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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 433-437

Chemotherapy-Induced Nausea and Vomiting in Breast Cancer Patients: A Multicenter Prospective Observational Study

1 Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, China
2 Department of Mammary Glands, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, China
3 Department of Nursing, University of South China, Hengyang, China
4 Department of Breast Cancer, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, China

Date of Submission01-Mar-2021
Date of Acceptance25-Mar-2021
Date of Web Publication31-May-2021

Correspondence Address:
PhD Xuying Li
Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apjon.apjon-2120

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Objective: This study aimed to assess the occurrence of chemotherapy-induced nausea and vomiting (CINV) in acute phase (24 h after chemotherapy) and delayed phase (2–5 days after chemotherapy) after standard antiemetic therapy and to explore the risk factors of CINV in the acute and delayed phases. Methods: This prospective and observational study analyzed the data of 400 breast cancer patients scheduled for chemotherapy in two hospitals. The self-report survey was developed to assess the occurrence of CINV and their associated factors. On day 2 and day 6 of chemotherapy, CINV was evaluated by the Multinational Association of Supportive Care in Cancer Antiemetic Tool (MAT). The incidence of acute and delayed CINV was expressed as frequency and percentage. Results: Among 400 patients, 29.8% and 23.5% experienced acute and delayed CINV, respectively. Logistic regression analysis showed that the risk factors associated with acute CINV included pain/insomnia, history of CINV, and highly emetogenic chemotherapy. The history of motion sickness (MS), history of CINV, number of chemotherapy cycles completed, and the incidence of acute CINV were significant risk factors for delayed CINV (all P < 0.05). Conclusions: The results of this study are helpful for nurses to identify high-risk patients with CINV, formulate effective treatment plans, and reduce the incidence of CINV.

Keywords: Antiemetic guidelines, breast cancer, chemotherapy-induced nausea and vomiting, risk factors

How to cite this article:
Huang X, Li X, Li J, Luo L, Chen H, Tan Y, Wei T, Li X, Guo L, Cheng J. Chemotherapy-Induced Nausea and Vomiting in Breast Cancer Patients: A Multicenter Prospective Observational Study. Asia Pac J Oncol Nurs 2021;8:433-7

How to cite this URL:
Huang X, Li X, Li J, Luo L, Chen H, Tan Y, Wei T, Li X, Guo L, Cheng J. Chemotherapy-Induced Nausea and Vomiting in Breast Cancer Patients: A Multicenter Prospective Observational Study. Asia Pac J Oncol Nurs [serial online] 2021 [cited 2021 Sep 17];8:433-7. Available from: https://www.apjon.org/text.asp?2021/8/4/433/317344

  Introduction Top

Breast cancer is a global public health problem.[1] Chemotherapy is one of the primary treatments of breast cancer, but a series of adverse reactions, such as chemotherapy-induced nausea and vomiting (CINV), are still inevitable.[2],[3] Clinically, the most common types are acute and delayed CINV. Acute CINV usually occurs within a few minutes to several hours after administration and commonly resolves within the first 24 h. Delayed CINV occurs more than 24 h after chemotherapy and can last for 6–7 days.[4]

Studies have shown that in the chemotherapy regimens used by breast cancer patients, the incidence of CINV is as high as 60%–90%,[5] especially late-onset nausea and vomiting, which is most difficult to control and accurately predict.[6],[7] Not only can CINV lead to such problems as electrolyte disorder and malnutrition, but also it can increase the patient's anxiety, depression, and other negative emotions, reduce the patients' adherence to treatment, and even lead to interruption of treatment, life-threatening.[8],[9],[10],[11] Besides, CINV also causes medical resource burden.[12],[13] Therefore, identifying its risk factors is crucial for effective symptom management.

The purpose of this study was to examine the incidence and factors associated with acute and delayed CINV among Chinese breast cancer patients.

  Methods Top

Study design and patients

The study adopted a prospective cohort design. Potential individuals were recruited from inpatient wards of two hospitals in Hunan province of China during the period November 2019 to July 2020. Eligible criteria were Chinese women who were over 18 years old, diagnosed with breast cancer, and scheduled to receive chemotherapy during the data collection period. Those who had cognitive or communication disorders, were participating in other related researches during the study period, and had other conditions that may cause nausea or vomiting (e.g., intestinal obstruction and pregnancy) were excluded from the study.


According to the CINV assessment tool of Multinational Association of Supportive Care in Cancer (MASCC),[14] the acute CINV was defined as cumulative number of vomiting episodes within 24 h ≥1 or nausea level >3, and the definition of delayed CINV was cumulative number of vomiting episodes within 2–6 days ≥1 or nausea >3. In this study, the occurrence of CINV was defined as over the past 24 h (acute CINV) and 2-5 days (delayed CINV) following the completion of chemotherapy.

Based on extensive literature reading,[15] combined with clinical practice and group discussion, a list of 26 CINV-related factors were identified [Table 1]. The Chinese version of MASCC Antiemetic Tool (MAT)[16] was used to identify the occurrence of acute and delayed CINV, and the Chinese version of Generalized Anxiety Disorder Scale-7 was adopted to assess the severity of anxiety.[17]
Table 1: Patients' characteristics (n=400)

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Data collection and ethical consideration

This study was approved by the Ethics Committee of Hunan Cancer Hospital (Approval No. 2019-21). A research nurse recruited eligible individuals on the 1st day admitted to the ward. Written informed consent was obtained from those who were willing to participate in the study.

All the consented participants were invited to have a face-to-face interview during the second day of chemotherapy to collect acute CINV data. A followed up telephone interview was conducted on the 6th day after chemotherapy to collect delayed CINV data.

Statistical analysis

All statistical analyses were performed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA). Demographic data of patients and the incidence of acute and delayed CINV were presented by frequency and percentage. Univariate analyses were conducted on the 26 factors listed in [Table 1] to identify potential risk factors for each type of CINV. Factors with P < 0.10 in univariate analysis were selected as candidate independent variables in a backward multivariable logistic regression analysis to delineate significant risk factors for each type of CINV. All statistical tests were two-sided, and P < 0.05 was considered statistically significant.

  Results Top

A total of 420 subjects were recruited, 20 patients were later excluded from the analysis because of incomplete data [Figure 1]. The background characteristics of the participants are presented in [Table 1]. The incidence rates of acute and delayed CINV were 29.8% (n = 400) and 23.5% (n = 400), respectively.
Figure 1: Patients' flowchart

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The multivariate logistic regression analysis revealed that pain/insomnia (odds ratio [OR] = 1.9, 95% confidence interval [CI]: 1.1–3.1, P = 0.016), history of CINV (OR = 4.0, 95% CI: 2.0–6.6, P < 0.001), and high emetic chemotherapy regimen (OR = 4.5, 95% CI: 2.3–8.5, P < 0.001) were significantly associated with an increased odds for an occurrence of CINV in acute phases [Table 2].
Table 2: Univariate and multivariable logistic regression to identify factors associated with acute chemoradiation-induced nausea and vomiting

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History of CINV (OR = 2.8, 95% CI: 1.6–5.0, P < 0.001), history of MS (OR = 1.7, 95% CI: 1.0–2.7, P = 0.045), and acute CINV occurred (OR = 2.6, 95% CI: 1.6–4.4, P < 0.001) were associated with an increased odds of delayed CINV. In contrast, the number of chemotherapy cycles completed was significantly associated with a decreased risk for CINV in delayed phase (OR = 0.5, 95% CI: 0.3–0.9, P = 0.031). The risk of CINV was higher in the first two chemotherapy cycle numbers than in subsequent rounds of chemotherapy [Table 3].
Table 3: Univariate and multivariate logistic regression to identify risk factors for delayed chemotherapy-induced nausea and vomiting

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  Discussion Top

The findings of the study highlight a considerable proportion of participants suffered from CINV and the associations of CINV with treatment and patient-related factors.

It is worth noting that in our study, CINV in the acute stage is even slightly higher than that in the delayed stage. It may be related to adequate antiemetic prophylaxis. Moreover, the discharged patient received dietary guidance and psychological comfort from nurses. This may be also helpful to control CINV in the delayed phase.

This study identified pain/insomnia, history of CINV, high emetic chemotherapy regimens are associated with an increased risk of acute CINV; these results are consistent with those reported in previous studies.[18],[19],[20] Pain/insomnia may aggravate the physical burden of patients, make their physical strength decline, reduce the ability to deal with adverse reactions, and may result in experiencing CINV. This suggests that more attention should be paid to the management of CINV for patients with symptoms such as pain and insomnia before chemotherapy. Previous history of nausea and vomiting is another factor of acute CINV. It may be due to nausea and vomiting are usually caused by conditioned stimuli, patients with a prior history of CINV are at higher risk of nausea and vomiting when exposed to the same stimuli. The emetic potential of drugs has long been recognized as an important factor influencing CINV. Although preventive treatment was provided in strict accordance with the guidelines during chemotherapy, the risk of acute CINV is still high. The treatment for this group of patients needs to be further improved.

Four influencing factors of delayed CINV were identified: history of MS, history of CINV, number of chemotherapy cycles completed, and acute CINV. Although patients with acute CINV received a higher dosage of antiemetic drugs, they still experience delayed CINV, indicating that individual factors determine who is more susceptible to CINV or unresponsive to antiemetic drugs, in particular those with history of CINV or MS. The findings of the study may be useful for nurses to identify the high-risk group of delayed CINV and provide timely education of symptom assessment and management to them. The risk after three or more cycles of chemotherapy is only 0.5 times that following the first two cycles. The possible reason may be due to patients who have experienced chemotherapy gradually acclimate to the drug and endure the adverse reactions in later cycles, the experience of nausea and vomiting is not obvious.

  Conclusions Top

The findings of the study highlight a considerable proportion of participants suffered CINV though the occurrence rate of CINV was lower than previous studies. This study is the first report to demonstrate that, among patients with breast cancer chemotherapy treatment, those having a pain/insomnia and chemotherapy cycle number <3 represent high-risk populations, whereas those who occur with CINV in the acute phase increase the risk of CINV in the delayed phase. The findings may help nurses working for Chinese population in identifying patients at risk for CINV and in planning effective symptom management.

Financial support and sponsorship

This study was funded by a Hunan province Education Department (Grant No. CX20190255), Hunan Provincial Health Commission (Grant No. 20201632), and Central South University (Grant No. 2019zzts199).

Conflicts of interest

There are no conflicts of interest.

  References Top

Barrios CH, Reinert T, Werutsky G. Global breast cancer research: Moving forward. Am Soc Clin Oncol Educ Book 2018;38:441-50.  Back to cited text no. 1
Gibbons A, Groarke A. Coping with chemotherapy for breast cancer: Asking women what works. Eur J Oncol Nurs 2018;35:85-91.  Back to cited text no. 2
Jodar M, Jacquin JP, Vallée J. Perception of adverse reactions of chemotherapy and hormone therapy by women treated for breast cancer. Therapie 2016;71:263-73.  Back to cited text no. 3
David S, Berger MJ, Barbour S, Bergsbaken J, Brandt D, Brown GE, et al. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Antiemesis,[EB/OL]. Antiemesis (Version 2. 2020). Available from: http://guide.medlive.cn/. [Last accessed on 2020 Apr 23].  Back to cited text no. 4
Chan VT, Yeo W. Antiemetic therapy options for chemotherapy-induced nausea and vomiting in breast cancer patients. Breast Cancer (Dove Med Press) 2011;3:151-60.  Back to cited text no. 5
Naito Y, Kai Y, Ishikawa T, Fujita T, Uehara K, Doihara H, et al. Chemotherapy-induced nausea and vomiting in patients with breast cancer: A prospective cohort study. Breast Cancer 2020;27:122-8.  Back to cited text no. 6
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Soefje SA. Strategies to improve CINV outcomes in managed care. Am J Manag Care 2018;24:S398-404.  Back to cited text no. 8
Wang SY, Yang ZJ, Zhang Z, Zhang H. Aprepitant in the prevention of vomiting induced by moderately and highly emetogenic chemotherapy. Asian Pac J Cancer Prev 2014;15:10045-51.  Back to cited text no. 9
Grunberg SM, Slusher B, Rugo HS. Emerging treatments in chemotherapy-induced nausea and vomiting. Clin Adv Hematol Oncol 2013;11:1-8.  Back to cited text no. 10
Carnio S, Galetta D, Scotti V, Cortinovis DL, Antonuzzo A, Pisconti S, et al. Chemotherapy-induced nausea and vomiting (CINV) in patients with advanced lung cancer during the first-line treatment: Assessment by physicians, nurses, and patients from an Italian multicenter survey. Support Care Cancer 2018;26:1841-9.  Back to cited text no. 11
Burke TA, Wisniewski T, Ernst FR. Resource utilization and costs associated with chemotherapy-induced nausea and vomiting (CINV) following highly or moderately emetogenic chemotherapy administered in the US outpatient hospital setting. Support Care Cancer 2011;19:131-40.  Back to cited text no. 12
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Molassiotis A, Coventry PA, Stricker CT, Clements C, Eaby B, Velders L, et al. Validation and psychometric assessment of a short clinical scale to measure chemotherapy-induced nausea and vomiting: The MASCC antiemesis tool. J Pain Symptom Manage 2007;34:148-59.  Back to cited text no. 14
Mosa ASM, Hossain AM, Lavoie BJ, Yoo I. Patient-Related risk factors for Chemotherapy-Induced nausea and vomiting: A Systematic Review. Front Pharmacol 2020;11:329.  Back to cited text no. 15
Li XF, Liu W, Qin Y. Reliability and validity of the Chinese version of MASCC antiemesis tool. Chin J Modern Nurs 2016;22:2669-73.  Back to cited text no. 16
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Molassiotis A, Aapro M, Dicato M, Gascon P, Novoa SA, Isambert N, et al. Evaluation of risk factors predicting chemotherapy-related nausea and vomiting: Results from a European prospective observational study. J Pain Symptom Manage 2014;47:839-48.e4.  Back to cited text no. 19
Bouganim N, Dranitsaris G, Hopkins S, Vandermeer L, Godbout L, Dent S, et al. Prospective validation of risk prediction indexes for acute and delayed chemotherapy-induced nausea and vomiting. Curr Oncol 2012;19:e414-21.  Back to cited text no. 20


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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