Release Date: October 31, 2017
Expiration Date: October 31, 2018
Media: Internet - based
Chemotherapy-induced nausea and vomiting (CINV) remains a significant concern for patients and care providers alike. The emergence of CINV has the potential to disrupt patient adherence to treatment protocols, reduce patient quality of life, and adversely influence other outcomes. In order to optimally manage patients who are receiving chemotherapy, clinicians need to be aware of recent changes in the classification of emetic risk with different therapy types, as well as advancements in the pharmacologic management of CINV. This educational activity has the dual objectives of updating healthcare providers on the latest advances in the management of CINV, as well as bringing greater attention to the patient perspective along the treatment continuum of care. This will be accomplished through a combination of didactic presentation (featuring audio clips of experts providing their perspectives on the state of the art in CINV management) and a patient panel discussion.
Acknowledgment of Commercial Support
This activity is supported by an educational grant from Merck Sharp & Dohme Corp.
CME/CE Activity Table of Contents
CINV: Scope of the Challenge
CINV Classification and Influence on Treatment Protocols
Clinical Vigilance to Minimize the Impact of CINV
Understanding the Evidence Supporting Pharmacologic Therapeutic Options
Overcoming Barriers to the Management of CINV
Patient Panel Discussion Video
Instructions For This Activity & Receiving Credit
You will need to login to participate in the activity.
Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
At the end of the activity, "educational content/video" will be available for your reference.
In order to receive a CME/CE certificate, participants must complete the activity.
Complete the posttest and pass with a score of 70% or higher, complete the evaluation and then click on request for credit. Participants may immediately download a CME/CE certificate upon completion of these steps.
This educational activity is directed toward oncologists, nurse practitioners, nurses, and physician assistants involved in the treatment and management of patients with cancer treatment-related symptoms. Pharmacists, researchers, fellows, and other healthcare professionals interested in the treatment of cancer may also participate.
At the conclusion of this activity, you should be better prepared to:
Describe the impact and occurrence of CINV with commonly used chemotherapy regimens
Discuss emerging clinical trial data and evidence-based recommendations on supportive care strategies as they apply to the management of CINV
Apply clinical practice guidelines and a multidisciplinary approach to optimize the prevention and management of CINV in patients with solid tumors and hematologic malignancies
Incorporate skills that promote effective communication and coordination of care regarding CINV between the provider and the patient/caregiver
Faculty, Staff, and Planners' Disclosures
Lee Schwartzberg, MD, FACP
Executive Director, West Cancer Center
Chief, Division of Hematology/Oncology
Professor of Medicine
University of Tennessee Health Science Center
Disclosure: Grant/Research Support: Helsinn, Tesaro; Consultant: Helsinn, Merck, Tesaro
Richard J. Gralla, MD, FACP
Professor of Medicine
Albert Einstein College of Medicine
Jacobi Medical Center
Disclosure: Grant/Research Support: NCI / NIH, Merck; Consultant: Merck, Helsinn, Heron, Chugai
James Natale, PharmD, BCOP
Clinical Pharmacy Specialist
UPMC Cancer Centers
Disclosure: Speaker’s Bureau: Amgen, Merck, Eisai
Elizabeth Ott, PA-C
West Cancer Center
Disclosure: No relevant financial relationships with commercial interests to disclose.
Lauren Wiener (Patient Interviewee)
Russel Wiener (Caregiver Interviewee)
Lauren Wiener and Russel Wiener have no relevant financial relationships with commercial interests to disclose.
The following individuals have no relevant financial relationships with commercial interests:
The staff of PER®.
Disclosure Policy and Resolution of Conflicts of Interest (COI)
It is the policy of PER® to ensure the fair balance, independence, objectivity, and scientific objectivity in all of our CME/CE activities. In accordance with ACCME guidelines, PER® requires everyone who is in a position to control the content of an educational activity, including spouses/partners, to disclose all relevant financial relationships with any commercial interest to participants as part of the activity planning process. PER® has implemented mechanisms to identify and resolve all conflicts of interest prior to release of this activity.
Off-Label Disclosure and Disclaimer
This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options for a specific patient's medical condition.
The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians' Education Resource®, LLC, or any of the companies that provided commercial support for this activity.
PER Pulse™ Recap
PER Pulse Recap (1 of 3)
Scope of the Challenge and Optimization of CINV Risk Assessment
The prospect of experiencing nausea and vomiting remains a substantial fear for patients who are preparing to receive chemotherapy for cancer treatment.1
Chemotherapy-induced nausea and vomiting (CINV) has the potential to limit adherence to chemotherapy regimens, as well as adversely influence patient quality of life (QoL). Although there are effective available treatment strategies, the primary objective in CINV management is prevention. CINV may disrupt QoL for patients receiving highly emetogenic chemotherapy (HEC) and moderately emetogenic chemotherapy (MEC) alike. Although there have been significant advances in the control of emesis, prevention of nausea remains more problematic, particularly in delayed nausea.2
The risk for development of CINV varies according to the emetogenicity of the chemotherapeutic regimen that is being employed. Several sets of guidelines are available regarding the classification of CINV risk according to treatment emetogenicity, including those published by American Society of Clinical Oncology (ASCO), Multinational Association for Supportive Care in Cancer (MASCC)/European Society for Medical Oncology (ESMO), and National Comprehensive Cancer Network (NCCN). Current NCCN guidelines categorize emetogenic potential for select intravenous antineoplastic agents (please see guidelines for complete listings), with recent modifications including the classification of any chemotherapy regimen containing an anthracycline and cyclophosphamide as highly emetogenic, as well as carboplatin area under the curve (AUC) ≥4.
CINV has a wide variety of clinical presentations, including anticipatory, acute, delayed, breakthrough, and refractory. The risk for development of CINV increases with the number of patient risk factors.3,4
Clinicians may have difficulty recognizing the true incidence of delayed CINV, particularly for patients receiving HEC or MEC. Although clinical investigation has shown that physicians and nurses often accurately estimate the incidence of acute CINV, more than 75% of providers in 1 study underestimated the incidence of delayed CINV following HEC or MEC.5
Dr Richard J. Gralla, MD, FACP, and Dr James Natale, PharmD, BCOP, discuss the classification and clinical presentation of CINV, as well as measures that can be used to assess risk for development of CINV; for more details, please visit http://www.gotoper.com/
1. Hesketh PJ. Chemotherapy-induced nausea and vomiting. N Engl J Med
. 2008;358(23):2482-2494. doi: 10.1056/NEJMra0706547.
2. Bosnjak SM, Gralla RJ, Schwartzberg L. Prevention of chemotherapy-induced nausea: the role of neurokinin-1 (NK1
) receptor antagonists. Support Care Cancer.
2017;25(5):1661-1671. doi: 10.1007/s00520-017-3585-z.
3. Dranitsaris G, Molassiotis A, Clemons M, et al. The development of a prediction tool to identify cancer patients at high risk for chemotherapy-induced nausea and vomiting. Ann Oncol
. 2017;28(6):1260-1267. doi: 10.1093/annonc/mdx100.
4. Broder MS, Faria C, Powers A, et al. The impact of 5-HT3RA use on cost and utilization in patients with chemotherapy-induced nausea and vomiting: systematic review of the literature. Am Health Drug Benefits.
5. Grunberg SM, Deuson RR, Mavros P, et al. Incidence of chemotherapy-induced nausea and emesis after modern antiemetics. Cancer
. 2004;100(10):2261-2268. doi: 10.1002/cncr.20230.
PER Pulse Recap (2 of 3)
Pharmacologic Management Options for CINV and Clinical Evidence
Prevention of nausea and emesis should be the goal of antiemetic therapy for patients with cancer. Selection of antiemetic regimens should be based upon multiple factors according to National Comprehensive Cancer Network guidelines, including items such as patient-specific factors, prior experience with antiemetics, and emetogenicity of the cancer treatment that the patient is undergoing. Pharmacologic treatment options for the management of chemotherapy-induced nausea and vomiting (CINV) continue to increase in number, with several new options becoming available over the past 20 years.
This activity reviews the clinical evidence supporting several of these treatment strategies, including the emergence of 5-HT3
receptor antagonists and NK-1 receptor antagonists.1-17
Dr Richard J. Gralla, MD, FACP, and Dr James Natale, PharmD, BCOP, discuss this evidence and the evolving treatment landscape for patients with CINV; for more details, please visit http://www.gotoper.com/
1. Jordan K, Jahn F, Aapro M. Recent developments in the prevention of chemotherapy-induced nausea and vomiting (CINV): a comprehensive review. Ann Oncol.
2015;26(6):1081-1090. doi: 10.1093/annonc/mdv138.
2. Gralla R, Lichnitser M, Van der Vegt S, et al. Palonosetron improves prevention of chemotherapy-induced nausea and vomiting following moderately emetogenic chemotherapy: results of a double-blind randomized phase III trial comparing single doses of palonosetron with ondansetron. Ann Oncol.
3. Hesketh PJ, Grunberg SM, Gralla RJ, et al. The oral neurokinin-1 antagonist aprepitant for the prevention of chemotherapy-induced nausea and vomiting: a multinational, randomized, double-blind, placebo-controlled trial in patients receiving high-dose cisplatin—the Aprepitant Protocol 052 Study Group. J Clin Oncol
. 2003;21(22):4112-4119. doi: 10.1200/JCO.2003.01.095.
4. Poli-Bigelli S, Rodrigues-Pereira J, Carides AD, et al. Addition of the neurokinin 1 receptor antagonist aprepitant to standard antiemetic therapy improves control of chemotherapy-induced nausea and vomiting. Results from a randomized, double-blind, placebo-controlled trial in Latin America. Cancer
. 2003;97(12):3090-3098. DOI: 10.1002/cncr.11433.
5. Aapro M, Carides A, Rapoport BL, et al. Aprepitant and fosaprepitant: a 10-year review of efficacy and safety. Oncologist
. 2015;20(4):450-468. doi: 10.1634/theoncologist.2014-0229.
6. Grunberg S, Chua D, Maru A, et al. Single-dose fosaprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with cisplatin therapy: randomized, double-blind study protocol—EASE. J Clin Oncol
. 2011;29(11):1495–1501. doi: 10.1200/JCO.2010.31.7859.
7. Hesketh PJ, Rossi G, Rizzi G, et al. Efficacy and safety of NEPA, an oral combination of netupitant and palonosetron, for prevention of chemotherapy-induced nausea and vomiting following highly emetogenic chemotherapy: a randomized dose-ranging pivotal study. Ann Oncol
. 2014;25(7):1340-1346. doi: 10.1093/annonc/mdu110.
8. Aapro M, Rugo H, Rossi G, et al. A randomized phase III study evaluating the efficacy and safety of NEPA, a fixed-dose combination of netupitant and palonosetron, for prevention of chemotherapy-induced nausea and vomiting following moderately emetogenic chemotherapy. Ann Oncol.
2014;25(7):1328-1333. doi: 10.1093/annonc/mdu101.
9. Gralla RJ, Bosnjak SM, Hontsa A, et al. A phase III study evaluating the safety and efficacy of NEPA, a fixed-dose combination of netupitant and palonosetron, for prevention of chemotherapy-induced nausea and vomiting over repeated cycles of chemotherapy. Ann Oncol.
2014;25(7):1333-1339. doi: 10.1093/annonc/mdu096.
10. Zhang L, Ku S, Feng F, et al. Phase III study of NEPA, a fixed combination of netupitant and palonosetron, versus an aprepitant regimen for prevention of chemotherapy-induced nausea and vomiting. J Clin Oncol.
2017;35(suppl 15; abstr 10090).
11. Morganroth J, Parisi S, Spinelli T, et al. High dose palonosetron does not alter ECG parameters, including QTc interval in healthy subjects: results of a dose-response, double blind, randomized, parallel EI4 study of palonosetron vs. moxifloxacin or placebo. Eur J Cancer Suppl
. 2007;5(4)(158; abstr 1156).
12. Spinelli T, Moresino C, Baumann S, et al. Effects of combined netupitant and palonosetron (NEPA), a cancer supportive care antiemetic, on the ECG of healthy subjects: an ICH EI4 thorough QT trial. Springerplus
. 2014;3:389. doi: 10.1186/2193-1801-3-389.
13. Schnadig ID, Modiano MR, Poma A, et al. Phase 3 trial results for rolapitant, a novel NK-1 receptor antagonist, in the prevention of chemotherapy-induced nausea and vomiting (CINV) in subjects receiving moderately emetogenic chemotherapy (MEC). J Clin Oncol.
2014;32(suppl 5s; abstr 9633).
14. Rapoport BL, Poma A, Hedley ML, et al. Phase 3 trial results for rolapitant, a novel NK-1 receptor antagonist, in the prevention of chemotherapy-induced nausea and vomiting (CINV) in subjects receiving highly emetogenic chemotherapy (HEC). J Clin Oncol
. 2014;32(suppl 15 abstr 9638).
15. Poma A, Christensen JC, Pentikis HP, et al. Rolapitant and its major metabolite do not affect the pharmacokinetics of midazolam, a sensitive cytochrome P450 3A4 substrate. Support Care Cancer
. 2013;21(S154; abstr 441).
16. Deeks ED. Granisetron extended-release injection: a review in chemotherapy-induced nausea and vomiting. Drugs
. 2016;76(18):1779-1786. doi 10.1007/s40265-016-0664-2.
17. Navari RM, Qin R, Ruddy KJ, et al. Olanzapine for the prevention of chemotherapy-induced nausea and vomiting. N Engl J Med
. 2016;375(2):134-142. doi: 10.1056/NEJMoa1515725.
PER Pulse Recap (3 of 3)
Engaging the Patient With CINV
In order to optimize patient outcomes, patients should receive education regarding the appropriate administration of prophylaxis against chemotherapy-induced nausea and vomiting (CINV), as well as appropriate treatment options for symptoms that are experienced.1
Clear communication should be provided to the patients regarding how to get in touch with the treatment team at all times, especially when patients are symptomatic, as well as instructions to obtain help immediately. Patient desire to “be strong by not complaining” is a commonly cited barrier to optimal CINV management.2
Other barriers include both patients and providers trying to limit the number of medications as well as expressing concern about adverse effects of CINV treatments.2
An expert panel recently advocated the use of real-time monitoring, such as the use of diaries or proactive phone calls, to accurately characterize symptoms that the patient may be experiencing between appointments.1
Prevention of CINV, particularly nausea, remains a significant challenge for practicing clinicians. Adherence to CINV treatment guidelines outlined by the Multinational Association of Supportive Care in Cancer and European Society of Medical Oncology, National Comprehensive Cancer Network, and American Society of Clinical Oncology is limited in clinical practice. Clinical investigation has demonstrated the benefits of using antiemetic strategies that are consistent with guidelines.3,4
The PEER study4
demonstrated that 59.9% of patients who received guideline-consistent CINV prophylaxis had complete response (no emesis or use of rescue medications during 5 days of cycle 1 chemotherapy) compared with 50.7% of patients who received prophylaxis inconsistent with guidelines. In the INSPIRE study,3
the incidence of no CINV over 5 days postchemotherapy was greater for patients receiving guideline-based prophylaxis than for those who had prophylaxis inconsistent with guidelines (53.4 vs 43.8%). Additionally, in the INSPIRE study, the incorporation of corticosteroids on days 2 to 4 for patients receiving highly emetogenic chemotherapy increased the incidence of guideline-consistent CINV prophylaxis from 28.7% to 89.8%; when NK-1 receptor antagonists were added after moderately emetogenic chemotherapy, guideline-consistent CINV prophylaxis increased from 73.1% to 97.8%.3
The use of electronic health records may help to increase adherence to CINV guidelines with standardized protocols, as long as protocols remain current.3
This activity features an extensive patient and caregiver interview, conducted by Dr Lee Schwartzberg, MD, FACP, which explores many features of management of CINV and places emphasis on the perspective of the patient who is experiencing or is susceptible to CINV.
1. Young A, Dielenseger P, Fernandez Ortega P, et al. Helping patients discuss CINV management: development of a Patient Charter. Ecancermedicalscience
. 2013;7:296. doi: 10.3332/ecancer.2013.296.
2. Salsman JM, Grunberg SM, Beaumonty JL, et al. Communicating about chemotherapy-induced nausea and vomiting: a comparison of patient and provider perspectives. J Natl Compr Canc Netw.
3. Gilmore JW, Peacock NW, Gu A, et al. Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting in US community oncology practice: INSPIRE study. J Oncol Pract.
2014;10(1):68-74. doi: 10.1200/JOP.2012.000816.
4. Aapro M, Molassiotis A, Dicato M, et al. PEER investigators. The effect of guideline-consistent antiemetic therapy on chemotherapy-induced nausea and vomiting (CINV): the Pan European Emesis Registry (PEER). Ann Oncol
. 2012;23(8):1986-1992. doi: 10.1093/annonc/mds021.