Patient Perceptions Associated with Chemotherapy-Induced Peripheral Neuropathy

with Cindy Tofthagen, PhD, ARNP, AOCNP®

2010-10-19 13:03:18 Stephanie@ons. Welcome to the ONS Virtual Journal club! We have Cindy Tofthagen with us today to discuss Patient Perceptions Associated with Chemotherapy Induced Peripheral Neuropathy
2010-10-19 13:03:38 Stephanie@ons. rnportland: do you have any questions for Cindy to start the chat off with?
2010-10-19 13:03:53 rnportland Not at this time
2010-10-19 13:04:35 Stephanie@ons. Welcome to the chat mcclungd! We are just getting started.
2010-10-19 13:05:14 Stephanie@ons. Cindy, what caused you to address the clinical issue in the article?
2010-10-19 13:07:15 cindytofthagen Hi everyone. I decided to look at this topic after spending 12 years as a chemo nurse and seeing the dramatic increase in chemotherapy induced peripheral neuropathy as more taxanes were used and then as oxaliplatin was approved for adjuvant treatment of colon cancer.
2010-10-19 13:07:27 Stephanie@ons. Welcome to the chat JOANNEF. Please feel free to ask Cindy questions that you have related to the article.
2010-10-19 13:08:01 cindytofthagen I saw what a negative affect it had on my patients' quality of life and I wanted to find ways to help.
2010-10-19 13:08:27 Stephanie@ons. Welcome to the chat koches!
2010-10-19 13:09:00 koches Thanks
2010-10-19 13:09:30 cindytofthagen I also found that we don't have great ways to assess or measure neuropathy and I thought since the patients are really the experts, I would ask them.
2010-10-19 13:09:52 cindytofthagen That is really how the article came about.
2010-10-19 13:09:53 rnportland Cheryl, Is your practice inpatient or outpatient?
2010-10-19 13:10:29 cindytofthagen Outpatient. I work in a medical oncology practice.
2010-10-19 13:10:58 cindytofthagen What have you guys seen in your practices?
2010-10-19 13:11:32 rnportland Do the nurses assess the patients each visit and do you utilize paper questionnaires?
2010-10-19 13:12:12 koches most often I think it gets categorized under pain, rather than on its own
2010-10-19 13:12:38 cindytofthagen When I started to study this topic, I will tell you that the nurses relied on the physician and NP/PA to assess neuropathy.
2010-10-19 13:13:22 JOANNEF Stephanie@ons. We rely on verbal only for now. However, I find most patients will not say anything about this side effect until prompted
2010-10-19 13:14:01 cindytofthagen We never used questionnaires but now we talk more to the patients about it, assess at every interaction, and really focus on the way that neuropathy is affecting their daily life.
2010-10-19 13:15:05 cindytofthagen Patients often think it is just something they have to put up with like losing their hair or they don't want their chemo to get discontinued so they don't bring it up.
2010-10-19 13:16:13 cindytofthagen Verbal information is a starting point but assessment of physical function is also extremely important.
2010-10-19 13:16:45 cindytofthagen A lot of people focus on the painful aspects but many patients don't have pain with it.
2010-10-19 13:16:51 koches You make a good point!! They will put up with anything, if it means getting rid of the cancer.
2010-10-19 13:17:16 cindytofthagen Absolutely Koches!
2010-10-19 13:18:54 cindytofthagen Even if they won't bring it up, it is so important to ask them about it. Sometimes they don't even connect their symptoms with chemo.
2010-10-19 13:19:09 rnportland I have worked both inpt. and outpt. and I have multiple questions re: this topic. First, does herpes zoster which may not be diagnosis since it may be disseminated be a potential contributing factor, second could a generalized fungal infection be contributing to these symptoms as well? After Cheryl's last comment possibly peripheral neuropathy is not what we sometimes believe it to be.
2010-10-19 13:22:20 cindytofthagen Herpes Zoster is a cause of neuropathy (postherpatic neuralgia) that causes severe neuropathic pain that can last long after any herpetic lesions are visible. It should be treated with the same medications we use to treat neuropathic pain (Neurontin, Lyrica, etc.)
2010-10-19 13:23:04 JOANNEF Are you having good success with Lyrica?
2010-10-19 13:23:24 cindytofthagen I have never heard of fungal infections exacerbating the problem but their is a lot we have left to learn.
2010-10-19 13:24:47 cindytofthagen My experience is that if the patient has PAINFUL neuropathy. Lyrica helps the pain but it doesn't help numbness, muscle aches, muscle weakness, loss of balance or improve physical functioning.
2010-10-19 13:25:42 cindytofthagen Patients often Lyrica makes them feel groggy or clouds their thinking.
2010-10-19 13:27:08 cindytofthagen It is so important that we assess their gait and balance because as the article points out, they may fall or hurt themselves.
2010-10-19 13:27:52 rnportland I have heard this same reply related to gabapentin
2010-10-19 13:28:15 cindytofthagen yes, the side effects of gabapentin are very similar
2010-10-19 13:29:37 cindytofthagen also frequent dose escalations are often necessary with both Lyrica and Neurontin and ,any physicians, NP's, and Pa's are not comfortably in doing that
2010-10-19 13:29:40 koches Is there a role for Rehab Therapy to help pt adapt to these changes? Do any of your facilities include Rehab?
2010-10-19 13:29:59 rnportland Is peripheral neuropathy more common in the <65 years group?
2010-10-19 13:31:00 cindytofthagen If I have a patient with any functional impairment at all from neuropathy, I refer them to both physical and occupational therapy and I do think that it helps.
2010-10-19 13:32:43 rnportland I recently read an article re: B12 deficiency and the part it plays in neuropathy. Probably a very important piece of the puzzle.
2010-10-19 13:32:44 cindytofthagen Their isn't a lot of data relating to age and the concern has usually been that older people might be at higher risk of developing CIPN but research evidence has not demonstrated an increased risk among older patients.
2010-10-19 13:33:07 JOANNEF Cindy thank you for presenting this topic. However, I have to leave. Good by to everyone.
2010-10-19 13:34:00 cindytofthagen B12 deficiency itself can cause neuropathy and if you have a patient with b12 deficiency getting neurotoxin chemotherapy, they have a very high risk
2010-10-19 13:34:17 Stephanie@ons. The full chat transcript will be posted on the ONS Website under the Virtual Journal Club.
2010-10-19 13:34:19 cindytofthagen Bye Joanne. Thanks for joining us.
2010-10-19 13:35:07 mcclungd Thank you!
2010-10-19 13:36:04 cindytofthagen What else are you guys using with your patients?
2010-10-19 13:38:30 cindytofthagen Back to the age issue, I think that younger patients may be more distressed by neuropathy because they are juggling so many roles at the same time.
2010-10-19 13:40:05 koches I was thinking along the same line, that maybe as part of the aging process, the elderly start to have some neuropathy prior to the treatments.
2010-10-19 13:40:31 rnportland The reason I asked about age is related to herpes zoster frequency increase in pt. who are older.
2010-10-19 13:41:54 cindytofthagen Rnportland, that is true. Of course our immune systems don't work as well as we age and when our immune systems are compromised, we are more likely to develop herpes zoster.
2010-10-19 13:42:11 rnportland Possibly we can separate the various diagnosis with assessment tools and be certain they are adequately tx and hopefully experience better outcomes.
2010-10-19 13:43:22 cindytofthagen Good point. We need to be certain that we are dealing with chemotherapy induced peripheral neuropathy and not something else.
2010-10-19 13:45:12 koches is there a guideline for an assessment tool out there somewhere?
2010-10-19 13:48:46 cindytofthagen There are several questionnaires that have been developed
2010-10-19 13:49:01 cindytofthagen And there are also some simple neuro tests like pin prick sensation, deep tendon reflexes, that can be used.
2010-10-19 13:51:01 cindytofthagen We used the data from this study to develop a questionnaire called the Chemotherapy Induced Peripheral Neuropathy Assessment Tool that assesses severity, distress, and frequency of neuropathic symptoms as well as interference with activities.
2010-10-19 13:52:47 cindytofthagen That study will be published soon in Cancer Nursing. I am also working on an algorithm for nurses to use when assessing CIPN. I am happy to share any of these with you if you email me.
2010-10-19 13:53:04 cindytofthagen My email address is ctofthag@health.usf.edu
2010-10-19 13:54:13 Stephanie@ons. Does anyone have any final questions for Cindy, as we get close to the end of our time?
2010-10-19 13:55:13 rnportland As nurses do we routinely question pts. in depth about their medical hx. Usually we focus on symptoms but maybe we need to investigate their prior medical hx more and be certain the md's are aware. Many time the pts. have told me things they never mentioned to their physicians.
2010-10-19 13:55:26 koches Thanks, Cindy, for discussing this. The assessment tool would be a great help!!
2010-10-19 13:57:00 koches Getting a baseline would be beneficial, and you are right that we can easily overlook the pre-cancer conditions otherwise.
2010-10-19 13:57:16 cindytofthagen I agree rnportland! It is important to know your patient's history. Diabetics may also be at a higher risk of developing CIPN and we all see a lot of diabetic patients.
2010-10-19 13:57:23 rnportland Thank you for inviting me to discuss this topic. I will be certain to review the assessment tool.
2010-10-19 13:57:59 cindytofthagen Thank you all for participating! I had a good time.
2010-10-19 13:58:35 cindytofthagen Koches, send me your email address and I will send you a copy of the instrument
2010-10-19 13:58:45 Stephanie@ons. Thank you all for joining us today for the chat. We will be chatting again Friday Oct 22 at 10am EDT.
2010-10-19 13:58:59 cindytofthagen Thanks Stephanie!
2010-10-19 13:59:29 Stephanie@ons. Thanks Cindy!! It went great! I will be online on Friday. See you then.
2010-10-19 13:59:41 cindytofthagen Bye :)