Very high on many cancer patients' list of unwanted side effects is nausea and vomiting. In years past, these fears were justified, and many people did develop these side effects, since many chemotherapy medications had to be administered without effective anti-nausea medications and techniques.

But today, for most people, nausea and vomiting is one of the most well-managed side effects. It may take some experimentation, but almost every patient receiving treatment today can expect to have this unpleasant side effect well-controlled. Today's antiemetic (nausea-fighting) medications and other medicines and techniques generally do an excellent job of controlling nausea and vomiting.

Controlling this side effect is very important, and it's critical to make the effort to achieve good control. Prolonged nausea and vomiting can lead to dehydration, loss of appetite, interference with healing wounds, and of course, it has a very negative impact on one's quality of life.

Your job as a patient (and caregivers, too, please take note) is to work with your health care team to make certain this side effect is controlled. While some people receive good results from just a single medication — more about those below — for others, some experimentation will be necessary. Be prepared to report symptoms to your health care team promptly, so the right treatment can be found for you.

There are several different kinds of nausea and vomiting, and all can be treated:

1. Anticipatory Nausea
   
   
   • This is felt before each cycle of chemotherapy or other treatment begins, and usually develops after a person has had nausea and vomiting as a result of an earlier treatment.
     
     
   • Research shows a variety of "triggers" can cause anticipatory nausea. These include odors in a treatment room or hospital, for example.
     
     
   • Some people develop anticipatory nausea even before leaving for treatment. This is a conditioned reflex (a response to earlier stimulus) than can happen repeatedly, each time a person faces the situation that triggers the reflex.
   
   
2. Acute nausea develops soon after treatment or within 24 hours of treatment.
   
   
3. Delayed or Late Nausea develops more than 24 hours after treatment, and may develop even days after treatment has ended.
   
   
4. Chronic Nausea, a condition that sometimes occurs in people with advanced cancer, it is usually unrelated to chemotherapy or other active treatments.
   
   
5. Radiation-Related Nausea can sometimes result if radiation is to the brain, whole body or gastrointestinal tract. The heavier the dose of radiation, the more likely nausea is to develop. This nausea is not usually long-lasting. Your health care team will tell you what to anticipate, based on the radiation prescribed for you.
   
   
6. Medication-Induced Nausea is the result of some pain medications, notably opioids. These medications can cause significant constipation if a patient is not actively treating the constipation. Severe constipation can cause a person to feel nauseated. Please see our sections on Constipation and on Pain for management suggestions.
   
   
7. A bowel obstruction can cause nausea. See information at Bowel Obstruction for more information.

Symptoms

The physical feelings of nausea and vomiting are very familiar to most people, and include:

• Feeling nauseated, and then vomiting
• Feeling nauseated, sometimes for a long time, and not vomiting
• Inability to eat or drink without feeling nausea and sometimes the urge to vomit
• Lack of appetite

Prevention

Prevention of nausea and vomiting is an absolute cornerstone of good medicine in treating people with cancer for nausea and vomiting occurrence. Your health care team should speak with you before treatment begins about how your possible nausea and vomiting will be pre-treated, and then treated if it should develop. Make sure that this very important discussion takes place.

Remember that not all chemotherapy drugs are equally likely to cause nausea and vomiting. See More Information for a listing of chemotherapy medications and their relative likelihood to cause this side effect.

A variety of medications to fight nausea, called antiemetics, can be used alone or in combination as preventive measures. A list of the most frequently used medications is provided below. Speak with your physician about which medications will be used for your care.

• Most-frequently used antiemetics are:
  
  
  • Ondansetron (Zofran)
  • Granisetron (Kytril)
  • Prochlorperazine (Compazine)
  • Metoclopramide (Reglan)
  
  
• Corticosteroids — often given with antiemetics:
  
  
  • Dexamethasone (Decadron)
  • Methylprednisolone (Medrol)
  
  
• Antacids and antiflatulents — medications used to combat heartburn and gas — some are over-the-counter, others are prescription. Your health care team will give you a recommendation if these medications are needed.
  
  
• Antidepressants — these are sometimes prescribed to accompany antiemetics and other medications and help some people significantly.
  
  
• THC (Marinol) — a legal derivative of marijuana in pill form that is occasionally used to try and help patients for whom nothing else has worked.

There are behavioral therapies and techniques that can also prove helpful in combating nausea and vomiting, including:

• Acupressure
• Acupuncture
• Biofeedback
• Distraction Therapy
• Hypnosis
• Relaxation
• Visualization/Imagery
• Rhythmic breathing

There are still other techniques and tactics that cancer patients and health care providers have tried over the years that help many patients thwart nausea and vomiting:

• Eating techniques:
  
  
  • Avoid large meals; consider several small meals instead.
    
    
  • Eat slowly, in a peaceful setting.
    
    
  • Drink liquids 30 minutes before a meal, rather than with the meal.
    
    
  • Avoid favorite foods if you feel nauseated.
    
    
  • Try cool or cold foods, if hot food is unappealing. Some suggestions include Jello, cottage or ricotta cheese, yogurt, pudding, sherbet, cold sandwiches, pasta or potato salads, and popsicles.
    
    
  • Some people favor dry foods, such as crackers, potatoes, bagels, etc.
    
    
  • If you feel nauseous when you wake up, steal a page from pregnancy handbooks and eat some crackers that you keep beside your bed.
    
    
  • Bland foods work well for many people: try toast, cereals, yogurt, ices, cookies, pretzels and skinless cooked chicken.
    
    
  • Avoid greasy foods: pizza, sausage and fried foods.
    
    
  • Avoid gas-producing vegetables, like broccoli, cauliflower, cucumbers, green peppers, brussels sprouts and sauerkraut, to name a few.
    
    
  • Some people do best if they avoid acidic foods, like vinaigrette salad dressing, tomatoes and fruit juices.
    
    
  • Food preparation can prove difficult for some people, because the smell of cooking food can be nauseating. If this is the case, and you must prepare your own food, consider using the microwave and the oven more frequently than stove-top cooking.
  
  
• Ask people to avoid unpleasant odors like smoking and heavy perfume around you.
  
  
• After eating, relax — but if possible, do not lie down; remain seated.
  
  
• If you must lie down, do so with your head well-elevated above your feet.
  
  
• If possible, enjoy a brief walk in the fresh air after eating.
  
  
• Avoid wearing tight, constricting clothing; be comfortable!
  
  
• For most people, avoiding alcoholic beverages helps with nausea.
  
  
• Distract yourself when eating alone — consider reading something, watching television, or listening to music you love.
  
  
• Understand your schedule for taking your anti-nausea medications, and stay on it. Don't decide to opt out of taking the medicine if at the moment you are feeling well. Nausea has a way of sneaking up on some people.
  
  
• Some anti-nausea medications can be constipating to some people. If you are one of them, consider adding more fluid to your diet once you begin these medicines. If this doesn't work, talk with your health care team about other treatment.
  
  
• Don't be passive about your care, hoping against hope that the preventive drugs will eventually work. It isn't likely. If your preventive medications don't work and you become nauseous and vomit, contact your health care team and arrange to try something different. Health care professionals caring for cancer patients anticipate that some trial-and-error will be needed for many patients, and they are there to help you.
  

Treatment

To repeat — the best medical practice is to pre-treat cancer patients for nausea and vomiting before chemotherapy is given, with a plan for continuing the medications while the danger of nausea continues.

However, this is not always all that is needed. Additional treatment is available for people for whom pre-treatment is not sufficient.

There are some warning signs that require immediate help from your health care team, if you're experiencing nausea and vomiting, and:

• Your vomit is black, bloody or looks like coffee grounds
  
• You feel ill, or faint
  
• You are having shortness of breath
  
• You are in pain

For anticipatory nausea (a condition where people feel nauseated even before chemotherapy or other treatment begins) traditional anti-nausea medications don't work well. However, there are additional approaches:

• Try relaxation techniques before treatment, including acupuncture, acupressure, hypnosis, progressive muscle relaxation with guided imagery, and distraction.
  
  
• Consider changing the time of day at which chemotherapy is given.
  
  
• For some patients, starting anti-nausea medications several days before chemotherapy helps.
  
  
• Combinations of medications may prove helpful, including the use of anti-anxiety medications. Your health care team can help with this.

For acute nausea, occurring within a few hours or a day or so of treatment, these approaches can help:

• Your health care team will probably recommend trying different combinations of medications, and timing the administration of different medications.
  
  
  • Be ready to experiment to learn which combination is right for you.
  
  
• Sometimes anti-psychotic medications can prove helpful. One such medication is haloperidol (Haldol), which is also a strong anti-nausea medication. Taking this medication for nausea does not mean you are psychotic.
  
  
• If you are having difficulty even keeping a pill down without vomiting, it is possible to deliver some medications by suppository or by injection. Your health care team will know if this is appropriate for you.

For delayed nausea, occurring more than a day or so after treatment has been given, patients are usually kept on a similar combination of medications that were given before treatment began, as long as this is successful for you. If this isn't working well, consult your health care team at once.

For breakthrough nausea — meaning nausea that occurs despite the use of anti-nausea medication — your health care provider should review your anti-nausea medication schedule and perhaps modify the timing of this medication to somewhat more frequent dosing. Analyze the pattern of breakthrough nausea to assess whether outside triggers, such as certain smells or activities, may be contributing to the problem. It may be possible to eliminate these.

For radiation-caused nausea, treatment recommendations will vary greatly, depending on the location of the body where radiation is delivered, the amount of radiation, and other factors. Your health care team will discuss management of this kind of nausea with you.

For chronic nausea in advanced cancer, traditional anti-nausea medication may not be the right approach. First your health care team needs to determine what is causing the nausea, and then plan treatment. Possible causes, other than chemotherapy, include bowel obstruction, constipation, and the progression of cancer.

Questions for Your Doctor

In treating nausea and vomiting, your health care team may include registered nurses, dieticians, oncologists, and gastroenterologists.

1. What is the plan to pre-treat me before I start chemotherapy? What medications will I take, and when will I take them?
   
   
2. What will be my anti-nausea medication schedule once I leave, after the day's treatment ends?
   
   
3. Are the chemotherapy medications I am taking likely to cause nausea and vomiting in most patients?
   
   
4. Have you been successful in treating nausea and vomiting in people like me?
   
   
5. If nausea and vomiting becomes a problem for me, who do I call for assistance?
   
   
6. What are my options in treating nausea and vomiting?
   
   
7. If my medications fail to control nausea, who should I contact for additional help?
   
   
8. What recommendations do you have regarding what I eat before and after treatment?
   
   
9. How can we arrange for me to consult with a dietician specializing in helping people being treated for cancer?
   
   
10. If I develop anticipatory nausea, what can we do to ease this problem?
    
    
11. If the pre-treatment and post-treatment plan isn't successful, what will we do next?
    
    
12. Will I experience nausea and vomiting from my radiation therapy?
    
    
13. What relaxation techniques do you recommend for me?
    

More Information

The American Society of Clinical Oncology (ASCO) has a rating system for chemotherapy medications and their risk of creating nausea and vomiting. Bear in mind that the amount of medication given can have a significant impact on its potential to cause nausea and vomiting. Here is a list of many chemotherapy medications that can trigger nausea and vomiting:

High Risk (Nausea and vomiting documented to occur in more than 99 percent of patients):

• Cisplatin (Platinol)

High-Risk Noncisplatin (Nausea and vomiting documented to occur in 30 percent to greater than 90 percent of patients):

• Dacarbazine (DTIC-Dome)
• Actinomycin-D (Cosmegan)
• Mechlorethamine (Mustargen)
• Streptozocin (Zanosar)
• Hexamethylmelamine (Hexalen)
• Carboplatin (Paraplatin)
• Cyclophosphamide (Cytoxan)
• Lomustine (CeeNU)
• Carmustine (BICNU)
• Daunorubicin (DaunoXome)
• Doxorubicin (Adriamycin)
• Epirubicin (Pharmorubicin)
• Idarubicin (Idamycin)
• Cytarabine (Cytostar)
• Ifosfamide (Iflex)

Intermediate Risk (Nausea and vomiting documented to occur in 10 percent to 30 percent of patients):

• Irinotecan (Camptosar)
• Mitoxantrone (Novantrone)
• Paclitaxel (Taxol)
• Docetaxel (Taxotere)
• Mitomycin (Mutamycin)
• Topotecan (Hycamtin)
• Gemcitabine (Gemzar)
• Etoposide (Vepesid)
• Teniposide (Vumon)

Low Risk (Nausea and vomiting documented to occur in less than 10 percent of patients):

• Vinorelobine (Navelbine)
• Fluorouracil (Efudex)
• Methotrexate (Rheumatrex)
• Thioguanine (Lanvis)
• Mercaptopurine (Purinethol)
• Bleomycin (Blenoxane)
• 1-asparaginase (Elspar)
• Vindesine (Eldisine)
• Vinblastine (Velban)
• Vincristine (Oncovin)
• Busulphan (Myleran)
• Chlorambucil (Leukeran)
• Melphalan (Alkeran)
• Hydoxyurea (Hydrea)
• Fludarabine (Fludara)
• 2-chlorodeoxyadenosine (Leustatin)
• Tamoxifen (Nolvadex)

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