**6.5 Radiotherapy-induced N/V**

Few randomized controlled clinical trials have evaluated the prevention or treatment of N/V associated with radiotherapy. As for CINV, RINV is classified according to the emetogenic risk of radiation (**Table 4**).

Patients experiencing high-emetic-risk radiation therapy should be received a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone before each fraction and on the day after each fraction if radiation therapy is not planned for that day. Optimal frequency and duration of prophylactic 5-HT3 receptor antagonist therapy and prophylactic dexamethasone therapy for high-emetic-risk single-fraction or multiple-fraction radiation are unclear. Previous studies administered prophylactic 5-HT3 receptor antagonist therapy for durations longer than, equal to, and shorter than the duration of radiation therapy. Randomized studies comparing these approaches are lacking [53, 54].

Patients receiving moderate-emetic-risk should be treated with a 5-HT3 receptor antagonist before each fraction, with or without dexamethasone before the first five fractions. Optimal frequency and duration of prophylactic 5-HT3 receptor antagonist therapy for moderate-emetic-risk, single-fraction or multiplefraction radiation therapy are unclear. Guidelines recommend prophylaxis before each fraction with careful monitoring of patients during radiation therapy schedules that span multiple weeks to detect symptoms experienced during interspersed days when radiation therapy and prophylaxis are not administered and to balance the benefits and toxicities of prolonged 5-HT3 receptor antagonist therapy. A study that involved moderate-emetic-risk radiation therapy demonstrated a benefit for a number of secondary end points by adding prophylactic dexamethasone therapy to prophylactic 5-HT3 receptor antagonist therapy before the first five fractions [55].

Patients treated with low- and minimal-emetic-risk radiation therapy should receive rescue therapy with a 5-HT3 receptor antagonist, dexamethasone, or a dopamine receptor antagonist.

Patients who are treated with concurrent radio-chemotherapy should receive antiemetic therapy that is appropriate for the emetic risk level of antineoplastic agents, unless the risk level of the radiation therapy is higher [56].

One trial evaluated the addition of fosaprepitant to palonosetron and dexamethasone among women who received low-emetic-risk pelvic radiation and concurrent weekly cisplatin.36 The other trial compared fosaprepitant with olanzapine—each given with palonosetron and dexamethasone—among patients with head and neck or esophageal cancers who received radiation therapy and concurrent cisplatin and fluorouracil.

A systematic review of RINV reported that the clinical trial designs varied considerably in the methodologies, endpoints, and outcome measures employed with


**159**

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

concomitant chemo-radiotherapy.

and adherence to antitumoral treatments.

**7. Conclusions**

**7.1 High-risk of emesis**

to avoid delayed emesis.

**7.3 Low-risk of emesis**

**7.2 Moderate-risk of emesis**

great difficult to conclude definitive recommendations [57]. Most of the patients will be suggested to take the antiemetic by the international antiemetic guidelines. A MASCC/ESMO consensus systematic review recently evaluated 18 publications. The only fully published randomized studies in prevention of RINV were two negative studies in acupuncture and green tea, respectively. No data to support new recommendations for antiemetic prophylaxis in RINV was available. The serotonin receptor antagonists are still the corner stone in antiemetic prophylaxis of nausea and vomiting induced by high and moderate emetic risk radiotherapy. The emetogenicity of craniospinal radiotherapy was reclassified from low to moderate emetic level along with some other minor changes [58]. Further investigations are warranted to explore RINV prophylaxis in single fraction, multiple fractions and

Although the mechanisms of acupuncture are not completely clear yet, a plenty

of high-quality clinical trials have been conducted to evaluate the efficacy and safety of this therapy and reported that acupuncture could reduce nausea and vomiting induce by chemotherapy and radiotherapy with less side effects [50, 59, 60]. Neural mechanism like stimulating the secretion of endogenous opioid endorphin has been proved one of mechanisms of acupuncture therapeutical effect, but

CINV represents a common adverse event of chemotherapy with potentially

The combination of a 5-HT3 receptor antagonist, dexamethasone and aprepitant

For moderate-risk agents different from and anthracycline plus cyclophosphamide regimen, a combination of a 5-HT3 receptor antagonist and dexamethasone should be administered before chemotherapy. Patients with moderate risk of emesis have moderate potential for delayed emesis. These patients should be treated with a

For patients receiving chemotherapy with low-risk of emesis, a single dose of dexamethasone or a dopaminergic before chemotherapy is currently recommended.

5-HT3 receptor antagonist or dexamethasone alone on days 2 and 3.

No routine prevention for delayed emesis is recommended.

before chemotherapy is currently the recommended strategy for chemotherapy with high- and moderate-risk of emesis. More robust data is available for cisplatinbased chemotherapy and anthracycline plus cyclophosphamide regimen, less robust data is available for other agents. Approximately 90% of patients receiving cisplatin-based chemotherapy and anthracycline plus cyclophosphamide regimen develop delayed emesis. These patients should receive a regimen with one of 5-HT3 receptor antagonists plus 3-days oral aprepitant plus dexamethasone on days 2 to 4

significant negative impact on quality of life for patients and their families. Prevention and management of CINV is crucial to increase patients' compliance

for RINV relative neural mechanisms have not been found yet [61].

**Table 4.**

*Classification of radiotherapy according to the risk ok emesis.*

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

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

patients treated with chemotherapy [51, 52].

according to the emetogenic risk of radiation (**Table 4**).

comparing these approaches are lacking [53, 54].

**6.5 Radiotherapy-induced N/V**

vomiting when wristbands were added to standard antiemetic treatment among

Few randomized controlled clinical trials have evaluated the prevention or treatment of N/V associated with radiotherapy. As for CINV, RINV is classified

Patients experiencing high-emetic-risk radiation therapy should be received a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone before each fraction and on the day after each fraction if radiation therapy is not planned for that day. Optimal frequency and duration of prophylactic 5-HT3 receptor antagonist therapy and prophylactic dexamethasone therapy for high-emetic-risk single-fraction or multiple-fraction radiation are unclear. Previous studies administered prophylactic 5-HT3 receptor antagonist therapy for durations longer than, equal to, and shorter than the duration of radiation therapy. Randomized studies

Patients receiving moderate-emetic-risk should be treated with a 5-HT3 receptor antagonist before each fraction, with or without dexamethasone before the first five fractions. Optimal frequency and duration of prophylactic 5-HT3 receptor antagonist therapy for moderate-emetic-risk, single-fraction or multiplefraction radiation therapy are unclear. Guidelines recommend prophylaxis before each fraction with careful monitoring of patients during radiation therapy schedules that span multiple weeks to detect symptoms experienced during interspersed days when radiation therapy and prophylaxis are not administered and to balance the benefits and toxicities of prolonged 5-HT3 receptor antagonist therapy. A study that involved moderate-emetic-risk radiation therapy demonstrated a benefit for a number of secondary end points by adding prophylactic dexamethasone therapy to prophylactic 5-HT3 receptor antagonist therapy before the first five

Patients treated with low- and minimal-emetic-risk radiation therapy should receive rescue therapy with a 5-HT3 receptor antagonist, dexamethasone, or a

Patients who are treated with concurrent radio-chemotherapy should receive antiemetic therapy that is appropriate for the emetic risk level of antineoplastic

One trial evaluated the addition of fosaprepitant to palonosetron and dexamethasone among women who received low-emetic-risk pelvic radiation and concurrent weekly cisplatin.36 The other trial compared fosaprepitant with olanzapine—each given with palonosetron and dexamethasone—among patients with head and neck or esophageal cancers who received radiation therapy and concurrent cisplatin and

A systematic review of RINV reported that the clinical trial designs varied considerably in the methodologies, endpoints, and outcome measures employed with

> **Low-risk of emesis (10–30%)**

Brain, head and neck, thorax, pelvis irradiation **Minimal-risk of emesis (<10%)**

Extremities, breast irradiation

agents, unless the risk level of the radiation therapy is higher [56].

**Moderate-risk of emesis** 

**(30–90%)**

*Classification of radiotherapy according to the risk ok emesis.*

Upper abdomen, craniospinal irradiation

**158**

**Table 4.**

fractions [55].

fluorouracil.

**High-risk of emesis (>90%)**

Total body irradiation

dopamine receptor antagonist.

great difficult to conclude definitive recommendations [57]. Most of the patients will be suggested to take the antiemetic by the international antiemetic guidelines. A MASCC/ESMO consensus systematic review recently evaluated 18 publications. The only fully published randomized studies in prevention of RINV were two negative studies in acupuncture and green tea, respectively. No data to support new recommendations for antiemetic prophylaxis in RINV was available. The serotonin receptor antagonists are still the corner stone in antiemetic prophylaxis of nausea and vomiting induced by high and moderate emetic risk radiotherapy. The emetogenicity of craniospinal radiotherapy was reclassified from low to moderate emetic level along with some other minor changes [58]. Further investigations are warranted to explore RINV prophylaxis in single fraction, multiple fractions and concomitant chemo-radiotherapy.

Although the mechanisms of acupuncture are not completely clear yet, a plenty of high-quality clinical trials have been conducted to evaluate the efficacy and safety of this therapy and reported that acupuncture could reduce nausea and vomiting induce by chemotherapy and radiotherapy with less side effects [50, 59, 60]. Neural mechanism like stimulating the secretion of endogenous opioid endorphin has been proved one of mechanisms of acupuncture therapeutical effect, but for RINV relative neural mechanisms have not been found yet [61].
