Taking a Dip After a Hurricane

Work in Progress has been on an unexpected summer hiatus. Who would have though that heading off to the mountains with two small children and molasses-like internet access would prove such a hindrance to blog posts? As it turned out, it’s been a hindrance to pretty much anything except spending time outdoors, so no complaints about that.

But as summer starts winding down, and in light of today’s ultra-beautiful blue sky (a very welcome arrival after yesterday’s storm), today seemed like a good time to take a break from my excitement about the upcoming Columbia County Fair for a small jaunt back into the land of health care, drug development, and all of the accompanying wonders, questions, ups and downs. Just a quick dip, like a cat in a new home taking its first, short walks out of its hiding place to discover its new surroundings.

What I won’t, but would like to, be blogging about today is drug shortages. No doubt you’ve heard the news reports about how many cancer drugs are in short or nonexistent supply. We definitely need to talk about this here. But considering all that’s already out there on this disturbing issue, I’ll wait until I have something useful to add to the conversation. Today, I got nothing.

What I happily share with you instead is some new information about a whole other kettle of fish (warning, major topic change coming): chemotherapy-induced nausea and vomiting. During a recent conversation with an oncologist focused on this area of cancer care, I was very surprised to hear about many strides that have been made in understanding and treating CINV, and thought you might like to hear about them, too. Because although the subject isn’t one that many people enjoy thinking about, the research is kind of amazing.

First of all, did you know that nausea can be more problematic than vomiting for cancer patients? Whenever I’ve read or written about CINV over the past several years, I always thought to myself, “why is nausea so problematic? So, the person is uncomfortable. Isn’t that a small thing to cope with when you’re having a deadly disease eradicated from your body?” And I thought that vomiting was dangerous because of the risk of dehydration. Well, it turns out that my thinking was silly (not the first time, I admit). Nausea can be more dangerous than vomiting because it can lead to not eating or drinking. Vomiting often brings relief, and in that window of comfort, calories can be tolerated. But nausea is constant discomfort, a perilous state for a person undergoing rigorous chemotherapy and in need of strength-giving food and water.

Next: There is now some evidence that ethnicity may be a factor in determining the best treatment for CINV. An observational study at a small hospital in Malaysia (a country with a great deal of ethnic diversity) found that among patients being treated for breast cancer, different ethnic groups had different responses to antiemetics—and differing severity of CINV (Chinese patients had more nausea and vomiting than did the Malay or Indian patients). Have you ever thought that CINV could be connected to some kind of genetic variant that differs according to ethnicity?

And here’s another thing: it turns out that although the N and the V are generally grouped together, they may actually be two distinct phenomena. N is not necessarily related to V, and so a treatment for N might not treat V, and vice versa of course. That’s important because most of the antiemetics approved for use in the United States have been approved based on their meeting a target endpoint of reducing vomiting. That is a much easier thing to measure than reducing nausea, but has the unfortunate side effect of diminishing the importance of addressing the N part of CINV. This slight shift in thinking could have significant ramifications for research, because nausea might be effectively treated by an appetite stimulant, whereas vomiting requires targeting a very different bodily pathway. This insight is also important because at least one survey (albeit form several years ago) found that doctors and nurses underestimated the amount of delayed nausea (ie, 2–5 days after chemotherapy administration) their patients were experiencing.

So there you are, a brief tour of some current advances in the field of CINV. Call me sentimental, but I have always found the idea of researching CINV somewhat moving. There is very little that is glamorous here, but very much that is central to the idea of caregiving. Yes, I know that successful antiemetics can carry a loud cha-ching sound, and maybe this gorgeous blue sky after some harrowing rain and wind has got me a bit starry-eyed, but I love that there are talented people out there trying to unravel how to make life a little more comfortable for people being treated for cancer.

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