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.