How to Address Patients’ Fear of Nausea During Chemotherapy

This transcript has been edited for clarity. 
Hello. This is Mark Kris, from Memorial Sloan Kettering, speaking today about a topic that really touches virtually every person with cancer receiving anticancer therapy, and that is the prevention of nausea and emesis. 
When they’ve done surveys of patients, what is it about cancer therapy that’s most feared? It’s pretty common that there’s one answer, and that is nausea. We, as oncologists, really need to tell patients that nausea can be prevented. At the very least, we will do everything we can to listen to the information we have, the data we have, and the drugs we have to do that.
There was a very nice paper in the Journal of Clinical Oncology from Japan. The first author was Dr Inui. This was a randomized trial in patients with lung cancer getting standard chemotherapy, but with carboplatin, which is the platinum drug that 90% of patients with lung cancer receive when they get therapy.
By the way, no matter what target you have in your cancer, whether it’s adeno or squamous or small cell, you’re always going to get chemotherapy and it will almost always contain carboplatin, so this is an extremely relevant paper. 
They use a standard therapy, and if you go to the NCCN guidelines, this is a highly emetogenic drug, and patients should get a 5-HT3 antagonist, an NK-1 antagonist, and dexamethasone.
Also, they should get olanzapine. If you go to the preferred antiemetic regimen for highly emetogenic therapy, like carboplatin over AUC4, you should be getting olanzapine. In this trial, they randomized 5 mg olanzapine daily for 4 days vs placebo. 
When you read the paper, you get the idea that not much good happened. The amount of complete control (which was no vomiting and no need for rescue therapy) in the placebo arm was 81%, but with the olanzapine arm, it was 87%. Nearly 90% of patients had that primary endpoint.
That didn’t meet their prespecified criteria, but to me, it kind of missed the point. Remember where we started today. What is it that our patients really fear? It’s nausea, and in both counts here, nausea control was significantly improved over placebo. Total control, which is really what we want, where there is no nausea and no vomiting, was also improved. Total control was improved by about 10% and nausea control was improved by 14%. Again, prevention, so there was no nausea. 
This is a very important paper. Adding in a drug that costs pennies that’s already a standard therapy — actually, if you’re following the preferred regimen for emetogenic chemotherapy via the NCCN guidelines, you should be giving olanzapine.
The other nice thing they did was give it at the 5 mg dose. There are many reasons why folks are uncomfortable with olanzapine, and using this — I’ll call it intermediate — 5 mg dose was good. 
The other thing about it is there’s this fear that it will lead to severe sedation. Again, looking at the data in this placebo-controlled, randomized trial, 59% of patients getting placebo had no somnolence, whereas 57% receiving olanzapine had no somnolence. There was a 2% difference in the amount of sleepiness that came on. There also was a significant improvement in people who had loss of appetite, again favoring the olanzapine.
Not a single patient had a side effect that caused the therapies to be discontinued. To me, this is a very important paper. It deals with a cancer regimen that is a standard of care worldwide. It’s a standard of care for everybody with lung cancer, regardless of cell type and regardless of molecular characteristics.
It shows that the drugs are very safe. Adding in olanzapine improves vomiting control, greatly improves nausea control, and is associated with no side effects that limit therapy. 
I urge you to read this paper and to use olanzapine. It answers a primary need that our patients have told us that they have, and it helps me, at least, to look my patient in the eye and say, “I did everything we can to prevent nausea in your cancer treatment.”