the PC6 point.
3. Take your thumb and index or middle finger and press firmly on the points on both sides of the wrist when you feel nauseous. You should feel relief in 10-30 seconds, but it can take up to 5 minutes.
4. You can also tap your wrists together gently at the acupressure points while taking deep breaths. Alternate with tapping the outsides of your hands together.
5. Purchase a wristband that applies pressure to the correct spot. They usually have a knob or flat button positioned over the acupressure point. You might feel relief as soon as you put it on, but after your body grows accustomed to the pressure, youll need to press down on the acupressure point for extra relief.
6. Another acupressure point that is commonly used for gastrointestinal discomfort, nausea and vomiting, and stress and fatigue is ST36. Measure four finger-widths down from the bottom of your kneecap, along the outer boundary of the shinbone.

If you are in the right place, a muscle should pop out as you move your foot up and down. To use this acupressure point, (1) locate the point then (2) apply downward pressure on the muscle, stimulating the area for 4-5 seconds.

Aromatherapy

Inhalation and massage aromatherapy are beneficial for chemotherapy-induced nausea and retching. Peppermint essential oil can be very helpful for nausea. Patients may carry a bottle and sniff it throughout the day when needed. One to two drops of peppermint oil can be added to a 12-oz bottle of water and consumed throughout the day.

Botanicals

Note: Please refer to the Passport to Whole Health, Chapter 15 on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

Ginger

Ginger (Zingiber officinale) is a well-known antiemetic and several studies have found it effective for CINV. It appears to be more effective for acute nausea and vomiting rather than delayed. The dose is powdered ginger root 1000 mg daily starting on the first day of chemotherapy and continued for 5 days. Another dosing is 500 mg every 4 hours starting on the first day of chemotherapy and continuing as long as needed. It may be consumed in capsule form, candied ginger, ginger ale (made from real ginger), and tea. Freshly diced ginger tea can be consumed on the day of chemotherapy and continued for as long as needed. Ginger is an anticoagulant, so use with caution in patients who are on blood thinners and avoid high doses in patients with a low platelet count.

Astragalus

Astragalus (Astragalus membranaceus) is a traditional Chinese medicinal herb that has also been found effective in reducing CINV. Since astragalus is often given in combination with other herbs, a dose as not been established.

Mind-Body

Most patients who experience CINV attribute these side effects to a psychological etiology, justifying the need for mind-body therapies in managing symptoms. Effective therapies include clinical hypnosis, Guided Imagery, progressive muscle relaxation, systematic desensitization, yoga,[17] and healing touch.[18] A health psychologist or a practitioner trained in these modalities can teach several of these techniques to patients. Patients may perform progressive muscle relaxation in conjunction to listening to Guided Imagery CDs before and during chemotherapy. (For more information, go to Progressive Muscle Relaxation Whole Health tool.) Guided Imagery CDs and MP3s for chemotherapy can be purchased at the Healthy Journeys website. Music therapy can have positive effects when used in conjunction with other mind-body techniques, but the data is inconsistent.[19][20] During chemotherapy treatment, encourage patients to use simple distractions, such as listening to a relaxation tape or soft music, drawing, knitting, reading, or doing crossword puzzles.

Manual Therapy

A study found that 20-minute hand or foot massage sessions given to breast cancer patients during chemotherapy significantly reduced nausea.[21]

General Dietary Recommendations

1. Eat several small meals frequently throughout the day.
2. Drink plenty of water, at least 8 cups per day, to stay well hydrated. Natural electrolyte-restoring drinks are also beneficial, but avoid ones high in sugar and artificial ingredients. Try sucking on ice chips with a little salt or fruit juice. Avoid drinking a lot of liquids during mealtime, as they increase the sensations of fullness and bloating.
3. Decrease spicy, fatty, fried, and acidic foods in the diet. Avoid foods with strong odors and high sugar content.
4. Room temperature and cold foods are easier to tolerate.
5. Eat slowly and try to relax. Avoid stressful situations and environments before and after eating. Use distractions while eating such as listening to music, watching TV, or engaging in conversation. Avoid lying down for 1 to 2 hours after eating. If foods have a metallic taste, try eating with plastic utensils.
6. Rinse your mouth to eliminate bad tastes, and suck on hard candies such as peppermints and lemon drops.
7. Avoid strong scents, smelly cooking areas, smoke, perfume, and warm stuffy rooms, especially while eating. Get plenty of fresh air while eating and wear loose-fitting clothing. Use unscented deodorants and soaps.
8. Eat soft, bland, easy-to-digest foods such as plain crackers, toast, dry cereals, plain yogurt, broth and clear soups, sorbets, rice cakes, pretzels, pita bread, plain rice, potatoes, oatmeal, applesauce, egg whites, and cooked vegetables. Choose nutritious, high-protein snacks such as nuts, and peanut butter on crackers. Use meal replacements or shakes when not tolerating food. Try eating some bland snacks in the morning before getting out of bed if the nausea occurs when you wake up.
9. For oral rehydration, start with sips of clear liquids 1 tbsp at a time. And increase to 1/4 cup at a time. Once food is tolerated, advance to the bland, starchy foods mentioned above.
10. Gentle exercise may be helpful in decreasing nausea and increasing appetite. Try to walk for 15 minutes when nausea hits.[22]

Summary of Treatments

Supplements & Botanicals

• Ginger
• Astragalus
• Peppermint Oil

Other Complementary Therapies

• Acupuncture and acupressure
• Massage
• Healing touch
• Music therapy

Mind-Body

• Clinical hypnosis
• Guided Imagery
• Progressive muscle relaxation
• Systematic desensitization
• Yoga

KEY POINTS

• Nausea and vomiting in children treated with chemotherapy is a serious problem.
• Anticipatory nausea and vomiting may occur in children.
• In children, acute nausea and vomiting is usually treated with drugs and other methods.
• Delayed nausea may be hard to detect in children.

Nausea and vomiting in children treated with chemotherapy is a serious problem.

Like adults, nausea in children receiving chemotherapy is more of a problem than vomiting. Children may have anticipatory, acute, and/or delayed nausea and vomiting.

Anticipatory nausea and vomiting may occur in children.

Children who have nausea and vomiting after a chemotherapy treatment may have the same symptoms before their next treatment when the child sees, smells, or hears sounds from the treatment room. This is called anticipatory nausea and vomiting.

When the child’s nausea and vomiting is well controlled during and after a chemotherapy treatment, the child may have less anxiety before the next treatment and less chance of having anticipatory symptoms.

Health professionals caring for children who have anticipatory nausea and vomiting have found that children may benefit from:

• Hypnosis.
• Drugs used to treat anxiety in doses adjusted for the age and needs of the child.

In children, acute nausea and vomiting is usually treated with drugs and other methods.

Drugs may be given before each treatment to prevent nausea and vomiting. After chemotherapy, drugs may be given to prevent delayed vomiting. Patients who are given chemotherapy several days in a row may need treatment for both acute and delayed nausea and vomiting. Some drugs last only a short time in the body and need to be given more often. Others last a long time and are given less often.

The following table shows drugs that are commonly used to prevent nausea and vomiting caused by chemotherapy and the type of drug. Different types of drugs may be given together to treat acute and delayed nausea and vomiting.

Drugs Used to Prevent Nausea and Vomiting Caused by Chemotherapy

Non-drug treatments may help relieve nausea and vomiting, and may help antinausea drugs work better in children. These treatments include:

• Acupuncture.
• Acupressure.
• Guided imagery.
• Music therapy.
• Muscle relaxation training.
• Child and family support groups.
• Virtual reality games.

Dietary support may include:

• Eating smaller meals more often.
• Avoiding food smells and other strong odors.
• Avoiding foods that are spicy, fatty, or highly salted.
• Eating "comfort foods" that have helped prevent nausea in the past.
• Taking antinausea drugs before meals.

Delayed nausea may be hard to detect in children.

Unlike in adults, delayed nausea and vomiting in children may be harder for parents and caregivers to see. A change in the child’s eating pattern may be the only sign of a problem. In addition, most chemotherapy treatments for children are scheduled over several days. This makes the timing and risk of delayed nausea unclear.

Studies on the prevention of delayed nausea and vomiting in children are limited. Children are usually treated the same way as adults, with doses of drugs that prevent nausea adjusted for age.