Table of contents
Chemotherapy-induced peripheral neuropathy
Background
Overview
Definition
CIPN is a common complication of chemotherapy, that is predominantly characterized by sensory neuropathy and may be accompanied by motor and autonomic changes.
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Pathophysiology
CIPN can occur in patients with platinum-based antineoplastic agents (oxaliplatin, cisplatin, carboplatin), epothilones (ixabepilone), taxanes (paclitaxel, docetaxel), immunomodulatory drugs (thalidomide), vinca alkaloids (vincristine, vinblastine, vinorelbine, vindesine), and proteasome inhibitors (bortezomib).
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Disease course
CIPN may affect sensory, motor, and/or autonomic functions to varying degrees. Symptoms include numbness, tingling, altered touch sensation, impaired vibration, paresthesias, dysesthesias, spontaneous burning, shooting or electric shock-like pain, allodynia, hyperalgesia, distal weakness, gait and balance disturbances, impaired movements, orthostatic hypotension, constipation, and altered sexual/urinary function. Disease progression may lead to loss of sensation, paresis, complete patient immobilization, severe disability, and reduced QoL.
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Prognosis and risk of recurrence
CIPN is not independently associated with increased mortality.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of chemotherapy-induced peripheral neuropathy are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2020), the European Oncology Nursing Society (EONS/EANO/ESMO 2020), and the American Cancer Society (ACS 2013).
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Diagnostic investigations
Initial assessment
As per ACS 2013 guidelines:
Obtain standardized assessment of CIPN including:
baseline assessment and risk profile
B
long-term follow-up at > 2-3 months after treatment
B
calculation of Total Neuropathy Score or Total Neuropathy Score clinical version
A
objective evidence of neurological deficits
A
patient-reported outcomes, such as FACT/GOG-Ntx, EORTC QLQ-CIPN20, PNQ, CIPN-R-ODS
A
nerve conduction studies in the clinical trials setting
A
Provide education regarding symptoms. Obtain ongoing patient surveillance
B
and assess the impact on function and QoL. A
Medical management
General principles: as per EANO/EONS/ESMO 2020 guidelines, focus on reduction or relief of neuropathic pain in patients experiencing chronic CIPN.
B
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Modification/discontinuation of chemotherapy
Duloxetine
Other systemic agents
Topical agents
Nonpharmacologic interventions
Physical therapies: as per ASCO 2020 guidelines, insufficient evidence to recommend exercise therapy or scrambler therapy for the treatment of CIPN outside the context of a clinical trial.
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Acupuncture
Specific circumstances
Patients with central neurotoxicity: as per EANO/EONS/ESMO 2020 guidelines, do not use exogenous albumin for the prevention of ifosfamide-induced acute encephalopathy. Do not use methylene blue, thiamine, and/or glucose 5% for the prevention or treatment of ifosfamide-induced acute encephalopathy.
D
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Preventative measures
Follow-up and surveillance
Monitoring for ototoxicity
As per EANO/EONS/ESMO 2020 guidelines:
Obtain a pure tone audiometry (including the wide spectrum of frequencies 500-8,000 Hz) for early detection of ototoxicity in adult patients receiving platinum agents.
B
Insufficient evidence to recommend prophylactic treatment with sodium thiosulfate because of the uncertainty regarding a possible tumor protection and lack of evidence in adult patients with cancer.
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