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Some people feel sick, or are sick, before a chemotherapy session, set off by the hospital or a smell: a learned reaction to sickness in earlier cycles. The best protection is good anti-sickness medicine from the first cycle. If it happens, tell your team: relaxation training helps, and a calming tablet such as lorazepam the night before and on the morning of treatment can be offered.
Anticipatory nausea and vomiting is a conditioned response that follows poorly controlled nausea in earlier cycles. MASCC/ESMO (2016, unchanged from 2009 and still the latest statement) recommend preventing it by optimal control of acute and delayed chemotherapy-induced nausea and vomiting, and treating it with benzodiazepines and behavioural therapies, in particular progressive muscle relaxation, systematic desensitisation and hypnosis; their 2016 search found no new trial meeting its criteria. eviQ (reviewed 2024) gives lorazepam 0.5 to 1 mg orally the night before and 1 to 2 hours before treatment. A 2024 meta-analysis for the Japanese antiemesis guideline found that systematic desensitisation reduced anticipatory nausea (risk ratio 0.60) and vomiting (0.54) in a few small, mostly high-risk-of-bias studies. In a randomised trial of 474 people, 20-minute nurse-delivered mindfulness relaxation or relaxing music reduced anticipatory nausea at the midpoint of chemotherapy but not at the end. The 2023 MASCC/ESMO update suggests progressive muscle relaxation, alone or with guided imagery, as an adjunct for chemotherapy-induced nausea generally [II, B].
Why: Anticipatory nausea is learned from bad experiences in earlier cycles; preventing that first bad experience is the most effective protection.
“The best management of anticipatory emesis is to ensure good control of acute and delayed emesis, starting from the initial anti-cancer treatment cycle.”
Why: It is easily missed unless asked about, and recognising it early allows treatment before it becomes entrenched.
“Anticipatory emesis: occurring before receiving next treatment of anti-cancer therapy. It is a conditioned response, typically occurring after a previous negative experience with anti-cancer therapy.”
Why: These techniques help unlearn the link between the treatment setting and feeling sick.
“Benzodiazepines and behavioral therapies, in particular progressive muscle relaxation training, systematic desensitization and hypnosis, continue to be recommended for the treatment of anticipatory nausea and vomiting.”
Why: A benzodiazepine reduces anxiety and the learned nausea that comes with it.
“For patients who do develop anticipatory emesis, non-pharmacologic methods such as behavioural/psychological techniques may be useful and/or benzodiazepines e.g. lorazepam 0.5 mg to 1 mg orally on the night before and then repeated the next day 1-2 hours before anti-cancer treatment.”
Why: Relaxation reduces nausea after chemotherapy as well, which helps prevent the bad experiences that anticipatory nausea grows from.
“The adjunctive use of PMRT (alone or with GI) is suggested for the management of CINV [II, B].”
MASCC/ESMO, ESMO Open 2024 · [II, B]
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
MASCC/ESMO 2016 remains the latest international statement (the 2023 update did not revisit anticipatory nausea): prevent it through optimal control of acute and delayed nausea from the first cycle, and treat it with benzodiazepines and behavioural therapy (progressive muscle relaxation, systematic desensitisation, hypnosis). eviQ (2024) agrees and gives the lorazepam dose. The evidence under the treatment recommendations is thin: MASCC/ESMO found no new trial meeting its criteria in 2016, and the Japanese guideline's 2024 meta-analysis supports systematic desensitisation from small, mostly high-risk-of-bias studies.
MASCC/ESMO, Supportive Care in Cancer 2017 · MASCC 2025 · eviQ, Cancer Institute NSW 2024 · International Journal of Clinical Oncology 2024
Where it differs: A 20-minute session given by an oncology nurse, of mindfulness relaxation or relaxing music, rather than a course of behavioural therapy from a psychologist.
Evidence: Randomised trial of 474 people (mostly women with early breast cancer): both reduced anticipatory nausea at the midpoint of chemotherapy against standard care (odds ratios 0.44 and 0.40) but not at the end, and did not change anticipatory vomiting or nausea after chemotherapy.
Where it differs: Singles out systematic desensitisation among behavioural methods; hypnotherapy and yoga could not be pooled.
Evidence: Meta-analysis of two studies: risk ratio 0.60 for anticipatory nausea and 0.54 for anticipatory vomiting; most included studies at high or unclear risk of bias. The authors call for further research before routine use.
Where it differs: In palliative care, gives lorazepam 500 micrograms to 1 mg sublingually (an unlicensed route), with diazepam or midazolam as second line, and pairs antiemetics with assessment and treatment of anxiety.
Evidence: National palliative care guideline (2025), based on an evidence review and expert opinion; not graded for this point.
Healthcare Improvement Scotland (Right Decision Service) 2025
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Anticipatory nausea is best prevented by optimal control of acute and delayed nausea “The guideline panel continues to recommend that anticipatory nausea and vomiting are best prevented through optimization of acute and delayed phase chemotherapy-induced nausea and vomiting control.” | MASCC/ESMO consensus recommendation (grade not shown in the abstract read) | MASCC/ESMO, Supportive Care in Cancer 2017 |
| Systematic desensitisation reduced anticipatory nausea “Among them, systematic desensitization significantly improved anticipatory CINV as compared to that in the control group (nausea: risk ratio [RR] = 0.60, 95% confidence interval [CI] = 0.49-0.72, p < 0.00001; vomiting: RR = 0.54, 95% CI = 0.32-0.91, p = 0.02).” | meta-analysis, RR 0.60 (95% CI 0.49 to 0.72) | International Journal of Clinical Oncology 2024 |
| Progressive muscle relaxation, alone or with guided imagery, as an adjunct for chemotherapy-induced nausea “The adjunctive use of PMRT (alone or with GI) is suggested for the management of CINV [II, B].” | [II, B] | MASCC/ESMO, ESMO Open 2024 |
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