Earlier recognition of chemotherapy-induced peripheral neuropathy (CIPN) and thorough assessment of patients may lead to better quality of life and better outcomes, according to Estelle Autissier, MSN, RN, of Columbia University, New York, York. In an article published in The Clinical Journal of Oncology Nursing, Ms Autissier writes that patients with cancer and cancer survivors are already a vulnerable population, and the development of CIPN can be devastating, especially if they are already experiencing decreased functional capacity. 

Ms Autissier contends that identifying and assessing CIPN should be a priority for oncology nurses. Currently, a host of assessment strategies enable clinicians to determine the severity of CIPN as well as its impact on physical functioning. “Regular risk assessment and falls prevention, both in the home and in the health care setting, are vital for protecting the future functionality of these patients,” Ms Autissier told Oncology Nurse Advisor.

THE STUDY

Symptoms of CIPN can manifest as sensory and motor neuropathies. CIPN can lead to treatment interruptions and chemotherapy dose reduction or discontinuation. To determine if falls and injuries are a consequence of CIPN, Ms Autissier conducted a literature search using MEDLINE®, PubMed®, and ScienceDirect, reviewing assessments, treatments, and interventions. The search identified 408 related articles, and 15 articles met the inclusion criteria for this research.

“While I was aware of the serious and lasting impacts of CIPN itself, as well as its limited treatment and prevention options, I was surprised to find how much it affected mobility and functionality. Additionally, it became very apparent that those who suffered from CIPN were at significantly higher risks of falling and suffering other sorts of mechanical injuries, even for years after the termination of their treatment,” said Ms Autissier.

Findings from the studies identified in the search demonstrated that cancer patients with CIPN symptoms are significantly more likely to suffer injuries and falls compared with those who have no neuropathic symptoms. One study reported that those with CIPN were nearly 3 times more likely to report a fall or near fall than those without CIPN symptoms.

WHAT WAS LEARNED

Findings discussed in Ms Autissier’s report included a review of 5880 patients with cancer. Among these patients, falls resulted in fractures (46%), superficial injuries (33%), open wounds (8%), and traumatic brain injury (TBI; 4%).  Falls currently are considered a leading cause of TBI in the United States, resulting in 79% of TBI-related emergency department (ED) visits, according to the Centers for Disease Control and Prevention (CDC). 

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Falls affect morbidity and mortality as well as restrict social contact. Despite this, no evidence-based methods for preventing CIPN were found in this review. In addition, current approaches prioritize CIPN symptoms in patient care plans. Currently, several grading tools are available to help nurses assess CIPN, including the Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status, the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE), and the Total Neuropathy Score (TNS).

Pharmacologic approaches tried for preventing CIPN include glutathione and IV magnesium and calcium, but none have demonstrated any statistical superiority over placebos. The antidepressant duloxetine given at 60 mg per day has been shown to have efficacy for CIPN, and gabapentin has been shown to be effective in reducing neuropathy symptoms, pain, and neurologic deficit at a dose of 300 mg 3 times per day. Opioids and topical combination of 2% ketamine and 4% amitriptyline also have been investigated, but yielded little benefit. Not surprisingly, physical therapy and exercise have been shown to improve balance, strength, and ability to complete activities of daily living.

IMPLICATIONS FOR NURSES

As the clinician on the front lines of cancer care, oncology nurses are the predominant health care providers for managing CIPN symptoms. Consults with physical or occupational therapists before discharge can identify and explain the patient’s limitations. The time can also be used to teach the patient muscle-strengthening exercises that can be performed in the hospital as well as at home.

“Nurses play an incredibly significant role in this process. As the first-line providers for a lot of these patients, nurses must be vigilant in assessing patients with known CIPN for their risk of falling and other injuries. Additionally, nurses must be educated and aware of CIPN in general, as early diagnosis and interventions may help manage mobility impairments down the line,” explained Ms Autissier.

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Even though research into pharmacologic and nonpharmacologic resolutions for CIPN has been disappointing, numerous novel prevention and treatment methods are being actively studied. Ms Autissier suggested that as new research becomes available, oncology nurses should seek to keep themselves aware of the most promising methods for mitigating the effects of CIPN.


John Schieszer is a medical reporter based in Seattle, Washington.


Reference

Autissier E. Chemotherapy-induced peripheral neuropathy: association with increased risk of falls and injuries. Clin J Oncol Nurs. 2019;23(4):405-410.

This article originally appeared on Oncology Nurse Advisor