Survey of Implementation of Antiemetic Prescription Standards in Indian Oncology Practices and Its Adherence to the American Society of Clinical Oncology Antiemetic Clinical Guideline

Abstract

Purpose: Adherence to international antiemetic prophylaxis guidelines like those of ASCO can result in better control of chemotherapy-induced nausea and vomiting; however, the extent of implementation of such guidelines in India is unknown. Therefore, this survey was planned.

Methods: This study was an anonymized cross-sectional survey approved by the ethics committee. Survey items were generated from the clinical questions given in the ASCO guidelines. The survey was disseminated through personal contacts at an oncology conference and via e-mail to various community oncology centers across India. The B1, B2, and B3 domains included questions regarding the optimal antiemetic prophylaxis for high, moderate, and low-minimal emetogenic regimens.

Results: Sixty-six (62.9%) of 105 responded and 65 centers (98.5%) were aware of the published guidelines. The partial, full, and no implementation scores were 92.5%, 4.5%, and 3.0%, respectively. Full implementation was better for the low-minimal emetogenic regimens (34.8%) than the highly emetogenic regimens (6.1%). The three most frequent reasons for hampered implementation of ASCO guidelines in routine chemotherapy practice cited by centers were a lack of sensitization (26 centers; 39.4%), lack of national guidelines (12 centers; 18.2%), and lack of administrative support (10 centers; 15.2%).

Conclusion: Awareness regarding ASCO antiemetic guidelines is satisfactory in Indian oncology practices; however, there is a need for sensitization of oncologists toward complete implementation of these guidelines in their clinical practice.

Fig 1

Implementation rate of ASCO guidelines in each of the domains. B1, B2, and B3 domains had question dealing with high, moderate, and low-minimal emetogenic agents respectively. Although overall calculation suggested ≥ 90% score in three centers, only two centers had consistent ≥ 90% scores in each domain. These two centers had 100% scores in all domains. The third center had 100% scores in B2 and B3 domains but had a score of 83.33% in the B1 domain.

Fig 2

Evidence-based algorithm for quick selection of appropriate antiemetic regimen. (*) NK-1 antagonist schedule: aprepitant 125 mg day 1 and 80 mg days 2 and 3 orally or fosaprepitant 150 mg IV day 1 only. (†) 5HT3 antagonist: granisetron 1 mg IV/oral or ondansetron 8 mg IV/oral or palonosetron 0.25 mg IV day 1 only. Emetogenic potential: High: AC/EC, carmustine (> 250 mg/m²), cisplatin (any dose), cyclophosphamide (> 1.5 g/m²), dacarbazine, doxorubicin (≥ 60 mg/m²), epirubicin (> 90 mg/m²), ifosfamide (≥ 2 g /m²), mechlorethamine. Moderate (NK-1 antagonist preferred): carboplatin, carmustine (≤ 250 mg/m²), dactinomycin, daunorubicin, doxorubicin (< 60 mg/m²), epirubicin (≤ 90 mg/m²), ifosfamide (< 2 g /m²), irinotecan, methotrexate (≥ 250 mg/m²). Moderate: cyclophosphamide (≤ 1.5 g/m²), IFN-alpha (≥ 10 million U/m²), oxaliplatin, temozolomide. Low: carfilzomib, liposomal doxorubicin, etoposide, eribulin, FU, floxuridine, gemcitabine, INF-alpfa ( > 5 to > 10 million units/m²), ixabepilone, methotrexate (> 50 to < 250 mg/m²), mitomycin, mitoxantrone, pemetrexed, topotecan, taxanes. Minimal: bevacizumab, bleomycin, cetuximab, methotrexate (≤ 50 mg/m²), nivolumab, panitumumab, pertuzumab, ramucirumab, temsirolimus, trastuzumab, vinca alkaloids. dexa, dexamethasone; FU, fluorouracil; IFN, interferon; inj, injection; IV, intravenous; NK-1, neurokinin-1; PO, orally.