Listen to the Cancer.Net Podcast: Managing Nausea and Vomiting Caused by Cancer Treatment, with Gary Lyman, MD, adapted from this content.
To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO) developed evidence-based recommendations on the use of antiemetics (drugs that prevent vomiting). These guidelines were updated in 2011 because the latest research showed better prevention of vomiting with new combinations of medications and some additional medications became available. This guide for patients receiving any type of chemotherapy or radiation therapy is based on these updated ASCO recommendations.
- The risk of nausea and vomiting depends on the specific chemotherapy and the type and location of radiation therapy you receive.
- With appropriate medications, vomiting can be prevented in most patients undergoing cancer treatment.
Emesis (vomiting or throwing up) is the act of expelling the contents of the stomach through the mouth. Nausea is the urge to vomit. Radiation therapy (the use of high-energy x-rays or other particles to kill cancer cells) and some types of chemotherapy (the use of drugs to kill cancer cells) cause nausea and vomiting, although not all patients who receive these treatments will have these side effects. Patients who often have motion sickness or have vomited after previous chemotherapy treatment are more likely to experience nausea and vomiting.
The best way to manage nausea and vomiting caused by cancer treatment is to prevent it. Fortunately, many medications are available that can prevent vomiting. These medications may also prevent nausea, but some patients may still have nausea even if they do not have vomiting. More research is needed to understand if these drugs prevent nausea.
Anticipatory emesis is vomiting that occurs before treatment in patients who have previously felt nauseous or vomited after chemotherapy. The prevention and treatment of anticipatory vomiting depends on the patient. Tell your doctor if you have experienced vomiting with previous chemotherapy treatment. Your doctor may be able to recommend medication or behavioral therapy to help reduce vomiting.
Recommendations for Preventing Vomiting Caused by Chemotherapy
Some chemotherapy is more likely to cause nausea and vomiting than other chemotherapy. The table (Table 1) below lists the likelihood that a certain intravenous (IV; given in a vein) chemotherapy will cause nausea and vomiting.
Table 1. The Risk of Nausea and Vomiting From Intravenous Chemotherapy
Nearly Always Causes Nausea and Vomiting
Usually Causes Nausea and Vomiting
Sometimes Causes Nausea and Vomiting
Rarely Causes Nausea and Vomiting
|Carmustine (Becenum, BiCNU, Carmubris)||Azacitadine (Mylosar, Vidaza)||Bortezomib (Velcade)||Bevacizumab (Avastin)|
|Cisplatin (Platinol)||Alemtuzumab (Campath)||Cabazitaxel (Jevtana)||Bleomycin (Blenoxane)|
|Cyclophosphamide (Cytoxan, Clafen, Neosar) at higher doses||Bendamustine (Treanda)||Catumaxumab (Removab)||Busulfan (Busulfex, Mitosan, Myleran)|
|Dacarbazine (DTIC-Dome)||Carboplatin (Paraplat, Paraplatin)||Cytarabine at lower doses||Cetuximab (Erbitux)|
|Dactinomycin (Cosmegen, Lyovac Cosmegen)||Clofarabine (Clofarex, Clolar)||Docetaxel (Taxotere)||2-Chlorodeoxyadenosine (cladribine, Leustatin)|
|Daunorubicin (Cerubidine, Rubidomycin) when combined with cyclophosphamide||Cyclophosphamide at lower doses||Doxorubicin HCL liposome injection (Doxil, Dox-SL, Evacet, LipoDox)||Fludarabine (Fludara)|
|Doxorubicin (Adriamycin) when combined with cyclophosphamide||Cytarabine (Cytosar-U, Tarabine PFS) at higher doses||Etoposide (Etopophus, Toposar, VePesid)||Pralatrexate (Folotyn)|
|Epirubicin (Ellence) when combined with cyclophosphamide||Daunorubicin||Fluorouracil (5-FU, Adrucil, Efudex, Fluoroplex)||Rituximab (Rituxan)|
|Idarubicin (Idamycin) when combined with cyclophosphamide||Doxorubicin||Gemcitabine (Gemzar)||Vinblastine (Velban, Velsar)|
|Mechlorethamine (Mustargen)||Epirubicin||Ixabepilone (Ixempra)||Vincristine (Vincasar PFS, Oncovin)|
|Streptozotocin (Zanosar)||Idarubicin||Methotrexate (multiple brand names)||Vinorelbine (Navelbine, Alocrest)|
|Ifosfamide (Cyfos, Ifex, Ifosfamidum)||Mitomycin (Mitozytrex, Mutamycin)|
|Irinotecan (Camptosar)||Mitoxantrone (Novantrone)|
|Oxaliplatin (Eloxatin)||Paclitaxel (Taxol, Abraxane)|
|Topotecan (Hycamtin, Brakiva)|
The recommended treatments for preventing nausea and vomiting are listed in Table 2.
Table 2. Recommendations for Preventing Vomiting Caused by Chemotherapy
Likelihood of Chemotherapy to Cause Nausea and Vomiting
Nearly Always Causes Nausea and Vomiting (High Risk)
Usually Causes Nausea and Vomiting (Moderate Risk)
Sometimes Causes Nausea and Vomiting (Low Risk)
Rarely Causes Nausea and Vomiting (Minimal Risk)
A three-drug combination of the following:
1. Aprepitant (Emend) on days 2 and 3 or fosaprepitant on day 1
2. Dolasetron (Anzemet; oral [by mouth] form only), granisetron (Kytril, Sancuso), ondansetron (Zofran), palonosetron (Aloxi), tropisetron (Navoban), or ramosetron (Nasea)
3. Dexamethasone (multiple brand names) on days 2 through 4
A two-drug combination of the following:
1. Palonosetron (this is the preferred treatment, but granisetron or ondansetron may also be used)
2.Dexamethasone on days 2 and 3
|Dexamethasone||No treatment required unless the patient has previously experienced vomiting with this treatment.|
Recommendations for Preventing Vomiting Caused by Radiation Therapy
The risk that radiation therapy will cause nausea and vomiting depends on where the radiation therapy is targeted and how much of the body is receiving treatment. The risks and recommended treatments of vomiting caused by radiation therapy are summarized in Table 3.
Risk of Nausea and Vomiting From Radiation
Area of the Body Being Treated
|High||Total body irradiation (entire body) or total nodal (lymph node) irradiation||One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron before each dose and after the last, with dexamethasone before treatments 1 through 5|
|Moderate||Upper abdomen (trunk or stomach), upper body, or half of the body||One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron before each treatment with dexamethasone before treatments 1 through 5|
Lower thorax (chest)
Head and neck
|One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron as needed|
|Minimal||Arms and legs
|One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron and metoclopramide (Reglan) or prochlorperazine (Compazine) as needed|
What This Means for Patients
Vomiting can be prevented with the appropriate medications for most patients undergoing cancer treatment. However, patients may still have nausea without vomiting. These medications should be taken as prescribed before treatment and continued after treatment as directed by your doctor because the risk of vomiting may continue for several days after treatment.
If you have nausea and vomiting, even if you take your medication as prescribed, let your doctor know. Your doctor can recommend other medications to reduce nausea and vomiting and help prevent these symptoms during future cycles of chemotherapy. It is very important to call or see your doctor if you cannot keep food or water in your body because of severe nausea and vomiting. This can cause serious dehydration and electrolyte imbalance. It is also important to talk to your doctor if your symptoms worsen throughout treatment.
Questions to Ask the Doctor
It is important to prevent vomiting before it occurs. Consider asking the following questions of your doctor:
- Does my treatment carry a high risk of nausea and vomiting?
- What can be done to manage nausea?
- What can be done to prevent vomiting?
- Are some medications preferred over others? Why?
- What are the instructions for taking these medications?
- Do these medications have side effects that I should know about?
- What are the costs of these medications?
- If I'm worried about managing the costs related to my cancer care, who can help me with these concerns?
- Where can I find more information?
To help doctors give their patients the best possible care, ASCO asks its medical experts to develop evidence-based recommendations for specific areas of cancer care, called clinical practice guidelines. Due to the rapid flow of scientific information in oncology, new evidence may have emerged since the time a guideline or assessment was submitted for publication. As a result, guidelines and guideline summaries, like this one, may not reflect the most recent evidence. Because the treatment options for every patient are different, guidelines are voluntary and are not meant to replace your physician's independent judgment. The decisions you and your doctor make will be based on your individual circumstances. These recommendations may not apply in the context of clinical trials.
The information in this patient guide is not intended as medical or legal advice, or as a substitute for consultation with a physician or other licensed health care provider. Patients with health-related questions should call or see their physician or other health care provider promptly and should not disregard professional medical advice, or delay seeking it, because of information encountered in this guide. The mention of any product, service, or treatment in this guide should not be construed as an ASCO endorsement. ASCO is not responsible for any injury or damage to persons or property arising out of or related to any use of this patient guide, or to any errors or omissions.
Read the entire clinical practice guideline published at www.asco.org/guidelines/antiemetics.
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