General Risk Factors and Etiologies

Not all cancer patients will experience nausea, vomiting (emesis), or both. The most common causes are emetogenic chemotherapy drugs and radiation therapy to the gastrointestinal (GI) tract, liver, or brain. Several patient characteristics have also been identified. These include incidence and severity of nausea and vomiting (N&V) during past courses of chemotherapy, history of chronic alcohol use, age, and gender. Patients with poor control of N&V during prior chemotherapy cycles are likely to experience N&V in subsequent cycles. N&V is less likely in patients with a history of chronic high intake of alcohol [1] and more likely in women [2,3] and in patients younger than 50 years.[2]

Other possible causes include fluid and electrolyte imbalances such as hypercalcemia, volume depletion, or water intoxication; tumor invasion or growth in the GI tract, liver, or central nervous system, especially the posterior fossa; constipation; certain drugs such as opioids; infection or septicemia; or uremia. The psychological variables of state anxiety (level of anxiety during chemotherapy infusions) and pretreatment expectations for N&V (self-fulfilling prophecy) have also been investigated as predictors of posttreatment nausea.[4,5,6,7,8,9] At present, studies have found mixed results that vary due to different research methods. Better designed studies, however, have found state anxiety and patient expectations for nausea to be predictors of posttreatment nausea, even after controlling for known physiological predictors (susceptibility to nausea during pregnancy and motion sickness) and emetogenic potential of the chemotherapy drugs.[6,7,8,10,11] It is important to note, however, that patients' fears and expectations about chemotherapy can be variable and change over time.[12] In a longitudinal study,[12] patients' anticipatory fears of vomiting decreased significantly from pretreatment to a period 3 to 6 months later, particularly when their chemotherapy included antiemetic medications.

Clinicians treating N&V must be alert to all potential causes and factors, especially in cancer patients who may be receiving combinations of several treatments and medications. (Refer to the PDQ summary on Pain for more information on opioid-induced N&V.)

References:

1. Sullivan JR, Leyden MJ, Bell R: Decreased cisplatin-induced nausea and vomiting with chronic alcohol ingestion. N Engl J Med 309 (13): 796, 1983.
2. Tonato M, Roila F, Del Favero A: Methodology of antiemetic trials: a review. Ann Oncol 2 (2): 107-14, 1991.
3. Roila F, Tonato M, Basurto C, et al.: Antiemetic activity of high doses of metoclopramide combined with methylprednisolone versus metoclopramide alone in cisplatin-treated cancer patients: a randomized double-blind trial of the Italian Oncology Group for Clinical Research. J Clin Oncol 5 (1): 141-9, 1987.
4. Cassileth BR, Lusk EJ, Bodenheimer BJ, et al.: Chemotherapeutic toxicity--the relationship between patients' pretreatment expectations and posttreatment results. Am J Clin Oncol 8 (5): 419-25, 1985.
5. Andrykowski MA, Gregg ME: The role of psychological variables in post-chemotherapy nausea: anxiety and expectation. Psychosom Med 54 (1): 48-58, 1992 Jan-Feb.
6. Jacobsen PB, Andrykowski MA, Redd WH, et al.: Nonpharmacologic factors in the development of posttreatment nausea with adjuvant chemotherapy for breast cancer. Cancer 61 (2): 379-85, 1988.
7. Haut MW, Beckwith BE, Laurie JA, et al.: Postchemotherapy nausea and vomiting in cancer patients receiving outpatient chemotherapy. Journal of Psychosocial Oncology 9(1): 117-130, 1991.
8. Roscoe JA, Hickok JT, Morrow GR: Patient expectations as predictor of chemotherapy-induced nausea. Ann Behav Med 22 (2): 121-6, 2000 Spring.
9. Hickok JT, Roscoe JA, Morrow GR: The role of patients' expectations in the development of anticipatory nausea related to chemotherapy for cancer. J Pain Symptom Manage 22 (4): 843-50, 2001.
10. Roscoe JA, Bushunow P, Morrow GR, et al.: Patient expectation is a strong predictor of severe nausea after chemotherapy: a University of Rochester Community Clinical Oncology Program study of patients with breast carcinoma. Cancer 101 (11): 2701-8, 2004.
11. Higgins SC, Montgomery GH, Bovbjerg DH: Distress before chemotherapy predicts delayed but not acute nausea. Support Care Cancer 15 (2): 171-7, 2007.
12. Passik SD, Kirsh KL, Rosenfeld B, et al.: The changeable nature of patients' fears regarding chemotherapy: implications for palliative care. J Pain Symptom Manage 21 (2): 113-20, 2001.