Many tools available to help APPs fight nausea in children with cancer

November 02, 2022

5 minute read


Disclosures: Beauchemin, Linder, Raybin and Zupanec do not report any relevant financial information.


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Nausea is one of the most common and distressing symptoms experienced by children and adolescents with cancer.

Patients and their parents report that nausea interrupts daily life at all phases of the cancer trajectory, from new diagnosis to advanced cancer and even at the end of life.



Nausea is a core symptom requiring regular evaluation in children and adolescents receiving <a class=cancer treatment. Source: Adobe Stock” class=”figure-img img-fluid” width=”800″/>
Nausea is a core symptom requiring regular evaluation in children and adolescents receiving cancer treatment. Source: Adobe Stock

Jennifer L. Raybin

Jennifer L. Raybin

Evidence is mixed, but data suggests that nausea worsens with age, as adolescents report more severe nausea and interference with daily activities compared to younger children, although younger children may not not have the language to express the concept of nausea.

Managing symptoms such as nausea is one of the primary goals of advanced practice providers, who aim to prevent and minimize negative symptoms related to cancer and its treatment. The Children’s Oncology Group (COG) and the Association of Pediatric Hematology/Oncology Nurses (APHON) collaborate closely to develop, share, and provide evidence-based guidance for PPAs providing supportive care in pediatric, adolescent clinical settings and young adults.

The Science of Nausea Symptoms

Nausea is a core symptom requiring regular evaluation in children and adolescents receiving cancer treatment. Collecting data directly from these young patients allows their voices to be heard, rather than relying on the perceptions of parents or caregivers.

Melissa P. Beauchemin, PhD, RN, CPNP-PC, CPON

Melissa Beauchemin

Investigators are also examining the use of electronic or mobile health apps to aid in symptom assessment in children and adolescents.

The NIH toolkit includes a recently published symptom assessment tool: Pediatric Patient-Reported Outcome Terminology Common Criteria for Adverse Events (Ped PRO-CTCAE). This resource was adapted from the adult-focused CTCAE and provides a valid and reliable approach to comparing patient-reported symptoms before and after interventions, as well as across diverse populations, across the treatment continuum. Because nausea is a prevalent and distressing symptom, interventions can and should be tested for their impact on symptom control using standardized symptom assessments.

Types of nausea

Nausea often occurs in the absence of vomiting; therefore, vomiting is not a reliable indicator of nausea. Additionally, there are several types of nausea, including chemotherapy-induced, anticipatory, disease-related, and acute or chronic, each requiring different management approaches. Uncontrolled nausea can lead to anorexia, weight loss and malnutrition and negatively impact the patient experience. The developmental stage and subjective reporting of the child or adolescent adds to the complexity of measuring nausea.

Lauri A. Linder

Lauri A. Linder

Reliable and valid tools for measuring nausea, such as the Pediatric Nausea Assessment Tool (PeNAT), are available. Emerging evidence also supports that quality of life measures can capture nausea and its relationship to overall well-being. PPAs need to be aware of these clinical tools, which could help us recognize nausea-related suffering and optimize treatment plans.

Treatment recommendations

New evidence regarding the optimal management of nausea continues to emerge. The dissemination of this information is a common objective of APHON and COG.

APHON has an evidence-based practice committee that develops symptom management practices. APHON also endorses published clinical guidelines with links to them on their website.

Within the COG, the Supportive Care Guidelines Committee includes APPs and reviews published clinical practice guidelines for approval.

APHON and COG have endorsed a published supportive care guideline for the management of nausea and vomiting (see references). Due to the complexity of nausea, the approved guideline addresses many aspects, including the prevention and treatment of acute, chronic, and anticipated nausea, as well as the levels of emetogenicity of chemotherapy regimens.

Fight against cancer and APP

APPs can be confused with the term cancer control, which focuses on supportive care and involves preventing symptoms rather than curing the disease. This area is highly relevant for APPs that manage distressing symptoms such as nausea. A unique opportunity exists for APPs to advocate or even conduct nausea management studies via COG or APHON. APPs are well suited to participate in all stages of clinical research, including protocol design, participant recruitment and consent, data collection and reporting. APPs may collaborate with physicians on cancer-focused therapeutic studies, but may find that working on cancer-fighting studies is more suited to our clinical roles. Additionally, with the shortage of clinical research coordinators, PPAs can fill a gap by helping to facilitate these studies during the daily routine care we provide.

Sue Zupanec

Sue Zupanec

PPAs should keep in mind that patients with nausea may be eligible to participate in open-label cancer control research studies investigating antiemetic strategies. Treatments in these studies often have evidence of safety and effectiveness in adults; however, more evidence is needed before they can be given to children and adolescents. This is the premise of clinical research, and APPs can help patients and their families understand the need and importance of these studies – to ultimately improve cancer care and the management of symptoms such as nausea in children and adolescents with cancer.

Conclusion

APPs will likely recognize the struggle to effectively prevent and manage nausea in patients. Even the experience of a brief viral gastrointestinal illness is a reminder of how terrible nausea is.

When trying to alleviate this suffering of children and adolescents with cancer, PPAs should turn to published guidelines for help. PPAs can also promote the search for new treatments through engagement with evidence-based practice, cancer control, and supportive care committees within the APHON or COG. Other unconventional strategies APPs can explore with multidisciplinary team support include acupuncture, aromatherapy, and medical marijuana, which have preliminary evidence of safety and efficacy for nausea control in pediatrics.

APPs have a key clinical role: to help patients manage symptoms. APPs can arm themselves with a toolbox of references, including creative and innovative ideas, to meet the needs and preferences of each patient.

Helio | HemOnc Today collaborated with the Association of Pediatric Hematology/Oncology Nurses (APHON) for the submission of this column.

References:

  • Beauchemin M, et al. App Clin Inform. 2021;doi:10.1055/s-0041-1728698.
  • Children’s oncology group. COG guidelines on supportive care. Available at: childrensoncologygroup.org/index.php/cog-supportive-care guidelines.
  • Dupuis LL, et al. Pharmacotherapy. 2006;doi:10.1592/phco.26.9.1221.
  • Hinds PS, et al. Pediatrician Leukemia. 2019;doi:10.1002/pbc.27606.
  • Linder LA, et al. Semin Oncol Nurses. 2015; doi:10.1016/j.soncn.2015.05.002.
  • Montgomery KE, et al. Cancer Nurses. 2020;doi:10.1097/NCC.0000000000000721.
  • Montgomery KE, et al. Nurses Outlook. 2021;doi:10.1016/j.outlook.2021.06.013.
  • Reeve BB, et al. J Natl Cancer Inst. 2020;doi:10.1093/jnci/djaa016.
  • Seelisch J, et al. Pediatrician Leukemia. 2019;doi:10.1002/pbc.27471.
  • Withycombe JS, et al. J Pediatrician Oncol Nurses. 2019;doi:10.1177/1043454219854983.
  • WolfeJ, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2014.59.1222.

For more information:

Mélissa Beauchemin, PhD, RN, CPNP, CPON, is an assistant professor of nursing at Columbia University School of Nursing. She can be reached at [email protected]

Lauri A. Linder, PhD, APRN, CPON, FAAN, FAPHON, is an associate professor in the College of Nursing at the University of Utah and a clinical nurse specialist at Primary Children’s Hospital in Salt Lake City. She can be contacted at [email protected]

Jennifer L. Raybin, Ph.D., RN, CPNP, is an Associate Professor of Nursing and Pediatric Hematological Oncology at Oregon Health & Science University and Doernbecher Children’s Hospital. She can be contacted at [email protected]

Sue Zupanec, MN, NP, is a Pediatric Nurse Practitioner at the Hospital for Sick Children in Toronto, Ontario, Canada, and Nursing Discipline Chair for the Children’s Oncology Group. She can be reached at [email protected]

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