BritishJoumalofCancer(1997)76(8),1055-1061
`©1997CancerResearchCampaign
`Patientperceptionsoftheside-effectsofchemotherapy:
`theinfluenceof5HT3antagonists
`MdeBoer-Dennert1,RdeWit',PIMSchmitz2,JDjontono1,VvBeurden',GStoterlandJVerweijl
`Departmentsof'MedicalOncologyand2Biometrics,RotterdamCancerInstitute(DanieldenHoedKliniek)andUniversityHospital,Rotterdam,TheNetherlands
`SummaryIn1983,Coatesconductedasurveythatrankedtheside-effectsperceivedbypatientsreceivingchemotherapyintheorderoftheir
`severity.Vomitingandnauseawerefoundtobethetwomostdistressingside-effects.Theyhaveanimpactonqualityoflifeandcompliance
`withtreatment.Thedevelopmentof5HT3antagonistshasbeenamajorstepforwardinthepreventionandtreatmentofchemotherapy-
`inducednauseaandvomiting.Presently,theseantiemeticsareroutinelyusedasconcomitanttherapyinemetogenicchemotherapy
`regimens.Thepurposeofthisstudywastoevaluatetheimpactof5HT3antagonistsonpatientperceptionsoftheside-effectsof
`chemotherapy.Coates'surveywasreplicatedinpatientswhoreceived5HT3antagonistsforacutenauseaandvomitingresultingfrom
`emetogenicchemotherapy.Patientsreceivedthesurveytoidentifythosephysicalandnon-physicalside-effectsthattheyattributedto
`chemotherapyandwereaskedtorankthefivemostdistressingside-effects.Ofthe197patientswhoconsentedtotakepartinthestudy,181
`wereevaluable.Nausea,hairlossandvomitingweredescribedasthethreemostdistressingside-effectsofchemotherapy.Eightypercentof
`allthepatientsactuallyexperiencednauseaand57%experiencedvomiting.Hairlossappearedtobemoredistressingtowomen(P<0.001)
`but,inotheraspects,gender,ageandmaritalstatusdidnotinfluencetherankingofthethreemostdistressingside-effects.Constipationwas
`rankedas6thandwasnotidentifiedas adistressingside-effectin1983.Nauseaandvomitingremaintobethefirstandthirdmostdistressing
`side-effectsofchemotherapy,eventhoughtheincidenceandseverityofacutenauseaandvomitingarenowsignificantlyreduced.
`Keywords:chemotherapy;nausea;vomiting;side-effects;serotoninantagonists
`Nauseaandvomitinghave beenreportedbypatients,nursesand
`physiciansasthemostdistressingside-effectsofchemotherapy
`(Coatesetal,1983;Loveetal,1989;Pritchard,1989;Cooper,
`1992;Martin,1992;Youngbloodetal,1994).Theintroductionof
`the5HT3antagonistsTropisetron,OndansetronandGranisetron
`havesignificantlyreducedtheincidenceofthesedistressingside-
`effects.Physiciansandnurseshaveobservedthat5HT3antago-
`nistshavecontributedtoanimprovementofqualityoflifeand
`compliancewithtreatment(Seynaeveetal,1991a).However,
`theimpactofthesenewdrugsonpatients'perceptionsof
`chemotherapy-inducedside-effectshasnotyetbeeninvestigated
`(Mansonetal,1993).Unfortunately,somehealthcareworkers
`extrapolatedataontheimprovementofantiemeticefficacyinthe
`phaseofacuteemesistorepresentthetotalexperienceofemesisin
`treatedpatients.Theytendtobelievethatadecreaseintheinci-
`denceandseverityofacuteemesisreducesthepatients'distress
`accordingly.Thismightnotbethecase(Loveetal,1989;Blisset
`al,1992;Schmoll,1992;Jansenetal,1993;deWitetal,1996)as
`delayedemesisremainsaseriousproblem.Therefore,webelieved
`areassessmentandre-rankingofthemostdistressingside-effects
`ofchemotherapyperceivedbypatientswaswarranted.Inaddition,
`themostdistressingside-effectsofchemotherapyduringeach
`courseoftreatmentmaybecrucialfor theplanningofappropriate
`Received20November1996
`Revised14April1997
`Accepted18April1997
`Correspondenceto:MdeBoer-Dennert,DepartmentofMedicalOncology,
`RotterdamCancerInstitute(DanieldenHoedKliniek)andUniversity
`Hospital,GroeneHilledijk301,3075EARotterdam,TheNetherlands
`interventionsandforidentifyingpossibleresearchquestions
`(Martin,1992;Youngbloodetal,1994;deWitetal,1996).
`Westudiedthepatients'perceptionsofphysicalandnon-phys-
`icalside-effectsofcurrentchemotherapy,usingthequestionnaire
`previouslyusedbyCoatesetal(1983)inanerabeforetheintro-
`ductionofthe5HT3antagonists.Patientsrankedtheirside-effects
`inorderofdistress.Influencingfactors,suchasthenumberof
`treatmentcoursesandpatientcharacteristics,werealsoanalysed
`fortheireffectontheorderofdistress.Therankingofnauseaand
`vomitingwasthancomparedwiththeresultspublishedbyCoates
`in1983andbyGriffinin1996.
`PATIENTSANDMETHODS
`Eligibilitycriteriaforthestudyincludedthefollowing:age218
`years;treatmentwithemetogenicchemotherapyandconcom-
`mitant5HT3antagonistsforthepreventionand/ormanagement
`ofacutenauseaandvomitingfromthefirsttreatmentcycleon.
`Patientsweretreatedwithchemotherapyintheoutpatientdepart-
`mentorwereadmittedtothehospital.Patientsenteredthestudy
`duringanycycleofchemotherapy.
`Forthepreventionofacutenauseaandvomiting,patientswere
`treatedwitheitherOndansetron8mgorTropisetron5mgas
`singleagentorincombinationwithdexamethason10mg.Both
`wereadministeredintravenously15minbeforethestartof
`chemotherapy.Fordelayednauseaandvomiting,various
`antiemeticswereprescribed.
`Patientswereinformedbytheparticipatingphysiciansorthe
`studynursesabouttheobjectivesofthestudy.Afterconsenting,
`thenurseexplainedhowthequestionnairewastobecompleted.
`Allpatientsgaveverbalinformedconsentaccordingtotherulesof
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`1056MdeBoer-Dennertetal
`Table1GroupA-physicalsymptoms Table2GroupB-non-physicalsymptoms
`Feelingsick(nausea)
`Beingsick(vomiting)
`Itchingatinjectionsite
`Shakingallover
`Changeinthewaythingstaste
`Changesinhowthingssmell
`Nothavingregularbowelaction(constipation)
`Lossofliquidorfrequentbowelaction(diarrhoea)
`Pinsandneedlesinfingersandtoes
`Numbnessinfingersortoes
`Lossofweight
`Weightgain
`Increasedhairgrowthonlegs
`Constantlytired
`Giddinessonstandingup
`Lossofappetite
`Soremouth
`Sorethroat
`Shortnessofbreath
`Skinrash
`Bruiseeasily
`Difficultysleeping
`Painpassingwater(painfulurination)
`Colouredurine
`Ringinginears
`Deafness
`Generalachesandpains
`Tummyache(abdominalpain)
`Swollentummy(abdominalfullness)
`Periodsstop
`Periodsbecomeirregular
`Changesinskincolour
`Hotflushes
`Heartbeatingfast(palpitations)
`Headache/migraine
`Lossofhair
`Increasedthirst
`Passingmorewaterthanusual(increasedurination)
`Dryskin
`Acne(pimples)
`Increasedappetite
`Troublewithswallowing
`Nosebleeds
`Cannottastethings
`Fingernailsgobrown
`ourinstitute.Thesurveywasconductedusingthequestionnaire
`usedpreviouslybyCoatesetal(1983).Side-effectsweredivided
`intwogroups:groupA(Table1)comprised45physicalside-
`effectsandgroupB(Table2)compised28non-physicalside-
`effects.Itwaspossibletoaddside-effectsexperiencedbythe
`patientthatwerenotincludedinthelistings.Patientswereasked
`tocircleallside-effectsthattheyattributedtotheirchemotherapy.
`Subsequently,theyrankedthefivemostdistressingside-effects
`thattheyexperiencedfromeachgroupinorderofseverity.The
`twogroupsoffivephysicalandnon-physicalside-effectswere
`combinedandpatientsthenrankedthefivemostdistressingside-
`effectsregardlessofgroup.Weagreedtouseaself-reportingques-
`tionnaireasitallowsforprivacyandfacilitatesthedisclosureof
`symptomsorside-effectsofasensitivenature(Youngbloodetal,
`1994).Foranalysisofthedata,weallocated5pointstothemost
`distressingside-effectdecreasingto1pointfortheside-effect
`rankedastheleastdistressing.Limiteddemographicdatawere
`collected;age,gender,maritalstatus,diagnosis,prior
`chemotherapyregimens,thecurrentchemotherapyregimenand
`numberoftreatmentsgiven,theantiemetictreatmentregimen
`2
`3
`4
`5
`6
`7
`8
`9
`10
`11
`12
`13
`14
`15
`16
`17
`18
`19
`20
`21
`22
`23
`24
`25
`26
`27
`28
`Lossofsexualfeeling
`Lossofsexualability(notgettingaroused)
`Feelinglow,miserable(depression)
`Thoughtofcomingfortreatment
`Lengthoftimetreatmenttakesattheclinic
`Feelingbadtempered(irritability)
`Havingtohaveaninjection
`HavingtocometoclinicratherthanpriVatedoctor
`Affectsmyfamilyorpartner
`Feelingofnotcopinggenerallywithtreatment
`Feelingofhavingtohavetreatmentthatdonotthinkwilldoanygood
`Feelingofhavingtohavetreatmentthatdonotwant
`Cryingmoreoften
`Feelingangry
`Cannotconcentrate
`Affectsmywork/homeduties
`Affectsmysocialactivities
`Infertility(cannothavechildren)
`Troublefindingsomewheretoparkneartheclinic
`Troublegettingtotheclinic
`Nothavingthechancetoaskthedoctorquestions
`Forgetthings
`Notseeingthesamedoctoreachtime
`Cannotgetclothestofit
`Notunderstandingwhatishappening
`Feelinganxiousortense
`Havingtowaitfortreatmentwithotherpatients
`Feelingthatthetreatmentisdamagingmybody
`andresponsetochemotherapy.Agewasgroupedintolessthan
`45years,45-60yearsandover60years.
`Chemotherapyregimensweregroupedintocisplatinbased,
`doxorubicinbasedandthosecomprisingneitherofthetwodrugs.
`Ifthestatisticalanalysislistedtwoitemsrankedasequally
`distressing,bothitemswereallocatedthenextlowernumberin
`sequence.Correctionswerenotmadefordisease-relatedsymp-
`tomsintheside-effectsthatpatientsreportedasrelatingtotheir
`chemotherapy.
`Therelativeseverityofside-effectswasanalysedusing
`descriptivestatisticalmethods(rankingthedata)andtabulated
`againstthepatientcharacteristics,diagnosis,treatmentand
`response.Whenacorrelationwasfoundwiththechi-squaretest,
`theexacttestforrxcwasformallyperformed.Patientcharacter-
`istics,diagnosis,treatmentandresponsewerecombinedwiththe
`severityofeachside-effectseparatelyandformallytestedwith
`Fisher'sexacttestfora2cktable;fortheseanalyses,severitywas
`expressedasadichotomy:belongingtothefivemostsevereside-
`effects(yes/no).Theusuallevelof5%wasusedasthelevelof
`statisticalsignificance.
`RESULTS
`Twohundredpatientswereaskedtoparticipateinthestudyand
`197patientscompletedthequestionnaire.Eightpatientsfilledout
`thequestionnaireincorrectlyanduponanalysiseightadditional
`questionnairesdemonstratedinconsistenciesandwerealso
`excludedfromthefinalanalysis.Thecharacteristicsofthe181
`evaluablepatientsareshowninTable3.Fifty-sixpatientswere
`treatedintheoutpatientdepartment,125receivedtheirtreatment
`asinpatients.Chemotherapyregimensandtheantiemeticsusedto
`preventchemotherapy-inducedacuteanddelayedemesisarelisted
`inTable4.Patientshadreceived1-20courses(mean,four)
`ofchemotherapyatthetimeofcompletingthequestionnaire;
`BritishJournalofCancer(1997)76(8),1055-1061
`2
`3
`4
`5
`6
`7
`8
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`11
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`13
`14
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`16
`17
`18
`19
`20
`21
`22
`23
`24
`25
`26
`27
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`29
`30
`31
`32
`33
`34
`35
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`37
`38
`39
`40
`41
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`0CancerResearchCampaign1997
`Page 2 of 7
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`Patients'perceptionofside-effectsofchemotherapy1057
`Table3Patientcharacteristics
`No.ofevaluablepatients
`Male/female
`Meanage(range)(years)
`Maritalstatus
`Spouse
`Nospouse
`Alone
`Notalone
`Tumourtypes
`Breastcancer
`Soft-tissuesarcoma
`Testicularcancer
`Small-celllungcancer(SCLC)
`Headandneckcancer
`Non-small-celllungcancer
`Ovariancancer
`Mesothelioma
`Miscellaneous
`181
`101/80
`50(18-78)
`141
`40
`24
`157
`50
`26
`20
`14
`13
`10
`9
`7
`32
`17patientshadreceivedpriorchemotherapy.Themeannumberof
`selectedphysicalside-effectswaseight(range0-26)andofnon-
`physicalside-effectswasfive(range0-17).Patientsranked
`nausea,hairlossandvomitingasthemostdistressingside-effects;
`thetenmostdistressingside-effectsarelistedinTable5.Table6
`liststheanalysisofthetenmostdistressingside-effectsbygender,
`ageandmaritalstatuscomparedwiththeoverallranking,whichis
`giveninthetoprowofthetable.Itemsrankedinthetopten
`subanalysisthatwerenotlistedinthetoptenoftheoverall
`analysisarelistedontherightsideofthetable.Therankingofthe
`fourmostdistressingside-effectswasquiteconsistentforgender,
`ageandmaritalstatus.
`Comparedwithmen,womenrankedhairlosssignificantly
`higherthanvomiting(P<0.001),andtheyalsorankedfeeling
`miserable(depression),anxiousortensehigherthanmen.Men
`weremoreconcernedbythethoughtofcomingfortreatment,the
`lengthoftimetreatmenttakesattheclinic(P=0.006)andby
`infertility.
`Infertilitycausedmoredistress intheyoungerpatients
`(P<0.001).Therankingofeffectsonfamilyandpartnerandof
`feelinganxiousortensedecreasedwithage,whiletherankingof
`constipationandofhavingtohaveaninjectionincreased.The
`thoughtofcomingfortreatmentaffectedolderpatientsless
`(P=0.045).Cryingmoreoftenwasimportanttothepatientsaged
`45-60years(P=0.048).
`Table4Chemotherapygivenandantiemeticsused
`Chembtherapy
`Includingcisplatin
`Cisplatin
`CisplatinAffosfamide
`BEP
`VIP
`Other
`Includingdoxorubicin
`DoxorubicinAffosfamide
`Other
`Neithercisplatinnordoxorubicin
`FEC
`CMF
`ICE
`Other
`Both
`Antiemetics
`Day1
`Ondansetron
`Ondansetron/dexamethasone
`Tropisetron
`Tropisetron/dexamethasone
`Days2-5
`Domperidon
`Metoclopramide
`Zofran±methylprednisolone
`Tropisetron
`Ondansetron+dexamethason
`Ondansetron
`Dexamethasone
`Various
`89
`40
`17
`15
`6
`11
`25
`15
`10
`65
`26
`21
`7
`11
`2
`11
`81
`32
`57
`63
`44
`10
`8
`6
`6
`4
`40
`BEP:bleomycin,etoposide,cisplatin;VIP:etoposide,ifosfamide,cisplatin;
`CDDP:cisplatin;VP16:etoposide;DOXO:doxorubioin;FEC:5-fluorouracil,
`epirubicin,cyclophosphamide;CMF:cyclophosphamide,methotrexate,
`fluorouracil;ICE:ifosfamide,carboplatin,etoposide;Other:lessthanfour
`equalregimens.
`Patientslivingalonewereobviouslylessconcernedaboutthe
`effectsonfamilyorpartner.Constipationwasrankedlowerin
`patientslivingalone,theinfluenceonlossofappetiteandtastewas
`rankedhigher.
`Table7showstheanalysisbytumourtypeandchemotherapy
`regimen.Thesubgroupsaresmallerandawidervariabilitywas
`found.Thetesticularcancerpatientswerepredominantlyinthe
`Table5Tenmostdistressingside-effectsofchemotherapy
`Rank 1983 1995
`1 Beingsick(vomiting) Feelingsick(nausea)
`2 Feelingsick(nausea) Lossofhair
`3 Lossofhair Beingsick(vomiting)
`4 Thoughtofcomingfortreatment Constantlytired
`5 Lengthoftimetreatmenttakesattheclinic(24) Havingtohave aninjection
`6 Havingtohaveaninjection Constipation(-)
`7 Shortnessofbreath(15) Thoughtofcomingfortreatment
`8 Constantlytired Affectsfamilyorpartner
`9 Difficultysleeping(21) Feelinglow,miserable(depression)(14)
`10 Affectsfamilyorpartner Feelinganxiousortense(13)
`Numbersinparenthesesindicatetherankingnumberintheoppositecolumn.
`BritishJournalofCancer(1997)76(8),1055-10610CancerResearchCampaign1997
`Page 3 of 7
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`1060MdeBoer-Dennertetal
`Table8Theincidenceofnauseaandvomitingvstheoveralltopfiverating
`CourseoftreatmentIncidence(%) Topfiverated(%) Meana
`Nausea
`1+2 76 59 4.1
`3 81 76 4.3
`4 77 78 3.8
`5 79 66 4.1
`>6 88 60 4.1
`Vomiting
`1+2 60 48 4.0
`3 61 68 3.2
`4 46 75 3.8
`5 52 55 3.5
`>6 65 58 3.3
`aThemeanrelativeseverityofthepointsallocatedfrom1(leastsevere)to5(mostsevere).
`youngerageranges.Theyrankedinfertilityasahighdistressor
`(P<0.001)andfeelingmiserable(depression)wasrankedlow.
`Noneoftheheadandneckcancerpatientsmentionedlossofhair
`andnoneofthesmall-celllungcancer(SCLC)patientlisted
`constipationorfeelinganxiousortenseasdistressingside-effects.
`Patientsreceivingdoxorubicinregimensreportedhairlossas
`mostdistressingandappearedmuchmoreconcernedwiththe
`effectsontheirfamiliesorpartner.Patientsreceivingcisplatin
`ratedthelengthoftimethatthetreatmenttakesintheclinicas
`highlydistressingcomparedwithotherpatients.Thiscouldbe
`relatedtothetimerequiredforpre-andpost-hydration.Statistical
`analysisrevealedthatvomiting(P=0.04),weightgain(P=0.01)
`andhotflushes(P=0.03)wereimportanttopatientsreceiving
`neithercisplatinnordoxorubicin;agrouppredominantly
`consistingofbreastcancerpatientsasseeninTable4.Table7
`showstheresultsaccordingtotumourtype,tumourresponseand
`thenumberofcourses.Respondingpatientshadconsiderablyless
`anxietyandtension,andlessdifficultywiththethoughtof
`comingfortreatmentsandhavinganeedle.Theywerevery
`concerned,however,abouttheeffectsontheirfamiliesorpartner.
`Thethoughtthatthetreatmenthaddamagedthebodywasexperi-
`encedashighlydistressingbypatientswhohadachieveda
`completeresponse(P<0.001).
`Analysisofthenumberoftreatmentcoursesgivendemon-
`stratedthatthethoughtofcomingfortreatmentanddepression
`becamemoredistressingaftermultipletreatmentcourses,whereas
`feelinganxiousortensedecreased.Duringmultipletreatment
`courses,thepatients'distressrelatedtotheaffectsonpartnerand
`familyfirstlyincreasedandthensubsequentlydecreased.Sleeping
`problemsarementionedmorefrequentlyduringcourse1and2.
`Fatigueispredominantbycourse3.
`Table8showsthepercentageofpatientswhoidentifiednausea
`andvomitingasaside-effectoftheirchemotherapypercourse
`numberand,subsequently,thepercentageofthesepatientswho
`includedtheseside-effectsintheiroveralltopfiveranking;in
`addition,themeanseverityascribedtotheseside-effectsis
`presented.
`DISCUSSION
`Theintroductionof5HT3antagonistsforthepreventionof
`chemotherapy-inducednauseaandvomitingisfrequentlyconsid-
`eredtobeoneofthemostimportantachievementsinsupportive
`careinthelastdecade.Nevertheless,physiciansandotherhealth
`careworkersmayoverestimatethisachievement.Thetenmost
`distressingside-effectsoftheoverallgroupsanalysisinthepresent
`studyandtheresultsreportedbyCoatesetal(1983)arelistedin
`Table5.Theobjectiveofthisstudywastoinvestigatethecurrent
`statusofpatientperceptionsofside-effectsratherthantocompare
`ourresultswiththosereportedbyCoatesetal(1983),andclearly
`severalfactorshampersuchacomparison.Firstly,ourpatients
`receivedmoreintensivechemotherapy,partlyrelatedtotheavail-
`abilityof5HT3antagonists;secondly,Coates'patientpopulation
`consistedpredominantlyofwomen.Still,ourresultsdoshowthat,
`despitetheuseof5HT3antagonistsasdenominatorforparticipa-
`tiontothisstudy,patientsrankednauseaandvomitingasthefirst
`andthirdmostdistressingside-effectsofchemotherapy,whichis
`almostsimilartotheresultsofoveradecadeago(Coatesetal,
`1983).ThisisalsoconsistentwiththefindingsofGriffinetal
`(1996)whoidentifiednauseaasthemajorprobleminasimilar
`survey.Obviously,thequestioniswhytheincreasedabilityto
`preventnauseaandvomitingisnotreflectedinthepatients'
`perceptionofthisside-effect.Firstofall,ashasalreadybeen
`suggestedbyothers(Cooper,1992),thefrequencyand/orseverity
`ofsymptomsmaynotbecorrelatedwiththelevelsofdistress
`expressedbythepatient.Forapatient,forinstance,10daysof
`minornauseamaybemoredistressingthan1dayofsevere
`vomiting.Secondly,the5HT3antagonistshaveimprovedthe
`preventionandtreatmentofacutenauseaandvomitingratherthan
`thedelayednauseaandvomiting.Thirdly,thestudiesthathave
`beenperformedontheefficacyof5HT3antagonistsovermultiple
`coursesappeartoshowthattheireffectisnotmaintained(deWit
`etal,1996).Withincreasingnumbersoftreatmentcycles,thereis
`aprogressivelossofefficacy.Thismayinfluencethepatients'
`perceptionforthewholetreatmentperiod.Table8demonstrates
`thatahighpercentageofpatientsalreadyexperiencesomenausea
`andvomitingduringthefirsttwocourses.Nevertheless,inthefirst
`twocoursesoftreatment,patientsrankednauseaandvomitingas
`highlydistressinginourstudy,againsuggestingtherelative
`importanceofthelevelofdistressvstheseverityandfrequencyof
`theside-effects.Ourstudywasnotdesignedinawaytoenable
`suchananalysis,buttheoptionshouldbeconsideredinfurther
`researchprojects.InadditionTable8outlinesthatthemajorityof
`thepatientswhoexperiencenauseaandvomitingdescribethe
`side-effectsasoneofthefivemostdistressingside-effectsand
`rankitveryhighly.
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`Patients'perceptionofside-effectsofchemotherapy1061
`Hairlossremainsanimportantdistressingside-effectfor
`patients,whichisnotsurprisinggiventhefactthatthereareno
`effectivemethodstocircumventthisside-effect.Thiswasalso
`foundinthestudyofGriffinetal(1996).Comparedwithmen,
`womenrankedhairlossasbeingmoredistressingthanvomiting,
`eventhoughitiswellknownthattheyaremoresusceptibletothe
`latter.Thisstressesthesociopsychologicalrelevanceofhairlossto
`women.Someofthegenderdifferenceswithreferencetohairloss
`mayalsobeexplainedbythefactthatmenareoftenfacedwith
`someage-relatedhairloss.Patientstreatedwithcisplatin-based
`regimensalsorankedhairlossashighlydistressing.Cisplatin
`monotherapydoesnotcausehairlossbut,inpatientsparticipating
`inthisstudy,itwascombinedwithdrugsthatarewellknownto
`inducehairloss.Headandneckcancerpatientsdidnotreporthair
`lossasadistressingside-effect,asnoneofthesepatientsreceived
`anydrugthatcauseshairloss.Incomparisontothestudy
`performedbyCoatesetal(1983),thelengthoftimetreatment
`takesintheclinicisnolongerperceivedasoneofthetenmost
`distressingfactors.Thismayreflectthefactthatinthelastdecade
`therehasbeenashiftfromhospitaladmissionstooutpatienttreat-
`ment.However,asintheCoates'study(Coatesetal.,1983),the
`lengthoftimethattreatmenttakes,aswellashavingtowaitfor
`treatment,didcausemoredistressinmen.
`Constipationisanewproblemcomparedwith1983,nowbeing
`perceivedasoneofthetenmostdistressingfactors.Thisisawell
`knownside-effectof5HT3antagonists(Seynaeveetal,1991b),
`andthefactthatallpatientsenteredinthisstudyreceivedthese
`drugspresumablyexplainsthehighrankingofthissymptom.This
`maybeaveryimportantobservation.Althoughweareableto
`controlnauseaandvomitingbetter,thisisnotreflectedinthe
`patients'perceptionofthisside-effectand,moreover,thiscontrol
`isachievedatthecostofotherside-effectssuchasconstipation,
`whichisapparentlyaddingtothelevelofdistressforthepatient-
`anotherreasonforacarefulreappraisaloftheimplementationand
`dosingofthe5HT3antagonists.Surprisingly,thiswasnotidenti-
`fiedasadistressingsymptombyGriffinetal(1996).
`Afewdistressingside-effectsarenolongerrankedhighinthe
`presentstudycomparedwiththepreviousstudyofCoatesetal
`(1983).Onesuchside-effectisshortnessofbreath;thereasonfor
`thisbeingnolongerrankedhighisunclear.Itmaybethatthe
`selectionofpatientshaschangedand,presently,mainlypatients
`withabetterperformancescoreand/oranearlierstageofdisease
`aretreatedwithchemotherapy.Difficultyinsleepingisalsoranked
`lower.Inviewofthefactthatfeelingdepressed,anxiousortense
`arestillrankedhigh,anyimprovementinthisrespectcanbe
`excludedintryingtoexplainthisfinding.Whethernightmedica-
`tioniseithermoreeffectiveorusedmoreappropriatelyremainsto
`beelucidated.
`Afewotherissuesalsowarrantattention.Infertilityasaresult
`ofchemotherapyappearedtobeofmajorconcerntopatientswith
`testicularcancer,eventhoughitiswellknownthatmanyofthese
`patientsappeartobeinfertilebeforethestartofchemotherapy
`(Drasgaetal,1983).Clearly,theinformationgiventothese
`patientsisnotsufficientinthisrespect.Youngpatientsaremore
`anxiousandaremoreconcernedwiththeeffectsontheirfamilies
`thanolderpatients.Thisperhapsreflectsanincreaseddifficultyin
`copingwiththefactofdeathduetodisease,forthefirstsymptom,
`andthehigherprobabilityforthesepatientstohaveimportant
`parentaltasks,forthelatter.
`Theresultsofourstudyindicatethatweshouldremainalertto
`thepatients'perceptionoftheside-effectsofchemotherapy,which
`maydifferfromtheperceptionofhealthcareworkers.Wedonot
`wanttounderestimatetheimportanceoftheintroductionofnew
`effectivemeansofsupportivecare,suchasthe5HT3antagonists,
`butwouldliketocautionforoveroptimisticinterpretationoftheir
`relevance.Onlyfullcontrolovernauseaandvomitingwillresultin
`achangeofpatients'perception.Forthisreason,'complete
`response'shouldbethemainendpointforstudiesonantiemetics
`aswellasforthedevelopmentofnewantiemetics.Thisisclearly
`notinagreementwiththeoptimisticresultsreportedinthelitera-
`ture,inwhichtheendpointisusuallymajorinsteadofcomplete
`control.
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