Delayed oxaliplatin-associated neurotoxicity following adjuvant chemotherapy for stage III colon cancer

Oxaliplatin-associated shock in stage III colorectal cancer patients: real-world evidence in Taiwan

Background

Oxaliplatin-associated shock (referred to as shock) is a rare but life-threatening adverse event.

Objectives

This pioneering cohort study aimed to quantitatively investigate the association between oxaliplatin use and shock in patients with stage III colorectal cancer (CRC), identify potential independent risk factors for shock, and assess the cycle-to-shock during oxaliplatin treatment.

Design

The study utilized a nested case-control (NCC) design to assess the association between oxaliplatin and shock and employed a case-crossover approach to address unmeasured confounders.

Methods

All newly diagnosed stage III CRC patients were identified from the CRC Health Database (2012-2016). Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CIs) for oxaliplatin's link to shock incidence.

Results

Among 6932 oxaliplatin recipients, 331 suffered shock. In all, 3309 controls were selected via risk-set sampling for the shock cases. Oxaliplatin use is associated with a doubled risk of shock (adjusted OR: 2.08, 95% CI: 1.23-3.52). Two independent risk factors were male sex (adjusted OR: 1.33, 95% CI: 1.05-1.69) and heart diseases (adjusted OR: 1.65, 95% CI: 1.17-2.32). The case-crossover analysis revealed a more than fourfold risk (OR: 4.4, 95% CI: 1.67-11.62). In total, 22 of 331 shock cases were exposed to oxaliplatin within 2 days of shock onset, with a median cycle-to-shock time at the seventh cycle.

Conclusion

Oxaliplatin use significantly increased shock risk in stage III CRC patients. Male sex and heart disease are two independent risk factors.

Delayed Oxaliplatin-Related Severe Neurotoxicity in Metastatic Colorectal Cancer: A Case Report

In patients receiving oxaliplatin-based chemotherapy, resulting in frequent peripheral neuropathy and requiring long-term management, anticancer drug-induced platinum-based peripheral neuropathy (mixed motor, sensory, and autonomic neuropathy) can result in the coasting phenomenon in which the symptoms worsen temporarily after two to three weeks, even after the cessation of the drug. The coasting phenomenon is difficult to manage due to the unpredictable nature of the symptoms. We encountered a patient with grade 3 peripheral neuropathy that developed rapidly in the second cycle after the treatment to switch from mFOLFOX6/bevacizumab to FOLFIRI/aflibercept. Supportive care with duloxetine was unsuccessful in this patient. Herein, we report the case.

DPYD and TYMS polymorphisms as predictors of 5 fluorouracil toxicity in colorectal cancer patients

Colorectal cancer (CRC) is the third most common cancer and the fourth leading cause of cancer death. 5-Fluorouracil (5-FU) is an essential component of systemic chemotherapy for CRC. Our objective was to determine the genotypic frequency of polymorphisms affecting dihydropyrimidine dehydrogenase (DPYD) and thymidylate synthetase (TYMS) genes and to correlate the genetic profile with the toxicity due to 5-FU, also considering nongenetic factors. This is a prospective study that involved 66 patients. We extracted DNA by salting out methods. We carried out the genotyping of the different polymorphisms by simple PCR for the TYMS 5'UTR and by PCR-RFLP for DPYD: 1905 + 1 G > A, 85 T > C, 496 A > G, 1679 T > G, c.483 + 18G > A and the TYMS: 5'UTR VNTR, 5'UTR G > C and 3'UTR. The study of the association of DPYD and TYMS polymorphisms with the various signs of toxicity under 5-FU revealed that the polymorphisms 496 A > G were significantly associated with hepatotoxicity: OR = 3.85 (p = 0.04). In addition, 85 T > C was significantly associated with mucositis and neurotoxicity: OR = 4.35 (p = 0.03), OR = 3.79 (p = 0.02). For TYMS, the only significant association we observed for 5'UTR with vomiting: OR = 3.34 (p = 0.04). The incidence of adverse reactions related to 5-FU appears to be influenced in patients with CRC by the identified DPYD and TYMS gene polymorphisms in the Tunisian population.

Oral administration of Cystine and Theanine ameliorates oxaliplatin-induced chronic peripheral neuropathy in rodents

Oxaliplatin frequently causes severe peripheral neuropathy as a dose-limiting toxicity. However, this toxicity lacks a strategy for prevention. Cystine/Theanine is a supplement, which includes precursors for the biosynthesis of glutathione. In this study, we investigated the effects of Cystine/Theanine on oxaliplatin-induced peripheral neuropathy using an in vivo model. Repeated injection of oxaliplatin (4 mg/kg intraperitoneally twice a week for 2 weeks) caused mechanical allodynia, cold hyperalgesia and axonal degeneration of the sciatic nerve in rats. Mechanical allodynia and axonal degeneration, but not cold hyperalgesia, were ameliorated by daily co-administration of Cystine [200 mg/kg orally (p.o.)] and Theanine (80 mg/kg p.o.). Moreover, co-administration of Cystine and Theanine to rats significantly increased the glutathione level in the sciatic nerve compared with the oxaliplatin group. Furthermore, Cystine and Theanine did not attenuate the tumour cytotoxicity of oxaliplatin in C-26 tumour cell-bearing mice. These findings suggest that Cystine and Theanine may be beneficial for preventing oxaliplatin-induced peripheral neuropathy.

Cisplatin-associated neuropathy characteristics compared with those associated with other neurotoxic chemotherapy agents (Alliance A151724)

PURPOSE

The current project was developed to obtain natural history information regarding cisplatin-induced peripheral neuropathy in males with testicular/germ cell cancers and to compare such neuropathy data with similarly obtained data in patients receiving other chemotherapy drugs in similarly conducted clinical trials.

METHODS

Patients without baseline neuropathy symptoms, who were initiating cisplatin-based chemotherapy, completed the EORTC CIPN 20 patient-reported instrument to evaluate chemotherapy-induced peripheral neuropathy (CIPN). Results were compared with EORTC CIPN 20 data obtained from independent study sets regarding patients receiving (1) paclitaxel, (2) combined paclitaxel and carboplatin, (3) oxaliplatin, or (4) a combination of doxorubicin and cyclophosphamide (AC). The last study set of patients on AC was selected to evaluate the use of EORTC CIPN 20 data in patients receiving chemotherapy not known to cause CIPN.

RESULTS

Cisplatin-induced neuropathy was more similar to neuropathy in patients receiving oxaliplatin than in those receiving paclitaxel. The cisplatin and oxaliplatin groups exhibited the coasting phenomenon and more prominent upper extremity symptoms than lower extremity symptoms during chemotherapy administration weeks. In contrast, paclitaxel-treated patients did not, on average, exhibit the coasting phenomenon; additionally, lower extremity symptoms were more prominent during the weeks when paclitaxel was administered. Cisplatin-induced neuropathy was less severe than was seen in patients in the other two groups, potentially because the cisplatin-receiving patients were younger. Patients receiving AC did not report substantial EORTC CIPN 20 changes.

CONCLUSION

Understanding neuropathy similarities and differences with various chemotherapy agents may help elucidate CIPN processes and facilitate means to prevent and/or treat established CIPN.

TRIAL REGISTRATION

NCT02677727.

Clinical Course of Oxaliplatin-Induced Neuropathy: Results From the Randomized Phase III Trial N08CB (Alliance)

PURPOSE

Given that the clinical course of oxaliplatin-induced neuropathy is not well defined, the current study was performed to better understand clinical parameters associated with its presentation.

METHODS

Acute and chronic neuropathy was evaluated in patients receiving adjuvant FOLFOX (fluorouracil, leucovorin, and oxaliplatin) on study N08CB (North Central Cancer Treatment Group, Alliance). Acute neuropathy was assessed by having patients complete daily questionnaires for 6 days with each cycle of FOLFOX. Before each dose of FOLFOX and as long as 18 months after chemotherapy cessation, chronic neurotoxicity was assessed with use of the 20-item, European Organisation for Research and Treatment of Cancer quality-of-life questionnaire for patients with chemotherapy-induced peripheral neuropathy.

RESULTS

Three hundred eight (89%) of the 346 patients had at least one symptom of acute neuropathy with the first cycle of FOLFOX; these symptoms included sensitivity to touching cold items (71%), sensitivity to swallowing cold items (71%), throat discomfort (63%), or muscle cramps (42%). Acute symptoms peaked at day 3 and improved, although they did not always resolve completely between treatments. These symptoms were about twice as severe in cycles 2 through 12 as they were in cycle 1. For chronic neurotoxicity, tingling was the most severe symptom, followed by numbness and then pain. During chemotherapy, symptoms in the hands were more prominent than they were in the feet; by 18 months, symptoms were more severe in the feet than they were in the hands. Patients with more severe acute neuropathy during the first cycle of therapy experienced more chronic sensory neurotoxicity (P < .0001).

CONCLUSION

Acute oxaliplatin-induced neuropathy symptoms do not always completely resolve between treatment cycles and are only half as severe on the first cycle as compared with subsequent cycles. There is a correlation between the severities of acute and chronic neuropathies.

Self-management of oxaliplatin-related peripheral neuropathy in colorectal cancer survivors

Purpose. The purpose of this study was to evaluate medications that cancer survivors with oxaliplatin-induced peripheral neuropathy take to control neuropathic symptom, and to explore self-management techniques used at home to provide temporary relief of painful neuropathy. This was a mixed methods, descriptive, cross-sectional study using self-reported data from colorectal cancer survivors previously treated with oxaliplatin. We analyzed demographic and medication data obtained from participants, along with written comments from an open-ended question regarding methods participants had tried to self-manage symptoms of neuropathy. Results. Twenty-nine percent of the sample reported taking some type of nutritional supplement with potential neuroprotective qualities. Opioids were being taken by 10% of the sample, and nonsteroidal anti-inflammatory and over-the-counter medications were taken by 15% of participants. Twelve percent of participants were taking antidepressants and 10% were taking anticonvulsants, primarily gabapentin. Recurrent themes for nonpharmacologic treatment included avoiding the cold/keeping warm, keeping moving, massaging or rubbing the affected area, and living with it. Conclusions. Patients treated with oxaliplatin for colorectal cancer utilize a variety of traditional pharmacologic agents and nutritional supplements in an effort to self-manage neuropathic symptoms. Patients also employ a variety of home-based therapies to provide temporary relief of peripheral neuropathy symptoms.

Oxaliplatin-induced peripheral neuropathy's effects on health-related quality of life of colorectal cancer survivors

Oxaliplatin is a highly neurotoxic chemotherapeutic agent routinely used for the treatment of colorectal cancer. Recent data suggest that oxaliplatin-induced peripheral neuropathy may be long-lasting; however, the effects of persistent neuropathy on colorectal cancer survivors' physical and emotional well-being are not well understood. This cross sectional, descriptive study included persons who had received oxaliplatin-based chemotherapy for treatment of colorectal cancer at Moffitt Cancer Center between 2003 and 2010. Questionnaires including the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool, Center for Epidemiological Studies Depression Scale (CES-D), Insomnia Severity Index, Medical Outcomes Study Short Form 36, and a demographic survey were administered. Pearson's correlations and linear regression analyses were used to examine relationships between neuropathy and depressive symptoms, sleep quality, and health-related quality of life (HRQOL). Eighty-nine percent of participants reported at least one symptom of peripheral neuropathy with a mean of 3.8 (±2.4) neuropathic symptoms. Depressive symptoms on the CES-D were significantly associated with more severe peripheral neuropathy(r = 0.38, p = 0.0001) and interference with activities (r = 0.59, p < 0.0001). Higher degrees of sleep disturbance on the Insomnia Severity Index (ISI) were significantly associated with more severe peripheral neuropathy (r = 0.35, p = 0.0004) and interference with activities(r = 0.52, p < 0.0001). HRQOL was significantly associated with peripheral neuropathy and interference with activities.

Development and psychometric evaluation of the chemotherapy-induced peripheral neuropathy assessment tool

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) can be a debilitating and dose-limiting adverse effect of chemotherapy. Comprehensive self-report tools for CIPN are needed for research and clinical practice.

OBJECTIVE

The purpose of this psychometric study was to describe the development and evaluate the reliability and validity of a new self-report tool designed to measure CIPN, the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool (CIPNAT).

METHODS

One hundred sixty-seven patients receiving outpatient chemotherapy with paclitaxel, docetaxel, cisplatin, or oxaliplatin completed the CIPNAT. Content validity, convergent validity, discriminant validity, test-retest reliability, and internal consistency reliability were assessed.

RESULTS

Content validity index was very acceptable at 0.95. Convergent validity data were provided by correlation with a measure of the same concept (r = 0.83, P < .001), and differences between contrasting groups (t = 7.66, P < .001) provided evidence of discriminant validity. High test-retest correlations (r = 0.92, P < .001), Cronbach α (α = .95), and significant item-to-total correlations ranging from 0.38 to 0.70 provided evidence of reliability.

CONCLUSIONS

Results provide evidence of the validity and reliability of the CIPNAT, which can be used for comprehensive assessment of CIPN.

IMPLICATIONS FOR PRACTICE

Use of the CIPNAT in research may lead to a better understanding of CIPN and guide nurses in developing and testing of interventions to relieve suffering and enhance quality of life for patients with CIPN.

Discrepancy between the NCI-CTCAE and DEB-NTC scales in the evaluation of oxaliplatin-related neurotoxicity in patients with metastatic colorectal cancer

BACKGROUND

Several oxaliplatin-specific scales have been proposed in clinical practice to evaluate oxaliplatin-related neurotoxicity. We investigated whether there might be a discrepancy between the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) and the Neurotoxicity Criteria of Debiopharm (DEB-NTC), the commonly used oxaliplatin-specific scales, in the evaluation of peripheral neurotoxicity.

PATIENTS AND METHODS

The subjects were 42 patients with metastatic colorectal cancer who received more than 6 cycles of first-line therapy with modified FOLFOX6 and more than 6 cycles of second-line therapy with FOLFIRI. The median number and cumulative dose of oxaliplatin administrations were 10.5 (range 6-22) and 889.4 mg/m(2) (range 484.5-1875.0 mg/m(2)), respectively. The peripheral neurotoxicity was evaluated during mFOLFOX6 therapy and after its discontinuation using NCI-CTCAE ver. 3.0 and DEB-NTC. Data were collected prospectively and analyzed retrospectively.

RESULTS

The concordance rate of the peripheral neurotoxicity grade determined by these criteria was low: 48.8% during mFOLFOX6 and 47.3% after discontinuation of therapy. The cumulative dose of oxaliplatin-related peripheral neurotoxicity in 50% of the patients was lower when evaluated by DEB-NTC for both grades 1 (P = 0.09) and 2 (P < 0.001). The cumulative rate of improvement from grade 2 to 1 (P < 0.001) and from grade 2 to 0 (P < 0.05) after discontinuation of mFOLFOX6 therapy was higher when NCI-CTCAE was used for the evaluation.

CONCLUSION

We found a discrepancy between the NCI-CTCAE and DEB-NTC scales in the evaluation of oxaliplatin-related neurotoxicity and suggest that the concomitant use of NCI-CTCAE and DEB-NTC would be useful to maintain oxaliplatin-based chemotherapy at higher quality.

Peripheral neuropathy in patients with colorectal cancer receiving oxaliplatin

Neuropathic side effects are commonly reported in patients receiving oxaliplatin, but little is known about the characteristics of peripheral neuropathy in this patient population. The purpose of this descriptive study was to explore the prevalence of neuropathic symptoms in patients with colorectal cancer receiving oxaliplatin as well as to explore symptom severity, distress, frequency, and neuropathic interference with activities. Thirty-three patients receiving oxaliplatin at two outpatient facilities completed the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool. Data were analyzed using descriptive statistics. Cold sensitivity, tingling in the hands, and numbness in the hands were the most prevalent neuropathic symptoms, and cold sensitivity, nerve pain, and trouble with balance were the most severe symptoms. Trouble with balance, muscle or joint aches, and neuropathic pain were the most distressing symptoms, and numbness in the fingers and hands and in the toes and feet were the most frequent symptoms. Patients reported that neuropathic symptoms interfered with numerous activities. Oncology nurses can use this information to help educate patients and families about potential side effects of oxaliplatin and to coordinate the care of patients with peripheral neuropathy using a symptom-focused, multidisciplinary approach.

Surviving chemotherapy for colon cancer and living with the consequences

BACKGROUND

This article discusses peripheral neuropathy as a long-term side effect of oxaliplatin based chemotherapy, from a colon cancer survivor's perspective. Peripheral neuropathy is a common side effect of chemotherapy that affects quality of life for many cancer survivors. Severe and debilitating neuropathy negatively impacts both physical and emotional well-being.

DISCUSSION

A better understanding of what cancer survivors with peripheral neuropathy experience is essential for health care professionals. More emphasis on symptom management and development of evidence based interventions will help improve quality of life for those who are affected by chemotherapy induced peripheral neuropathy.

The Value of Dihydrouracil/Uracil Plasma Ratios in Predicting 5-Fluorouracil-Related Toxicity in Colorectal Cancer Patients

This study investigated the relationship between the dihydrouracil/uracil (UH2/U) plasma ratio, a surrogate marker of dihydropyrimidine dehydrogenase (DPD) activity, and 5-fluorouracil (5-FU)-related early toxicity. Plasma UH2/U ratios were determined in 68 colorectal cancer patients and 100 healthy controls. A cutoff value indicative of DPD deficiency was calculated using receiver operator characteristics. Patients experiencing toxicity were screened for the DPD G-to-A point mutation within the 5′-splicing donor site of intron 14 (IVS14+1G>A). Overall, 24/68 patients (35%) experienced toxicity (all grades) and abnormal UH2/U ratios were demonstrated in 21/24 (87.5%) patients. Drug concentrations up to 130 times the recommended level were found in 13/24 (54%) patients experiencing toxicity. One patient experiencing toxicity was a heterozygous carrier of the IVS14+1G>A mutation. A low UH2/U plasma ratio had a sensitivity of 0.87 and specificity of 0.93 for predicting 5-FU-induced toxicity. Systematic detection of DPD-deficient patients using the UH2/U ratio could optimize 5-FU-based chemotherapy and minimize life-threatening toxicity.

Variants in the Dihydropyrimidine Dehydrogenase, Methylenetetrahydrofolate Reductase and Thymidylate Synthase Genes Predict Early Toxicity of 5-Fluorouracil in Colorectal Cancer Patients

Adverse drug reactions to 5-fluorouracil (5-FU)-based chemotherapy have been reported to be due, in part, to genetic variants of the genes for the drug-related enzymes thymidylate synthase (TS; TYMS gene), methylenetetrahydrofolate reductase ( MTHFR gene) and dihydropyrimidine dehydrogenase (DPD; DPYD gene). This study investigated whether selected genetic variants of the TYMS, MTHFR and DPYD genes predict 5-FU-related early toxicity. The prevalence of the genetic variants was determined in 122 colorectal cancer patients and in a reference population of 320 blood donors. Subgroup analysis of 68 of the colorectal cancer patients was carried out to determine the relationship between selected gene variants detected in peripheral mononuclear cells and tolerability during the first or second cycle of 5-FU based treatment. Toxicity was linked to the TYMS 2R/2R variant (relative risk [RR] 1.66; sensitivity 0.37; specificity 0.77) and to the MTHFR c1298 C/C genetic variant (RR 1.77; sensitivity 0.17; specificity 0.91). Patients with the genetic variant IVS14+1 G/A or c1896 C/T in the DPYD gene had a statistically significant increased risk of experiencing toxicity (RR 2 and 6, respectively), both having a high specificity (0.97 and 0.98, respectively) and low sensitivity (0.04 and 0.13, respectively). It is concluded that pre-treatment detection of genetic variants can help to predict early toxicity experienced by patients receiving 5-FU-based chemotherapy.

Patients' Perceptions of Physician-Patient Discussions and Adverse Events with Cancer Therapy

Objectives

Patients with cancer who are treated with chemotherapy report adverse events during their treatment, which can affect their quality of life and increase the likelihood that their treatment will not be completed. In this study, patients' perceptions of the physician-patient relationship and communication about cancer-related issues, particularly adverse events were examined.

Methods

We surveyed 508 patients with cancer concerning the occurrence of adverse events and their relationship and communication with their physicians regarding cancer, treatment, and adverse events.

Results

Most individuals surveyed (>90%) discussed diagnosis, treatment plan, goals, and schedule, and potential adverse events with their physicians before initiating chemotherapy; approximately 75% of these individuals understood these topics completely or very well. Physician-patient discussions of adverse events were common, with tiredness, nausea and vomiting, and loss of appetite discussed prior to chemotherapy in over 80% of communications. These events were also the most often experienced (ranging in 95% to 64% of the respondents) along with low white blood cell counts (WBCs), which were experienced in 67% of respondents. Approximately 75% of the individuals reported that their overall quality of life was affected by adverse events.

Conclusions

These findings suggest that discussions alone do not provide patients with sufficient understanding of the events, nor do they appear to adequately equip patients to cope with them. Therefore, efforts to improve cancer care should focus on developing tools to improve patients' understanding of the toxicities of chemotherapy, as well as providing resources to reduce the effects of adverse events.

A review on oxaliplatin-induced peripheral nerve damage

Platinum compounds are a class of chemotherapy agents that posses a broad spectrum of activity against several solid malignancies. Oxaliplatin (OXL) is a third-generation organoplatinum compound with significant activity mainly against colorectal cancer (CRC). Peripheral neuropathy is a well recognized toxicity of OXL, usually resulting in dose modification. OXL induces two types of peripheral neuropathy; acute and chronic. The acute oxaliplatin-induced peripheral neuropathy (OXLIPN) may be linked to the rapid chelation of calcium by OXL-induced oxalate and OXL is capable of altering the voltage-gated sodium channels through a pathway involving calcium ions. On the other hand, decreased cellular metabolism and axoplasmatic transport resulting from the accumulation of OXL in the dorsal root ganglia cells is the most widely accepted mechanism of chronic oxaliplatin-induced peripheral neuropathy (OXLIPN). As a result, OXL produces a symmetric, axonal, sensory distal primary neuronopathy without motor involvement. The incidence of OXLIPN is usually related to various risk factors, including treatment schedule, dosage, cumulative dose and time of infusion. The assessment of OXLIPN is primarily based on neurologic clinical examination and quantitative methods, such as nerve conduction study. To date, several neuroprotective agents including thiols, neurotrophic factors, anticonvulsants and antioxidants have been tested for their ability to prevent OXLIPN. However, the clinical data are still controversial. We herein review and discuss the pathogenesis, incidence, risk factors, diagnosis, characteristics and management of OXLIPN. We also highlight areas of future research.