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Supportive Management of Treatment-related Effects VideoTranscript

治疗相关作用的支持性管理视频文本

Professional Oncology Education Supportive Management of Treatment-related Effects Time: 21:26

专业人员肿瘤教学讲座治疗相关作用的支持性管理时间： 21:26

Cynthia Abarado, DNP, RN, GNP-BC Advanced Practice Nurse Genitourinary Medical Oncology The University of Texas MD Anderson Cancer Center

德克萨斯大学 MD Anderson 癌症中心生殖泌尿系统肿瘤医学科高级专科护士

Cynthia Abarado, DNP, RN, GNP-BC

Supportive Management of Supportive Management of Supportive Management of Supportive Management of

TreatmentTreatmentTreatmentTreatment----related Effectsrelated Effectsrelated Effectsrelated Effects

Supportive Management of Supportive Management of

TreatmentTreatment--related Effects related Effects

Cynthia Abarado, DNP, RN, GNP-BC

Advanced Practice Nurse

Genitourinary Medical Oncology

Hello, my name is Cynthia Abarado. I am an Advanced Practice Nurse at the Department of Genitourinary Medical Oncology here at The University of Texas MD Anderson Cancer Center in Houston, Texas. I am going to talk to you about supportive management of treatment-related effects.

你好，我叫 Cynthia Abarado。我是德克萨斯州休士顿德克萨斯大学 MD Anderson 癌症中心生殖泌尿系统肿瘤科的高级专科护士。我将向大家介绍治疗相关作用的支持性管理。

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Objectives

Upon completion of this lesson, participants will

be able to:

• Identify common treatment-related effects

• Recognize signs and symptoms of these conditions

• Identify management options to minimize

these effects

Objectives of this presentation are as follows: to identify common treatment-related effects, recognize signs and symptoms of these conditions, and identify management options to minimize these effects.

本次讲座的目的如下：确定常见治疗相关作用，识别这些病症的体征和症状,并确定尽可能降低这些作用的管理方案。



Anemia

• Anemia is defined as a hemoglobin less than 11 g/dl.

• Causes of anemia:

– Blood loss

– Hemolysis

– Suppression of erythropoiesis and erythropoietin products by inflammatory cytokines

– Chemotherapy

– Radiation

– Nutritional deficiencies

– Renal impairmentNCCN GuidelinesTM, 2007, www.nccn.org

Anemia is one of the most common cancer treatment-related effects. Anemia is defined as a hemoglobin less than 11 g/dl. Some causes of anemia [are] related to blood loss, hemolysis, suppression of erythropoiesis and erythropoietin products by inflammatory cytokines, chemotherapy, radiation, nutritional deficiencies, as well as renal impairment.

贫血是最常见的癌症治疗相关作用之一。贫血的定义是血红蛋白低于 11 g/dl。贫血的部分相关病因是失血、溶血、造血功能和红细胞生成素的生成受到炎症性细胞因子、化疗、放射、缺乏营养以及肾脏损伤的抑制。

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Manifestations of Anemia

• CNS

– Fatigue

– Dizziness, vertigo

– Depression

– Impaired cognitive function

• GI System

– Anorexia

– Nausea

• Vascular System

– Pallor

– Low skin temperature

Some of the manifestations of anemia are fatigue, dizziness, vertigo, depression, impaired cognitive function, anorexia, nausea, pallor, low skin temperature.

贫血的部分表现包括疲乏、头晕眼花、眩晕、抑郁、认知能力受损、厌食、恶心、脸色苍白、皮肤温度过低。



Manifestations of Anemia

• Immune System

– Impaired t-cell and macrophage function

• Cardiovascular system

– Exertional dyspnea

– Tachycardia, palpitations

– Increased pulse pressure

– Risk of life-threatening cardiac failure

• Genital Tract

– Menstrual problems

– Loss of libido

Impaired T-cell and macrophage function, exertional dyspnea, tachycardia, palpitations, increased pulse pressure, risk of life-threatening cardiac failure, as well as menstrual problems and loss of libido.

T 细胞和巨噬细胞的功能受损、运动性呼吸困难、心动过速、心悸、脉搏压力增加、危及生命的心力衰竭的风险、以及月经失调和丧失性欲。

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Laboratory Assessment of Anemia

• Hemoglobin – the amount of hemoglobin or

the oxygen capacity of the peripheral blood

• Hematocrit – the space or volume occupied

by the red cells in relation to the blood volume

• MCV – (mean corpuscular volume) the

average volume or size of a single RBC

in a given blood sample

Some of the laboratory assessment of anemia include measurements of hemoglobin, which is the amount of oxygen capacity of the peripheral blood; hematocrit, which is the space or volume occupied by the red cells in relation to the blood volume; MCV or mean corpuscular volume, which is the average volume or size of a single RBC in a given blood sample.

某些评估贫血的化验包括测量血红蛋白，即外周血能够运输氧气的数量；红细胞压积，即红细胞占血液体积的空间或体积百分比；MCV 或红细胞平均体积，即特定血样中单个红细胞的平均体积或大小。



Laboratory Assessment of Anemia

• MCH – (mean corpuscular hemoglobin) the average

weight of hemoglobin in each RBC

• MCHC – (mean corpuscular hemoglobin

concentration) the average hemoglobin

concentration or color of the RBC

• RDW – (red cell distribution width) an automated

calculation of variation in size, which provides

homogeneity (normal RDW) or heterogeneity (high

RDW)

Other measurements are MCH, or the mean corpuscular hemoglobin or the average weight of hemoglobin in each RBC; the MCHC, which is the average hemoglobin concentration or color of the red blood cell; RDW, which is an automated calculation of variation in size providing the homogeneity or heterogeneity of the red cell distribution width.

其他测量包括 MCH，即平均红细胞血红蛋白量，这是每个红细胞内的血红蛋白平均重量；MCHC，即平均血白蛋白浓度或红细胞的颜色；RDW，即自动计算的大小变异程度，说明红细胞分布宽度的同质性或异质性。

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Assessment of Types of Anemias

• Reticulocyte count

• Ferritin

• Transferrin

• Serum iron

• Coomb’s test

• Serum B12 and folate levels

Some other assessments for different types of anemias include measurement of the reticulocyte count, ferritin, transferrin, serum iron, Coombs test, serum B12, and folate levels.

不同类型贫血的一些其他评估项目包括测量网织红细胞计数、铁蛋白、转铁蛋白、血清铁、库姆斯检测、血清 B12 和叶酸水平。



Treatment of Anemia

• Parenteral iron administration

• Blood transfusion

• Erythropoiesis-stimulating-epoetin, darbepoetin

- Indications/side effects

• Interruption or modification based on hemoglobin

levels of patients; reports increased mortality and

thrombotic vascular events

• Adverse reactions including pure red cell aplasia,

pulmonary embolism, DVT and edema

Some of the strategies in treatment of anemia include parenteral iron administration, blood transfusion, as well as administration of the erythropoiesis-stimulating factors. Indications for the erythropoiesis-stimulating factors have side effects and these include: interruption or modification based on hemoglobin levels of patients, reports [of] increased mortality, and thrombotic vascular events. So patients have to be monitored for a risk of pulmonary embolism, DVT, and edema.

治疗贫血的部分策略包括肠胃外给铁、输血以及给予红细胞刺激因子。红细胞刺激因子有副作用，表现为：根据患者的血红蛋白水平出现中断或调整，报告的死亡率有所增加，以及血管栓塞事件。所以必须监测患者的情况，注意有无肺栓塞、DVT 和水肿的风险。

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Impact of Anemia

• Quality of life

• Significant effects on therapeutic outcomes

• Physical impact

• Psychosocial impact

• Prognosis and survival

How does anemia affect an individual? It can affect the patient’s quality of life. It has significant effects on therapeutic outcomes. It has also an impact on the patient’s physical functioning and performance status, as well as psychosocial effects. It affects the prognosis and overall survival as well.

贫血会对个体造成什么样的影响呢？贫血可影响患者的生活质量，会显著影响治疗结果。贫血还会影响患者的身体功能和机能状态，以及社会心理方面的作用。贫血会影响预后以及整体生存时间。



Neutropenia

• Diagnosed by absolute neutrophil count (ANC)

– Normal range 2,500 - 6,000 per cubic millimeter of blood (primary white cell)

– ANC < 2,000 = neutropenia

– ANC < 500 places a patient at severe risk for infection

– Nadir

• Time when WBCs are at their lowest point

• Typically 10 to 14 days after chemotherapy

• Recovery may take 3 to 4 weeks

The other cancer treatment-related effect is neutropenia. It is diagnosed by absolute neutrophil count. Absolute neutrophil count of less than 2,000 is neutropenia. The patient’s normal range of the ANC is around 2,500-6,000/mm

3 of blood or primary

white cell. ANC of less than 500 places a patient at severe risk for infection. Nadir is the time when the white cell counts are at their lowest point. Typically, it occurs at around 10 to 14 days after chemotherapy and requires 3 to 4 weeks for recovery.

另一项治疗相关作用是嗜中性细胞减少症。嗜中性细胞减少症是根据嗜中性细胞的绝对计数进行诊断，绝对计数低于 2000 即患有嗜中性细胞减少症。患者 ANC 的正常范围是每立方毫米血液有 2500-6000 个嗜中性细胞或主要白细胞。ANC 低于 500 的患者有发生感染的严重风险。最低点是指白细胞计数最低时。通常情况下，最低点发生在化疗后 10 至 14 天左右，恢复需要 3 至 4 周。

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Neutropenic Infection

• Symptoms/signs

– Fever greater than 100.4°F (38°C)

– Chills/sweating

– Sore throat or cough

– Mouth ulcers

– Diarrhea

– Burning sensation during urination

– Redness, pain, or swelling around a wound or sore

If the patient is neutropenic, he is at risk for developing infection. And some of the signs and symptoms of infection are temperature of greater than 38

°C or 100.4°F, chills, sweating, sore throat,

mouth ulcers, diarrhea, burning sensation during urination, or redness, pain, or swelling around a wound or sore.

如果患者有嗜中性细胞减少症，则有可能发生感染。感染的部分体征和症状是体温超过 38°C 或 100.4°F、寒颤、出汗、喉咙痛、口疮、腹泻、排尿时有烧灼感，或者在伤口或溃疡周围有发红、疼痛或肿胀。



Management of Neutropenia

• Prophylactic use of growth factors, when indicated:

pegfilgrastim, filgrastim

• Good hand-washing technique

• Early detection and treatment of infection

• Follow treatment guidelines to reduce mortality

NCCN GuidelinesTM, 2007, www.nccn.org

How do we manage neutropenia? After chemotherapy, a prophylactic use of growth factors

when indicated, such as Neupogen or Neulasta, is recommended. The best prevention for infection is a good hand washing technique. Also early detection and treatment of infection can have positive outcome and prevent sepsis or infection. The NCCN Guidelines

TM recommend following

treatment guidelines to reduce mortality in the management of neutropenia.

如何管理嗜中性细胞减少症？如果有适应症，则建议在化疗后预防性使用生长因子，例如 Neupogen 或

Neulasta。预防感染的最佳途径是正确的洗手方式。而且如果能早期发现和治疗感染也可以产生良好的结果，从而预防发生败血症或感染。 NCCN

GuidelinesTM

建议遵循治疗指南，降低管理嗜中性细胞减少症时的死亡率。

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Treatment-related Nutritional Effects

• Chemotherapy and radiation therapy

– Weight loss

– Fatigue

– Nausea/vomiting

– Taste alterations

– Oral mucositis

– Constipation (chemo only)

– Xerostomia

– Anorexia

Other treatment-related side effects are very significant in the nutritional effects of chemotherapy and nutrition and some of these are manifested as in weight loss, fatigue, nausea, vomiting, taste alterations, oral mucositis, constipation (only in chemotherapy though because radiation would have more of a diarrhea side effect), xerostomia, and anorexia.

其他治疗相关副作用是化疗在营养方面的严重反应，其中部分表现为体重下降、疲乏、恶心、呕吐、味觉改变、口腔黏膜炎、便秘（只见于化疗，因为放射更多是腹泻副作用）、口干症和厌食。



Treatment-related Nutritional Side-effects

• Surgery – Weight loss

– Fatigue

– Nausea/vomiting

– Diarrhea

– Loss of appetite

• Immunotherapy – Weight loss

– Fatigue

– Oral mucositis

– Diarrhea

– Anorexia

Specifically surgery can also cause weight loss, fatigue, nausea, vomiting, diarrhea, and loss of appetite. Immunotherapy again can cause weight loss, fatigue, oral mucositis, diarrhea, as well as anorexia.

具体来说，手术也可能造成体重下降、疲乏、恶心、呕吐、腹泻和食欲不振。免疫治疗也可以造成体重下降、疲乏、口腔黏膜炎、腹泻以及厌食。

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Oral Mucositis

• Most common complication associated

with chemotherapy

• Affects 40% of individuals on chemotherapy

– 80% of individuals receiving bone

marrow transplant

– 100% of individuals receiving head

and neck radiation

The most devastating treatment-related side effect, in terms of the digestive tract, is a development of oral mucositis, which is the most common complication associated with chemotherapy. Around 40% of individuals on chemotherapy develop mucositis, 80% of individuals receiving bone marrow transplant and 100% of individuals receiving head and neck radiation would develop oral mucositis.

消化道最严重的治疗相关副作用是发生口腔黏膜炎。这种并发症最常见于化疗。大约 40% 使用化疗的人士，80% 接受骨髓移植的人士，以及 100% 接受头颈部放射的人士会出现口腔黏膜炎。



Mucositis

• Mucosal injury characterized by ulceration in

the oro-esophageal and gastrointestinal mucosa

• Effects:

– Pain

– Dysphagia

– Diarrhea

– Dehydration

• Risk factor for bacteremia and sepsis

So, what is mucositis? It is a mucosal injury characterized by ulceration in the oral esophageal and gastrointestinal mucosa. Some of the effects from mucositis are related to pain, dysphagia, diarrhea, dehydration and also it poses as the greatest risk for bacteremia and sepsis.

那么，什么是黏膜炎呢？黏膜炎是黏膜损伤，特点是口腔、食道和胃肠道黏膜出现溃疡。黏膜炎的部分作用包括疼痛、吞咽困难、腹泻、脱水。而且黏膜炎也是造成菌血症和败血症的最大风险。

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Pathogenesis: Oral Mucositis

1) Initiation: DNA and non-DNA damage, direct cellular

injury to basal epithelial cells, generation of reactive

oxygen species

2) Primary damage response: Damage in genes is

followed by upregulation of genes, which results in

the production of a range of destructive proteins and

molecules such as the proinflammatory cytokines

that lead to apoptosis and tissue injury

Scully C et al. Oral Dis 2006 12(3):229

How does oral mucositis develop? There are several phases that occur. And with the introduction of the chemotherapy and radiation the first stage is the initiation where DNA and non-DNA damage direct cellular injury to basal epithelial cells and generation of reactive oxygen species occur. A second phase is the primary damage response. Damage in the genes is followed by upregulation of genes, which results in the production of a range of destructive proteins and molecules such as the proinflammatory cytokines that lead to tissue injury.

口腔黏膜炎是如何发生的呢？口腔黏膜炎的发生分成几个阶段。随着开始使用化疗和放疗，首先是起始期发生的 DNA 和非 DNA 损伤，基底上皮细胞的直接细胞损伤以及产生活性氧。第二阶段是原发性损伤应答。基因受损之后会发生基因上调，产生一系列破坏性蛋白和分子，例如促炎性细胞因子，导致组织损伤。



Pathogenesis: Oral Mucositis

3) Signal amplification: Substances from the damage

response phase provide a positive feedback loop that

drives the destructive process forward

4) Ulceration: The oral epithelium breaks down and

ulcerates. Infections may occur at this stage as it

frequently corresponds with neutropenia and an

increase in gram-negative organisms

5) Healing: biologically dynamic phase with signaling

from the submucosal extracellular matrix, stimulating

the migration, differentiation, and proliferation of the

healing epithelium Scully C et al. Oral Dis 2006 12(3):229

The third phase is a signal amplification, where substances from the damage response phase provide a positive feedback loop that drives the destructive process forward resulting to ulceration. The oral epithelium breaks down and ulcerates. At this point, infection can occur at any stage of this phase, frequently corresponding to the stage of neutropenia, and mostly it is associated with an increase in gram-negative organisms. The fifth phase is the healing phase, which is the biologically dynamic phase with signaling from the submucosal extracellular matrix stimulating the migration, differentiation, and proliferation of the healing epithelium.

第三阶段是信号放大。在此阶段，损伤应答期产生的物质产生正反馈环路，加重破坏性过程，造成溃疡。口腔上皮破溃，产生溃疡。此时，感染可在这一阶段的任一期发生，常常发生在嗜中性细胞减少期，大多数与革兰氏阴性微生物增多有关。第五阶段是愈合阶段，即生物动态期。此时黏膜下细胞外基质发出信号，刺激正在愈合的上皮移行、分化和增殖。

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Phases of MucositisPhases of MucositisPhases of MucositisPhases of Mucositis

Adapted from Sonis ST. Nat Rev Cancer 2004 4(4):227

This is just a summary or an illustration of the different phases of mucositis. Phase 1 which is the DNA initiation, and then phase 2 is the signaling, phase 3 is the amplification of the response, and phase 4 is the ulceration, and phase 5 is the healing stage.

这是黏膜炎不同阶段的图示总结。第 1 阶段是 DNA 起始，然后第 2 阶段发送信号，第 3 阶段是应答放大，第 4 阶段是溃疡，第 5 阶段是愈合期。



Oral Mucositis

• Incidence among cancer patients with grade

3-4 mucositis

– Radiation for head and neck – 85-100%

– Stem cell-transplantation – 75-100%

– Solid tumors with myelosuppression – 5-40%

The incidence of oral mucositis in cancer patients with grade 3 to 4 is very significant. Among patients receiving radiation for head and neck, the incidence is 85 to 100%. Among patients receiving small or stem cell transplantation, it affects 75 to 100%, and for solid tumor with myelosuppression, 5 to 40%.

3 至 4 级癌症患者的口腔黏膜炎发生率非常高。接受头颈部放射的患者，发生率为 85 至 100%。接受干细胞移植的患者有 75 至 100% 发生口腔黏膜炎，有骨髓抑制的实体肿瘤患者，发生率为 5 至 40%。

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Effect of Oral Mucositis on Nutrition

• Decreased dietary intake because of taste

changes, dry mouth and or pain

• Malnutrition

• Weight loss

• Dehydration

What are the effects of oral mucositis on nutrition? It can cause malnutrition. It can cause a lot of dietary decrease because of the taste changes, dry mouth, and pain. It can also cause weight loss and dehydration.

口腔黏膜炎对营养的影响如何呢？口腔黏膜炎可引起营养不良。可因为味觉变化、口干和疼痛造成饮食显著减少。也可造成体重下降和脱水。



Toxicity Criteria of Oral Mucositis

• NCI toxicity criteria (version 2.0)

– 0 = none

– 1 = erythema of the mucosa

– 2 = patchy ulcerations or pseudomembranes

– 3 = confluent ulcerations or pseudomembranes,

bleeding with minor trauma

– 4 = tissue necrosis, significant spontaneous bleeding,

life-threatening consequences

www.cancer.gov

The NCCN or --- correction, the National Cancer Institute Toxicity Criteria classifies toxicity into 0 to 4. Zero, none, 1 is the erythema of the mucosa, 2 is the patchy ulcerations or pseudomembranes, 3 is the confluent ulcerations of pseudomembranes with bleeding and minor trauma, and 4 is the tissue necrosis, significant spontaneous bleeding, which can have life-threatening consequences.

美国国家癌症研究所毒性标准将毒性分为 0 至 4 级。零级是没有任何作用。1 级是黏膜出现红斑；2 级时出现斑块状溃疡或假膜；3 级假膜的溃疡出现融合，伴有出血和轻度创伤；4 级出现组织坏死、严重自发性出血，可产生危及生命的后果。

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Oral ExaminationOral ExaminationOral ExaminationOral Examination

• Examination of:– Buccal mucosa

– Soft and hard palate

– Dorsum and border of tongue

– Floor of mouth

• Assess for: – Erythema

– Ulceration

– Pseudomembranes

– Bleeding

– Ability to eat

– Pain

– Difficulty swallowing

Assessment of the oral mucosa is very important when managing mucositis. Examination should involve examination or assessment of the buccal mucosa, soft and hard palate, the dorsum and border of the tongue as well as the floor of the tongue, assessed for erythema, ulcerations, pseudomembranes, bleeding, ability to eat, pain, and difficulty in swallowing.

评估口腔炎对于管理黏膜炎非常重要。检查应包括检查或评估颊黏膜、软硬腭、舌背面和边缘以及舌底，评估是否有红斑、溃疡、假膜、出血、进食能力、疼痛和吞咽困难。



Management of Mucositis

• Oral care with salt and soda mouthwashes

• Avoid caffeine, alcohol and tobacco

• Avoid foods that could irritate the mouth

• Promote good oral hygiene

How do we manage mucositis? A proactive prevention program is the best treatment. Oral care with salt and soda mouthwashes is recommended. Also, avoidance of caffeine, alcohol and tobacco, avoidance of food that could irritate the mouth as well as promotion of good oral hygiene are some of the strategies.

如何管理黏膜炎？积极预防是最好的治疗。建议使用盐水和苏打漱口水进行口腔护理。其他一些预防方法包括避免摄食咖啡因、酒精和烟草，避免可刺激口腔的食物，以及宣传良好的口腔卫生。

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Oral Care

• Good oral hygiene

• Cryotherapy

• Oral care protocol

– Multinational Association of Supportive Care in

Cancer

For oral care again good oral hygiene is recommended. Some have used cryotherapy and the Multinational Association of Supportive Care has an oral care protocol which can be referred to.

对于口腔护理而言，仍然建议良好的口腔卫生。一些患者使用过冷冻疗法，也可以参考多国癌症支持治疗协会的口腔护理操作程序。



Oral Mucositis

• Most common complication associated

with chemotherapy

• Affects 40% of individuals on chemotherapy

– 80% of individuals receiving bone marrow transplant

– 100% of individuals receiving head and neck radiation

Oral mucositis again is the most common complication associated with chemotherapy. Again, it affects 40% of individuals on chemotherapy, 80% with those with bone marrow transplant, and 100% with head and neck radiation.

如前所述，口腔黏膜炎是最常见的化疗相关并发症。40% 使用化疗的人士，80% 接受骨髓移植的人士，100% 接受头颈部放射的人士会出现口腔黏膜炎。

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Effect of Oral Mucositis on Nutrition

• Decreased dietary intake because of taste

changes, dry mouth and or pain

• Malnutrition

• Weight loss

• Dehydration

As we have mentioned, it has a lot of side effects, which can lead to malnutrition, weight loss, and dehydration.

如前所述，口腔黏膜炎有大量的副作用，可导致营养不良、体重下降和脱水。



Strategies

• Oral care with salt and soda mouthwashes

• Avoid caffeine, alcohol and tobacco

• Avoid foods that could irritate the mouth

• Promote good oral hygiene

We have gone through different strategies.

我们已经讨论了不同的策略。

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Taste Alterations

• Common among cancer patients receiving

chemotherapy and among those with head

and neck radiation

• Affects 35% - 70% of cancer patients

• Types include:

– Hypogeusia (most common) – reduction in

taste sensitivity

– Ageusia – an absence of taste sensations

– Dysgeusia – distortion of normal taste

Now, we will go to the taste alterations related to oral mucositis. Taste alterations affect 35 to 70% of cancer patients. And the major types of taste alterations include hypogeusia, or reduction in taste sensitivity, ageusia, which is an absence of taste sensation, and dysgeusia, which is the distortion of normal taste.

现在我们来谈谈与口腔黏膜炎相关的味觉改变。味觉改变见于 35 至 70% 的癌症患者。味觉改变的主要类型包括味觉减退，即味觉敏感度下降；味觉丧失，即丧失味觉敏感度；和味觉倒错，即正常味觉失真。



Causes of Taste Alterations

• Damages in taste buds

• Dry mouth

• Oral mucosal infection

• Dental problems

• Chemotherapy side-effects – metallic taste

So, what are the causes of taste alterations? It has damaged taste buds. Dry mouth can lead to taste alterations, again oral mucosa infection as well as dental problems. Taste alterations can also be caused by chemotherapy side effects, often described by patients as peculiar metallic taste.

那么，味觉改变的病因是什么呢？是因为味蕾受损。口干可造成味觉改变、口腔黏膜感染和牙科问题。味觉改变也可由化疗的副作用造成，患者常常描述为特殊的金属味。

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Strategies for Taste Alterations

• Recommend tart or sour foods

• Serve cold foods

• Recommend use of plastic utensils if metallic

taste is present

• Recommend rinsing with salt and soda

mouthwashes before eating

• Recommend frozen fruits

So, what are some of the strategies for improving or --- improving patient’s outcome for taste alterations? The recommendations are to serve cold foods, serve tart or sour foods, also use plastic utensils instead of metallic to prevent metallic taste, that is. Recommend rinsing with salt and soda mouthwashes before eating and recommending frozen fruits.

有哪些策略可以改善患者味觉改变的转归呢？建议提供冷食、酸味食物，以及使用塑料餐具替换金属餐具，来预防金属味道。建议在进食之前用盐水和苏打漱口水漱口，而且建议食用冷冻水果。



Cancer-induced Nausea and Vomiting (CINV)

• 70% to 80% of all cancer patients receiving

chemotherapy experience nausea and/or vomiting

• 10% to 44% experience anticipatory nausea

and/or vomiting

The other major cancer treatment-related side effects involve cancer-induced nausea and vomiting. This affects 70 to 80% of all cancer patients receiving chemotherapy and 10 to 44% experience anticipatory nausea and/or vomiting.

另一项重要的癌症治疗相关副作用是癌症引发的恶心和呕吐。所有接受化疗的患者中有 70 至 80% 会发生恶心和呕吐，10 至 44% 会出现预期性恶心和/或呕吐。

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Incidence of CINVIncidence of CINVIncidence of CINVIncidence of CINV

Grunberg SM et al. Cancer. 2004 100(10):2261

This is one of the --- illustration or a graph that shows a study result where the practitioner prediction of cancer-induced nausea and vomiting is measured against actual experiences of the patient. As you can see, the dark orange here has really significant --- significant incidence of patients having actual experiences after a chemotherapy administration.

这张图示显示了一项研究结果，将医务人员对癌症引发恶心和呕吐发生率的预期值与患者实际的发生率相比较。大家可以看到，这里的暗橙色显示，在给予化疗之后患者实际的发生率很高。



Pathophysiology of Emesis

• Triggered by afferent impulses to the vomiting

center (located in the medulla) from the chemoreceptor

trigger zone (CTZ), pharynx and gastrointestinal (GI)

tract (via vagal afferent fibers), and cerebral cortex

• Efferent impulses are sent from the vomiting

center to the salivation center, abdominal muscles,

respiratory center, and cranial nerves

So, what is the cause of cancer-induced nausea and vomiting? The pathophysiology of emesis is interesting. And it is theorized as triggered by the afferent impulses to the vomiting center located in the medulla from the chemoreceptor trigger zone, pharynx, and gastrointestinal tract via the vagal afferent fibers of cerebral cortex. The efferent impulses are sent from the vomiting center to the salivation center, abdominal muscles, inspiratory center, and cranial nerves.

那么，癌症引发恶心和呕吐的病因是什么呢？呕吐的病理生理学引人关注。理论上，呕吐的触发过程来自化学感受器触发区、咽和胃肠道的传入冲动，通过大脑皮质的迷走传入纤维到达位于延髓的呕吐中枢。呕吐中枢向唾液分泌中枢、腹肌、呼吸中枢和颅神经传出冲动。

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Pathophysiology of CINVPathophysiology of CINVPathophysiology of CINVPathophysiology of CINV

• The CTZ, vomiting center, and GI tract have

many neurotransmitter receptors. Activation of

these receptors by chemotherapeutic agents or their

metabolites may be responsible for chemotherapy-

induced emesis.

• Principal neuroreceptors involved

– Serotonin (5-hydroxytryptamine [5-HT3])

– Dopamine receptors

– Others include acetylcholine, corticosteroid, histamine,

cannabinoid, opiate, and neurokinin-1 (NK-1) receptors

The CTZ/vomiting center and GI tract have many neurotransmitter receptors and these are activated by chemotherapeutic agents or their metabolites. And they are responsible for the chemotherapy-induced emesis. Some of the principle neuroreceptors include serotonin, the dopamine receptors, and also acetylcholine, corticosteroid, histamine, cannabinoid, opiate, and neurokinin receptors.

CTZ/呕吐中枢和胃肠道有许多神经递质受体，这些受体由化疗剂或其代谢物激活，从而导致化疗引发呕吐。一些主要神经受体包括 5-羟色胺受体、多巴胺受体，还有乙酰胆碱、皮质类固醇、组织胺、大麻、阿片和神经激肽受体。



Types of Emesis

• Acute onset – occurs few minutes to several hours

after drug administration and commonly resolves

within 24 hours

• Delayed onset – develops 24 hours after

chemotherapy administration

• Anticipatory nausea or vomiting – occurs before

patients receive their next chemotherapy

There are different types of emesis. These are classified into acute onset, which occurs [a] few moments to several hours after drug administration and commonly resolves within 24 hours. There is emesis related --- or described having delayed onset, which develops 24 hours after chemotherapy administration, and then anticipatory nausea and vomiting, which occurs before patients even receive their next chemotherapy.

呕吐有几种不同的类型，分为急性发作，即在给药后片刻至数小时内发生，通常在 24 小时内缓解。有延迟发作的呕吐，在给予化疗后 24 小时发生。还有预期性恶心和呕吐，在患者接受下次化疗之前发生。

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Types of Emesis

• Breakthrough

– Vomiting that occurs despite prophylactic

treatment or “rescue” medication

• Refractory

– Refers to emesis that occurs during subsequent

treatment cycles when antiemetic prophylaxis

have failed in earlier cycles

Another classification is a breakthrough emesis, which is vomiting that occurs despite prophylactic treatment or rescue medication. And then a refractory emesis refers to emesis that occurs during subsequent treatment cycles when antiemetic prophylaxis have failed in earlier cycles.

另一种分类是突破性呕吐。这时尽管采取了预防性治疗或救援性用药，仍然发生呕吐。然后是顽固性呕吐，指的是早期的抗呕吐预防治疗失败后，在后续治疗周期发生的呕吐。



Important Principles on Emesis Control

• Prevention of nausea/vomiting is the goal

• The risk of emesis and nausea for persons receiving chemotherapy of high and moderate emetic risk lasts for at least 4 days

• Patients need to be protected throughout the full period of risk

NCCN™ Guidelines, 2007, www.nccn.org

What are some of the important principles on emesis control? Again, prevention of nausea and vomiting is the goal. So, the risk of emesis and nausea for persons receiving chemotherapy of high and moderate emetic risk lasts for at least four days. Patients need to be protected throughout the full period of risk.

控制呕吐的重要原则有哪些？和前面一样，预防恶心和呕吐是目标。对于接受具有中高度呕吐风险的化疗的患者，发生呕吐和恶心的风险会持续至少四天。需要在整个风险期间保护患者。

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Principles of CINV Control

• Oral and IV antiemetic formulations have

equivalent efficacy

• Use the lowest fully efficacious dose of

the antiemetic(s) prior to chemotherapy or

radiation therapy

• Consider the toxicity of the specific antiemetic(s)

• Choice of antiemetic(s) used should be based

on the emetic risk of the therapy as well as

patient factors

NCCN™ Guidelines, 2007, www.nccn.org

Some other principles involve oral and IV antiemetic formulations --- have equivalent efficacy, so we have to consider that. Use the lowest fully efficacious dose of antiemetics prior to chemotherapy or radiation therapy. Consider the toxicity of specific antiemetics and choice of antiemetic or antiemetics should be used based on the emetic risk of the therapy as well as patient factors.

其他一些原则包括口服和静脉使用抗呕吐制剂，口服和静脉用药的疗效相同。我们可以考虑使用。在化疗或放疗之前使用全效的最低抗呕吐剂剂量。考虑具体抗呕吐剂的毒性，应该根据治疗造成的呕吐风险和患者个体因素，选择使用一种或多种抗呕吐剂。



Types of Antiemetic Therapies

• Serotonin (5-HT3)-receptor antagonists

– Ondansetron

– Granisetron

• NK-1-receptor antagonist

– Aprepitant

• Other non-5-HT3-receptor antagonists

– Phenothiazines

– Benzodiazepenes

Some major classifications of antiemetic therapies

include serotonin, some examples are Zofran and

Kytril; NK-1receptor antagonist or aprepitant; other non-5-HT3-receptor antagonists, such as phenothiazines and benzodiazepines.

抗呕吐治疗的部分重要分类包括 5-羟色胺受体，部分实例为 Zofran 和 Kytril；NK-1 受体拮抗剂或阿瑞匹坦；其他非 5-羟色胺受体拮抗剂，例如酚噻嗪类和苯二氮卓类。

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Other Causes of Emesis

• Partial or complete bowel obstruction

• Vestibular dysfunction

• Brain metastases

• Electrolyte imbalance

– Hypercalcemia

– Hyperglycemia

– Hyponatremia

• Uremia

• Concomitant drug treatments including opiates

• Gastroparesis

• Anxiety

There are some other causes of emesis that could aggravate or increase nausea and vomiting related to cancer treatment-related effects. Some of these factors are partial or complete bowel obstruction; vestibular dysfunction; brain metastases; some electrolyte imbalances, such as hypercalcemia, hyperglycemia, and hyponatremia; uremia; concomitant drug treatments including opiates; gastroparesis; and anxiety

还有一些呕吐病因，可加重或增加与癌症治疗相关的恶心和呕吐。其中部分因素包括部分或完全性肠梗阻；前庭功能障碍；脑转移；某些电解质失调，例如高钙血症、高糖血症和低钠血症；尿毒症；伴随药物治疗，包括阿片类药物；胃轻瘫；和焦虑。



Conclusions

• Anemia, neutropenia, mucositis and nausea/vomiting

are common side-effects of anti-cancer treatments

• Patients with symptoms of these conditions need

prompt evaluation and treatment

• Various supportive care measures are available to

review symptoms and reduce complications of

treatment-related effects

So, to summarize, we just discussed some of the common side effects of anti-cancer treatments including anemia, neutropenia, mucositis, and nausea and vomiting. Patients with symptoms of these conditions need prompt evaluation and treatment to prevent complications. There are various supportive care measures available and it is important to review symptoms and reduce complications of these problems. So, this is the end of my presentation and I would like to thank you very much for your attention. We would appreciate any feedback as to how this program has helped you in any way. So, again thank you very much and send us your e-mail regarding your feedbacks.

综上所述，我们讨论了抗癌症治疗的一些常见副作用，包括贫血、嗜中性细胞减少症、黏膜炎和恶心及呕吐。需要对具有这些病症综合征的患者进行评估和治疗，以预防并发症。可以使用不同的支持性护理措施，而且务必要查看症状，减少这些问题的并发症。本次讲座到此结束，我要感谢各位的参与。我们很希望各位能够提供反馈，让我们了解本次计划对大家有什么样的帮助。再次感谢，请给我们发送反馈电子邮件。

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