The purpose of this document is to provide guidance to minimise and where possible, prevent radiation therapy 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 2019r, ASCO antiemetic guidelines update 2020 r and NCCN Clinical Practice Guidelines in Oncology - Antiemesis guidelines v1.2021.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 radiation therapy 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 radiation therapy.r
Nausea can be one of the earliest side effect of radiation therapy 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 the patient 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 the body being treated/in the treatment field
- total body irradiation
- epigastric region
- para-aortic area
- pelvis fields extending into the abdomen
- chemoreceptor trigger zone (CTZ) in the cerebral cortex of the brain (in rare cases)
- the size of the treatment areas/field
- the per fraction and total dose of radiation delivered.
Patient related factors that may increase the risk of RINV include:
- concurrent or recent chemotherapy
- younger age (<50 years)
- previous history of RINV
- little or no previous alcohol use (chronic high consumption of alcohol appears to protect against RINV).
- history of motion sickness
- pregnancy related nausea/emesis
- anxiety/high pre-treatment expectation of nausea
- poor performance status.
Levels of emetic risk with radiation therapy
The likelihood of experiencing RINV can be divided into the following 4 groups:r
||Area of treatment
|High (greater than 90%)
||Total body irradiation (TBI)
|Moderate (30 to 90%)
||Upper abdomen, craniospinal irradiation
|Low (10 to 30%)
||Brain, head & neck, thorax, pelvis
|Minimal (less than 10%)
RINV is generally milder than anti-cancer therapy induced nausea and vomiting (AINV). Patients having concurrent chemoradiation therapy should receive antiemetic prophylaxis according to the emetogenicity of anti-cancer therapy, unless the emetic risk with the planned radiation therapy is higher. Link to prevention of anti-cancer therapy induced nausea and vomiting.