Nausea occurs when you feel queasy or sick to your stomach. In many cases nausea may be followed by vomiting (throwing up).(1) Until the mid 90’s nausea and vomiting caused by chemotherapy, were two major factors that forced up to one fifth of the cancer patients to postpone or refuse potentially curative treatment.(2)

Common causes of nausea for the cancer patient

Chemotherapy medicines, painkillers and antibiotics seem to be important causal factors of nausea. Following radiotherapy treatment such as treatments to the abdomen, back, head and pelvis, might also trigger nausea mechanisms. In addition nausea might occur because of bowel problems such as constipation, pain after surgery and anxiety during the cancer treatment period.(3)

(p>There are several risk factors that contribute to the development of chemotherapy induced nausea and the whole mechanism is complex and linked with a combination of clinical factors and socioeconomic, personal, demographic, educational and behavioral ones.(4) Patient risk factors including young age, female gender, a history of low alcohol intake, experience of emesis (vomiting) during pregnancy, impaired quality of life and previous experience of chemotherapy are known to increase the risk of nausea and vomiting after chemotherapy.(5)

Mechanisms

Chemotherapy-radiation induced nausea and vomiting, are classified into two categories. The first category is the acute onset nausea which occurs within the first 24 hours after the administration of treatment. The second category is the delayed onset nausea that occurs 24 hours to five days after the administration of treatment.

A number of overlapping pathological pathways contribute to the pathogenesis of nausea. The emetic center is situated in the medulla oblongata and consists of a network of neurons. Chemotherapy agents are considered as a factor that triggers the release of neurotransmitters, such as serotonin, which activates vagal afferents leading to stimulation of the area postrema. What follows is the combination of sensory inputs in vagal afferents and the area postrema at the emetic center, resulting in efferent signals that lead to contraction of abdominal muscles, the diaphragm, stomach, and esophagus, producing a reflexive emetic response. A number of neurotransmitters are thought to be involved in this process and include serotonin, dopamine, and substance P. The knowledge of the role of these neurotransmitters helped in the development of drugs that antagonize their action in order to act as prophylactic therapies for cancer induced nausea and vomiting.(6)

Chemotherapy-induced nausea and vomiting can have a profound effect on the cancer treatment experience and is associated with negative effects on daily life and overall quality of life, including effects on food intake, weight loss, social interactions, dehydration, difficulty with sleeping, and anxiety. In a qualitative study of patients’ experiences, unmanaged nausea was constant in some patients and made them exhausted for long periods after chemotherapy, making recovery between cycles longer. The impact of nausea is greater than that of vomiting, and nausea has proven to be more difficult to control. The direct and indirect costs of the experience of nausea and vomiting, especially of delayed symptoms, are considerable.(7)

A number of antiemetic drugs are currently used and the most effective are 5-HT3 serotonin receptor antagonists. Another category of antiemetics is TachykininNK1 receptor antagonist aprepitant. Dexamethazone which is a steroid is a key factor in the prevention of cancer-induced nausea and is a component of most of the antiemetic regimen. Olanzapine, which is an antipsychotic drug, exhibits interesting antiemetic properties. Benzodiazepines could also be a useful addition to antiemetic regimens in certain circumstances. Although, modern antiemetics are able to prevent nausea in the majority of cancer patients, some of them are not satisfied or face adverse side effects, so they ask for alternative or natural treatments that will possible improve their quality of life.(5)

1. Ginger

A number of studies have evaluated ginger’s potential benefit in preventing chemotherapy-induced nausea. In a well conducted, multi-center study, cancer patients submitted to chemotherapy were randomly assigned to four arms (placebo, 0.5 g ginger, 1 g ginger, 1.5 g ginger). Patients, co-treated with 5-HT3 receptor antagonists on day 1 of all cycles, received treatments ginger preparations or placebo for 6 days, starting 3 days before the first day of chemotherapy. The researchers concluded that all doses of ginger significantly reduced acute nausea severity compared to placebo on day 1 of chemotherapy. The largest reduction in nausea intensity occurred with 0.5 g and 1.0 g of ginger. Another study evaluated the effects of ginger against both acute and delayed forms of chemotherapy-induced nausea and vomiting in a population with advanced breast cancer. There were two groups of women with advanced breast cancer, the ones who received ginger plus standard antiemetic regimen and the group that received the standard antiemetic regimen alone. The researchers observed a significantly lower prevalence of nausea in the ginger group during the 6 to 24 hours post chemotherapy.(8)

Another study was recently contacted in order to assess the efficacy of inhaled ginger aromatherapy on nausea, vomiting in chemotherapy breast cancer patients. Scientists who conducted this study concluded that the evidence derived is not sufficiently convincing that inhaled ginger aromatherapy is an effective complementary therapy for chemotherapy induced nausea and vomiting.(9)

In 2013 researchers did a systematic literature review on Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting. Seven studies met the inclusion criteria of the review, with three demonstrating a positive effect, two in favor but with caveats, and two showing no effect on measures of chemotherapy induced nausea and vomiting. The above conflicting results indicate the need of future studies in order to ensure the effectiveness of ginger as an tool against chemotherapy-induced nausea.(10)

2. Acupuncture

Acupuncture, a known ancient medical treatment from China, is gaining popularity and acceptance as a valid intervention in medical practice. In 1998, a National Institute of Health consensus statement on acupuncture stated, “There is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting,” but acupuncture is still not accepted as a standard treatment.(11) The most popular acupoints applied in this problem are P6 and S36, both of which belong to the Chinese stomach meridian.(12) Several studies reported effects of P6-stimulation on gastric myoelectrical activity, vagal modulation and cerebellar vestibular activities in functional magnetic resonance imaging. About 40 randomized controlled trials show that acupuncture is a potential preventive factor of nausea and vomiting.(13) Recent evidence in clinical trial indicates that acupuncture is beneficial for chemotherapy-induced nausea and vomiting. Also oncology nurses are encouraged to increase their knowledge of the available evidence in the use of acupuncture in the supportive care of cancer patients.(14)

According to a 2013 literature review published in Journal of Clinical Oncology “acupuncture is an appropriate adjunctive treatment for chemotherapy-induced nausea/vomiting, but additional research is needed to increase the reliability of these findings”.(15)

3. Herbs

Some studies report that decoctions of Radix Astragali (Huang-Qi in Chinese) compounds could reduce the number of cancer patients under chemotherapy who experience nausea and vomiting. According to other studies Poria cocos as one of the most frequently used herbs combined with the FOLFOX4 regimen chemotherapy, could reduce chemotherapy-related adverse events including neutropenia, nausea and vomiting. An additional study reported that when combined chemotherapy and Shenqifuzheng (traditional Chinese Herbal formula) injection, they improve quality of life and decrease adverse events like nausea.(16)

4. Yoga

A study of 2009 compared the effects of an integrated yoga program with supportive therapy in breast cancer outpatients undergoing adjuvant radiotherapy.

The researchers of the study reported that Yoga might have a role in managing self-reported psychological distress and modulating circadian patterns of stress hormones in early breast cancer patients undergoing adjuvant radiotherapy.(17)

5. Eating habits that help you avoid nausea

According to the National Cancer Institute, eating 5 or 6 small meals is essential so that your stomach is never empty and it this also helps you divide the amounts of food consumed. For the same reason cancer patients under treatment should not skip meals and snacks. Eating foods that are easy on the stomach and appeal to the patient help for the better tolerance of food. Patients should sip small amount of liquid during meals and during the day sip slowly the liquids using a straw.(1)

Cancer patients under treatment are advised to avoid the smell of food or cooking. Cold foods seem to smell less. Some foods might trigger nausea. These foods might be greasy or fried foods, spicy foods and foods with a strong smell. Some foods that might help are salty foods such as crisps, or crackers, dry foods such as biscuits, toast, plain cake or bland foods like chicken.(3)

Each patient treated for cancer is an individual case. There are many parameters that affect the occurrence of nausea, including exposure to chemotherapy, alcohol use, personality, age, gender and this is the reason complete prevention remains challenging.(18)

References:

1) National Cancer Institute, Support for People with Cancer. Eating Hints, Before, During, and After Cancer Treatment U.S. Department of Health and Human Services, National Institutes of Health NIH Publication No.11-2079, Printed January 2011.

2) Nausea and emesis: still an unsolved problem in cancer patients? Herrstedt J. Support Care Cancer. 2002 Mar;10(2):85-7. Epub 2002 Jan 31

3) The Christie , NHS Foundation Trust, Your A-Z of coping with nausea and vomiting. A guide for patients and their carers. www.christie.nhs.uk

4) J Pain Symptom Manage. 2014 May;47(5):839-848.e4. doi: 10.1016/j.jpainsymman.2013.06.012. Epub 2013 Sep 24. Evaluation of risk factors predicting chemotherapy-related nausea and vomiting: results from a European prospective observational study. Molassiotis A, Aapro M, Dicato M, Gascon P, Novoa SA, Isambert N, Burke TA, Gu A, Roila F.

5) Eur J Pharmacol. 2014 Jan 5;722:197-202. doi: 10.1016/j.ejphar.2013.09.073. Epub 2013 Oct 21. International antiemetic guidelines on chemotherapy induced nausea and vomiting (CINV): content and implementation in daily routine practice. Jordan K, Gralla R, Jahn F, Molassiotis A.

6) Ther Clin Risk Manag. 2015 May 5;11:713-29. doi: 10.2147/TCRM.S68130. eCollection 2015. Update on the management of chemotherapy-induced nausea and vomiting – focus on palonosetron. Zhou M, Popovic M, Pasetka M, Pulenzas N, Ahrari S, Chow E, DeAngelis C.

7) J Pain Symptom Manage. 2014 Jan;47(1):12-25. doi: 10.1016/j.jpainsymman.2013.03.007. Epub 2013 Apr 17. The effectiveness of acupressure for the control and management of chemotherapy-related acute and delayed nausea: a randomized controlled trial. Molassiotis A, Russell W, Hughes J, Breckons M, Lloyd-Williams M, Richardson J, Hulme C, Brearley SG, Campbell M, Garrow A, Ryder WD.

8) Eur Rev Med Pharmacol Sci. 2015 Apr;19(7):1291-6. Can nausea and vomiting be treated with ginger extract? Giacosa A, Morazzoni P, Bombardelli E, Riva A, Bianchi Porro G, Rondanelli M.

9) Complement Ther Med. 2015 Jun;23(3):396-404. doi: 10.1016/j.ctim.2015.03.009. Epub 2015 Apr 21. Effects of inhaled ginger aromatherapy on chemotherapy-induced nausea and vomiting and health-related quality of life in women with breast cancer. Lua PL, Salihah N, Mazlan N.

10) Nutr Rev. 2013 Apr;71(4):245-54. doi: 10.1111/nure.12016. Epub 2013 Mar 13. Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review. Marx WM, Teleni L, McCarthy AL, Vitetta L, McKavanagh D, Thomson D, Isenring E

11) NIH Consensus Conference: Acupuncture. JAMA 280:1518-1524, 1998

12) J Altern Complement Med. 2006 Jun;12(5):489-95. Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting. Ezzo J, Streitberger K, Schneider A.

13) Auton Neurosci. 2006 Oct 30;129(1-2):107-17. Epub 2006 Sep 1. Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Streitberger K, Ezzo J, Schneider A.

14) Semin Oncol Nurs. 2005 Aug;21(3):190-5. Acupuncture for side effects of chemoradiation therapy in cancer patients. Lu W.

15) J Clin Oncol. 2013 Mar 1;31(7):952-60. doi: 10.1200/JCO.2012.43.5818. Epub 2013 Jan 22. Systematic review of acupuncture in cancer care: a synthesis of the evidence. Garcia MK, McQuade J, Haddad R, Patel S, Lee R, Yang P, Palmer JL, Cohen L.

16) Biosci Trends. 2015 Feb;9(1):16-34. doi: 10.5582/bst.2015.01019. The advantages of using traditional Chinese medicine as an adjunctive therapy in the whole course of cancer treatment instead of only terminal stage of cancer. Qi F1, Zhao L, Zhou A, Zhang B, Li A, Wang Z, Han J.

17) Psychooncology. 2006 Oct;15(10):891-7. A pilot study of yoga for breast cancer survivors: physical and psychological benefits. Culos-Reed SN1, Carlson LE, Daroux LM, Hately-Aldous S.

18) BMC Pharmacol Toxicol. 2015 Mar 28;16:5. doi: 10.1186/s40360-015-0005-1. Cohort study of consistency between the compliance with guidelines for chemotherapy-induced nausea and vomiting and patient outcome. Inoue M , Shoji M, Shindo N, Otsuka K, Miura M, Shibata H