Discussion
To the best of our knowledge, this is the first comprehensive review of the incidence and severity of CINV, and the first pediatric study to evaluate the use of a validated tool to capture the incidence and severity of CINV in pediatric patients in Saudi Arabia. Aseeri et al. evaluated the use of prophylactic antiemetics in a single-center pediatric oncology patient receiving moderate and HEC and concluded that premedication was underutilized in two-thirds of the patients; however, they did not investigate the incidence or severity of CINV.
The overall diagnoses distribution in our study matched the estimated proportions of malignancies reported globally. Similarly, the distribution of age and sex were consistent with the globally reported pediatric malignancy statistics. The incidence and severity of CINV in children vary depending on the type of chemotherapy administered, with some regimens having higher rates than others. In our study, the incidence of acute and delayed nausea was 30–33%, which is either less or consistent with previously published studies. In addition, we found that most patients who experienced acute or delayed nausea and vomiting received either high or moderate emetogenic chemotherapy, which is similar to that in previously published literature locally and internationally.
Flank et al. explored the impact of CINV on the use of parenteral nutrition and whether CINV affected the incidence of gut graft-versus-host disease10. Their data showed that most patients (83%) had received HEC regimens. A distinct indication was found that patients who experienced nausea or vomiting in the acute phase were likely to develop delayed nausea and/or vomiting. Our findings also revealed the same important productions regarding the severity of nausea and emesis, and the direct association between the acute and delayed phases. Although this was an exploratory study, we report a link between CINV and food intake tolerance. As nausea is very difficult to assess, especially in such a sensitive population, we included food tolerance as an indirect indicator to potentially aid in a thorough assessment. Over 50% of the patients indicated that they had a certain degree of food intake intolerance. Food intolerance was high among the patients with severe nausea and vomiting, and it was strongly associated with the type of chemotherapy emetogenicity.
In 2012, the POGO guidelines for the prevention and management of CINV in children were endorsed by several pediatric organizations such as the Children’s Oncology Group (COG). Incorporating these guidelines into clinical practice is imperative for better clinical outcomes. Similar to previously published studies, our study found a low rate of adherence to POGO guidelines. This finding showed that the rate of adherence differed depending on the diagnosis. Two main ways for the low rate of adherence were observed. The first was by using a 5-HT3 receptor antagonist (granisetron or ondansetron) for patients receiving minimal chemotherapy when none was indicated. The second was by not prescribing NK-1 antagonist for the patients receiving HEC. Clinicians are still cautious about potential drugs/drug interactions and prescribing medications, such as aprepitant, to prevent CINV. The primary reasons for non-adherence to the guidelines were the omission of dexamethasone in the patient’s antiemetic prophylaxis and prescribing antiemetics for patients with minimal emetogenic potential for which no antiemetics were indicated. Further research should seek strategies to better implement and standardize these guidelines.
This study has strengths and limitations. The strengths include the report being prospective in nature, allowing for inclusion of heterogeneous populations with differing diagnoses, ages, and chemotherapy regimens, both in ambulatory and inpatient settings, since both are likely to experience CINV. In addition, we performed the assessment twice to evaluate acute and delayed CINV and ensure that these phases of therapy were captured. Moreover, we included food intake tolerance as a valuable indirect indicator of nausea because it is difficult to assess. The limitation includes this study being a single-center analysis, which posed a challenge in completing the survey during the delayed phase in the outpatient setting, resulting in approximately a 10% loss of follow-up.
Adherence to the CINV guidelines and building a standardized approach in the institutions can decrease food intake intolerance, prevent delays in the chemotherapy protocol, decrease hospitalization, and improve patient quality of life. In addition to ensuring the practice of the latest and best available evidence-based medicine in the hospital, this study laid the foundation for establishing local data to implement a CINV assessment tool, which currently does not exist at our center. The study findings indicate the importance of integrating the BARF scale as an everyday assessment tool in pediatric oncology patients, and, therefore, preemptively treating children receiving chemotherapy before further deterioration. A proactive assessment approach will improve the patients’ and their families quality of life. If implemented, the tool has great potential in decreasing healthcare costs by reducing the number of readmissions secondary to excessive CINV. Finally, the role of clinical assessment by healthcare professionals remains a strong path toward the most suitable and correct decisions in managing CINV.