Listen to Your Patients: Improving Antiemetic Regimens

Dr Mark Kris discusses antiemetic regimens for patients with cancer, and the need to do better for patients.
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-- TRANSCRIPT --
Hello. This is Mark Kris from Memorial Sloan Kettering. I'm speaking today about an extremely important topic to all of us, and particularly our patients, which is the prevention of nausea and vomiting following anticancer therapy.
You know that when you do a survey of the main concerns of our patients that are about to begin, particularly chemotherapy, it's nausea, vomiting, and alopecia or alopecia, nausea, and vomiting. Those big three are on patients' minds. The more assurance we can give our patients that we can prevent these problems, I think, the better their whole outlook can be and the better the decency of their life. Please remember that there's no real treatment for nausea and vomiting brought on by cancer therapies. It's all about prevention.
Decades of research have shown that, particularly for the drugs that are very likely to cause emesis - cisplatin would be the leader there, and the other common one is the combination of cyclophosphamide and doxorubicin, used in adjuvant treatment of breast cancer and other cancers - if you receive those regimens, you're going to have nausea and emesis and you need our best drugs.
Research has shown that a 5-HT3 antagonist, dexamethasone given for several days, an NK1 antagonist, and olanzapine- giving four drugs is the recommended best therapy by guideline panels. I'm going to pick on the NCCN and ASCO guidelines, as I think those are the ones that most of us use. It's clear that all four of those drugs need to be used.
I'm going to talk about a great paper in The New England Journal of Medicine, by Dr Navari, that showed olanzapine 10 mg, dexamethasone, a 5-HT3 antagonist, and an NK1 antagonist was the best. By the way, that trial was about as pure as you can get. It was multicenter, randomized, placebo-controlled, not sponsored by pharma, and funded by your tax dollars. It was perfect.
The interesting thing about it is that folks just didn't embrace it. They particularly didn't embrace the olanzapine. The beautiful thing about olanzapine, though, is it controlled the biggest problem we have now, which isn't vomiting but nausea. In the Navari trial, the control of nausea went from 22% without olanzapine to 37%. This is the prevention of nausea, so that was big.
Why am I doing this today? There was a paper published in The Lancet Oncology by Bajpai. This was a randomized trial that compared an unconventional antiemetic regimen that really didn't contain multiple days of dexamethasone, with 2.5 or 10 mg olanzapine. What they found was really not good at all. Their complete control rate, what they said was only "mild nausea and no vomiting," was only 44% and 45% in the two arms. The majority of patients did not have so-called complete control. So-called total control, where people had no nausea, was 14% vs 16%. Those numbers are really inadequate.
What particularly concerned me is that this wasn't a trial to see if something was better. It was a trial to show noninferiority. Why would we want to show noninferiority for regimens that are clearly inadequate? It just made no sense to me. It really got to me because nausea is the greatest concern of our patients. We do have drugs that can help with nausea, and we can do better.
A couple of things. Number one, please use the guidelines that are out there now. They have been developed over nearly 40 years. It's extremely safe. They're available. Please use them and use them religiously.
Please listen to your patients. The prevention of nausea is absolutely critical, and I would pull out all the stops to do that. Look for ways that we can do a better job. It's kind of tough, actually. The one class of drugs that's out there now would probably be cannabinoids. Those deserve, I think, to be tested, particularly to treat nausea.
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