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Corticosteroids Underemployment in Delayed Chemotherapy-Induced Nausea and Emesis With Poor Adherence to American Society of Clinical Oncology Guidelines: Is This a Reasonable Clinical Choice for the Elderly?

Division of Medical Oncology, "S.G. Moscati" Hospital, Avellino, Italy

To the Editor: As the control of chemotherapy-induced acute emesis has improved, attention has increasingly focused on delayed-onset emesis, which represents a therapeutic challenge. Approximately 50% of patients still experience delayed emesis with a reduced desire to eat and drink, as well as an impaired quality of life.¹ It has been shown in the paper by Mertens et al² that the drugs indicated by the American Society of Clinical Oncology (ASCO) guidelines for preventing delayed chemotherapy-induced nausea and emesis (CINE) are underemployed, and it was further shown that it was not easy to modify the approach as such to clinical practice. Although clinicians have been provided with ample clear evidence of poor compliance to guidelines, it is only apparent through patient CINE experience. The incomplete adoption of guidelines regarded more extensively the prescription of dexamethasone than 5HT₃ receptor antagonists or metoclopramide.

We appreciated the feedback-method used by Mertens et al² for assessing and improving adherence to antiemetic prescribing guidelines. In general, the authors discussed the conceptual barriers to physicians’ adherence to clinical practice guidelines: knowledge (lack of awareness and familiarity with the guidelines); attitudes (disagreement with evidence-based medicine and specific guidelines); and behavior (patient’s preference). In our opinion, corticosteroid underemployment in the prevention of delayed CINE could often find reasonable clinical explanations, whereas considering the low cost of corticosteroids, cost containment issues do not seem to be reasonable.

In our view, two main arguments could explain poor corticosteroid prescription in this clinical setting; namely, the presence of comorbidities and polypharmacy. These issues are mainly a problem among the elderly.

With regard to comorbidity,³ we have a wide experience with chemotherapy in elderly lung cancer patients. Specifically, in the Multicenter Italian Lung Cancer in the Elderly Study trial performed in about 700 elderly advanced non–small-cell lung cancer patients (> 70 years), cardiovascular comorbidities were registered in 60.2% and diabetes in 11.2% of patients, respectively.⁴ Diabetes and hypertension are undoubtedly two clinical conditions that make usage of corticosteroids (if not contraindicated) at least critical. Some may argue that comorbidity is a topic specific to the elderly population, but recent data showing that the elderly account for 61% of all new cancer cases⁵ have indicated the relevance of this population in clinical practice.

Polypharmacy is common among cancer patients, especially if they are 65 years or older.⁶ In our opinion, polypharmacy may interfere with the physician’s prescription of dexamethasone in the prevention of delayed CINE. In fact, cancer patients often are already undergoing treatment with nonsteroidal anti-inflammatory drugs as analgesics when starting with chemotherapy, and their risk of gastrointestinal bleeding might be increased by corticosteroids. Moreover, cancer patients are often already being administered corticosteroids other than dexamethasone as supportive care, and physicians are unable to be convinced to change the type of corticosteroid. Thus, patients could receive inadequate doses or inappropriate types of corticosteroids for emesis prevention. Finally, polypharmacy at baseline may induce physicians to reduce the number of new and temporary drugs, aiming at preserving the patient’s compliance with more health-essential drugs (cardiovascular, diabetic, analgesics, and so on), mainly in the elderly.

In conclusion, although ASCO guidelines are the best tools for the treatment and prevention of CINE, there are some clinical conditions, mainly in the elderly, that could explain underemployment of corticosteroids for delayed CINE prevention.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following authors or their immediate family members have indicated a finanical interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Acted as a consultant within the last 2 years: Cesare Gridelli, Aventis, Eli Lilly, AstraZeneca, Roche. Received more than $5,000 a year from a company for either of the last 2 years: Cesare Gridelli, Aventis, Eli Lilly, Roche, AstraZeneca, GlaxoWellcome, Pierre Fabrie, Bristol-Myers Squibb, Dompe, Biotech; Antonio Rossi, Pierre Fabre.

REFERENCES

1. Gridelli C: 5-HT3-receptor antagonists in the control of delayed-onset emesis. Anticancer Res 23: 2773–2782, 2003[Medline]

2. Mertens WC, Higby DJ, Brown D, et al: Improving the care of patients with regard to chemotherapy-induced nausea and emesis: the effect of feedback to clinicians on adherence to antiemetic prescribing guidelines. J Clin Oncol 21:1373–1378, 2003[Abstract/Free Full Text]

3. Yancik R, Ganz PA, Varricchio CG, et al: Perspectives on comorbidity and cancer in older patients: approaches to expand the knowledge base. J Clin Oncol 19:1147–1151, 2001[Abstract/Free Full Text]

4. Gridelli C, Perrone F, Gallo C, et al: Chemotherapy for elderly patients with advanced non-small-cell lung cancer: the Multicenter Italian Lung Cancer in the Elderly Study (MILES) phase III randomized trial. J Natl Cancer Inst 95:362–372, 2003[Abstract/Free Full Text]

5. Yancik R, Ries LA: Aging and cancer in America. Demographic and epidemiologic perspectives: Hematol Oncol Clin North Am 14:17–23, 2000

6. Corcoran ME: Polypharmacy in the older patient with cancer. Cancer Control 4:419–428, 1997[Medline]

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