**3. Clinical presentation**

Cancer patients often experience N/V together but not necessarily. It is possible to experience nausea without emesis or emesis without nausea. The events of nausea and vomiting are generally protecting reflexes to rid intestine and stomach of toxic substances.

Nausea is described as a subjective and diffuse feeling of unease and discomfort often perceived as an urge to vomit. It can be considered a prodromal phase to the act of vomiting. It is characterized by sickness in the stomach, epigastrium and/or throat. Vomiting or emesis means the expulsion of stomach contents beyond the mouth and is accompanied by shivering and salivation.

The use of single agent cisplatin led to classify CINV into five types: acute, delayed, anticipatory, breakthrough and refractory according to the timing of appearance and in the absence of effective antiemetic prevention [5]. Acute CINV occurs within 24 hours of the chemotherapy administration, while delayed CINV occurs after 24 hours and could persist for 2–3 weeks after the administration of chemotherapy. Chemotherapeutic agents such as cisplatin, carboplatin, cyclophosphamide, anthracyclines are generally related to delayed CINV [6]. Anticipatory CINV involves patients who had already experienced N/V and occurs prior to the impending administration of chemotherapy triggered by the just thinking of it through a sensorial way (sight, smell). The incidence of anticipatory CINV has decreased in recent years because of the improved strategies for controlling acute and delayed emesis. Breakthrough CINV is vomiting and/or nausea that occurs within five days of chemotherapy administration after the use of guideline directed prophylactic antiemetic agents. This type of CINV usually requires immediate treatment or requires "rescue" with additional antiemetics. Refractory CINV is defined as vomiting and/or nausea occurring after chemotherapy in subsequent chemotherapy cycles after guideline directed prophylactic antiemetic agents have failed in earlier cycles (**Table 1**).

Patients with CINV should be assessed with a visual analog scale (0 to 10, with 0 no nausea and 10 maximum nausea). The frequency, severity, time of appearance and any associated activities (meals, drugs) should be requested. Recent treatment with chemotherapy and/or radiation therapy should then be noted with evaluation of single agent or combination of chemotherapy. The physical examination should include a complete assessment of the abdomen in order to identify a possible

**151**

**Table 2.**

**4. Risk factors**

**High-risk of emesis**

**(>90%)**

Breakthrough CINV

**Table 1.**

*Chemotherapy-Induced Nausea and Vomiting DOI: http://dx.doi.org/10.5772/intechopen.96194*

*Clinical presentation and physiopathology of CINV.*

organic cause of the emesis such as gastritis, bowel obstruction, an inflammatory process. A complete neurologic examination should also be performed to determine the search focal neurologic signs suggesting intracranial hypertension or meningeal carcinosis. Weight loss, appetite, anorexia, and/or cachexia should be evaluated to investigate the possible etiology of N/V and to help the differential diagnosis.

**Clinical presentation and physiopathology**

Delayed CINV After 24 hours of initial administration of chemotherapy to 2–3 weeks.

Mainly by 5-HT3 release from the enterochromaffin cells

Triggered by taste, smell, sight, thoughts of a previous CINV.

Within 5 days of initial administration of chemotherapy.

Mainly by substance P release, disruption of the blood–brain barrier and disruption

**Low-risk of emesis (10–30%)**

Ifosfamide Lapatinib Vinblastine Irinotecan Methotrexate Vincristine Oxaliplatin Mytomicin Vinorelbine

> Paclitaxel Pemetrexed Topotecan Trastuzumab

**Minimal-risk of emesis (<10%)**

Acute CINV Within 24 hours of initial administration of chemotherapy.

of the gastrointestinal motility.

Refractory CINV After chemotherapy despite prophylactic antiemetic agents

Anticipatory CINV After a previous cycle of chemotherapy.

The occurrence of CINV can depend on several factors. The risk factors for CINV are both patient- and treatment-related. The most common patient-related risk factors are age, gender, previous motion sickness and/or pregnancy-related N/V and previous CINV. Patients younger than 50 years, females, patients with a history of previous motion sickness and/or pregnancy-related N/V have a greater

Carmustine Procarbazine Bortezomib Bevacizumab Cisplatin Carboplatin Cetuximab Bleomycin Cyclophosphamide Cyclophosphamide Docetaxel Busulfan Dacarbazine Cytosine arabinoside Etoposide Capecitabine Mechlorethamine Doxorubicin 5-fluorouracil Chlorambucil Streptozotocin Epirubicin Gemcitabine Fludarabine

Melphalan Mitoxantrone

**Moderate-risk of emesis**

**(30–90%)**

*Classification of antitumoral therapy according to the risk of emesis.*

*Chemotherapy-Induced Nausea and Vomiting DOI: http://dx.doi.org/10.5772/intechopen.96194*

**Table 1.**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

the overall adherence to guidelines was just 29% [3].

mouth and is accompanied by shivering and salivation.

going radiotherapy will suffer [4].

failed in earlier cycles (**Table 1**).

**3. Clinical presentation**

substances.

CINV involves about 60–80% of patients with cancer increasing the risk of patients' discomfort and chemotherapy's discontinuation [1]. The prevention of CINV is mainly important in reducing morbidity and total healthcare costs, as well as increasing the quality of care in patients receiving emetogenic chemotherapy. Patients experiencing CINV may refuse treatment, request or require dose reductions or seek alternative therapy options. Acute CINV may be prevented in 50% to 90% of patients using effective preventive strategies [2]. In a large European observational study, 1000 patients who had received guideline antiemetic treatment had significantly better CINV control than those who did not receive guideline treatment. The complete control rates were 60% versus 51%, respectively; however,

Radiotherapy-induced nausea and vomiting (RINV) is one of the most common side effects during radiation, from which about 50% to 80% of the patients under-

Cancer patients often experience N/V together but not necessarily. It is possible to experience nausea without emesis or emesis without nausea. The events of nausea and vomiting are generally protecting reflexes to rid intestine and stomach of toxic

Nausea is described as a subjective and diffuse feeling of unease and discomfort often perceived as an urge to vomit. It can be considered a prodromal phase to the act of vomiting. It is characterized by sickness in the stomach, epigastrium and/or throat. Vomiting or emesis means the expulsion of stomach contents beyond the

The use of single agent cisplatin led to classify CINV into five types: acute, delayed, anticipatory, breakthrough and refractory according to the timing of appearance and in the absence of effective antiemetic prevention [5]. Acute CINV occurs within 24 hours of the chemotherapy administration, while delayed CINV occurs after 24 hours and could persist for 2–3 weeks after the administration of chemotherapy. Chemotherapeutic agents such as cisplatin, carboplatin, cyclophosphamide, anthracyclines are generally related to delayed CINV [6]. Anticipatory CINV involves patients who had already experienced N/V and occurs prior to the impending administration of chemotherapy triggered by the just thinking of it through a sensorial way (sight, smell). The incidence of anticipatory CINV has decreased in recent years because of the improved strategies for controlling acute and delayed emesis. Breakthrough CINV is vomiting and/or nausea that occurs within five days of chemotherapy administration after the use of guideline directed prophylactic antiemetic agents. This type of CINV usually requires immediate treatment or requires "rescue" with additional antiemetics. Refractory CINV is defined as vomiting and/or nausea occurring after chemotherapy in subsequent chemotherapy cycles after guideline directed prophylactic antiemetic agents have

Patients with CINV should be assessed with a visual analog scale (0 to 10, with 0 no nausea and 10 maximum nausea). The frequency, severity, time of appearance and any associated activities (meals, drugs) should be requested. Recent treatment with chemotherapy and/or radiation therapy should then be noted with evaluation of single agent or combination of chemotherapy. The physical examination should include a complete assessment of the abdomen in order to identify a possible

**2. Epidemiology**

**150**

*Clinical presentation and physiopathology of CINV.*

organic cause of the emesis such as gastritis, bowel obstruction, an inflammatory process. A complete neurologic examination should also be performed to determine the search focal neurologic signs suggesting intracranial hypertension or meningeal carcinosis. Weight loss, appetite, anorexia, and/or cachexia should be evaluated to investigate the possible etiology of N/V and to help the differential diagnosis.