Introduction Nausea and vomiting are two of the most frequent and troubling side effects patients experience during chemotherapy, interfering with compliance with cancer therapies and quality of life. While newly available treatments have improved our ability to manage nausea and vomiting, anticipatory and delayed nausea and vomiting are still major problems for patients receiving chemotherapy. Many cancer patients consider delaying future chemotherapy cycles and some contemplate stopping chemotherapy altogether because of their fear of experiencing further nausea and vomiting. Areas Covered The purpose of this article is to provide an overview of the patho-psychophysiology of chemotherapy-induced nausea and vomiting, the recommended guidelines for treatment, current agents in late-stage clinical trials, and future research needs to address the continued challenges of treatment-related nausea and vomiting. Expert Opinion Despite advances in pharmaceutical and behavioral therapies, and the provision of standard clinical guidelines for effectively managing chemotherapy-induced nausea and vomiting (CINV), patients continue to experience CINV. Moreover, control of nausea, acute and delayed, and anticipatory nausea and vomiting (ANV) remains an important, unmet need among cancer patients. It is critical to focus attention on better understanding the mechanisms underlying nausea, anticipatory symptoms, and delayed symptoms.

As a specific variation of chemotherapy-induced nausea and vomiting, anticipatory nausea and vomiting (ANV) appears particularly linked to psychological processes. The three predominant factors related to ANV are classical conditioning; demographic and treatment-related factors; and anxiety or negative expectancies. Laboratory models have provided some support for these underlying mechanisms for ANV. ANV may be treated with medical or pharmacological interventions, including benzodiazepines and other psychotropic medications. However, behavioral treatments, including systematic desensitization, remain first line options for addressing ANV. Some complementary treatment approaches have shown promise in reducing ANV symptoms. Additional research into these approaches is needed. This review will address the underlying models of ANV and provide a discussion of these various treatment options.

Purpose Fatigue is a prevalent, distressing side effect of cancer and cancer treatment which commonly co-exists with insomnia. Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve insomnia in cancer patients, but less is known about its ability to impact fatigue. This work is the analysis for a secondary aim of a 4-arm RCT study assessing the combined and comparative effect of CBT-I and a wakefulness-promoting agent, armodafinil (A), to improve sleep and daytime functioning in cancer survivors. Herein, we examine the effect of CBT-I, with and without A, on fatigue in cancer survivors. Patients and Methods This study was a four arm factorial study with CBTI-I (Yes/No) versus A (Yes/No). It consisted of 96 cancer survivors (Average age 56 years; 88% female; 68% breast cancer). Fatigue was assessed by the Brief Fatigue Inventory (BFI) and the FACIT-Fatigue scale. The analysis assessed the additive effects of CBT-I and A, and possible non-additive effects where the effect of CBT-I changes depending on the presence or absence of A. Results Analyses adjusting for baseline differences showed that CBT-I improved fatigue as measured by two separate scales (BFI: P=0.002, Std. Error=0.32, effect size (ES)=0.46; FACIT-Fatigue: P<0.001, Std. Error=1.74, ES=0.64). Armodafinil alone did not show a statistically significant effect on fatigue levels (all Ps>0.40), nor did the drug influence the efficacy of CBT-I. Structural equation analysis revealed that reductions in insomnia severity were directly responsible for improving cancer-related fatigue. Conclusions CBT-I with and without armodafinil resulted in a clinically and statistically significant reduction of subjective daytime fatigue in cancer survivors with chronic insomnia. Armodafinil did not improve CRF and did not change the efficacy of CBT-I. Patients reporting CRF should be screened and, if indicated, treated for insomnia as part of a comprehensive fatigue management program.

CBT-I results in significant and durable improvements in insomnia and sleep quality. A did not significantly improve the efficacy of CBT-I or independently affect insomnia or sleep quality.