Chemotherapy-Induced Peripheral Neuropathy: Use of an Electronic Care Planning System to Improve Adherence to Recommended Assessment and Management Practices

Exploring Chemotherapy-Induced Peripheral Neuropathy Management Practice Patterns Among Oncology Clinicians

OBJECTIVES

Approximately 60% of cancer survivors receiving neurotoxic chemotherapy experience chemotherapy-induced peripheral neuropathy (CIPN) (eg, hand and foot numbness, tingling, or pain). There is only one recommended pharmacological treatment (duloxetine) and one modestly beneficial nonpharmacological treatment (exercise) for CIPN. However, data suggest national guideline recommendations are not routinely practiced. Further, less is known about nurses' CIPN management practices. The purpose of this convergent mixed methods study was to explore oncology clinicians' self-reported practices and perceptions regarding CIPN prevention and management.

METHODS

Oncology clinicians at three cancer centers completed a survey about their recommendations for CIPN prevention and management in practice. A subset of clinicians also participated in a semi-structured interview to explore their perspectives of and motivations for implementing CIPN assessment, prevention, and management in practice. Quantitative data were described (eg, frequency or median) and qualitative data were analyzed using inductive content analysis.

RESULTS

This study (N = 44 survey responses; n = 9 interviews) resulted in four themes: (1) clinicians primarily recommend gabapentin for CIPN management and often observe cryotherapy used for CIPN prevention, but these interventions are complicated by discomfort, intolerable side effects, and efficacy concerns; (2) clinicians perceive CIPN as troublesome and desire additional information and resources regarding CIPN prevention and management; (3) CIPN-related education provided by clinicians may be limited by patient retention of the amount of education received about cancer treatment and other factors; (4) clinicians use subjective CIPN assessment to screen at each visit for common CIPN symptoms (eg, numbness or tingling) and the impact of symptoms on day-to-day activities.

CONCLUSIONS

Discrepancies persist between evidence-based guidelines on CIPN management and current oncology clinician practices.

IMPLICATIONS FOR NURSING PRACTICE

Clinician involvement is needed when developing education and resources to help oncology clinicians provide the most evidence-based care to potentially prevent and manage their patients' CIPN.

Knowledge levels of oncology nurses regarding evidence-based practices in the assessment and management of chemotherapy-induced peripheral neuropathy

Objective

The study aimed to determine the level of oncology nurses' knowledge of evidence-based practice for assessing and managing chemotherapy-induced peripheral neuropathy (CIPN).

Methods

This study employed a descriptive and cross-sectional research design. It was carried out with oncology nurses who were working at a university hospital in the Western Region of Turkey and who were members of the Oncology Nursing Association. The sample of the study consisted of 96 nurses who met the inclusion criteria.

Results

The study sample comprised 94.8% female oncology nurses, 57.3% of whom held an undergraduate degree, and over half (58.5%) of whom were employed as clinical nurses. A majority of nurses (76.0%) indicated that they had not received any training in peripheral neuropathy. 35.4% of the nurses assessed patients receiving neurotoxic chemotherapy for peripheral neuropathy at each visit/each chemotherapy cycle. A total of 43.8% of nurses indicated that they frequently assessed patients for peripheral neuropathy at the conclusion of the treatment protocol. The oncology nurses assessed the patient-reported symptoms of motor neuropathy (58.3%), sensory neuropathy (56.3%), autonomic neuropathy (51.0%), neuropathic pain (55.2%), and co-occurring symptoms (52.1%) on a frequent basis. The nurses reported that they assessed muscle strength (56.3%), gait and balance (58.3%), and quality of life (52.1%) "frequently". In contrast, they assessed deep tendon reflex (41.7%), neurological tests (36.5%), and social activities (46.8%) "rarely".

Conclusions

The study findings indicated that oncology nurses require further education and training in evidence-based practices for the assessment and management of CIPN.

Exploring Patients' Understanding of Chemotherapy-Induced Peripheral Neuropathy

Little quantitative evidence exists surrounding patients' level of understanding of chemotherapy-induced peripheral neuropathy (CIPN) symptoms (numbness, tingling, pain in the hands/feet) and consequences (e.g., negatively affect physical functioning or chemotherapy dosing) at the beginning of chemotherapy. The purpose of this cross-sectional, secondary analysis was to describe CIPN knowledge and education patterns among adults early in a course of neurotoxic chemotherapy for the treatment of cancer (< three infusions). Following consent, participants completed an electronic questionnaire about their perceptions of CIPN symptoms, incidence, and education. Participants (N = 92) were mainly female (76%), white (91%), and diagnosed with breast (46%) or gastrointestinal (40%) cancers. Most participants without CIPN (n = 48) did not expect to develop CIPN (45%) or were unaware of CIPN as a side-effect (30%). Furthermore, 71% of participants without CIPN (n = 31) estimated CIPN to occur in ≤ 30% of patients receiving neurotoxic chemotherapy. Overall, participants learned about CIPN from their doctor or nurse prior to beginning chemotherapy (90%). Clinicians delivered education about CIPN symptoms (75%), but less frequently delivered education about CIPN management (14%), or the impact of CIPN on the ability to continue chemotherapy (16%) or physical functioning (24%). Finally, participants reported that a discussion with their doctor/nurse would be the best way to learn about CIPN (92%). Results revealed that participants without CIPN were largely unaware of the adverse consequences or incidence of CIPN during treatment. Further research is needed to investigate optimal methods to promote patient-clinician communication about CIPN during chemotherapy to enhance patients' retention of CIPN information and activation in their care.

Exploring Clinicians' Perspectives of Barriers to Chemotherapy-Induced Peripheral Neuropathy Assessment and Management in Oncology Practice: A Qualitative Analysis of Semi-structured Interviews

BACKGROUND

Quantitative reports suggest that the assessment and management of chemotherapy-induced peripheral neuropathy (CIPN) in practice is suboptimal.

OBJECTIVE

The purpose of this qualitative analysis was to explore clinician-related perspectives of CIPN assessment, management, and the use of a CIPN decision support tool.

METHODS

Clinicians from the breast oncology, gastrointestinal oncology, or multiple myeloma disease centers at Dana-Farber Cancer Institute who interacted with a CIPN clinician decision support algorithm were eligible to participate in the semi-structured interviews. The interview guide included questions about CIPN assessment, management, and clinician-decision support tool use. All interviews were audio-recorded, transcribed, and analyzed using inductive content analysis.

RESULTS

Of the 39 eligible clinicians, 15 agreed to be interviewed. Interviewed clinicians were mainly physicians (73.3) and White, non-Hispanic (93.3%). Main themes from the interviews included (1) CIPN management practice patterns (eg, endorsement of non-recommended management strategies or lack of standardization for chemotherapy dose reduction) and barriers (eg, insurance prior authorizations required for duloxetine prescription), (2) CIPN assessment practice patterns (eg, use of subjective instead of objective CIPN assessment approaches) and barriers (eg, difficult to interpret patients' CIPN report between visits), and (3) utilization of the clinician decision support tool (eg, all assessment tasks lead to same management options).

CONCLUSIONS

There are several barriers to clinicians' use of evidence-based CIPN assessment and management strategies.

IMPLICATIONS FOR PRACTICE

Future work should be focused on addressing barriers to duloxetine prescription, developing evidence-based CIPN assessment and management strategies, improving symptom monitoring, and facilitating referrals to existing supportive care services.

Correlates of Taxane-Induced Neuropathy, an Electronic Health Record Based Observational Study

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common therapeutic complication affecting cancer patients' quality-of-life. We evaluated clinical characteristics, demographics, and lifestyle factors in association with CIPN following taxane treatment.

METHODS

Data were extracted from the electronic health record of 3387 patients diagnosed with a primary cancer and receiving taxane (i.e., paclitaxel or docetaxel) at Vanderbilt University Medical Center. Neuropathy was assessed via a validated computer algorithm. Univariate and multivariate regression models were applied to evaluate odds ratios (ORs) and 95% confidence intervals (CIs) of CIPN-associated factors.

RESULTS

Female sex (OR = 1.28, 95% CI = 1.01-1.62), high body-mass index (BMI) (OR = 1.31, 95% CI = 1.06-1.61 for overweight, and OR = 1.49, 95% CI = 1.21-1.83 for obesity), diabetes (OR = 1.66, 95% CI = 1.34-2.06), high mean taxane dose (OR = 1.05, 95% CI = 1.03-1.08 per 10 mg/m2), and more treatment cycles (1.12, 95% CI = 1.10-1.14) were positively associated with CIPN. Concurrent chemotherapy (OR = 0.74, 95% CI = 0.58-0.94) and concurrent radiotherapy (OR = 0.77, 95% CI = 0.59-1.00) were inversely associated with CIPN. Obesity and diabetes both had a stronger association with docetaxel CIPN compared to paclitaxel, although interaction was only significant for diabetes and taxane (p = 0.019). Increased BMI was associated with CIPN only among non-diabetic patients (OR:1.34 for overweight and 1.68 for obesity), while diabetes increased CIPN risk across all BMI strata (ORs were 2.65, 2.41, and 2.15 for normal weight, overweight, and obese, respectively) compared to normal-weight non-diabetic patients (p for interaction = 0.039).

CONCLUSIONS

Female sex, obesity, and diabetes are significantly associated with taxine-induced CIPN. Further research is needed to identify clinical and pharmacologic strategies to prevent and mitigate CIPN in at-risk patient populations.

Self-Reported Severity, Characteristics, and Functional Limitations of Chemotherapy-Induced Peripheral Neuropathy

BACKGROUND

The early identification of chemotherapy-induced peripheral neuropathy (CIPN) (e.g., numbness or tingling in the fingers or toes) is important due to its frequency and the few effective treatment options available. The identification of common patient-reported CIPN characteristics and associated functional limitations may help to facilitate patient-clinician discussions of CIPN in practice.

AIMS

To quantify the severity, duration, location, characteristics, and associated functional limitations of chemotherapy-induced peripheral neuropathy (CIPN) in patients receiving neurotoxic chemotherapy.

DESIGN

Exploratory secondary analysis of a prospective, two-phase study SETTING: Breast, gastrointestinal, and multiple myeloma clinics at Dana-Farber Cancer Institute.

PARTICIPANTS

142 individuals who planned to receive at least three more cycles of neurotoxic chemotherapy after consent.

METHODS

Participants self-reported CIPN using standardized measures (i.e., PRO-CTCAE™ Numbness and Tingling Items or 0-10 numerical rating scale of worst CIPN pain intensity) and/or study team generated follow up questions about CIPN location, duration, characteristics, and functional limitations prior to three consecutive clinic visits (T1, T2, T3). Participants' responses to the CIPN self-report questionnaires were described by chemotherapy type and age.

RESULTS

Over approximately 36.5 days (T1-T3), the percentage of participants reporting at least mild CIPN increased from 59.3% to 71%. At T3, patients with non-painful (n = 98) or painful neuropathy (n = 34) frequently reported symptoms in the fingers (non-painful = 83.5%, painful = 76.5%) or toes (non-painful = 49.5%, painful = 41.2%) and characterized symptoms as numbness (non-painful = 54.1%, painful = 50%) or tingling (non-painful = 68.4%, painful = 82.4%). Self-reported CIPN functional limitations (n = 55) included difficulties with buttoning a shirt (38.2%) or walking (25.5%). Paclitaxel-related CIPN (n = 33) was frequently characterized as "continuous" (30.3%), whereas oxaliplatin-related CIPN (n = 51) was frequently characterized as "intermittent" (41.2%). Young adults (15-39 years old, n = 15) frequently reported moderate-severe non-painful CIPN (46.7%), painful CIPN (40%), and CIPN interference (33.3%).

CONCLUSIONS

Consistent with qualitative research, participants frequently described CIPN as numbness and/or tingling in the fingers and/or toes.

Measurement properties of brief neuropathy screening items in cancer patients receiving taxanes, platinums, or proteasome inhibitors

BACKGROUND

Timely detection of chemotherapy-induced peripheral neuropathy (CIPN) is critical to effectively tailor chemotherapy dose levels and offer supportive care. The purpose of this secondary analysis was to determine the reliability and validity of the two Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™) numbness and tingling severity and interference items to screen for CIPN in patients receiving taxanes, platinums, or proteasome inhibitors.

METHODS

Participants (N = 142) completed the two PRO-CTCAE items, a 0-10 numerical rating scale of worst CIPN pain intensity, and the Quality of Life Questionnaire-CIPN20 (QLQ-CIPN20) prior to three clinical visits (T1, T2, T3) during neurotoxic chemotherapy. Participants completed the two PRO-CTCAE items again following the T3 clinical visit (T4). In addition, study staff administered the modified Total Neuropathy Score-Clinical Version (TNSc©) at T3. We examined floor (i.e., no CIPN severity or interference) and ceiling effects, test-retest reliability, concurrent validity, longitudinal validity, construct validity of the response categories, and sensitivity and specificity of the two PRO-CTCAE items.

RESULTS

At T3, 29% of participants had PRO-CTCAE severity scores at the floor; 60.1% of participants reported interference item scores at the floor. Agreements between scores reported at T3 and T4 for PRO-CTCAE severity (ICC = 0.79) and interference (ICC = 0.73) were moderate to strong. The PRO-CTCAE severity and interference items correlated moderately-strongly with QLQ-CIPN20 sensory (Spearman's ρ-range = 0.53-0.72) and motor (Spearman's ρ-range = 0.50-0.58) subscale scores. The Cohen's d from T1 to T3 for the PRO-CTCAE items were small (severity: d = 0.32, interference: d = 0.40) and comparable to the effect sizes for change observed with the QLQ-CIPN20. The PRO-CTCAE severity (0-3) and interference (0-2) response categories distinguished respondents with significantly different levels of QLQ-CIPN20 sensory and motor subscale scores (p < 0.001 via Jonckheere-Terpstra tests). The sensitivity and specificity of the PRO-CTCAE severity item (cutoff > 0) to detect probable sensory peripheral neuropathy were 95.83% and 65.22%, while the sensitivity and specificity of the PRO-CTCAE™ interference item (cutoff > 0) were 51.39% and 73.91%.

CONCLUSION

Preliminary evidence supports the reliability and validity of the PRO-CTCAE numbness and tingling items for CIPN screening, although there may be floor effects and limitations in the capacity of the PRO-CTCAE items to identify the full range of CIPN sensory and motor features beyond numbness and tingling. Trial Registration ClinicalTrials.Gov, NCT03514680. Registered 21 April 2018. https://clinicaltrials.gov/ct2/show/NCT03514680.

Yoga for chronic chemotherapy-induced peripheral neuropathy pain: a pilot, randomized controlled trial

PURPOSE

To determine the feasibility of implementing a yoga intervention for cancer survivors with chronic CIPN pain, as well as the impact of the intervention on patient-reported outcomes.

METHODS

Cancer survivors with chronic CIPN pain were recruited from the breast, gastrointestinal, and gynecological oncology centers at Dana-Farber Cancer Institute. Participants were randomized (2:1) to receive an 8-week yoga intervention or usual care. After 21/50 of participants were enrolled, the COVID-19 pandemic required the yoga intervention to be delivered virtually (i.e., Zoom). Pre- and post-intervention, participants self-reported CIPN and co-occurring symptom severity. Adherence to the intervention was defined as practicing ≥ 12 yoga sessions over the 8-week intervention period. Changes in patient-reported outcomes between groups were compared using Wilcoxon's rank-sum tests.

RESULTS

Participants (n = 28 yoga, n = 16 control) were mainly female (96%) and diagnosed with stage III/IV disease (66%). Overall, 19/28 (67.8%) of yoga group participants were adherent to the yoga protocol. Yoga group participants experienced significant within-group improvements in all patient-reported outcomes, including worst CIPN pain (median change =  - 1.7, p < 0.0001) and sensory CIPN (median change =  - 14.8, p < 0.0001), but only improvements in fatigue (p = 0.05) and depression (p = 0.04) were significant compared to the control. There were no differences (p > 0.05) in changes in patient-reported outcomes between in-person (n = 6) or virtual (n = 15) yoga group participants.

CONCLUSIONS

Yoga is a feasible non-pharmacological modality for cancer survivors with CIPN, but more information is needed regarding its impact on CIPN and other symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03824860 IMPLICATIONS FOR CANCER SURVIVORS: Oncology clinicians may consider referring cancer survivors to yoga for chronic CIPN pain, but yoga cannot be currently recommended as an efficacious treatment.

CE: Chemotherapy-Induced Peripheral Neuropathy

ABSTRACT

Chemotherapy-induced peripheral neuropathy (CIPN) occurs in more than 68% of patients receiving the neurotoxic chemotherapy agents commonly used to treat breast, gastrointestinal, gynecologic, and hematologic malignancies. CIPN, often experienced initially as numbness, tingling, or pain in the upper or lower extremities, may progress to the point where the resultant decline in physical function requires a reduction in the chemotherapy dose. This article provides nurses with strategies to use in assessing, managing, and educating patients who are at risk for or who are already experiencing CIPN. Currently, the American Society of Clinical Oncology endorses only one treatment for CIPN: duloxetine 60 mg/day. Discussing CIPN with patients before chemotherapy is initiated and throughout the course of treatment promotes its early identification and management, which may minimize its impact on physical function and chemotherapy dosing, reducing the patient's risk of experiencing chronic symptoms after chemotherapy ends.

Exploring the impact of a decision support algorithm to improve clinicians' chemotherapy-induced peripheral neuropathy assessment and management practices: a two-phase, longitudinal study

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) negatively affects physical function and chemotherapy dosing, yet, clinicians infrequently document CIPN assessment and/or adhere to evidence-based CIPN management in practice. The primary aims of this two-phase, pre-posttest study were to explore the impact of a CIPN clinician decision support algorithm on clinicians' frequency of CIPN assessment documentation and adherence to evidence-based management.

METHODS

One hundred sixty-two patients receiving neurotoxic chemotherapy (e.g., taxanes, platinums, or bortezomib) answered patient-reported outcome measures on CIPN severity and interference prior to three clinic visits at breast, gastrointestinal, or multiple myeloma outpatient clinics (n = 81 usual care phase [UCP], n = 81 algorithm phase [AP]). During the AP, study staff delivered a copy of the CIPN assessment and management algorithm to clinicians (N = 53) prior to each clinic visit. Changes in clinicians' CIPN assessment documentation (i.e., index of numbness, tingling, and/or CIPN pain documentation) and adherence to evidence-based management at the third clinic visit were compared between the AP and UCP using Pearson's chi-squared test.

RESULTS

Clinicians' frequency of adherence to evidence-based CIPN management was higher in the AP (29/52 [56%]) than the UCP (20/46 [43%]), but the change was not statistically significant (p = 0.31). There were no improvements in clinicians' CIPN assessment frequency during the AP (assessment index = 0.5440) in comparison to during the UCP (assessment index = 0.6468).

CONCLUSIONS

Implementation of a clinician-decision support algorithm did not significantly improve clinicians' CIPN assessment documentation or adherence to evidence-based management. Further research is needed to develop theory-based implementation interventions to bolster the frequency of CIPN assessment and use of evidence-based management strategies in practice.

TRIAL REGISTRATION

ClinicalTrials.Gov, NCT03514680 . Registered 21 April 2018.

Characterizing patient-clinician chemotherapy-induced peripheral neuropathy assessment and management communication approaches

OBJECTIVE

To describe the frequency and characteristics of chemotherapy-induced peripheral neuropathy (CIPN) assessment and management communication approaches between patients receiving neurotoxic chemotherapy and clinicians.

METHODS

The data used in this analysis originated from a randomized controlled trial in which adults with cancer self-reported treatment-related symptoms using web-based symptom assessment technology. Three-to-six weeks after study initiation, each participant's outpatient visit was audio-recorded. Audio recordings and associated clinician notes for 159 participants who received platinum and/or taxane-based chemotherapy were coded for the presence of several CIPN assessment and management communication characteristics.

RESULTS

Participants received low cumulative neurotoxic chemotherapy doses (75%) at the time of audio recording. CIPN was discussed and documented in 44% and 46% of participant-clinician encounters. In symptomatic participants, clinicians asked an average of 0.7 open-ended questions, appropriately managed 70% of cases, and asked upper and lower extremity CIPN questions in 25% of cases.

CONCLUSIONS

Clinicians infrequently discussed and documented CIPN in participants with low CIPN severity, however appropriately managed mild CIPN. Development of interventions to translate existing recommended CIPN communication approaches into practice are required.

PRACTICE IMPLICATIONS

Effective participant-clinician communication is required at each clinic visit during chemotherapy treatment to identify initial signs of CIPN and offer appropriate treatment.

Exploring the efficacy of an electronic symptom assessment and self-care intervention to preserve physical function in individuals receiving neurotoxic chemotherapy

Background

Impaired physical function due to chemotherapy-induced peripheral neuropathy (CIPN) symptoms may lead to diminished quality of life. However, even with the knowledge of the effects of CIPN on physical function, clinicians infrequently assess and manage CIPN. Interventions that prioritize the early identification of CIPN to provide prompt treatment may reduce the impact of CIPN on physical function. The purpose of this paper is to compare self-reported physical function in individuals receiving neurotoxic chemotherapy between Electronic Symptom Assessment-Cancer (ESRA-C) intervention group (e.g., opportunity for symptom screening, self-care recommendations, communication coaching, and symptom tracking) and control group participants (i.e., electronic assessment alone). Secondary outcomes include pain intensity, sensory/motor CIPN, depression, fatigue, and insomnia.

Methods

The data used in this paper are a subset of a randomized controlled trial that examined the impact of the ESRA-C intervention on symptom distress in individuals receiving cancer treatment. Since the interest in this analysis is on the effects of neurotoxic chemotherapy on physical function, subjects were included if they received platinum and/or taxane-based chemotherapy and completed the baseline and end-of-treatment measures. Participants completed standardized questionnaires of physical function, CIPN, fatigue, depression, pain intensity, and insomnia prior to treatment, 3–6 weeks after treatment initiation, and after the completion of treatment. Changes in mean scores are compared between groups using linear mixed models adjusting for age.

Results

Intervention group participants reported significantly less reduction in physical functioning (baseline: 87.4/100; end-of-treatment: 84.5/100) relative to the control (baseline: 90.2/100; end-of-treatment: 81.8/100) (p = 0.011). For secondary measures, significantly less depression (p = 0.005) was observed in the intervention group as compared to the control, but otherwise, there were no between-group differences. Among participants who received high cumulative doses of neurotoxic chemotherapy, the intervention group reported significantly less severe sensory (p = 0.007) and motor CIPN (p = 0.039) relative to the control.

Conclusion

Use of the ESRA-C intervention led to less reduction in physical function in comparison to the control in individuals receiving neurotoxic chemotherapy. Further research is needed to confirm our findings and to identify how electronic symptom assessment technology may mediate physical function preservation.

Trial registration

ClinicalTrials.Gov NCT00852852. Registered 27 February 2009.