Editor’s note: One in a series of articles on managing cancer-related symptoms from the Oncology Nursing Society.
Chemotherapy-induced peripheral neuropathy (CIPN) is a major concern for patients with cancer and the healthcare professionals who treat them. This quality-of-life issue affects patients’ functioning abilities and comfort levels. Peripheral neuropathy is defined as a dysfunction of peripheral, motor, sensory, and autonomic neurons resulting in peripheral neuropathic signs and symptoms (Postma & Heiman, 2000). As many as 50% of patients treated with vincristine will develop paresthesias of the hands and feet (Visovsky, Collins, & Belansky, 2009), and up to 90% of patients on cisplatin and 62% of patients on paclitaxel will develop CIPN (Weiss, 2001).
Nurses working with patients who may be at risk for CIPN should perform a baseline assessment prior to chemotherapy initiation. Common assessment tools include the Common Terminology Criteria for Adverse Events, the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group—Neurotoxicity, and the Peripheral Neuropathy Scale. In addition, assessment should be conducted at regular intervals once treatment has begun, focusing mainly on patient comfort and safety. Signs of CIPN manifestation include numbness, tingling, weakness, and pain (Visovsky et al., 2009) (See Assessment indicators for CIPN.) In addition, patients on oxaliplatin should be checked for cold-induced symptoms. Management strategies should be developed and enacted when appropriate because the onset and duration of symptoms, as well as their effect on daily activities, are relevant to patient quality of life (Visovsky et al., 2009).
Assessment indicators for CIPN
- History of diabetes
- Arthritis or other connective tissue disease
- Peripheral vascular disease
- Chronic alcohol use
- History of HIV/AIDS
- History of previous neurotoxic chemotherapy
- Taxanes, epothilones, vinca alkaloids, platinum compounds, angiogenesis agents, and proteasome inhibitors
- Current symptoms of neuropathy
- Medication list (healthcare provider should review)
- Physical examination
- Deep tendon reflexes
- Cutaneous sensation
- Muscle strength
- Gait and balance
Note. Based on information from Visovsky et al., 2009; Wickham, 2007; Wilkes, 2004.
Putting evidence into practice
To promote nursing practice that is based on evidence, ONS launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice.
Benefits balanced with harms
Although there are no items recommended for practice or likely to be effective, one treatment intervention, assistive devices, was listed under benefits balanced with harms (clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances).
Assistive devices include items such as a cane or an orthotic. No studies have been conducted to date that included patients with cancer as the focus group, but two small, nonrandomized studies of assistive device use by patients with diabetes showed benefits, including prevention of foot drop and improved balance (Ashton-Miller, Yeh, Richardson, & Galloway, 1996; Richardson, Thies, DeMott, & Ashton-Miller, 2004). The use of assistive devices will not reduce the effects of peripheral neuropathy, but some patients may find them beneficial (Visovsky et al., 2009). Healthcare professionals unfamiliar with these devices should refer patients to a physical therapist for fittings and education.
Effectiveness not established
Interventions that are listed as effectiveness not established (in which insufficient or conflicting data or data of inadequate quality currently exists) are broken down into two categories: treatment intervention and prevention intervention. The treatment interventions include carbamazepine, lamotrigine, acupuncture, capsaicin, physical activity or exercise, spinal cord stimulation, pulsed infrared light therapy (also called Anodyne® therapy), and transcutaneous electrical nerve stimulation and high-frequency external muscle stimulation (Oncology Nursing Society [ONS], 2008). Prevention interventions are acetyl-L-carnitine, alpha-lipoic acid, amifostine, calcium and magnesium, gabapentin, glutamine, glutathione, nortriptyline, vitamin E, and recombinant human leukemia inhibitory factor (ONS, 2008).
Interventions that are considered low risk, are consistent with sound clinical practice, are suggested by an expert in a peer-reviewed publication, but for which limited evidence exists are listed as expert opinions. For CIPN, the following (Visovsky et al., 2009) are identified:
- Educate patients about the signs and symptoms of CIPN and instruct them on how to report these issues to their healthcare providers.
- Teach patients strategies for managing personal safety. This includes removing throw rugs, clearing walkways of clutter, using skid-free bathroom mats, etc.
- Alert patients about the importance of foot care, including the use of properly fitting shoes.
- Educate patients about the risk of ischemic or thermal injury (i.e., related to water temperature) from loss of sensation in their extremities.
- Teach strategies to prevent autonomic dysfunction, such as dangling the legs before rising and eating a high-fiber diet along with plenty of fluid intake.
Sean Pieszak is a copy editor in the Publications department at the Oncology Nursing Society in Pittsburgh, PA. More information about the ONS PEP classification for Peripheral Neuropathy can be found at http://www.ons.org/Research/PEP/Peripheral.
Ashton-Miller, J., Yeh, M., Richardson, J.K., & Galloway, T. (1996). A cane reduces loss of balance in patients with peripheral neuropathy: Results from a challenging unipedal balance test. Archives of Physical Medicine and Rehabilitation, 77, 446–452.
Oncology Nursing Society. (2008). Quick view for peripheral neuropathy. Retrieved from http://www.ons.org/Research/PEP/media/ons/docs/research/outcomes/peripheral/quickview.pdf
Postma, T.J. & Heiman, J.J. (2000). Grading of chemotherapy-induced peripheral neuropathy. Annals of Oncology, 11, 509–513.
Richardson, J.K., Thies, S., DeMott, T., & Ashton-Miller, J.A. (2004). Interventions improve gait regularity in patients with peripheral neuropathy while walking on a regular surface under low light. Journal of the American Geriatrics Society, 52, 510–515.
Visovsky, C., Collins, M.L., & Belansky, H. (2009). Peripheral neuropathy. In L.H. Eaton & J.M. Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 235–252). Pittsburgh, PA: Oncology Nursing Society.
Weiss, R.B. (2001). Miscellaneous toxicity: Neurotoxicity. In V.T. DeVita, Jr., S. Hellman, & S.A. Rosenberg (Eds.), Cancer: Principles and practice of oncology (6th ed., pp 2964–2976). Philadelphia, PA: Lippincott Williams and Wilkins.
Wickham, R. (2007). Chemotherapy-induced peripheral neuropathy: A review of the implications for oncology nursing practice. Clinical Journal of Oncology Nursing, 11, 361–376.
Wilkes, G.M. (2004). Peripheral neuropathy. In C.H. Yarbro, M.H. Frogge, & M. Goodman (Eds.), Cancer symptom management (3rd ed., pp. 333–358). Sudbury, MA: Jones and Bartlett.