1/21/14. Barriers to Assessment and Management of Chemotherapy- Induced Peripheral Neuropathy. Conflicts of Interest. Learning Objective

Transcription

1 Barriers to Assessment and Management of Chemotherapy- Induced Peripheral Neuropathy Connie Visovsky, PhD, RN, ACNP-BC Associate Dean University of South Florida College of Nursing Conflicts of Interest Constance Visovsky has no conflicts of interest to disclose. Learning Objective Explain barriers to and clinical strategies to improve assessment and management of chemotherapyinduced peripheral neuropathy (CIPN) 1

2 Assessment of Peripheral Neuropathy Assessment and grading of peripheral neuropathy (PN) is not straightforward. Many different grading scales are available, but no standard method for administering or interpreting these scales has been developed. Available grading scales have many limitations. Visovsky, C., et al. (2009). Cancer Nurs, 3, ; Visovsky, C. (2013). J Adv Pract Oncol, 4, National Cancer Institute s (NCI) Common Terminology Criteria for Adverse Events (CTCAE) Used to establish cut points for treatment toxicity, delays, and/or reductions Not a comprehensive measure of the CIPN symptom experience Lacks sensitivity regarding past treatment impact (previous neurotoxicity) Brief assessment of functional status Methods of use vary widely, interpretation inconsistent Visovsky, C., et al. (2009). Cancer Nurs, 3, ; Visovsky, C. (2013). J Adv Pract Oncol, 4, Diagnostic Studies and Limitations Studies* EMG NCV QST Epidermal skin biopsy *These diagnostic studies fail to measure pain, a major manifestation of CIPN Limitations of EMG/NCV Insensitive in acute injury Normal result does not rule out neuropathic pain Cannot assess function of small-fiber nerves involved in most neuropathic pain 2

3 Question 1 What is the most important evaluation that should be included in a patient assessment for peripheral neuropathy? A. Patient-reported symptoms/functional disturbances B. Touch, vibration sensation, and deep tendon reflexes C. Pain rating scale and nerve conduction studies D. Assessment of proprioception, gait, and balance Age Assessment of Associated Factors Dose of chemotherapy agent Cumulative dose received Therapy duration Coadministration of other neurotoxic agents Preexisting conditions (diabetes, alcoholism) Genetic polymorphisms (SCN2A R19K, GSTP1 Ile 105 Val) Wickham, R. (2007). Clin J Oncol Nurs, 11, ; Argyriou, A. A., et al., (2009). Oncology, 77, ; Mir, O., et al. (2009). Ann Oncol, 20, Assessment of CIPN Subjective assessment: Pain, numbness, burning, tingling, paresthesias, autonomic signs and effect on ADL and other functions (i.e., work) Objective assessment: Touch, vibration, gait and balance, proprioception, reflexes, muscle strength, Lhermitte s sign, and perception of sharp/dull are recommended as an adjunct to the subjective symptom assessment Stubblefield, M. D., et al. (2009). J Natl Comp Cancer Netw, 7(suppl 5), S1-S26. 3

4 Touch: Monofilament Testing Patient closes eyes; apply finest filament perpendicularly to specified locations on each hand and foot in a 3-second sequence Instruct patient to note when he/she feels filament If he/she does not feel filament at a specific location after 2 attempts, next larger monofilament used for testing Kamei, et al. (2005); Lee, et al. (2006). Sharp/Dull Perception: The Pinprick Test Using a sharp safety pin, alternate the sharp/dull ends and ask the patient to report the sensation perceived. Visovsky, C., et al. (2004). J Am Acad Nurse Pract, 16, Vibration Testing Test bony surfaces of the index finger or great toe. Move from distal to proximal areas if no vibration is felt. Vibration testing is highly correlated with findings in nerve conduction studies. Visovsky, C., et al. (2004). J Am Acad Nurse Pract, 16,

5 Weakness Gait disturbance Balance disturbance Difficulty with fine motor skills Buttoning clothing Writing Motor Symptoms Visovsky, C., et al. (2007). Clin J Oncol Nurs, 11, Gait Assessment Wilkes, G. (2007). Semin Oncol Nurs, 23, Proprioception: Romberg Test Have the patient stand still with heels together Ask the patient to remain still and close his/her eyes If the patient loses balance, the test is considered positive Hausheer, F. H., et al. (2006). Semin Oncol, 33, 15-49; Khasnis, A., et al. (2003). J Postgrad Med, 49,

6 Deep Tendon Reflexes Strike the Achilles and patellar tendons Reflexes are graded from 0 (absent) to 4 (enhanced) Reflexes are diminished or absent when sensation is lost The grading of reflexes is often difficult, with a blurring between higher grades Wilkes, G. (2004). CIPN Measurement Tools Patient-reported outcomes q QLQ-CIPN 20 q FACT-GOG/neurotoxicity q FACT-Taxane Neurologic testing composite instrument q TNS Pain assessment scale q Brief Pain Inventory GOG = Gynecologic Oncology Group; TNS = total neuropathy scale. Postma et al, 2005; Calhoun et al, 2003; Cella et al, 2003; Almadrones et al, 2004; Cavaletti et al, Question 2 What evidence-based intervention(s) are most likely to be effective in the prevention or treatment of peripheral neuropathy? A. No evidence-based treatments exist B. Treatment of pain with anti-epileptics C. Non-pharmacologic therapies (i.e., massage,tens) D. Infusion of calcium and magnesium prior to chemotherapy 6

7 CIPN Prevention and Treatment: Issues Surrounding Neurotoxicity Trials Few well-conducted trials in literature q Sample size is too small, underpowered q Non-randomized, no placebo control q Mix of chemotherapy agents allowed q Mix of palliative and adjuvant settings Limited success observed so far in neurotoxicity prevention and treatment trials could be a result of shortcomings in trial design Prevention of CIPN Chemoprotectants Amifostine Recombinant human leukemia inhibitory factor (rhulif) Nimodipine (Ca+ channel antagonist) Anticonvulsants Carbamazepine, oxcarbazepine Antidepressants Amitriptyline, venlafaxine Visovsky, C., et al. (2007). Clin J Oncol Nurs, 11, ; Stubblefield, M. D., et al. (2009). J Natl Compr Canc Netw, 7(suppl 5), S1-S26. Ca Mg infusions Vitamin E Glutathione Org 2766 Acetyl-L-carnitine Glutamate/Glutamine DDTC Prevention of CIPN Loprinzi, C. L., et al. (2013). J Clin Oncol, Dec 2 [epub ahead of print]; Visovsky, C., et al. (2007). Clin J Oncol Nurs, 11, ; Stubblefield, M. D., et al. (2009). J Natl Compr Canc Netw, 7(suppl 5), S1-S26. 7

8 Treatment of CIPN Topical BAK (baclofen, amitriptyline, ketamine) Tricyclic antidepressants (amitriptyline, nortriptyline) Anticonvulsants (gabapentin, lamotrigine) Duloxetine Barton, D. L., et al. (2011). Support Care Cancer, 19, ; Hammack, J., et al. (2002). Pain, 98, ; Kautio, A. L., et al. (2008); J Pain Symptom Manage, 35, 31-39; Rao, R. D., et al. (2007). Cancer, 110, ; Mitchell, S. A., et al. (n.d.). Weight of evidence. Retrieved from Rao, R. D., et al. (2008). Cancer, 112, ; Cascinu, S., et al. (1995). J Clin Oncol, 13, 26-32; Cascinu, S., et al. (2002). J Clin Oncol, 20, ; Smyth, J. F., et al. (1997). Ann Oncol, 8, ; Wang, W. S., et al. (2007). Oncologist, 12, ; Smith, E. M., et al. (2013). JAMA, 309, Thank You for All You Do for People With Cancer! For CIPN: 8