The purpose of this document is to provide guidance to minimise and where possible prevent radiation induced nausea and vomiting (RINV).
This document has been developed for the Australian clinical context using the most recent international guidelines including MASCC/ESMO antiemetic guidelines 2016,r ASCO guidelines antiemetic Update 2017r (including the 2016 focused guideline updater) and NCCN guidelines v.2 2017.r
Nausea and vomiting occur when neurotransmitters are stimulated and an impulse is sent to the autonomic nervous system, causing nausea, and to the somatic and visceral system to produce vomiting.r
The incidence and severity of RINV are influenced by the specific RT regimen and by patient-specific factors. Frequency has been reported in 28-39% of patients.rr Furthermore, uncontrolled nausea and vomiting may result in patients delaying or refusing further radiotherapy.r
Nausea can be one of the earliest side-effect of radiotherapy to develop and can appear 1 to 3 days after the commencement of treatment, lasting for several hours after treatment is completed. The first few days after the onset of RINV can be the most severe.
There are multiple risk factors that predispose to the development and severity of RINV. These risk factors can include (but are not limited to) treatment and patient related factors.
Treatment related factors that affect the emetic risk include:
- the area of/in the treatment field:
- total body irradiation
- the abdomen
- the brain
- extended pelvis fields
- the epigastric region
- the para-aortic area
- in rare cases the chemoreceptor trigger zone (CTZ) in the cerebral cortex of the brain
- the size of the treatment field
- the dose of radiation delivered per fraction and total dose.
Patient related factors that may increase the risk of RINV include:
- concurrent or recent chemotherapy
- younger age (<50 years)
- history of motion sickness and/or nausea in pregnancy
- poor performance status
- no alcohol consumption (i.e. less likely if high chronic alcohol intake)
- previous episodes of RINV
- tumour stage
*Due to feelings of anxiety or nervousness at the prospect of receiving radiotherapy or as a conditioned response to previous vomiting, patients may experience anticipatory nausea prior to treatment commencing.r
The likelihood of experiencing RINV can be divided into the following 4 groups:r
Levels of emetic risk with radiation therapy
||Area of treatment
|High (greater than 90%)
||Total body irradiation (TBI)
|Moderate (30 to 90%)
||Upper abdomen, craniospinal
|Low (10 to 30%)
||Brain, head & neck, thorax region, pelvis
|Minimal (less than 10%)
*For patients having concurrent chemoradiotherapy, patients should receive antiemetic prophylaxis according to the emetogenicity of chemotherapy, unless the emetic risk with the planned radiotherapy is higher. Link to prevention of chemotherapy induced nausea and vomiting.