Barriers to Implementation

Perhaps in part because of the inconsistencies between the ASCO, NCCN, and MASCC/ESMO clinical guidelines and resulting confusion about which guidelines should be followed, antiemetic recommendations have not been consistently implemented in oncology centers, despite evidence that implementation of individual guidelines’ recommendations can reduce the severity of acute treatment-associated nausea and vomiting and can reduce cancer care costs.3 Guideline nonadherence also stems from institutional policies and traditions.3

However, as with the empirical evidence base for CINV and RINV prevention and management, the evidence for implementation of antiemetic guidelines is represented in only a handful of published studies and more research on adherence is needed.3 Successful clinical implementation of guideline recommendations will likely require interdisciplinary coordination, clinician education, clinical workflow reminders, clinical practice audits, and pharmacist interventions to promote antiemetic prescribing, according to one recent review.3

Guidelines are “only effective if they are put into practice,” noted a review of antiemetic recommendations for RINV.3 “There is a necessity for the implementation of systems that promote guideline adherence and aid healthcare providers to prescribe the optimal RINV antiemetic regimens in order to optimize quality of life for patients.”

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1. Treatment-Related Nausea and Vomiting (PDQ®) — Health Professional Version. National Cancer Institute website. Accessed March 12, 2019.

2. Razvi Y, Chan S, McFarlane T, et al. ASCO, NCCN, MASCC/ESMO: a comparison of antiemetic guidelines for the treatment of chemotherapy-induced nausea and vomiting in adult patients. Support Care Cancer. 2019;27(1):87-95.

3. McKenzie E, Zaki P, Raman S, et al. Radiation-induced nausea and vomiting: a comparison between MASCC/ESMO, ASCO and NCCN antiemetic guidelines. Support Care Cancer. 2019;27(3):783-791.

4. Rao KV, Faso A. Chemotherapy-induced nausea and vomiting: optimizing prevention and management. Am Health Drug Benefits. 2012;5(4):232-240.

5. Molassiotis A, Lee PH, Burke TA, et al. Anticipatory nausea, risk factors, and its impact on chemotherapy-induced nausea and vomiting: results from the Pan European Emesis Registry Study. J Pain Sympt Manag. 2016;51(6):987-993.

6. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017;35(28):3240-3261.

7. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. Accessed March 12, 2019.

8. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol. 2016;27(suppl 5):v119-v133.

9. Ettinger DS, Berger MJ, Aston J, et al. NCCN Guidelines Insights: Antiemesis, Version 2.2017. J Natl Compr Canc Netw. 2017;15(7):883-893.