In 2017, the National Comprehensive Cancer Network and American Society of Clinical Oncology released new antiemetic guidelines that recommended adding an NK1 receptor antagonist (RA) to standard 5-hydroxytryptamine RA plus dexamethasone upfront for patients receiving carboplatin area under the curve (AUC) ≥ 4.

In January 2018, the Centers for Medicare and Medicaid Services instituted a new quality outcome measure, OP-35, which assesses “potentially avoidable” acute care for nausea, vomiting, or eight other common chemotherapy-related toxicities (anemia, dehydration, diarrhea, fever, neutropenia, pain, pneumonia, and sepsis).

Researchers assessed the impact of the revised guidelines in patients receiving carboplatin and observed substantial noncompliance with the guidelines and a high rate of potentially avoidable acute care. Rudolph M. Navari, MD, PhD, Kathryn J. Ruddy, MD, MPH, Thomas W. LeBlanc, MD, MA, MHS, FAAHPM, Rebecca Clark-Snow, RN, BSN, OCN®, Gary Binder, MBA, Tammy Coberly, PharmD, Ravi Potluri, MBA, Luke M. Schmerold, BS, Eros Papademetriou, and Eric Roeland, MD, presented the results in “Impact of the Addition of Carboplatin AUC ≥ 4 to Antiemetic Guidelines for Triple Antiemetic Prophylaxis: A Gap in Quality of Care and Guideline Adoption” as part of the e-poster sessions on November 2 and 3 during the 2018 JADPRO Live conference in Hollywood, FL.

They assessed the IBM Explorys Watson Health database, which includes 39 large, U.S.-integrated delivery networks representing approximately 55 million patient lives. The researchers identified 10,239 carboplatin courses of therapy (defined as at least 14-day cycles as a proxy for AUC ≥ 4) initiated between quarter four of 2012 through quarter one of 2018. They compared outcomes with 73,053 patients receiving other courses of chemotherapy.

The investigators assessed guideline compliance (defined as triple prophylaxis at chemotherapy initiation) and 30-day post-chemotherapy acute care (defined as inpatient admission or emergency department use) associated with nausea and vomiting and other toxicities.

Upfront triple prophylaxis for carboplatin increased from 13% in 2013 to 16% in 2016, with quarterly rates ranging from 9%–19%. During the 12 months after the guideline update, quarterly rates of upfront triple prophylaxis use increased by an average of 15%, ranging from 11%–20%, with no apparent trend over time.

Thirty-one percent of carboplatin courses resulted in 30-day acute care use, of which one or more of the OP-35 toxicities were observed in 75.5% of patients. Nausea and vomiting were reported in 25% of carboplatin courses and accounted for 28% of total OP-35 acute care events.

Rates for nausea and vomiting, as well as rates of OP-35-related acute care events after carboplatin, were similar to those of patients receiving other highly emetogenic chemotherapy (HEC) or oxaliplatin and higher than those receiving non-HEC IV treatment or oral HEC/moderately emetogenic chemotherapy agents.

The researchers said that the recommendation’s slow uptake may be because of a lack of awareness or a belief that triple prophylaxis is not required for carboplatin-containing regimens. They hypothesized reasons for gaps in overall use of antiemetic prophylaxis, including subordination of physician attention to supportive care relative to therapeutic interventions, physicians neither seeking nor receiving reports of chemotherapy-induced nausea and vomiting symptoms, and clinical inertia.

“Oncology advanced practitioners are well-suited to lead the educational and behavior-change efforts required for practices to effectively implement this recent guideline recommendation and foster improvements in patient care and outcomes,” the researchers concluded.