INHA UNIV HOSPITAL, KOREA MI SOOK HAN, APN April 29. 2016
Chemotherapy Induced Peripheral Neuropathy in Breast Cancer Patients
Chemotherapy Induced Peripheral Neuropathy in Breast Cancer Patients
Presentation outline Definition of peripheral neurotoxicity Peripheral neurotoxicity symptoms Managing Peripheral neurotoxicity : Assessment Prevention & Treatment Nursing care
Definition Peripheral neuropathy Peripheral neuropathy is a set of symptoms caused by damage to the nerves that are away from the brain and spinal cord. These distant nerves are called peripheral nerves. They carry sensations (feeling) to the brain and control the movement of our arms and legs. They also control the bladder and bowel.
2015 American Cancer Society
Causes Peripheral neuropathy Tumor related nerve compression Radiation-induced nerve injury Paraneoplastic neurologic disorders(PND) Common side effect of chemotherapy agent - Type and severity depend on the drugs and dose used - Coexistence of disease with neurotoxic potential (Diabetes)
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Pathophysiology
CA CANCER J CLIN 2013;63:419–437
Symptoms
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Symptoms Sensory Paresthesia Hyperesthesia Hyposthesia Dysesthesia Pain Numbness and tingling Hypoflexia or areflexia Diminished or absent proprioception Diminished or absent vibration sensation Diminshed absent of discrimination sharp and dull
Autonomic Constipation Urinary retention Sexual dysfunction Blood pressure alterations
Motor Weakness Gait disturbance Difficulty with fine motor skill (e.g. buttoning clothing, writing)
Clinical Journal of Oncology Nursing, December2007. Volum11.Number6
Agents
Paltinum componds -Cisplantin, Carboplatin, Oxaliplatin
Vinca alkaloids -Vincristine,vinblastine..
Taxanes -Paclitaxel, Docetaxel, Abraxane
Others -Bortezomib, lxabepilone, Thalidomide..
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Agents Drug
Taxanes Incidence
Onset Dose
Clinical Manifestation
Recovery
Paclitaxel
57%–83% (overall), 2%–33% (severe) + Cisplatin: 7%–8% (severe) + Carboplati n: 4%–16% (severe)
100–300 mg/㎡
Symmetrical painful paresthesia or numbness in stocking-glove distribution, decreased vibration or proprioception, occasionally weakness, sensory ataxia, and gait dysfunction
Resolution usually within 3 months, may persist
Abraxane (albumin bound paclitaxel)
73% (overall) 10%–15% (severe)
unclear
Similar to paclitaxel
Resolution usually within 3 weeks
Docetaxel
11%–64% (overall) 3%–14% (severe)
75–100 mg/㎡
Similar to paclitaxel
Resolution usually within 3 months, may persist
Taxanes
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Agents
Taxanes
The first 300 consecutive patients out of 1,060 randomized patients in the N-SAS BC 02 were included in this CIPN and HRQOL study between November 2001 and May 2003
Kojiro Shimozuma et al.KSupport Care Cancer (2012)20:3355~3364
Agents
Taxanes
Kojiro Shimozuma et al.KSupport Care Cancer (2012)20:3355~3364
Agents
Taxanes
Cancer Treatment Reviews 36 (2010) 69–74
Agents Drug
Platinum Incidence
Onset Dose
Clinical Manifestation
Recovery
Platinum compounds Cisplatin
28%–100% (overall) + paclitaxel: 7%–8%
300 mg/㎡
Symmetrical painful paresthesia or numbness in a stocking-glove distribution, sensory ataxia with gait dysfunction
Partial, symptoms may progress for months after discontinuation
Carboplatin
6%–42% (overall) + paclitaxel: 4%–9% (severe)
800–1600 mg/m2
Similar to cisplatin but milder
Similar to cisplatin
Oxaliplatin (acute)
85%–95% (overall)
any
Cold-induced painful dysesthesia
Resolution within a week
Oxaliplatin (persistent/ chronic
FOLFOX: 10%–18% (severe)
750–850 mg/m2
Similar to cisplatin
Resolution in 3 months, may persist long-term
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Assessment Risk Factors Endocrine diseases
Nutritional diseases
- Diabets mellitus,
- Alcoholism, Vitamine B12. VitamineE, Thiamine, Folate deficency, Crohn
Hypothyroidism
Connective tissue diseases -Rheumatoid arthritis ..
Infectious diseases
Metal neuropathy
Hereditary diseases
-Mercury, Thallium..
- Charcot-Marie-Tooth syndrome
Other
Medications
-Amyloidosis, Sarcoidsis…
- Idoniszid, ethambutol, Phenytoin, Cimetidine…
- AIDS, Lyme disease
Wickham, Rita Clinical Journal of Oncology Nursing; Jun 2007; 11, 3; ProQuest Health & Medical Complete
Assessment Subjective
J Korean Acad Nurs Vol.45 No.6, 783- 801
Assessment Sample Questions • Do you feel numbness or tingling in your hands or feet? • Do you feel pain in your hands and feet? (Rate it on a scale of 0 to 10.) • Do you feel like having gloves and stockings on? • Do these sensations bother you? Are they getting worse? • Do you feel weakness in your arms and legs? • Do you drop things often? • Have you fallen recently? • Do you have difficulty walking or climbing stairs? • Do these sensations interfere with your work or daily activities?
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Assessment Objective • Chemotherapy regimen • Combination chemotherapy agents • Dosage • Duration • Past history • Vital sign • Cranial nerve assess
Journal of the National Comprehensive Cancer Network. September 2009.Vol.7,No.5
Assessment Physical Vibration sense (turning fork) Touch Perception of Sharp vs Dull
128Hz turning fork, Distal Proximal ( reflex damage to large sensory neurons)
Semmes-Weinstein monofilament
Coin, Key, Clip …
Proprioception
Romberg test Finger-to-nose test Thumb-to-finger test
Nerve conduction test
Decreased sensory nerve conduction velocity, Decreased amplitude, Loss of H-reflex
Electromyography, Electroneurogrphy
Distal muscle denervation
Assessment Grading Scales-1 Type
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
WHO
None
Paresthesia Tendon reflex ↓
Severe paresthesia Mild weakness
Intolerable paresthesia Marked motor loss
Paralysis
ECOG
None
Mild paresthesia DTR ↓ Mild constipation
DTR (-) Mild weakness Severe constipation
Disabling sensory loss Severe pph neuropathic pain Severe weakness Obstipation Bladder dysfunction
Paralysis Respiratory dysfunction Secondary to weakness Obstipation requiring op
None
Asymptomatic; loss of deep tendon reflexes or paresthesia (including tingling) without interfering function
Sensory alreation or Paresthesia (including tingling) Interfering with activity of daily living
Sensory alreation or Paresthesia Interfering with activity of daily living
Permanent sensory loss with interfering function
NCI-CTC Neuropat hy Sensory Subscale
CA CANCER J CLIN 2013;63:419–437
Assessment Grading Scales-2 (TNS) Type
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
Sensory symptoms
None
Symptoms limited to fingers or toes
Symptoms extend to ankle or wrist
Symptoms extend to knee or elbow
Symptoms above knees or elbows, or functionally disabling
Motor symptoms
None
Slight difficulty
Moderate difficulty
Require help/assistance
Paralysis
Autonomic symptoms
0
1
2
3
4 or 5
Pin sensibility
Normal
Reduced in fingers/toes
Reduced to wrist/ankle
Reduced to elbow/knee
Reduced to above elbow/knee
Vibration sensibility
Normal
Reduced in fingers/toes
Reduced to wrist/ankle
Reduced to elbow/knee
Reduced to above elbow/knee
Strength
Normal
Mild weakness
Moderate weakness
Severe weakness
Paralysis
Deep tendon reflexes
Normal
Ankle reflex reduced
Ankle reflex absent
Ankle reflex absent, others reduced
All reflexes absent
CA CANCER J CLIN 2013;63:419–437
Assessment
etc
• Functional Assessment of Cancer Therapy-Taxane scale (FACT-Taxane) • Functional Assessment of Cancer Therapy/Gynecologic Oncology GroupNeurotoxicity scale (FACT/GOG-Ntx) • Qualityof-life Uniscale (single-item measurement of global QoL on a numeric analog scale from 1 to 100) • Profile of Mood States (POMS) Short Form (30-item scale to assess mood states) • Short Form-McGill Pain Questionnaire (assess different characteristics of neuropathic pain: throbbing, gnawing, shooting, aching, burning) • Brief Pain Inventory-Short From (BPI) • Subjective Global Impression of Change (SGI: 7-point scale) • Symptom Distress Scale (5-point scale)
Prevention Vitamin E Glutamate and glutamine Goshajinkigan (GJG) Acetyl-l-carnitine (ALC) Alpha-lipoic acid (ALA) Omega-3 fatty acids (O3FA) Acupuncture Massage Physical therapy
Prevention
C. Brami et al. / Critical Reviews in Oncology/Hematology 98 (2016) 325–334
Prevention vitaminE
Vitamin E
C. Brami et al. / Critical Reviews in Oncology/Hematology 98 (2016) 325–334
Prevention Glutamate Glutamate/Glutamine
C. Brami et al. / Critical Reviews in Oncology/Hematology 98 (2016) 325–334
Prevention Goshajinkign(GJG), Omega-3
Small Number Study !
C. Brami et al. / Critical Reviews in Oncology/Hematology 98 (2016) 325–334
Prevention
Acetyl-L-carnitine(ALC)
C. Brami et al. / Critical Reviews in Oncology/Hematology 98 (2016) 325–334
Prevention
Acupuncture
Acupucture
C. Brami et al. / Critical Reviews in Oncology/Hematology 98 (2016) 325–334
Treatment Antidepressant -Amitriptyline -Nortriptyline -Venlafaxine -Duloxetine
Antiepileptic -Gabapentin -Lamotrigine
Topical -Baclofen, amitriptyline,and ketamine gel -Amitriptyline and ketamine(AK) cream
Etc -Capsaicin, TENS, Nimotrigine….
Treatment Antidepressant
Meghna S. et al, Management of PICN , AJHO , Jan. 2015,10
Treatment Antidepressant
Meghna S. et al, Management of PICN , AJHO , Jan. 2015,10
Treatment Antiepileptic
Meghna S. et al, Management of PICN , AJHO , Jan. 2015,10
Treatment Topical
Meghna S. et al, Management of PICN , AJHO , Jan. 2015,10
Nursing care
Kim et el, Disturbance in ADL from Chemotherapy-induced Peripheral Neuropathy and Quality of Life in Cancer Patients: The Mediating Effect of Psychological Distress, J Korean Acad Nurs Vol.45 No.5, 661- 670
Nursing care Education & Support • CIPN Sign, Symptoms • Safety Strategy • Foot care base principle • Autonomic neuropathy symptoms & Self care methods • Evaluation of QOL
Summary
(Neuropathy Assessment Algorithm)
Baseline Clinical Evaluation Baseline History -Paresthesias, Neuropathic pain - Autonomic Dysfunction -DM,ETOH,CMT,CIO\DP, CTS - Gait
Baseline Physical Examination -Strength, Reflexes - Sensation -Coordination - Cranial nerves, Balance, Gait
Neuropathic Sign or Symptoms Refer for rehab Intervention Specialized Neuromuscular Assessment
No Neuropathic Signs or Symptoms Administer Neurotoxic Chemotherapy Assess For emerging or Worsening neuropathy or Balance impairment 2 ~3wks
Grade≥2 Neuropathy/ Worsening balance Refer tor rehab Intervention
Neuropathy in Breast Cancer,Stubblefield et al April 2015,2012
Summary CIPN Symptom Management
Treatment of Negative Symptoms Treatment of Positive Symptoms • Pharmacological Agents - Anticonvulsants - Antidepressants - Topical Anesthetics - Opioids
• Pain Procedures - Soft tissue infections - Nerve blocks
• Neuromuscular Stimulations - TENS, - ES
• Complementary and Alternative Medicine - Acupuncture - Massage
• Education on Safety -Falls/ injury prevention
• Fall Prevention -Balance retraining -Gait retraining -Gait aids
• Functional retraining - Therapeutic exercise - Assistive Devices - Adaptive Equipment
• Muscle strengthening - Resistance exercise
• Strategies to maintain physical activity - Aerobic exercise
Neuropathy in Breast Cancer,Stubblefield et al April 2015,2012
End of document
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Chemotherapy Induced Peripheral Neuropathy in Breast Cancer Patients