CINV (Chemotherapy Induced Nausea and Vomiting) – Evaluating the distance we have traveled on the road to better oncological practices and treatments.
The big question has always been, and is still constantly being asked: How far have we come to making CINV something patients no longer have to fear? Concerns relevant to these questions were voiced by respected oncologist, Dr. Lee S. Schwartzberg, MD, in a segment of OncLine Peer Exchange in July 2017. A year later, there is still both promise and challenges.
Researchers continually plug in new clues to what proves to be an old constant in regards to cancer care. Progressive treatments and care standards are steadily increasing and expanding in terms of how the scientific community is addressing the needs and concerns of cancer patients. As oncologists sift through the layers of research, the interest has intensified surrounding the discovery of oncolytic-virotherapies and PD-1 FDA clinical trials. Clinical studies indicate that patient tolerance of immunotherapy interventions, coupled with PD-1 type drug interventions, is significantly improved.
Why the CINV Conversation is Worth Prioritizing
Despite the substantial progress made in CINV prophylaxis, as many as 40 percent of patients with cancer still experience nausea, vomiting, or both, following receipt of chemotherapy. [1} While nausea and vomiting are often considered a unified symptom, the precise physiology and risk factors that contribute to nausea are poorly understood, and many of the antiemetic agents currently available do little to relieve chemotherapy-induced nausea. The medical community recognizes the need for both acute CINV and delayed CINV and indicates the benefits to representative of both patient and hospital administrations effectively. Validating the potential financial consequences, the NIH released a study indicating the significant cost of health care-related resources utilized in the treatment of HEC-related CINV emergency care visits.
The Benefits Associated with Improved CINV Management and Efficacy
- Improved patient outcomes
- Reduced allocation of healthcare resources
- Reduction in patient urgent/emergency room care visits
- Patient is able to complete full scope of treatment
- Improved patient quality of life
- Improved overall patient wellness
- Improved immune function and conjunctive drug therapy efficacy
Trending CINV Methodology
The landscape of cancer treatments is geared heavily toward advancements in immunotherapy. Consequently, we have on the horizon a new outlook for the treatment of CINV. Substandard patient outcomes have raised concerns on drug efficacy. Leading the topic, Dr. Lee S. Schwarzberg indicated in a recent article that drug efficacy was only part of the equation.  The other components pointing at guideline adherence seemed to play an integral role in the controlling the first cycle of CINV and preventing anticipatory emetic responses, thus halting cycles two and three. In randomized clinical trials, NK-1 receptor antagonists were studied to see if they helped in delayed HEC CINV responses compared to placebo. Results were favorable when added to 5-HT3 receptors.
Journal contributions referencing Dr. Lee S. Schwartzberg's most recent clinical research highlighting clinical trials of Pherexa™, in the treatment of HER-2 metastatic breast cancer reveal marked improvement with regards to patient outcome.  While there wasn't a direct correlation indicating a reduction of CINV or patient tolerances, there have been corresponding studies citing conclusive evidence immunotherapies and oncolytic viral therapies are significantly better tolerated than traditional treatment modalities. Immuno-oncology refines the immune signaling pathways of receptor cells. In turn, endpoint assessments of immunotherapies reveal they are an attractive alternative to chemotherapy. Immunotherapies indicate a reduced instance of nausea, vomiting, and hair loss. Depending on the type of immunotherapy used, the side effects typically mimic a virus. 
Current CINV clinical applications in practice are: Serotonin (5-hydroxytryptamine or 5-HT3) receptor antagonists, neurokinin-1 (NK-1) receptor antagonists, and the atypical antipsychotic olanzapine. This year, the FDA approved an IV formulation of netupitant, palonosetron to be used alongside dexamethasone for the treatment of acute HEC CINV. 
In conclusion, it is clear that there is a progressive movement, as medical experts continue to travel the road to providing quality patient care. The goal of both oncologists and patient advocates is to find a bridge where cancer treatment side effects can be lessened and completed successfully. Through the success of viral immunotherapy and concurrent CINV drug efficacy and standards, the pathway for optimal patient outcomes is clearing rapidly. As of this writing, 2015 to 2017, the number of combination studies listed on ClinicalTrials.gov combining PD-1 or PD-L1 inhibitors with other therapies has surged to exceed over 200 active studies. 
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1) ASCO 2018: Abstract Recommendations - Dr. Lee Schwartzberg
2) Getting It Right the First Time: Recent Progress in Optimizing Antiemetic Usage - L Schwartzberg. Support Care Cancer 26 (Suppl 1), 19-27. 2018 Mar 19.
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