What is the assessment of chemotherapy-induced peripheral neuropathy?

From the Guidelines

Assessment of chemotherapy-induced peripheral neuropathy should include regular clinical evaluations before, during, and after treatment, using standardized tools like the Total Neuropathy Score (TNS) or the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) to objectively measure symptoms, as recommended by the most recent guidelines 1. The assessment should evaluate sensory symptoms (numbness, tingling, pain), motor function (weakness, coordination), and autonomic symptoms (orthostatic hypotension, constipation).

• For patients on neurotoxic agents like platinum compounds (cisplatin, oxaliplatin), taxanes (paclitaxel, docetaxel), vinca alkaloids (vincristine), or bortezomib, more frequent monitoring is recommended 2.
• Physical examination should include testing of deep tendon reflexes, vibration sense, proprioception, temperature sensation, and muscle strength.
• Nerve conduction studies and quantitative sensory testing can provide objective measurements of nerve damage. Early detection is crucial as dose modification or supportive care interventions may prevent progression of neuropathy.
• Currently, there are no FDA-approved medications specifically for chemotherapy-induced peripheral neuropathy prevention, though duloxetine (30-60 mg daily) has shown benefit for treatment 3. Non-pharmacological approaches including physical therapy, occupational therapy, and cryotherapy (cold therapy during chemotherapy infusions) may also help manage symptoms. It is essential to identify predictors of chronic neuropathy or susceptibility for severe neuropathy symptoms based on the chemotherapy duration or dosage, and to use self-reporting questionnaires dedicated to neuropathy, such as the CIPN subscale of the EORTC QOL Questionnaire or the Module NTX of the FACT questionnaire 1. Supportive care such as physiotherapy, physical activity, referral to podiatrists, patient education, i.e., adequate footwear, acupuncture, support in daily activities can be helpful, and vitamin B supplementation can be discussed 1. If neuropathy induces chronic pain, patients can be referred to a neurologist for further investigation or to introduce medication including gabapentin, selective serotonin reuptake inhibitor (i.e., venlafaxine), or norepinephrine reuptake inhibitor with usually limited efficacy 1.

From the Research

Assessment of Chemotherapy-Induced Peripheral Neuropathy

The assessment of chemotherapy-induced peripheral neuropathy (CIPN) is a complex process that involves evaluating the presence and severity of neuropathic symptoms in patients receiving chemotherapy.

• CIPN is commonly associated with platinum-based drugs, taxanes, and vinca alkaloids 4.
• The Total Neuropathy Score (TNSr) is used to combine clinical and electrophysiological values to assess the severity of CIPN 4.
• Neurological examination and nerve conduction studies (NCS) are used to confirm the presence of neuropathy 4.
• The assessment of CIPN also involves evaluating the impact of neuropathy on patients' quality of life and symptom burden 5, 6.

Diagnosis and Treatment of CIPN

The diagnosis of CIPN is based on the presence of neuropathic symptoms, such as reduced feeling and heightened sensitivity to pressure, pain, temperature, and touch 7.

• Duloxetine is considered a first-line treatment for CIPN, while gabapentin, pregabalin, tricyclic antidepressants, and topical compounding creams may be used for neuropathic pain control 5, 6.
• Home-based, low-to-moderate walking, and resistance exercise during chemotherapy can reduce the severity and prevalence of CIPN symptoms, especially in older patients 5.
• Pre-habilitation and rehabilitation are recommended for all patients receiving cytotoxic chemotherapies to reduce the risk of CIPN 5.

Risk Factors for CIPN

Several risk factors for CIPN have been identified, including:

• Older age 8
• Chemotherapy regimen (platinum-based chemotherapy is more commonly associated with CIPN than taxane-based chemotherapy) 4, 8
• History of neuropathy 8
• Symptom burden 8
• Number of chemotherapy cycles received 8
• Alcohol intake 8
• Use of statins and diabetes may also be implicated in the development of CIPN 8