Treatment and care of neurotoxicity from taxane anticancer agents

Chemotherapy dose reduction due to chemotherapy induced peripheral neuropathy in breast cancer patients receiving chemotherapy in the neoadjuvant or adjuvant settings: a single-center experience

Purpose

Taxanes are a cornerstone treatment in early and advanced stage breast cancer and in other common solid tumor malignancies; however, the development of chemotherapy induced peripheral neuropathy (CIPN) often necessitates dose-reduction, which may hamper the effectiveness of the drug and compromise survival outcomes especially when used in the adjuvant setting. Limited literature is available on the prevalence and severity of dose reduction due to CIPN. We sought to determine the frequency and severity of CIPN-induced dose reduction in early stage breast cancer patients who received taxane-based chemotherapy in the neoadjuvant or adjuvant settings.

Methods

We conducted a retrospective single-institution breast cancer clinic chart review of 123 newly diagnosed breast cancer patients and treated with taxane-based neoadjuvant/adjuvant chemotherapy at the University of Maryland Greenebaum Cancer Center between January 2008 and December 2011.

Results

Forty-nine of 123 (40%; 95% CI: 31-49%) patients required dose reduction. Twenty-one (17%; 95% CI: 11-25%) of these patients were dose-reduced specifically due to CIPN that developed during treatment. The median relative dose intensity (received dose/planned dose) for the 21 CIPN-induced dose reduction patients was 73.4% (range, 68.0-94.0%). Patients with diabetes appeared to have a higher risk of taxane-induced dose reduction (p-value=0.01). African-American patients and those treated with paclitaxel (rather than docetaxel) experienced a higher-risk of CIPN-induced dose reduction (p-values are <0.001 and 0.001, respectively).

Conclusions

The incidence of CIPN-associated dose reduction in our patient population was 17%. African-American patients, diabetics and subjects treated with paclitaxel had a higher risk for CIPN-associated dose reduction in our study.

Quality-of-life considerations with taxane-based therapy in metastatic breast cancer

As with many other types of chemotherapy, taxanes are associated with side effects that can affect patients' quality of life. One of the major side effects of taxane therapy is taxane-induced peripheral neuropathy (TIPN). The development of TIPN is accompanied by troublesome burning, tingling, and numbness; TIPN also can affect patient safety because of the decreased ability to perceive sensations (e.g., pain, heat). Pain and fatigue are common side effects of taxane therapy. These particular symptoms may hinder patients from working or performing daily activities, thus affecting quality of life. This case vignette provides an example of the symptoms that can accompany taxane therapy, including TIPN. The case vignette also demonstrates the long-lasting effects that TIPN can have on patients receiving taxane-based therapy, as well as the hindrance to the ability to work and perform daily activities because of numbness, pain, and fatigue. In addition, identification and management of taxane-related side effects are explored from the nursing perspective, and important aspects of patient education are discussed.

Proposed medications for taxane-induced myalgia and arthralgia (Review)

Taxanes inhibit the disassembly of microtubules, which are involved in mitosis and axoplasmatic transport, and may cause the degeneration of peripheral, mainly small, sensory nerves. Peripheral neurotoxicity is a dose-limiting side-effect of taxanes. Neuroprotective agents may aid in the reduction of neurotoxicity, thus allowing the intensification of cytostatic therapy in patients. An increasing number of medications for the prevention of taxane-induced arthralgia and myalgia are becoming available to oncology teams. The most widely studied medications include so-called analgesics such as Shakuyaku-kanzo-to (a herbal medicine), corticosteroids and antihistamines. Arthralgias and myalgias (muscle spasms, fasciculations and prolonged contractions) may be extremely distressing for patients. New anti-epileptic drugs, particularly gabapentin and pregabalin, have proven to be safe and effective in the treatment of taxane-induced neurotoxicity. The aim of this review was to examine the topical choices available for the protective management of taxane-induced neurotoxicity monitored in preliminary case studies and clinical trials. At present, there is no standard of care for the prevention of taxane-induced arthralgia and myalgia. In combination with taxane-based chemotherapeutic regimens, these medical agents may be crucial in the treatment of a variety of types of cancer.

Statistical identification of predictors for peripheral neuropathy associated with administration of bortezomib, taxanes, oxaliplatin or vincristine using ordered logistic regression analysis

Chemotherapy-induced peripheral neuropathy (CIPN) is a major drug-induced adverse reaction that becomes a dose-limiting toxicity. However, effective strategies for preventing or treating CIPN are lacking. Accordingly, this study aimed to statistically identify predictors for CIPN. Retrospective analysis was carried out for 190 patients who had been treated with bortezomib (n=28), taxanes (paclitaxel or docetaxel; n=58), oxaliplatin (n=52) or vincristine (n=52) at our hospital between April 2005 and December 2008. The severity of CIPN was assessed at the time of chemotherapy completion, graded as grade 0-5 in accordance with the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. Multivariate ordered logistic regression analysis was used to investigate predictors for CIPN. Predictors for CIPN in patients that were administered bortezomib were no co-administration of dexamethasone [odds ratio (OR), 0.455; confidence interval (CI), 0.208-0.955; P=0.0376] and sex (male) (OR, 3.035; CI, 1.356-6.793; P=0.0069). For taxanes (paclitaxel or docetaxel), the predictor for CIPN was a large number of chemotherapy cycles (OR, 2.379; CI, 1.035-5.466; P=0.0412). For oxaliplatin, the predictors for CIPN were a large number of chemotherapy cycles (OR, 3.089; CI, 1.598-5.972; P=0.0008) and no co-administration of non-steroidal anti-inflammatory drugs (OR, 0.393; CI, 0.197-0.785; P=0.0082). For vincristine, predictors for CIPN were a large number of chemotherapy cycles (OR, 6.015; CI, 1.880-19.248; P=0.0025) and co-administration of an analgesic adjuvant (OR, 3.907; CI, 1.383-11.031; P=0.0101). In conclusion, our study indicates that CIPN will be alleviated by the co-administration of dexamethasone with bortezomib and non-steroidal anti-inflammatory drugs with oxaliplatin.

Melatonin, a promising role in taxane-related neuropathy

Purpose:

Melatonin has neuroprotective effects in animal studies and has been suggested to decrease adverse reactions of chemotherapy including neuropathy. This pilot trial aimed at assessing whether melatonin, given during taxane chemotherapy for breast cancer, will decrease the incidence and/or severity of neuropathy.

Methods:

Twenty two consecutive patients beginning chemotherapy for breast cancer with paclitaxel, or docetaxel were enrolled. Patients received melatonin 21 mg daily at bedtime. Incidence and severity of neuropathy were assessed using neurological examinations, toxicity assessment per NCI-CTC 3.0 scale and FACT-Taxane quality of life questionnaire.

Results:

Neuropathy was seen in 45% (n = 10) of patients, 23% (n = 6) grade 1 and 22% (n = 5) Grade 2 neuropathy. No grade 3 neuropathies were reported. The majority (55%) of all patients reported no neuropathy. Compliance with melatonin (>60% of dose) was seen in most patients (86%) No patient reported daytime sedation. The median FACT-Taxane quality of life end of study score was 137, with only a 0.5 median decline from baseline.

Conclusion:

Patients receiving melatonin during taxane chemotherapy had a reduced incidence of neuropathy. Melatonin may be useful in the prevention or reduction of taxane-induced neuropathy and in maintaining quality of life. Larger trials are warranted to further explore the role of melatonin in neuropathy treatment and prevention.

Prospective assessment of chemotherapy-induced peripheral neuropathy due to weekly paclitaxel in patients with advanced or metastatic breast cancer (CSP-HOR 02 study)

GOALS OF WORK

The aim of this study was to prospectively evaluate chemotherapy-induced peripheral neuropathy (CIPN) using a patient-based instrument, the Patient Neurotoxicity Questionnaire (PNQ) and a physician-based instrument, the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) in patients with advanced or metastatic breast cancer who were treated with weekly paclitaxel.

MATERIALS AND METHODS

CIPN symptoms were prospectively assessed in 35 patients using the PNQ, NCI-CTC, and the Functional Assessment of Cancer Therapy (FACT)-Taxane including neurotoxicity component (Ntx) at the baseline, and 8 and 16 weeks after starting chemotherapy.

RESULTS

For sensory neuropathy symptoms, the reported incidence of CIPN was significantly increased during active treatment in terms of both the PNQ and NCI-CTC assessments. In contrast, there was a notable increase of patient motor neuropathy symptoms that were elucidated only by the PNQ. The PNQ grades of CIPN were widely distributed in the patient population as compared with the NCI-CTC grades for both sensory and motor neuropathy. The sensory PNQ grade was correlated with sensory NCI-CTC grade (r = 0.58) and Ntx (r = 0.51), and the motor PNQ grade was correlated with Ntx (r = 0.57).

CONCLUSIONS

The PNQ appears to be more sensitive and responsive than the NCI-CTC for CIPN; the PNQ appears to have diagnostic validity for evaluating CIPN in patients who are receiving neurotoxic chemotherapy.

Rehabilitation in Women with Breast Cancer

The diagnosis and treatment of breast cancer in women has undergone profound changes in the past century. Although much research and clinical attention has been focused on saving the lives of women with this condition, less focus has been on rehabilitation aspects. This postacute care should be a distinct phase of treatment. The field of physical medicine and rehabilitation has much to offer women who undergo extremely toxic although life-prolonging therapies for breast cancer. The focus of rehabilitation should include improving strength and cardiovascular conditioning, alleviating pain and improving fatigue. With respect to exercise, this can help women to physically recover from treatment and potentially prevent cancer recurrence. Many exciting opportunities will be available for rehabilitation specialists to improve the care of women with breast cancer and to participate in research in the field of oncology rehabilitation.

Diagnosis, management, and evaluation of chemotherapy-induced peripheral neuropathy

Peripheral neuropathy induced by cancer chemotherapy represents a large unmet need for patients due to the absence of treatment that can prevent or mitigate this common clinical problem. Chemotherapy-induced peripheral neuropathy (CIPN) diagnosis and management is further compounded by the lack of reliable and standardized means to diagnose and monitor patients who are at risk for, or who are symptomatic from, this complication of treatment. The pathogenesis and pathophysiology of CIPN are not fully elucidated, but there is increasing evidence of damage or interference with tubulin function. The diagnosis of CIPN may present a diagnostic dilemma due to the large number of potential toxic etiologies and conditions, which may mimic some of the clinical features; the diagnosis must be approached with care in such patients. The incidence and severity of CIPN is commonly under-reported by physicians as compared with patients. The development of new and reliable methods for the assessment of CIPN as well as safe and effective treatments to prevent this complication of treatment would represent important medical advancements for cancer patients.