It is important that oncology nurses recognize the widespread problem of CIPN in patients receiving peripherally neurotoxic chemotherapy agents. Moreover, it is critical that oncology nurses continually assess patients for evidence of CIPN during and after cancer treatment. It is not uncommon for CIPN to worsen after treatment, especially in the presence of coexisting conditions such as diabetic neuropathy.
Oncology nurses must be familiar with evidence regarding the effectiveness of pharmacological and nonpharmacological approaches to managing CIPN. Visovsky et al have evaluated and summarized the evidence for CIPN treatment strategies in “Putting Evidence Into Practice.” This resource provides useful information to guide the care of patients and evidence to support practice.
Nursing assessment of CIPN begins with a comprehensive approach to collecting subjective information from the patient, as well as assimilating clinical findings from physical examinations or neurological tests. Oncology nurses should evaluate sensory symptoms, motor symptoms, and autonomic symptoms (constipation, urinary retention, sexual dysfunction, blood pressure alterations).
Standards of care for patients at risk for or with CIPN are based on a thorough assessment of sensory symptoms such as pain; diminished or heightened sensations; cutaneous hypersensitivity of the hands and feet (allodynia or hyperalgesia); the ability to discriminate sensations of cold, sharp, and dull; and absence of the ability to detect stimuli (numbness), response to vibration, and positioning of distal areas such as the toes and fingers. The character and quality of pain are evaluated by word descriptors such as “sharp,” “dull,” “burning,” “shooting,” or “electric-shock–like.”
Patients should have a thorough neurological examination, including assessment of gait, motor and sensory functions, deep tendon reflexes, and nerve conduction tests. Grading systems for peripheral neuropathy previously discussed can be used to categorize the degree of neurological impairments. It is important to recognize that most such systems are just global assessments of peripheral neuropathy and lack the sensitivity to precisely quantify the degree of neurological dysfunction. Nonetheless, these systems are particularly useful in documenting early CIPN and assessing changes over time.
Patients with more severe peripheral neuropathies (Grade 3 or 4) can be advised of the consequences of continuing treatment with neurotoxic chemotherapeutic agents, and dose adjustments for chemotherapy can be made based on these findings. In some cases, more specific and reliable tests can be performed, such as QST (quantitative sensory testing), a noninvasive assessment and quantification of sensory nerve function (ie, tactile and thermal thresholds) in patients with symptoms. Generally, QST is performed by a neurologist or pain specialist.
JB has described her difficulty performing specific activities and tasks. She also has reported abnormal sensations (dysesthesias) in her hands and feet, and the quality and character of her pain. The oncology nurse asks her to rate her levels of pain using a numeric (0 to 10) rating scale. JB says that the average pain intensity in her hands and feet ranges from 4 to 5, and her worst pain levels are often at 6 or 7.
A nurse practitioner performs a neurologic examination on JB. There is a significant decrease in detection of pain and temperature in the plantar aspects of her feet, bilaterally. There is diminished or absent sense of discrimination between sharp (pinprick) and dull stimuli on the hand (dorsal and palmar) and foot (dorsal and plantar) surfaces, as well as medial and lateral areas. She has full range of motion, but weakness in muscle strength is noted in just her lower extremities. Deep tendon reflexes are normal, with the exception of the Achilles reflexes, which are absent bilaterally. Proprioception is reduced and vibration sense is diminished in great toes bilaterally. Her gait is slightly unsteady. The rest of her physical examination is unremarkable. JB is diagnosed with a NCI CTCAE Grade 3 sensory neuropathy, but has progressed to a Grade 2 motor neuropathy (symptomatic weakness, interfering with function, but not interfering with activities of daily living).
Upon reviewing JB’s history for risks of peripheral neuropathy, it is important to consider her cancer treatment and health history. This patient completed her last course of chemotherapy 13 months ago. The risk of Grade 2, 3, and 4 CIPN is increased with weekly paclitaxel vs every-3-week dosing. Coexisting diabetes in patients treated with paclitaxel or other neurotoxic chemotherapeutic agents also increases the likelihood for developing CIPN.[4,29] Lyme disease, if untreated, can result in peripheral neuropathy, and nicotine from cigarette smoking constricts blood vessels that supply nutrients to the peripheral nerves (see Table 1). She is referred to a neurologist for QST, which reveals sensory and motor neuropathy. JB is most likely experiencing long-term CIPN related to treatment with paclitaxel that is complicated by a peripheral neuropathy from her poorly controlled diabetes. The nurse practitioner consults with JB’s medical oncologist, and they agree to initiate therapy with gabapentin at 200 mg twice a day for 5 days, then 200 mg three times a day for 5 days, followed by an increase to 300 mg three times a day. The effectiveness of gabapentin for CIPN has been documented, but in one study it was not effective. Gabapentin is beneficial, however, for treatment of diabetic neuropathy. If JB’s symptoms of depression persist after titrating gabapentin to an effective dose for pain relief, which can be up to 3,600 mg per day, then duloxetine (Cymbalta) at 60 mg per day could be added to her treatment regimen. Duloxetine is also useful not only for depression, but also for neuropathic pain from diabetic neuropathy.
Patient education is an important part of nursing care for patients with CIPN. Several comprehensive reviews outline the responsibility of all healthcare professionals caring for cancer patients and survivors to teach these individuals how to self-manage their care when experiencing neurologic damage from cancer treatment.[3,26,27,33] Simple measures can and should be taken to protect hands and feet from injury. These include wearing oven mitts when cooking; gloves when gardening; properly fitting shoes; protective wear in the cold; assessing water temperature to prevent exposure to extreme cold or heat; and preventing falls by keeping rooms well lit, clearing walkways, and using nonskid mats in showers and bathtubs (see Table 2).
It is important for nurses to support patients and their families by helping them adapt to temporary or perhaps lifelong changes in daily routines. CIPN can cause patients to lose their balance or have difficulty with motor skills such as picking things up, buttoning clothes, opening jars, or inserting keys in keyholes. Fatigue and depression are also commonly associated with CIPN. Patients and families should report any sensory, motor, or autonomic symptoms to their healthcare professionals. Referrals to local and national resources can be helpful to many cancer survivors with CIPN (see Table 3). For example, the Neuropathy Association (reachable at 800-247-6968 or online at www.neuropathy.org) is a national organization that works toward increasing public awareness of the problem and promoting development of better therapies for this condition. It offers information, self-help resources, and support group networks to patients with peripheral neuropathy.
Financial Disclosure: The author has no signifi
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