Chemotherapy Induced Peripheral Neuropathy in Breast Cancer Patients

INHA UNIV HOSPITAL, KOREA MI SOOK HAN, APN April 29. 2016 Chemotherapy Induced Peripheral Neuropathy in Breast Cancer Patients Chemotherapy Induced ...
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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

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