Falls in persons with chemotherapy-induced peripheral neuropathy

A. T. Agbor F, Jenkins A, Lavoie Smith EM. Exploring social determinants of health on chemotherapy-induced peripheral neuropathy severity in ovarian cancer: An integrative review

Ovarian cancer remains a significant public health concern for women despite advancements in cancer management. Despite comprising only 2.5 % of cancers in women, ovarian cancer ranks as the fifth leading cause of cancer-related deaths among women, with patients frequently receiving late diagnoses. Chemotherapy, a primary treatment, frequently causes chemotherapy-induced peripheral neuropathy (CIPN), affecting over 60 % of patients and leading to severe sensory, motor, and autonomic nerve impairments. This often necessitates dosage reduction or discontinuation of treatment, thereby increasing mortality. While CIPN's impact on patients is well-documented, there is a paucity of knowledge of how structural and intermediary social determinants of health factors (SDOH), such as socioeconomic and political context, material circumstances such as living and walking conditions, area deprivation, and food availability, affect CIPN severity. The aim of this article was to explore the association between various SDOH and CIPN severity in ovarian cancer, identifying potential research gaps and future research directions. This article seeks to inform targeted interventions to mitigate CIPN's impact by elucidating these associations.

The associations of oxaliplatin-induced peripheral neuropathy, sociodemographic characteristics, and clinical characteristics with time to fall in older adults with colorectal cancer

Our purpose was to investigate the associations between falls and oxaliplatin-induced peripheral neuropathy (OIPN), sociodemographic characteristics, and clinical characteristics of older patients with colorectal cancer. The study population consisted of older adults diagnosed with colorectal cancer whose data were obtained from the Surveillance, Epidemiology, and End Results database combined with Medicare claims. We defined OIPN using specific (OIPN 1) and broader (OIPN 2) definitions of OIPN, based on diagnosis codes. Extensions of the Cox regression model to accommodate repeated events were used to obtain overall hazard ratios (HRs) with 95% CIs and the cumulative hazard of fall. The unadjusted risk of fall for colorectal cancer survivors with versus without OIPN 1 at 36 months of follow-up was 19.6% versus 14.3%, respectively. The association of OIPN with time to fall was moderate (for OIPN 1, HR = 1.37; 95% CI, 1.04-1.79) to small (for OIPN 2, HR = 1.24; 95% CI, 1.01-1.53). Memantine, opioids, cannabinoids, prior history of fall, female sex, advanced age and disease stage, chronic liver disease, diabetes, and chronic obstructive pulmonary disease all increased the hazard rate of falling. Incorporating fall prevention in cancer care is essential to minimize morbidity and mortality of this serious event in older survivors of colorectal cancer.

The effect of hand-foot exercises on chemotherapy-induced peripheral neuropathy-related pain, falls, and quality of life in colorectal cancer: A randomized controlled trial

PURPOSE

The aim of this study is to determine the effect of hand-foot exercises on chemotherapy-induced peripheral neuropathy-related pain severity, falls, and quality of life in patients with colorectal cancer.

METHODS

The study was conducted in the outpatient chemotherapy unit of a public hospital between 25 April-31 December 2022. The enrolled 39 patients were randomly assigned to the intervention (n:19) and control (n:20) groups. The hand-foot exercises program was applied to the intervention group in three sessions a day and three days a week fashion for 8 weeks at home. No intervention was applied to the control group other than routine treatment and care. Data were collected through face-to-face interviews in the first interview and the 2nd, 4th, 6th, 8th weeks. The exercise program adherence of the intervention group was followed up through telephone/face-to-face interviews in weeks 1-8. Data were collected using the Numerical Pain Rating Scale, Fall Follow-Up Form, the CIPNAT scale, EORTC QLQ-C30 and EORTC QLQ-CR29 scales. Mann-Whitney U Test, Chi-square test, Wilcoxon signed test, and Friedman test were used to analyze the data.

RESULTS

The study found that as of week 4th, the intervention group experienced less pain severity than the control group (p < 0.001); at week 8th, the peripheral neuropathy symptoms of the intervention group decreased compared to the control group (p < 0.05); at weeks 2nd,4th,6th,8th, there was no statistically significant difference in falls (p > 0.05); at week 8th, while there was no significant difference between the groups regarding colorectal cancer quality of life (p > 0.05), the overall cancer quality of life improved in the intervention group (p < 0.05).

CONCLUSIONS

The hand-foot exercises program is effective in chemotherapy-induced peripheral neuropathy-related symptoms, pain severity, and overall cancer quality of life.

TRIAL REGISTRATION

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CLINICALTRIALS

gov, NCT05873829.

Association of oxaliplatin-containing adjuvant duration with post-treatment fall-related injury and fracture in patients with stage III colon cancer: a population-based retrospective cohort study

PURPOSE

Oxaliplatin-containing adjuvant chemotherapy yields a significant survival benefit in stage III colon cancer and is the standard of care. Simultaneously, it causes dose-dependent peripheral neuropathy that may increase the risk of fall-related injury (FRI) such as fracture and laceration. Because these events carry significant morbidity and the global burden of colon cancer is on the rise, we examined the association between treatment with a full versus shortened course of adjuvant chemotherapy and post-treatment FRI and fracture.

METHODS

In this overlap propensity score weighted, retrospective cohort study, we included patients aged ≥ 18 years with resected stage III colon cancer diagnosed 2007-2019 and treated with oxaliplatin-containing adjuvant chemotherapy (oxaliplatin plus a fluoropyrimidine; capecitabine [CAPOX] or 5-fluorouracil and leucovorin [FOLFOX]). Propensity score methods facilitate the separation of design from analysis and comparison of baseline characteristics across the weighted groups. Treatment groups were defined as 50% (4 cycles CAPOX/6 cycles FOLFOX) and > 85% (7-8 cycles CAPOX/11-12 cycles FOLFOX) of a maximal course of adjuvant chemotherapy to approximate the treatment durations received in the IDEA collaboration. The main outcomes were time to any FRI and time to fracture. We determined the subdistribution hazard ratios (sHR) estimating the association between FRI/fracture and treatment group, accounting for the competing risk of death.

RESULTS

We included 3,461 patients; 473 (13.7%) received 50% and 2,988 (86.3%) received > 85% of a maximal course of adjuvant therapy. For post-treatment FRI, median follow-up was 4.6 years and total follow-up was 17,968 person-years. There were 508 FRI, 301 fractures, and 692 deaths. Treatment with > 85% of a maximal course of therapy conferred a sHR of 0.84 (95% CI 0.62-1.13) for post-treatment FRI and a sHR of 0.72 (95% CI 0.49-1.06) for post-treatment fracture.

CONCLUSION

For patients with stage III colon cancer undergoing treatment with oxaliplatin-containing adjuvant chemotherapy, any potential neuropathy associated with longer durations of treatment was not found to result in greater rates of FRI and fracture. Within the limits of this retrospective study, our findings suggest concern about FRI, while mechanistically plausible, ought not to determine treatment duration.

Chemotherapy-Induced Peripheral Neuropathy (CIPN): A Narrative Review and Proposed Theoretical Model

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and debilitating symptom experienced by cancer survivors. Despite the burden of CIPN-related symptoms, interventions remain limited.

OBJECTIVES

This narrative review seeks to propose a framework for CIPN predisposing, precipitating, and perpetuating factors (3Ps), which will provide a foundation for future research and clinical interventions aimed at mitigating CIPN-related symptoms and morbidity.

METHODS

A comprehensive literature search was performed using PubMed, guided by keywords related to "chemotherapy-induced peripheral neuropathy." Studies were limited to those with full text available in English.

RESULTS

Predisposing factors outlined in this framework, such as older age and comorbid conditions, can be used to identify patients who have a higher risk of developing CIPN. The major precipitating factor of CIPN is the delivery of chemotherapy to peripheral nerves, which may be mitigated via cryotherapy or compression therapy during chemotherapy. Perpetuating factors can offer insight into psychological, cognitive, and behavioral modifications that could be treatment targets for CIPN management.

CONCLUSION

The proposed 3P model can guide the development of effective interventions for CIPN by suggesting modifiable psychological and behavioral treatment targets that may mitigate the impact of CIPN for cancer patients.

The alteration of static and dynamic postural stability among women with breast cancer during taxane-based chemotherapy: a descriptive study

INTRODUCTION

Women with breast cancer who underwent taxane-based chemotherapy demonstrate diminished postural stability. However, the data concerning dynamic postural stability among women with breast cancer during taxane-based chemotherapy remains insufficient.

PURPOSE

To investigate postural stability among women with breast cancer during taxane-based chemotherapy.

METHODS

Fifteen women with breast cancer participated in this study. Postural stabilities were assessed at five intervals during the course of chemotherapy treatment. Static postural stability was measured during single leg with eyes open (SEO) and eyes closed (SEC) conditions, while dynamic postural stability was measured during performance of the limit of stability test (LOS). Postural stability was described using 95% confidence ellipse area (EA), center of pressure (COP) path length (PL), and COP average velocity (AV).

RESULTS

For static postural stability assessment, SEO condition was found to have significant increases in EA, PL, and AV (p = .001, p < .001, and p = .02, respectively). For dynamic postural stability assessment, a significant difference in EA was observed in the forward, backward, right, and left directions (p = .02, p = .02, p < .001, and p = .01, respectively). In addition, a significant difference in PL was found while performing in a backward direction (p = .02).

CONCLUSIONS

The findings showed that women with breast cancer may have experienced decreased static and dynamic postural stability.

The impact of scrambler therapy on pain and quality of life for chemotherapy-induced peripheral neuropathy: A pilot study

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating disturbance among patients who received chemotherapy, with no effective treatment available. Scrambler therapy (ST) is a noninvasive treatment capable of improving multiple quality-of-life symptoms beyond pain. We aimed to evaluate the efficacy of ST for pain and nonpain symptoms related to CIPN.

METHODS

Ten patients with moderate to severe CIPN symptoms for >3 months were enrolled in a single-arm trial of ST for 10 daily sessions. CIPN-related symptoms were measured throughout the treatment period and up to 6 months thereafter.

RESULTS

The worst pain was reduced by 6 months (p = 0.0039). QST demonstrated the greatest improvement in pressure of 60 g (p = 0.308, Cohen's d = 0.42) and cold temperature threshold of 2.5°C (p = 0.9375, Cohen's d = 0.51) in the gastrocnemius area. Symptoms of numbness, tingling, trouble walking, and disturbed sleep had significant improvements at 6 months. Pain medication use decreased by 70% at the end of treatment and by 42% at 6 months. Patient satisfaction was high (82%) and no adverse events with ST treatment were reported.

CONCLUSIONS

The results of this pilot trial support the use of ST by demonstrating improvement in multiple domains of quality of life for CIPN patients during an extended follow-up of 6 months. However, further large-scale studies are needed to confirm our findings.

The association of chemotherapy-induced peripheral neuropathy with reduced executive function in chemotherapy-treated cancer survivors: A cross-sectional study

INTRODUCTION

Chemotherapy-induced peripheral neuropathy (CIPN) is common and disabling among cancer survivors. Little is known about the association of CIPN with other measures of the nervous system's integrity, such as executive dysfunction. We compared measures of executive function in older chemotherapy-treated cancer survivors with and without CIPN.

MATERIALS AND METHODS

This cross-sectional study enrolled 50 chemotherapy-treated cancer survivors (65.6 ± 11.5 years, 88% female) post-chemotherapy treatment who were previously referred for outpatient rehabilitation at the request of the cancer survivor or a medical provider. Twenty-two participants (44%) had CIPN defined by patient-reported distal paresthesia or numbness, which began with chemotherapy and continued to the time of cognitive testing. Measures of executive function included Trails-B, Stroop, and rapid reaction accuracy (RRA) and were evaluated between cancer survivors with and without CIPN using t-tests. Multivariable models were then used to determine whether CIPN was an independent determinant of the measures of executive function (Trails-B, Stroop Incongruent, and RRA). Models were adjusted for age, sex, history of anxiety, and benzodiazepine use due to their known associations with CIPN and executive function.

RESULTS

Cancer survivors with CIPN (CIPN+) had reduced executive function compared to survivors without CIPN (CIPN-) on Trails-B (CIPN+: 84.9 s ± 44.1 s, CIPN-: 59.1 s ± 22.5 s, p = 0.01), Stroop (CIPN+: 100.6 s ± 38.2 s, CIPN-: 82.1 s ± 17.3 s, p = 0.03), and RRA (CIPN+: 60.3% ± 12.9%, CIPN-: 70.6% ± 15.7%, p = 0.01). There were no differences in cancer stage severity or functional status by patient report or sit-to-stand function. The association between CIPN and reduced executive function was found in multivariable models after adjusting for age, sex, anxiety, and benzodiazepine use for Trails-B (ß:17.9, p = 0.046), Stroop (ß:16.9, p = 0.02), and RRA (ß:-0.072, p = 0.03).

DISCUSSION

In this population, CIPN is associated with reduced executive function in older cancer survivors treated with chemotherapy. Future research is required to further understand this preliminary association, the causality, and the potential risk factors.

Acute, long-term or non-vincristine-induced peripheral neuropathy among non-Hodgkin lymphoma survivors: Symptoms, daily activities, functional status, and quality of life

PURPOSE

This study aimed to explore the incidence and severity of vincristine-induced peripheral neuropathy (VIPN) in non-Hodgkin lymphoma (NHL) survivors (primary aim) and its impact on daily life by comparing common cancer symptoms, functional status, and quality of life (QoL) among survivors with acute, long-term, and non-VIPN (secondary aim).

METHODS

This cross-sectional study examined 144 NHL survivors. Standardized questionnaires were used to assess common cancer symptoms, functional status, and QoL with the European Organization for the Research and Treatment of Cancer - Quality of Life Questionnaire (EORTC-QLQ-C30). VIPN (Chemotherapy-Induced Peripheral Neuropathy) status was classified using EORTC-QLQ-CIPN20. A self-designed interference scale was developed to determine the impact of the VIPN on daily activities. The Kruskal-Wallis test and Spearman rank correlation were used in this study.

RESULTS

Among the survivors of acute and long-term VIPN, the highest incidences and most severe symptoms were found for hand numbness and foot cramps. A significant moderate correlation was found between disturbances in daily activities and acute or long-term VIPN, including gait changes, going up or down the stairs, and imbalance-related falls. Acute and long-term VIPN survivors showed worse symptoms (fatigue, insomnia, and constipation) and lower QoL than non-VIPN survivors did. In acute VIPN, social function was significantly affected, whereas in long-term VIPN, emotional and cognitive functions were affected.

CONCLUSION

Numbness and cramps should be addressed in survivors of acute and long-term VIPN. Preventing falls is recommended for NHL survivors with VIPN, and psychological support is suggested for long-term VIPN survivors.

Incidence, description, predictors, and consequences of persistent taxane-induced peripheral neuropathy

PURPOSE OF REVIEW

This review aims to provide insights into persistent taxane-induced peripheral neuropathy (TIPN). The primary objective is to describe the incidence, predictors, and consequences of TIPN lasting at least 1 year after the end of taxane treatment.

RECENT FINDINGS

Studies show varying rates of TIPN persistence, with an estimated 30-40% and 40-60% resolving by 1- and 3-year post-treatment. TIPN in the feet and motor symptoms show less resolution post-treatment. Patients who are older or have higher body weight may experience less TIPN resolution, but results may be confounded by TIPN development during treatment. Persistent TIPN negatively impacts long-term functional ability, including gait, balance, and the ability to work. It also reduces overall quality of life (QOL), particularly affecting physical and social aspects.

SUMMARY

Clinicians should be aware of the potential for persistent TIPN and its impact on patients' function and QOL. Future research should focus on large prospective studies with systematic TIPN assessments during and after treatment to better understand which symptoms and patient characteristics predict resolution. This information can guide treatment decisions, balancing the need for effective chemotherapy with minimizing long-term impairments in function and QOL.

The Effect of Anthropometric Shoes on Lactic Acid Reduction in Nurses: A Mixed-Methods Study from Indonesia

Background

The mobilization characteristics of nurses' work, such as standing, walking, and transferring patients for a long time, can increase the risk of musculoskeletal disorders. Repetitive activities nurses perform can cause foot problems such as discomfort and insecurity, characterized by increased lactic acid levels. Anthropometric shoes are specifically designed to reduce complaints on nurses' feet.

Purpose

This study aimed to determine the effect of individual anthropometric shoes on lactic acid levels in nurses at the hospital.

Methods

This study used a mixed-method study design. This study involved 71 nurses in the quantitative study and 15 nurses in the qualitative study. Nurses in Emergency Room, Central Surgical Installation, Inpatient Room, Intensive Care Unit, and Outpatient Installation were randomly selected using a stratified random sampling technique. The instruments used were the Accutrend Lactacyd tool, demographic questionnaire and interview questionnaire. Bivariate data analysis was using Statistical Package for Social Sciences (SPSS) and qualitative data analysis using thematic analysis.

Results

This mixed-method study shows that anthropometric shoes can reduce nurses' lactic acid levels. In the quantitative study; there was a significant difference in lactic acid levels of nurses before and after using anthropometric shoes with the average results of measuring lactic acid levels, namely pre-test (22.48 mg/dL) and post-test (16.27 mg/dL), with a p-value (0.000). The qualitative study data revealed positive results related to increased nurse knowledge, positive views on the effect of shoes on nurse performance, and the impact of using anthropometric shoes in providing comfort and safety, such as decreased muscle fatigue and pain.

Conclusion

The findings of this study highlight the effect of individualized anthropometric shoes on lactic acid levels in nurses in Indonesian hospitals. It is essential to conduct further research and evaluate the results in a broader setting to ensure that anthropometric shoes can directly affect lactic acid levels.

Patient perceptions of altering chemotherapy treatment due to peripheral neuropathy

PURPOSE

Clinical practice guidelines recommend altering neurotoxic chemotherapy treatment in patients experiencing intolerable chemotherapy-induced peripheral neuropathy (CIPN). The primary objective of this survey was to understand patient's perspectives on altering neurotoxic chemotherapy treatment, including their perceptions of the benefits of preventing irreversible CIPN and the risks of reducing treatment efficacy.

METHODS

A cross-sectional online survey was distributed via social networks to patients who were currently receiving or had previously received neurotoxic chemotherapy for cancer. Survey results were analyzed using descriptive statistics and qualitative analysis.

RESULTS

Following data cleaning, 447 participants were included in the analysis. The median age was 57 years, 93% were white, and most were from the UK (53%) or USA (38%). Most participants who were currently or recently treated expected some CIPN symptom resolution (86%), but 45% of those who had completed treatment more than a year ago reported experiencing no symptom resolution. Participants reported that they would discontinue chemotherapy treatment for less severe CIPN if they knew their symptoms would be permanent than if symptoms would disappear after treatment. Most patients stated that the decision to alter chemotherapy or not was usually made collaboratively between the patient and their treating clinician (61%). The most common reason participants were reluctant to talk with their clinician about CIPN was fear that treatment would be altered. Participants noted a need for improved understanding of CIPN symptoms and their permanence, better patient education relating to CIPN prior to and after treatment, and greater clinician understanding and empathy around CIPN.

CONCLUSIONS

This survey highlights the importance of shared decision-making, including a consideration of both the long-term benefits and risks of altering neurotoxic chemotherapy treatment due to CIPN. Additional work is needed to develop decision aids and other communication tools that can be used to improve shared decision making and help patients with cancer achieve their treatment goals.

Outpatient Oncology Fall Risk: A Quality Improvement Project

Introduction

Patients receiving cancer treatment are at high risk for falls. No current guidelines or standards of care exist for assessment and prevention of outpatient oncology falls. This quality improvement project's purpose was to 1) describe and evaluate outpatient oncology falls data to determine root cause(s), and develop, implement, and evaluate intervention strategies for future policy refinement, and 2) compare fall rates pre/post implementation of a system-wide Ambulatory Fall Risk Bundle.

Methods

Retrospective data were used to describe and categorize fall incidence for the University of Kansas Cancer Center over 12 months. Further analyses were conducted to describe fall rates per 10,000 kept appointments pre/post implementation of an Ambulatory Fall Risk Bundle protocol. Semi-structured interviews were conducted with medical assistants and nurse managers to evaluate the initiative's impact, staff satisfaction, and recommendations for refinement.

Results

The initial 12-month assessment yielded 58 patient falls retained for further analyses. Most patients were receiving chemotherapy (46, 79%). Common contributing symptoms included dizziness/ faintness and weakness (25, 43%). Tripping/falling over a hazard (12, 24%) and falls during transfer (10, 5.8%) also were cited. Subsequent analyses of fall rates indicated no change. Recommendations resulting from the qualitative interviews included: orthostatic vital sign protocol implementation, redesign of the electronic medical record fall risk alert, stakeholder involvement in protocol development, staff training, and related patient education strategies, and the procurement of additional assistive devices/equipment.

Conclusions

System-related policy and culture change, investment in physical and human resource enhancements, and evidence-based protocols are needed to improve outpatient oncology fall rates.

Effect of exercise before and/or during taxane-containing chemotherapy treatment on chemotherapy-induced peripheral neuropathy symptoms in women with breast cancer: systematic review and meta-analysis

PURPOSE

To systematically review and meta-analyse the efficacy of exercise interventions delivered before and/or during taxane-containing chemotherapy regimens on chemotherapy-induced peripheral neuropathy (CIPN), fatigue, and health-related quality of life (HR-QoL), in women with breast cancer.

METHODS

Seven electronic databases were systematically searched for randomised controlled trials (RCTs) reporting on the effects of exercise interventions in women with breast cancer receiving taxane-containing chemotherapeutic treatment. Meta-analyses evaluated the effects of exercise on CIPN symptoms, fatigue, and HR-QoL.

RESULTS

Ten trials involving exercise interventions ranging between 2 and 12 months were included. The combined results of four RCTs consisting of 171 participants showed a reduction in CIPN symptoms following exercise compared with usual care (standardised mean difference - 0.71, 95% CI - 1.24 to - 0.17, p = 0.012; moderate-quality evidence, I2 = 76.9%). Pooled results from six RCTs with 609 participants showed that exercise interventions before and/or during taxane-containing chemotherapy regimens improved HR-QoL (SMD 0.42, 95% CI 0.07 to 0.76, p = 0.03; moderate-quality evidence, I2 = 49.6%). There was no evidence of an effect of exercise on fatigue (- 0.39, 95% CI - 0.95 to 0.18, p = 0.15; very low-quality evidence, I2 = 90.1%).

CONCLUSIONS

This systematic review found reduced levels of CIPN symptoms and an improvement in HR-QoL in women with breast cancer who exercised before and/or during taxane-based chemotherapy versus usual care controls.

IMPLICATIONS FOR CANCER SURVIVORS

This evidence supports the role of exercise as an adjunctive treatment for attenuating the adverse effects of taxane-containing chemotherapy on CIPN symptoms and HR-QoL.

GET FIT: A Randomized Clinical Trial of Tai Ji Quan Versus Strength Training for Fall Prevention After Chemotherapy in Older, Postmenopausal Women Cancer Survivors

PURPOSE

To compare the efficacy of tai ji quan versus strength training to prevent falls after chemotherapy in older, postmenopaual women.

METHODS

We conducted a three-arm, single-blind, randomized controlled trial where older (50+ years), postmenopausal women cancer survivors participated in one of three supervised group exercise programs (tai ji quan, strength training, or stretching control) twice weekly for 6 months and were followed up 6 months after training stopped. The primary outcome was the incidence of falls. Secondary outcomes included fall-related injuries, leg strength (1 repetition maximum; kg), and balance (sensory organization [equilibrium score] and limits of stability [LOS; %] tests).

RESULTS

Four hundred sixty-two women were enrolled (mean age, 62 ± 6.3 years). Retention was 93%, and adherence averaged 72.9%. In primary analysis, there was no difference in the incidence of falls between groups after 6 months of training, nor during 6-month follow-up. A post hoc analysis detected a significantly reduced incidence of fall-related injuries within the tai ji quan group over the first 6 months, dropping from 4.3 falls per 100 person-months (95% CI, 2.9 to 5.6) at baseline to 2.4 falls per person-months (95% CI, 1.2 to 3.5). No significant changes occurred during 6-month follow-up. Over the intervention period, leg strength significantly improved in the strength group and balance (LOS) improved in the tai ji quan group, compared with controls (P < .05).

CONCLUSION

We found no significant reduction in falls for tai ji quan or strength training relative to stretching control in postmenopausal women treated with chemotherapy.

Determination of the Influence of Peripheral Neuropathy Symptoms on Quality of Life in Breast Cancer Patients: A Cross-Sectional Study with Four Follow-Ups

AIM

This study aims to evaluate the impact of peripheral neuropathy symptoms throughout with monthly follow-ups during 4 months of paclitaxel treatment.

METHODS

This prospective cross-sectional study was conducted with 79 patients. The study population consisted of female patients with breast cancer between August 2018 and January 2019. ''Chemotherapy-Induced Peripheral Neuropathy Assessment Tool'' and ''EORTC C30 Cancer Quality of Life Questionnaire'' were applied with four follow-ups. The study was undertaken in accordance with the STROBE checklist for cross- sectional studies.

RESULTS

The Chemotherapy-Induced Peripheral Neuropathy Assessment Tool except for the general activity subdimension were statistically significant in the ratings of second, compared to first; third compared to first and second; fourth compared to first, second, and third follow-up periods. The overall mean of the EORTC C30 Cancer Quality of Life Questionnaire, functioning, symptom, and global health status were statistically significant in the evaluations of second, compared with first; third compared with first and second; fourth compared with first, second, and third follow-up periods.

CONCLUSION

Findings from this study suggest that the increase in neuropathy symptoms during cures negatively affects the quality of life.

Falls during oxaliplatin-based chemotherapy for gastrointestinal malignancies - (lessons learned from) a prospective study

This prospective cohort study aimed to characterise the impact of oxaliplatin-based chemotherapy and its neurotoxic side effects (i.e., chemotherapy-induced neuropathy) on functional fall-risk and falls. Twenty chemotherapy-naïve participants (mean age, 59 years; 16 males) were consecutively included. A multimodal fall risk assessment was performed at four time points within 6 months. Polyneuropathy was assessed using the Neurologic Disability Scale; the fall risk was assessed by functional tests (Tinetti Test, Chair-Rising Test, and Timed up and Go Test). Patient-reported outcomes comprised the Hospitality Anxiety and Depression Scale (HADS), the Falls Efficacy Scale - International (FES-I) to assess the fear of falling, and the Physical Activity for the Elderly (PASE) questionnaire. Three falls occurred during the study. All fallen participants had a high fall risk-index (≥4 more risk factors) compared to only 30% of the non-fallen participants (p = 0.03) and suffered more frequently from pre-existing mild polyneuropathy (p = 0.049). Study discontinuation (n = 12) was associated with a higher rate of polypharmacy (p = 0.045), anxiety (HADS-A, p = 0.03), and specific fear of falling (FES-I, p = 0.025). In contrast, study completers (n = 8) reported an improvement in physical activity (PASE) (p = 0.018). In summary, pre-existing fall-risk factors impacted more falls than chemotherapy. A fall risk index offers a time-efficient screening option in an outpatient oncological setting.

External Validation of Risk Factors for Unplanned Hospitalization in Older Adults With Advanced Cancer Receiving Chemotherapy

BACKGROUND

Older adults (age ≥65 years) receiving chemotherapy are at risk for hospitalization. Predictors of unplanned hospitalization among older adults receiving chemotherapy for cancer were recently published using data from a study conducted by the Cancer and Aging Research Group (CARG). Our study aimed to externally validate these predictors in an independent cohort including older adults with advanced cancer receiving chemotherapy.

METHODS

This validation cohort included patients (n=369) from the GAP70+ trial usual care arm. Enrolled patients were aged ≥70 years with incurable cancer and were starting a new line of chemotherapy. Previously identified risk factors proposed by the CARG study were ≥3 comorbidities, albumin level <3.5 g/dL, creatinine clearance <60 mL/min, gastrointestinal cancer, ≥5 medications, requiring assistance with activities of daily activities (ADLs), and having someone available to take them to the doctor (ie, presence of social support). The primary outcome was unplanned hospitalization within 3 months of treatment initiation. Multivariable logistic regression was applied including the 7 identified risk factors. Discriminative ability of the fitted model was performed by calculating the area under the receiver operating characteristic (AUC) curve.

RESULTS

Mean age of the cohort was 77 years, 45% of patients were women, and 29% experienced unplanned hospitalization within the first 3 months of treatment. The proportions of hospitalized patients with 0-3, 4-5, and 6-7 identified risk factors were 24%, 28%, and 47%, respectively (P=.04). Impaired ADLs (odds ratio, 1.76; 95% CI, 1.04-2.99) and albumin level <3.5 g/dL (odds ratio, 2.23; 95% CI, 1.37-3.62) were significantly associated with increased odds of unplanned hospitalization. The AUC of the model, including the 7 identified risk factors, was 0.65 (95% CI, 0.59-0.71).

CONCLUSIONS

The presence of a higher number of risk factors was associated with increased odds of unplanned hospitalization. This association was largely driven by impairment in ADLs and low albumin level. Validated predictors of unplanned hospitalization can help with counseling and shared decision-making with patients and their caregivers.

CLINICALTRIALS

gov identifier: NCT02054741.

Neurological Outcomes of Chemotherapy-Induced Peripheral Neuropathy in Patients With Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review and meta-analysis aimed to determine whether chemotherapy-induced peripheral neuropathy (CIPN) affects the risk of falls and physical function in patients with cancer.

METHODS

A literature search was conducted in the CINAHL, Scopus, and PubMed databases for articles published from January 1950 to April 2022. Seven review authors retrieved studies using predetermined eligibility criteria, extracted the data, and evaluated the quality.

RESULTS

Nine studies were included in the analysis. Patients with CIPN had a significantly higher risk of falls than those without CIPN (risk ratio = 1.38, 95% confidence interval [CI] =1.18-1.62). Patients with CIPN had lower grip strength (standardized mean difference [SMD] =-0.42, 95% CIs = -0.70 to -0.14, P = .003), longer chair stand time (SMD = 0.56, 95% CIs = -0.01 to 1.17, P = .05), worse timed up and go test time (SMD = 0.79, 95% CIs = 0.41 to 1.17, P < .0001), and lower mean Fullerton Advanced Balance scale score (SMD = -0.81, 95% CIs = -1.27 to -0.36, P = .005) than patients without CIPN. There were no significant differences in gait speed (P = .38) or Activities-specific Balance Confidence Scale score (P = .09) between patients with and without CIPN.

CONCLUSIONS

This systematic review and meta-analysis demonstrated that patients with CIPN are prone to falls and impaired balance function and muscle strength.

Association of fall rate and functional status by APOE genotype in cancer survivors after exercise intervention

PURPOSE/OBJECTIVES

Cancer treatment survivors often report impaired functioning and increased falls. Not all survivors experience the same symptom burden, suggesting individual susceptibilities. APOE genotype is a potential genetic risk factor for cancer treatment related side effects. Lifestyle factors such as physical activity can mitigate the effect of APOE genotype on measures of clinical interest in individuals without a history of cancer. We tested the hypothesis that APOE genotype influences cancer treatment related side effects and symptoms as well as response to exercise intervention.

MATERIALS AND METHODS

Data from a subsample of a study of fall prevention exercise in post-treatment female cancer survivors aged 50-75 years old (https://clinicaltrials.gov NCT01635413) were used to conduct a secondary data analysis. ApoE genotype was determined by serum sampling. Physical functioning, frequency of falls, and symptom burden were assessed using survey instruments.

RESULTS

Data from 126 female cancer survivors a median of 49 months out from cancer diagnosis were analyzed. ApoE4 carriers trended toward a higher fall rate at baseline (p = 0.059), but after exercise intervention had a fall rate lower than E4 non-carriers both immediately after structured intervention (p = 0.013) and after 6 months of follow up (p = 0.002). E2 carriers did not show improved measures of depressive symptoms and self-report disability after exercise intervention. E3 homozygotes showed increased self report physical activity after the 6 month exercise intervention, but E4 and E2 carriers did not.

CONCLUSIONS

APOE genotype may modulate cancer treatment related side effects and symptoms and response to exercise intervention.

Psychometric Properties of the Korean Version of the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool

BACKGROUND AND PURPOSE

Chemotherapy-induced peripheral neuropathy (CIPN) is a multidimensional symptom cluster induced by neurotoxic chemotherapy agents among patients with cancer. A well-developed tool for assessing CIPN can help with the early detection and timely management of patients. This study assessed the reliability and validity of the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool (CIPNAT) in Korean women with breast cancer who were treated with chemotherapy.

METHODS

A psychometric analysis of the Korean version of CIPNAT was conducted with 207 patients with breast cancer who were treated with chemotherapy. Patients were assessed using the CIPNAT and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Chemotherapy-Induced Peripheral Neuropathy-20 (CIPN-20). Analyses of internal consistency reliability, concurrent validity, and construct validity (based on structural and discriminant validity testing) were performed to evaluate the psychometric properties.

RESULTS

The Korean version of the CIPNAT had good internal consistency (Cronbach's alpha = 0.95; the item-total correlation coefficients ranged 0.34-0.76). The CIPNAT and CIPN-20 were moderately correlated (r = .67). Confirmatory factor analyses showed a four-factor structural model with acceptable model fit indices. Discriminant validity was supported by differences between individuals treated with and without taxane-based chemotherapy (p < .001).

IMPLICATIONS FOR PRACTICE

The Korean version of the CIPNAT was a valid and reliable screening tool for identification of CIPN symptoms and functional interference in Korean women who received chemotherapy for breast cancer. The instrument can be useful for the timely and routine assessment of CIPN symptoms and functional limitations of patients with cancer by oncology nurses.

The Impact of Footwear on Occupational Task Performance and Musculoskeletal Injury Risk: A Scoping Review to Inform Tactical Footwear

The aim of this scoping review was to investigate the impact of footwear on worker physical task performance and injury risk. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews protocol and registered in the Open Science Framework. Key search terms were entered into five academic databases. Following a dedicated screening process and critical appraisal, data from the final articles informing this review were extracted, tabulated, and synthesised. Of 19,614 identified articles, 50 articles informed this review. Representing 16 countries, the most common populations investigated were military and firefighter populations, but a wide range of general occupations (e.g., shipping, mining, hairdressing, and healthcare workers) were represented. Footwear types included work safety boots/shoes (e.g., industrial, gumboots, steel capped, etc.), military and firefighter boots, sports shoes (trainers, tennis, basketball, etc.) and various other types (e.g., sandals, etc.). Occupational footwear was found to impact gait and angular velocities, joint ranges of motion, posture and balance, physiological measures (like aerobic capacity, heart rates, temperatures, etc.), muscle activity, and selected occupational tasks. Occupational footwear associated with injuries included boots, conventional running shoes, shoes with inserts, harder/stiffer outsoles or thin soles, and shoes with low comfort scores-although the findings were mixed. Occupational footwear was also linked to potentially causing injuries directly (e.g., musculoskeletal injuries) as well as leading to mechanisms associated with causing injuries (like tripping and slipping).

Risk factors for falls in hospitalized patients with cancer: A systematic review and meta-analysis

A primary cancer diagnosis has been confirmed as an important risk factor for falls, and the incidence of falls has been shown to be higher in patients who have undergone cancer treatment than in those who have not undergone cancer treatment. Falls during hospitalization increase the medical costs of additional treatment and falls-related mortality. Many falls are preventable and a good understanding of the predictors of falls in this population is needed. However, the risk factors for falls have not yet been identified. The purpose of this review was to identify the risk factors for falls in hospitalized patients with cancer. Eleven English and Chinese electronic databases were searched from their inception to April 2022 and the methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Five studies involving 1237 patients with cancer were included. The meta-analysis identifies eleven risk factors for falls in hospitalized patients with cancer, including age, history of falls, opiates, benzodiazepines, steroids, antipsychotics, sedatives, radiation therapy, chemotherapy, the use of an assistive device and length of hospitalization. Based on the evidence presented in this article, healthcare workers have the capacity to help reduce fall risk through the development of preventive support strategies in this population. Multicenter, prospective studies of patients with cancer should be conducted to further identify and validate their risk factors for falls.

Fall predictors in hospitalized patients living with cancer: a case-control study

PURPOSE

To identify fall predictors and develop an assessment tool to be used for screening hospitalized cancer patients at risk for fall.

METHODS

A retrospective case-control study was conducted in 2018 at a cancer center in Northern Italy. The study participants were 448 adult cancer patients admitted to the oncology ward from 2009 to 2013. The case group consisted of 112 patients presenting at least one fall, while controls were randomly chosen by matching each case for age, sex, and admission period with three patients who did not fall. Data for the fall predictors were extracted from the electronic medical records. Conditional logistic regression was used to evaluate the association between patient's characteristics and fall risk.

RESULTS

The overall prevalence of patients having at least one candidate fall predictor was high (98%). Seven of the studied variables showed an independent association with fall risk at multivariate analysis. These were tumor site, the presence of neurologic diseases, gait imbalance disorders, fatigue, and the assumption of certain medications such as diuretics, hypnotics, and opioids (odds ratios and 95% confidence intervals in brackets were 3.78 (1.78-8.13), 2.26 (1.08-4.77), 4.22 (1.87-9.52), 2.76 (1.45-5.26), 2.66 (1.52-4.66), 2.41 (1.20-4.85), and 3.03 (1.68-5.45), respectively).

CONCLUSIONS

In this study, we identified falling risk factors in an Italian population of hospitalized cancer patients and developed a new risk assessment tool. An external validation is necessary before implementing our screening tool in clinical practice.

Incidence and risk factors associated with falls among women with breast cancer during taxane-based chemotherapy

PURPOSE

This study aims to evaluate the falling incidence density and examine the potential risk factors associated with falling among women with breast cancer during taxane-based chemotherapy.

METHODS

One hundred and twenty-three women with breast cancer participated in this study. The fall incidence density, taxane-induced peripheral neuropathy (TIPN) symptoms, and physical performance tests were evaluated at five time points throughout chemotherapy treatment. A fall diary was used to record fall incidence during treatment. The fall incidence density was calculated by dividing the number of first fall occurrences by person-time at risk. The risk factors associated with time to first fall were analyzed using the Cox proportional hazards model. The Kaplan-Meier curve illustrated the probability of survival from a fall during chemotherapy treatment.

RESULTS

Over the course of treatment, 29 (23.58%) participants reported falls. The fall incidence density was 3 per 1000 person-day. This study discovered a significant link between age (adjusted HR (HR_adj) = 1.07; 95% CI: 1.02-1.13) and BMI (HR_adj = 1.11; 95% CI: 1.02-1.21) and falling.

CONCLUSIONS

Women with breast cancer could fall for the first time at any time after starting chemotherapy until the end of the follow-up period. Furthermore, time to first fall was associated with age and BMI. Early detection of falling in women with breast cancer, particularly among older persons and those with a high BMI, may be essential to preventing falls.

Pharmacological and Nonpharmacological Management of Chemotherapy-Induced Peripheral Neuropathy: A Scoping Review of Randomized Controlled Trials

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and debilitating side effect of cancer treatment with no effective preventative strategy or definitive treatment. Purpose: To synthesize empiric literature from randomized controlled trials (RCTs) of pharmacological and nonpharmacological management of CIPN. Data Sources: Articles published between January 1, 2010, and February 28, 2021, were identified using keywords searching Medline, PubMed, CINAHL, Web of Science, Cochrane Library, and Embase. Study Selection: RCTs that recruited individuals who were post-chemotherapy and experienced persistent CIPN symptoms. Data Extraction and Synthesis: Three independent reviewers screened a total of 2023 abstracts. After screening, full-text review, and quality appraisal, 22 articles were included in this review. Data related to study design, participant characteristics, interventions, controls, outcome measures, and relevant findings were extracted from full texts. Descriptive quantitative summaries were calculated and narrative analysis was performed. Results: Of the 22 studies, 4 investigated pharmacologic treatments, 2 compared acupuncture to pharmacologic treatments, and 16 studies examined nonpharmacologic treatments. Pharmacologic studies reported mixed results with evidence of participant response varying by history of chemotherapeutic agent. Acupuncture, exercise/physical therapy, and neurofeedback appear to be effective treatments for CIPN. Evidence regarding biophysical agents and cognitive-behavioral therapy is equivocal. Scrambler therapy is not supported. Limitations: Studies included in this review share several limitations, including widely variable outcome measures, small and demographically homogenous samples, and nonstandardized treatment protocols. Conclusion: This scoping review summarized the current body of high-quality RCTs investigating treatment for CIPN. The majority of studies in this review reports benefits of pharmacologic and nonpharmacologic interventions, although management may require a multipronged approach and should be tailored to the individual. Clinical implications are proposed and suggestions made for future research include implementation of standardized intervention protocols, use of outcome measures representative of the spectrum of CIPN symptoms, and stratification by the chemotherapeutic agent.

Endoplasmic Reticulum Stress in Chemotherapy-Induced Peripheral Neuropathy: Emerging Role of Phytochemicals

Chemotherapy-induced peripheral neuropathy (CIPN) is a significant dose-limiting long-term sequela in cancer patients undergoing treatment, often leading to discontinuation of treatment. No established therapy exists to prevent and/or ameliorate CIPN. Reactive oxygen species (ROS) and mitochondrial dysregulation have been proposed to underlie the pathobiology of CIPN. However, interventions to prevent and treat CIPN are largely ineffective. Additional factors and mechanism-based targets need to be identified to develop novel strategies to target CIPN. The role of oxidative stress appears to be central, but the contribution of endoplasmic reticulum (ER) stress remains under-examined in the pathobiology of CIPN. This review describes the significance of ER stress and its contribution to CIPN, the protective role of herbal agents in countering ER stress in nervous system-associated disorders, and their possible repurposing for preventing CIPN.

Neural circuit mechanisms of sensorimotor disability in cancer treatment

Cancer survivors rank sensorimotor disability among the most distressing, long-term consequences of chemotherapy. Disorders in gait, balance, and skilled movements are commonly assigned to chemotoxic damage of peripheral sensory neurons without consideration of the deterministic role played by the neural circuits that translate sensory information into movement. This oversight precludes sufficient, mechanistic understanding and contributes to the absence of effective treatment for reversing chemotherapy-induced disability. We rectified this omission through the use of a combination of electrophysiology, behavior, and modeling to study the operation of a spinal sensorimotor circuit in vivo in a rat model of chronic, oxaliplatin (chemotherapy)-induced neuropathy (cOIN). Key sequential events were studied in the encoding of propriosensory information and its circuit translation into the synaptic potentials produced in motoneurons. In cOIN rats, multiple classes of propriosensory neurons expressed defective firing that reduced accurate sensory representation of muscle mechanical responses to stretch. Accuracy degraded further in the translation of propriosensory signals into synaptic potentials as a result of defective mechanisms residing inside the spinal cord. These sequential, peripheral, and central defects compounded to drive the sensorimotor circuit into a functional collapse that was consequential in predicting the significant errors in propriosensory-guided movement behaviors demonstrated here in our rat model and reported for people with cOIN. We conclude that sensorimotor disability induced by cancer treatment emerges from the joint expression of independent defects occurring in both peripheral and central elements of sensorimotor circuits.

Feasibility of a Remotely Delivered Strength and Balance Training Program for Older Adults with Cancer

Falls are a major issue among older adults with cancer and lead to interruptions in cancer treatment. Resistance and balance training can prevent falls in older adults, but minimal evidence is available regarding the older cancer population, who often have unique risk factors. We used a pre-post design to assess the feasibility of a remotely delivered exercise program that progressed in difficulty and its efficacy on lower body strength, balance, and falls in older adults with cancer who had prior in-person exercise experience. Twenty-six older adults with cancer completed the intervention. Attendance rate for the virtual component was 97.6% and for the independent component was 84.7%. Participants perceived the program as rewarding and enjoyable (100%), felt this program prepared them to exercise on their own (92%), were confident to continue exercising on their own (81%), and would recommend the program to other patients (100%). The median balance score at baseline and end-of-study was 4 (IQR = 0). The median chair-stand time decreased from 9.2 s (IQR = 3.13) to 7.7 s (IQR = 4.6). A statistically significant difference in lower body strength (r = 0.68, p = 0.001) was detected post-intervention. The findings from this study can inform the design of a larger randomized trial.

Oncology clinic nurses' attitudes and perceptions regarding implementation of routine fall assessment and fall risk screening: A survey study

Falls in older adults with cancer are often under-recognized and under-reported. The objective of this study was to explore oncology clinic nurses' willingness and perceived barriers to implement routine falls assessment and falls screening in their practice. Nurses working in outpatient oncology clinics were invited to complete an online survey. Data were analyzed using descriptive statistics and sorted into thematic categories. The majority of respondents indicated willingness to routinely ask older patients about falls (85.7%) and screen for fall risks (73.5%). The main reasons for unwillingness included: belief that patients report falls on their own, lack of time, and lack of support staff. Findings from this study show many oncology nurses believe in the importance of routine fall assessment and screening and are willing to implement them routinely, although falls are not routinely asked about or assessed. Future work should explore strategies to address barriers nurses face given the implications of falls amongst this vulnerable population.

Évaluation systématique des chutes et du risque de chutes : Sondage sur l’attitude et les perceptions des infirmières cliniques en oncologie

Chez les personnes âgées atteintes de cancer, les chutes sont un problème souvent sous-estimé et peu rapporté. La présente étude visait à explorer la volonté des infirmières cliniques en oncologie à évaluer et à dépister systématiquement les chutes dans leur pratique; l’étude examinait également les obstacles perçus à l’évaluation et au dépistage systématique. Les infirmières ont donc été invitées à remplir un sondage en ligne. Les données ont été analysées à l’aide de statistiques descriptives. La majorité des infirmières ayant répondu ont dit qu’elles accepteraient de poser systématiquement des questions sur les chutes (85,7 %) et de dépister les risques de chutes (73,5 %) chez les personnes âgées. Voici les principales raisons des réticences : conviction que les patients signalent les chutes d’euxmêmes, manque de temps, pénurie de personnel de soutien. Selon les résultats de l’étude, beaucoup d’infirmières en oncologie trouvent important d’évaluer et de dépister systématiquement les chutes, et sont d’accord pour l’intégrer à leur pratique bien que, d’habitude, les chutes ne fassent pas automatiquement l’objet de questions ou d’une évaluation. Étant donné les conséquences des chutes sur ces patients vulnérables, la recherche à venir devra explorer les stratégies permettant de surmonter les obstacles auxquels se butent les infirmières.

Type of exercise may influence postural adaptations in chemotherapy-induced peripheral neuropathy

OBJECTIVE

Traditional posturography measurements characterize postural instability in patients with chemotherapy-induced peripheral neuropathy (CIPN), while underlying postural control mechanisms remain unclear. Taking a model-based approach can yield insights into these mechanisms. This study's aim was to characterize the modifications in postural control of CIPN patients associated with exercise in relation to the postural behavior of healthy control participants (hCON) via an exploratory approach.

METHODS

Thirty-one CIPN patients were randomly assigned to two interventions (balance plus moderate endurance training vs. moderate endurance training only) and exercised twice per week over 12 weeks. Baseline data were compared to 36 matched hCONs. We recorded spontaneous sway and postural reactions to platform tilts using Optotrak and a Kistler force platform pre- and post-intervention. Data interpretation relied on a model-based parameter identification procedure.

RESULTS

Spontaneous sway amplitudes were larger and postural reactions smaller, with a relative phase advance, in our pre-intervention patients than the hCONs. Post-intervention, spontaneous sway, and postural reactions were reduced and the sensory-motor ratio larger in both groups, while the postural reaction timing differed between groups.

INTERPRETATION

The abnormally small postural reactions in CIPN patients before the intervention can be interpreted as the consequence of abnormally strong velocity control-a strategy modification that may serve as a prediction mechanism to compensate for the lack of timely and accurate proprioceptive signals. While both groups reduced postural sway and showed an adapted sensory-motor ratio post-intervention, the interventions seemed to trigger different velocity control strategies. This study emphasizes the need for taking a more differentiated perspective on intervention effects.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) number: DRKS00005419, prospectively registered on November 19, 2013.

Balance and vestibular function and survival in US cancer survivors

BACKGROUND

Cancer and its treatment damage the musculoskeletal system and induce neurotoxicity, affecting the key sensory inputs for maintaining balance. The present study describes the pattern of balance impairment and evaluated its association with mortality among US cancer survivors.

METHODS

Data on a nationally representative sample of cancer survivors from the US National Health and Nutrition Examination Survey from 1999 to 2015 was analyzed. Sensory-specific balance impairment was measured at baseline by the modified Romberg test of standing balance on firm and compliant support surfaces. The linked mortality data were updated through December 31, 2015.

RESULTS

Among 511 cancer survivors, 282 (48.3%) had a balance impairment, predominantly attributing to vestibular dysfunction (251; 89.0% of 282 and 44.5% of 511). A higher prevalence of balance impairment was observed among cancer survivors with advanced age, lower socioeconomic status or educational attainment, body mass index <25 kg/m² , and an inactive lifestyle. During up to 16.4 years of follow-up (median, 11.3 years; 5088 person-years), 253 cancer survivors had died. Cancer survivors with a balance impairment had a 63% higher risk of death from all causes (hazard ratio, 1.63; 95% confidence interval [CI], 1.12-2.38) after adjusting for sociodemographic factors, comorbidities, and cancer type. Specifically, those with vestibular dysfunctions had approximately 1.54 (95% CI, 1.05-2.27) times the risk of death compared to those without any balance impairment. These associations were stronger in males than in females.

CONCLUSIONS

In a US nationally representative sample of cancer survivors, balance impairment and vestibular dysfunctions were prevalent and associated with heightened all-cause mortality.

The detrimental association between fear of falling and motor performance in older cancer patients with chemotherapy-induced peripheral neuropathy

BACKGROUND

Cancer patients with chemotherapy-induced peripheral neuropathy (CIPN) are at increased risk of falls and developing fear of falling (FoF). Although FoF may continue to impair motor performance and increase the risk of falling even further, this association remains unexplored in CIPN.

RESEARCH QUESTION

Does high FoF in patients with CIPN further deteriorate motor performance beyond the impairment from CIPN-related sensory deficits?

METHODS

In this secondary analysis of data collected from two clinical trials, gait parameters during habitual walking condition and postural sway parameters during 30-second quiet standing (eye-open and eyes-closed) were compared among older participants (≥ 65 years) with CIPN and high FoF (CIPN FoF+; n=16), older participants with CIPN and low FoF (CIPN FoF-; n=19) and normal older controls (i.e., non-cancer, non-diabetic, non-neurologic, and non-orthopedic; n=16). We measured gait and postural sway parameters using wearable sensors (BioSensics, Newton, MA, USA), and FoF severity using the Falls Efficacy Scale-International.

RESULTS

The largest between-group differences were found in gait speed. The CIPN FoF + group had significantly slower gait speed (0.78 ± 0.21 m/s) than the CIPN FoF- (0.93 ± 0.17 m/s) and normal control groups (1.17 ± 0.13 m/s) (all p < .05; effect sizes = 0.79 and 2.23, respectively). We found a significant association between gait speed and FoF severity (R2 = 0.356; p < .001) across all participants with CIPN. Among participants with CIPN, no significant differences in postural sway parameters were found between the CIPN FoF+and CIPN FoF- groups.

SIGNIFICANCE

Our results suggest that gait performance further deteriorates in patients with CIPN and high FoF beyond the impairment from CIPN-related sensory deficits. Our results also suggest further research is needed regarding FoF, and fall risk, as FoF is a simple tool that healthcare providers can use in clinical practice.

A Randomized Controlled Trial to Assess the Effectiveness of Muscle Strengthening and Balancing Exercises on Chemotherapy-Induced Peripheral Neuropathic Pain and Quality of Life Among Cancer Patients

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is the presence of tingling, burning, itching, and unpleasant sensations in hands and feet due to nerve damage by chemotherapy. Exercise rehabilitation has potential to prevent or alleviate CIPN.

OBJECTIVE

The aim of this study was to assess the effectiveness of muscle strengthening and balancing exercises on CIPN pain and quality of life (QOL) among cancer patients.

METHODS

The randomized controlled trial included 45 cancer patients from a tertiary care hospital in India receiving chemotherapeutic drugs paclitaxel and carboplatin and found to have CIPN. Subjects were randomly allocated to exercise (n1 = 22) and usual care (n2 = 23) groups. The exercise group received home-based muscle strengthening and balancing exercise for 10 weeks. Data regarding demographic, clinical characteristics, CIPN, neuropathic pain, and QOL were collected by structured questionnaires Chemotherapy-Induced Peripheral Neuropathy Assessment Tool, nerve conduction velocity, Leeds Assessment of Neuropathic Symptoms and Signs pain scale, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire.

RESULTS

The 2 groups were homogenous regarding demographic variables. In clinical characteristics, the exercise group had larger body surface area and received a higher dose of paclitaxel. Significant reduction in neuropathic pain scores (P < .0001) and improvement in Functional QOL (P = .0002), Symptom QOL (P = .0003), Global Health Status QOL (P = .004) scores were observed after intervention in the exercise group than the usual-care group.

CONCLUSION

Muscle strengthening and balancing exercises are effective in reducing CIPN pain and improving QOL among cancer patients.

IMPLICATIONS FOR PRACTICE

Muscle strengthening and balancing exercises can be used as a complementary therapy for effective management of CIPN.

The effects of exercise on chemotherapy-induced peripheral neuropathy symptoms in cancer patients: a systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis of current studies to determine whether exercise affects chemotherapy-induced peripheral neuropathy (CIPN) symptoms in cancer patients.

DESIGN

The Medline, Embase, Cochrane Library, CINAHL, PubMed, and National Central Library databases, and the reference lists of the included studies were surveyed. The Consolidated Standards of Reporting Trials (CONSORT) extension checklist for non-pharmacologic treatment was used to evaluate the literature.

SETTING AND PARTICIPANTS

Exercise interventions offered in hospitals or at home. A total of 178 participants from 5 studies were assessed in the meta-analysis, with their mean age ranging from 48.56 to 71.82 years.

METHODS

The randomized control trials were summarized in a systematic review. The effects of the exercise interventions were compiled for meta-analysis. A forest plot was constructed using a fixed effect model to obtain a pooled mean difference.

RESULTS

The pooled results indicated that exercise interventions significantly improved the CIPN symptoms of the participants (mean difference: 0.5319; 95% confidence interval: 0.2295 to 0.8344; Z = 3.45; P = 0.0006). A combination of exercise protocols including a nerve gliding exercise intervention was found to have improved CIPN symptoms. In addition, a sensorimotor-based exercise intervention was found to have reduced CIPN-induced loss of postural stability.

CONCLUSIONS AND IMPLICATIONS

The findings indicated that the effects of exercise could improve CIPN symptoms in cancer patients. Nevertheless, further investigations of different exercise protocols and intensity of intervention utilizing larger sample sizes and more specific outcome measures will further inform the best practices for cancer patients.

Expanding Beyond Maximum Grade: Chemotherapy Toxicity over Time by Age and Performance Status in Advanced Non-Small Cell Lung Cancer in CALGB 9730 (Alliance A151729)

BACKGROUND

Prior comparisons of chemotherapy adverse events (AEs) by age and performance status (PS) are limited by the traditional maximum grade approach, which ignores low-grade AEs and longitudinal changes.

MATERIALS AND METHODS

To compare fatigue and neuropathy longitudinally by age (<65, ≥65 years) and PS (0-1, 2), we analyzed data from a large phase III trial of carboplatin and paclitaxel versus paclitaxel for advanced non-small cell lung cancer (CALGB 9730, n = 529). We performed multivariable (a) linear mixed models to estimate mean AE grade over time, (b) linear regression to estimate area under the curve (AUC), and (c) proportional hazards models to estimate the hazard ratio of developing grade ≥2 AE, as well as traditional maximum grade analyses.

RESULTS

Older patients had on average a 0.17-point (95% confidence interval [CI], 0.00-0.34; p = .049) higher mean fatigue grade longitudinally compared with younger patients. PS 2 was associated with earlier development of grade ≥2 fatigue (hazard ratio [HR], 1.56; 95% CI, 1.07-2.27; p = .02). For neuropathy, older age was associated with earlier development of grade ≥2 neuropathy (HR, 1.41; 95% CI, 1.00-1.97; p = .049). Patients with PS 2 had a 1.30 point lower neuropathy AUC (95% CI, -2.36 to -0.25; p = .02) compared with PS 0-1. In contrast, maximum grade analyses only detected a higher percentage of older adults with grade ≥3 fatigue and neuropathy at some point during treatment.

CONCLUSION

Our comparison of complementary but distinct aspects of chemotherapy toxicity identified important longitudinal differences in fatigue and neuropathy by age and PS that are missed by the traditional maximum grade approach. Clinical trial identification number: NCT00003117 (CALGB 9730) IMPLICATIONS FOR PRACTICE: The traditional maximum grade approach ignores persistent low-grade adverse events (AEs) and changes over time. This toxicity over time analysis of fatigue and neuropathy during chemotherapy for advanced non-small cell lung cancer demonstrates how to use longitudinal methods to comprehensively characterize AEs over time by age and performance status (PS). We identified important longitudinal differences in fatigue and neuropathy that are missed by the maximum grade approach. This new information about how older adults and patients with PS 2 experience these toxicities longitudinally may be used clinically to improve discussions about treatment options and what to expect to inform shared decision making and symptom management.

A review of movement disorders in chemotherapy-induced neurotoxicity

Chemotherapy agents used in the standard treatments for many types of cancer are neurotoxic and can lead to lasting sensory and motor symptoms that compromise day-to-day movement functions in cancer survivors. To date, the details of movement disorders associated with chemotherapy are known largely through self-reported symptoms and functional limitations. There are few quantitative studies of specific movement deficits, limiting our understanding of dysfunction, as well as effective assessments and interventions. The aim of this narrative review is to consolidate the current understanding of sensorimotor disabilities based on quantitative measures in cancer survivors who received chemotherapy. We performed literature searches on PubMed and found 32 relevant movement studies. We categorized these studies into three themes based on the movement deficits investigated: (1) balance and postural control; (2) gait function; (3) upper limb function. This literature suggests that cancer survivors have increased postural sway, more conservative gait patterns, and suboptimal hand function compared to healthy individuals. More studies are needed that use objective measures of sensorimotor function to better characterize movement disabilities and investigate the underlying causes, as required for developing targeted assessments and interventions. By updating our understanding of movement impairments in this population, we identify significant gaps in knowledge that will help guide the direction of future research.

Evaluation of Fall and Fracture Risk Among Men With Prostate Cancer Treated With Androgen Receptor Inhibitors: A Systematic Review and Meta-analysis

Importance

A high incidence of fall and fracture in a subset of patients treated with androgen receptor inhibitors (ARIs) has been reported, although the relative risk (RR) of fall and fracture for patients who receive ARI treatment is unknown.

Objective

To evaluate whether treatment with ARIs is associated with an elevated relative risk for fall and fracture in patients with prostate cancer.

Data Sources

Cochrane, Scopus, and MedlinePlus databases were searched from inception through August 2019.

Study Selection

Randomized clinical trials comparing patients with prostate cancer treated with any ARI or placebo were included.

Data Extraction and Synthesis

Two independent reviewers used a standardized data extraction and quality assessment form. A mixed effects model was used to estimate the effects of ARI on relative risk, with included studies treated as random effects and study groups treated as fixed effects in the pooled analysis. Sample size for each study was used to weight the mixed model. Statistical analysis was performed from August to October 2019.

Main Outcomes and Measures

The primary outcome was RR of fall and fractures for patients receiving ARI treatment.

Results

Eleven studies met this study's inclusion criteria. The total population was 11 382 men (median [range] age: 72 [43-97] years), with 6536 in the ARI group and 4846 in the control group. Participants in the ARI group could have received enzalutamide, apalutamide, or darolutamide in combination with androgen deprivation therapy or other enzalutamide combinations; patients in the control group could have received placebo, bicalutamide, or abiraterone. The reported incidence of fall was 525 falls (8%) in the ARI group and 221 falls (5%) in the control group. The incidence of fracture was 242 fractures (4%) in the ARI group and 107 fractures (2%) in the control group. Use of an ARI was associated with an increased risk of falls and fractures: all-grade falls (RR, 1.8; 95% CI, 1.42-2.24; P < .001); grade 3 or greater fall (RR, 1.6; 95% CI, 1.27-2.08; P < .001); all-grade fracture (RR, 1.59; 95% CI, 1.35-1.89; P < .001), and likely grade 3 or greater fracture (RR, 1.71; 95% CI, 1.12-2.63; P = .01).

Conclusions and Relevance

Use of ARI was associated with an increase in falls and fractures in patients with prostate cancer as assessed by a retrospective systematic review and meta-analysis. Further studies are warranted to identify and understand potential mechanisms and develop strategies to decrease falls and fractures associated with ARI use.

The Impact of Peripheral Cooling on Chemotherapy-Induced Peripheral Neuropathy: An Integrative Review

Chemotherapy-induced peripheral neuropathy (CIPN) is a prevalent, potentially long-lasting side effect of select chemotherapies. It contributes to suboptimal chemotherapy dosing, and its symptoms negatively impact patients’ quality of life. To date, interventions to effectively prevent this toxicity have not been established, and interventions to treat CIPN have produced only modest results. The purpose of this integrative review is to examine the impact of regional cooling applied to distal extremities on the severity of CIPN. A literature review was performed using SCOPUS and PubMed databases. The search was not restricted by date but was restricted to English language. Forty-two articles were identified in the search, and six were included in the review after applying inclusion and exclusion criteria. Results related to protective effects from peripheral cooling against CIPN were variable. Four out of six studies demonstrated benefit of peripheral cooling in reducing the severity of CIPN. There was evidence to suggest that applying a relatively greater degree of cooling compared with a lesser degree may confer benefit in reducing the severity of CIPN. Both direct application of cooling and use of compression to achieve fingertip cooling showed potential benefit.

Falls in older adults with cancer: an updated systematic review of prevalence, injurious falls, and impact on cancer treatment

PURPOSE

This update of our 2016 systematic review answers the following questions: (1) How often do older adults with cancer fall? (2) What are the predictors for falls? (3) What are the rates and predictors of injurious falls? (4) What are the circumstances and outcomes of falls? (5) How do falls in older patients affect subsequent cancer treatment? and a new research question, (6) Which fall reduction interventions are efficacious in this population?

METHODS

MEDLINE, PubMed, CINAHL, and Embase were searched (September 2015-January 25, 2019). Eligible studies included clinical trials and cohort, case-control, and cross-sectional studies published in English in which the sample (or subgroup) included adults aged ≥ 60, with cancer, in whom falls were examined as an outcome.

RESULTS

A total of 2521 titles were reviewed, 67 full-text articles were screened for eligibility, and 30 new studies were identified. The majority involved the outpatient setting (n = 19) utilizing cross-sectional method (n = 18). Sample size ranged from 21 to 17,958. Fall rates ranged from 1.52 to 3.41% per 1000 patient days (inpatient setting) and from 39%/24 months to 64%/12 months (outpatient setting). One out of the 6 research questions contributed to a new finding: one study reported that 1 in 20 older patients experienced impact on cancer treatment due to falls. No consistent predictors for falls/fall injuries and no studies on fall reduction interventions in the geriatric oncology setting were identified.

CONCLUSION

This updated review highlights a new gap in knowledge pertaining to interventions to prevent falls. Additionally, new knowledge also emerged in terms of impact of falls on cancer treatment; however, further research may increase generalizability. Falls and fall-related injuries are common in older adults with cancer and may affect subsequent cancer treatment. Further studies on predictors of falls, subsequent impacts, and fall reduction in the oncology setting are warranted.

Falls: descriptive rates and circumstances in age-unspecified patients with locally advanced esophageal cancer

PURPOSE

Falls can occur in older cancer patients, but few studies have examined falls in an age-unspecified group of patients with locally advanced esophageal cancer. Because these patients are often administered neuropathy-inducing agents, are weak, and can develop orthostatic symptoms, examining falls appears relevant.

METHODS

Electronic medical records were used to examine falls and their circumstances in locally advanced esophageal cancer patients treated with chemotherapy and radiation and often surgery.

RESULTS

Among 300 patients, 62 (21%) suffered a fall, yielding 6 falls per 100 patient years. The median age at first fall was 64 years (range 31 to 83). The median time from cancer diagnosis to first fall was 11 months (range 0 to 107). Forty-two patients (68%) who fell had active cancer; 20 (32%) were cancer-free. Fall-related injuries occurred in 42 patients and included fractures, hematomas, and other musculoskeletal events. Eighteen patients (29%) fell repeatedly. Neuropathy, general weakness, and orthostatic symptoms were associated with falls ("He does state his neuropathy is more bothersome…. He did have a fall last week…." "He has been increasingly weak to the point where he fell down last week…." "Upon rising… [he] felt like somebody had put a sheet over his eyes, felt very lightheaded, and fell to the floor…."). At times, falls occurred under commonplace circumstances, such as slipping on ice or tripping on an underfoot pet.

CONCLUSION

Regardless of patient age, clinicians should remain vigilant for fall risk in adult patients with locally advanced esophageal cancer.

Falls and Cancer

Falls among older people are common and are associated with substantial morbidity, mortality and healthcare costs. Increasingly cancer is becoming a disease of older people and fall rates are higher in elders living with cancer. Cancer and its treatments potentiate important risk factors for falls, including muscle weakness, poor balance, proprioception, cognitive impairment and functional disability. Sarcopenia refers to the progressive deterioration in muscle strength, mass and quality with ageing. Chronic conditions and cancer amplify this decline and are associated with a greater negative effect on function. Age-related impairments of lower limb neurological function are commonly exacerbated by neurotoxic chemotherapy, resulting in gait and balance deficits. Postural instability and falls erode confidence and result in a negative cycle of diminishing activity levels, further deconditioning and a higher risk of further falls. Cancer-related fatigue, sleep and mood disturbances compound this progressive frailty, further worsening treatment tolerance and outcomes. Cognitive impairment is a potent risk factor for falling and is frequently associated with gait abnormalities. The well-recognised effects of cancer treatment on working memory, attention, processing speed and executive function are often apparent (when their presence is sought) before treatment and may be as much the result of the cancer itself as they are 'chemo brain'. Structured exercise programmes focusing on progressively challenging strength and balance training are of proven benefit in falls prevention. Regular aerobic exercise accrues additional benefits in improved cardiorespiratory resilience and concomitant positive effects on treatment tolerance. Increased activity levels positively influence cognition, mood and foster an improved sense of well-being. Simple, practicable clinic-based tests of physical functioning, cognition and neurological function can help to identify those at high risk of falls and functional decline. The use of such instruments can aid judicious treatment planning and identify those most likely to benefit from more detailed specialist comprehensive geriatric assessment.

Assessment of Fall-Related Self-Efficacy: Characteristics that Influence the Perception of Patients with Chemotherapy-Induced Peripheral Neuropathy

OBJECTIVE

The present study aims to describe fall-related self-efficacy as perceived by patients with chemotherapy-induced peripheral neuropathy (CIPN). The characteristics of patients associated with low perceived self-efficacy of preventing falls were investigated.

METHODS

A cross-sectional study of four hospitals in Japan. In this study, 100 outpatients who were receiving chemotherapy for cancer and experiencing CIPN were recruited. Participants completed an anonymous, self-administered questionnaire. Self-efficacy was measured with the falling self-efficacy (FSE) scale, and the severity and impact of CIPN was assessed with the Comprehensive Assessment Scale for CIPN in Survivors of Cancer (CAS-CIPN). Data about the demographic information of the patients, cancer diagnosis and treatment, pain and fatigue symptoms, and history of previous falls were collected. Logistic regression analysis was used to assess relationships between variables.

RESULTS

A total of 81 (81.0%) participants with CIPN completed the questionnaire. They reported experiencing fear of falling during their daily activities, which include the act of standing up, walking, and using the stairs. Small events, such as unstable postures and uncomfortable situations, affected their confidence of preventing falls. Logistic regression revealed that low FSE scores were significantly associated with female sex (P = 0.022), low body mass index (BMI; P = 0.026), and the CAS-CIPN score (P < 0.001).

CONCLUSIONS

Female patients with CIPN and low BMI might have an increased need for enhanced fall-related self-efficacy. A comprehensive assessment of CIPN in patients at risk of low FSE scores is likely to be beneficial.