Preventing and Managing Peripheral Neuropathy, with Charles Loprinzi, MD, FASCO

July 14, 2020
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Today, ASCO published a new guideline on the prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers. Dr. Charles Loprinzi discusses the guideline recommendations and what this guideline means for patients. 



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Brielle Gregory: Hi, everyone. I'm Brielle Gregory, a member of the Cancer.Net content team, and I'll be your host for today's Cancer.Net Podcast. Cancer.Net is the patient information website of ASCO, the American Society of Clinical Oncology. Today, we're going to be talking about chemotherapy-induced peripheral neuropathy. Our guest is Dr. Charles Loprinzi. Dr. Loprinzi is the Regis Professor of Breast Cancer Research at the Mayo Clinic in Rochester, Minnesota, where he is an emeritus chair of the Division of Medical Oncology and an emeritus vice-chair of the Department of Oncology. He is also the Cancer.Net Associate Editor for Psychosocial Oncology. Thanks for joining us, Dr. Loprinzi.

Dr. Loprinzi: My pleasure to be here.

Brielle Gregory: Today, ASCO is publishing a new guideline on the prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers. Dr. Loprinzi served as the co-chair and lead author for this guideline. Before we begin, we should mention that Dr. Loprinzi has relationships to disclose related to this guideline. You can find his full disclosure statement on Cancer.Net. Now, let's talk a little bit about what this guideline means for people with cancer and those who care for them. So, Dr. Loprinzi, to get started, what is peripheral neuropathy?

Dr. Loprinzi: Peripheral neuropathy is pathology of nerves that's in the peripheral part of the body. But my English teacher in high school, a Catholic nun, would not like me to define a term with using the actual words there. So it's disease of the nerves—I'm going to use nerves instead of neuropathy—that's in the part of the body that's at the end of the extremities, the hands and the feet. It's caused by chemotherapy. Not all chemotherapy drugs cause neuropathy or pathology of the nerves, but some do. And that's what we're talking about today. And it is the symptoms that people get, numbness, tingling, and pain. Mostly numbness and tingling start, and then pain can come later on, but they're all three quite obviously.

Brielle Gregory: Thank you for explaining that. So why is this guideline on chemotherapy-induced peripheral neuropathy important for patients?

Dr. Loprinzi: It's important because it's a very prominent problem. It's very, very common. Again, not all chemotherapy drugs we give caused this particular problem, but some of them that we give-- and a good number of them that we give can cause this problem. And the problem can be bothersome while the patient's getting chemotherapy, and it can also last for a long time after chemotherapy is done. And that when I say a long time, that sometimes is months or years, and it could be a very prominent problem for some patients, a minority of patients there. There are some chemotherapy drugs like oxaliplatin, one of the drugs we give, that actually that neuropathy gets worse, the nerve problems get worse in the three months after stopping chemotherapy, and so you don't know the full extent of it for some time after you're done with the chemotherapy.

Brielle Gregory: That's really important to note. So when it comes to preventing chemotherapy-induced peripheral neuropathy, what does this guideline say about preventing chemotherapy-induced peripheral neuropathy?

Dr. Loprinzi: There have been a lot of studies that have looked at ways to try to prevent neuropathy. Unfortunately, there's no proven means of doing this, other than not giving the chemotherapy, and the reason for giving the chemotherapy is to try to kill off cancer cells so we don't like that part of it. And the drugs that we used that caused this neuropathy are some of the better drugs against the particular cancers that patients have. There is some suggestions that giving cold therapy, putting ice packs or cold gloves on hands and feet, with cold socks for the feet part of that. That can decrease the amount of blood flow and decrease the amount of nerve trouble that people get. It's not proof of benefit there. You always have to be somewhat careful, there have been occasional episodes of people who have gotten frostbite from that. But that's one of the things that looks like it might be doing some good. Again, more studies is needed.

Another way to try to decrease the blood flow is to put tight gloves on the hands, and therefore, the same sort of thing where you decrease the blood flow with cold therapy. There's some data that suggests that might be beneficial. And there are data that suggests that exercise could be beneficial. Patients who exercise more before and during chemotherapy seems to get less neuropathy than those patients who do not.

Brielle Gregory: All right. So let's move on to talking about treating chemotherapy-induced peripheral neuropathy. What does ASCO recommend in treating chemotherapy-induced peripheral neuropathy for patients who are currently receiving chemotherapy?

Dr. Loprinzi: So for patients who are getting chemotherapy, and for an example, when we're giving adjuvant chemotherapy which means that patients have had a surgical procedure and all known cancer has been removed, but we know based on the size of the cancer and whether it's involved lymph nodes and etc. things, even though we've removed everything we can see, we know that it comes back in a percentage of patients, in the future. And this is again from past experience. And the chance of the cancer coming back might be 10% chance or 20% chance or 50% chance or some other different number from that.

So we give 12 weeks of therapy to try to improve the chance that it won't come back. So that's the reason why we give the chemotherapy. But if a patient's getting neuropathy and fairly significant neuropathy, knowing it can get worse if you give more, and it gets worse even after you finish in many patients or in some patients. The doctor's role as per the guidelines is to think about how much additional benefit if I go from stopping at 8 cycles, if I go to the whole 12 cycles, how much additional benefit do we think that would decrease the cancer from coming back? Will that decrease it from coming back by 1 percentage point? Or will that be 5 percentage points? Or will that be 10 percentage points? Those are different numbers.

And then with that information, being able to share that with the patients and also share the neuropathy story and how much worse it might get depending on how badly it is getting so that decisions could be made. Should we stop short of what we were planning to do? Given that we do not want to have this neuropathy to be a problem that's around for months or years after finishing chemotherapy. So that's the one suggestion that was made by the guidelines. Having said that, there's no proof of any of this process that's the best way to go, but it's the best recommendation that we get.

Brielle Gregory: Now, what about for patients who have completed chemotherapy? What does ASCO recommend in treating chemotherapy-induced peripheral neuropathy for them?

Dr. Loprinzi: For those patients who have the problem after finishing chemotherapy, there is one drug that's around. It's a drug called duloxetine. It was developed as an antidepressant, but it also has been shown to be helpful in some pain situations. It's also been shown to be helpful in some pain situations. This drug is the one that in placebo-controlled trials, trials that randomized patients to get the drug or something that looked like it, just a sugar pill, if you will, that it does decrease pain and some tingling that patients get. It significantly decreases it. Having said that, it doesn't decrease it by a lot, and significant is a statistical term that says that this decrease did not happen by just chance alone.

So that's the one drug that's recommended in this particular situation. There are some things that look promising that you could argue would be worth trying, but do not have proof of benefit. And in that setting, we're trying to do more experiments to see if we can prove that these things are beneficial. And those three things are, one, acupuncture, two, exercise just like in the prevention mode, exercise seems to be helpful for decrease in the symptoms. And something else called scrambler therapy which is a type of nerve-stimulation therapy that's given on the skin of patients done by a machine in a doctor's office. So those are the three things that looked promising. Again, more work needs to be done to prove the true benefits and risks associated with these approaches.

Brielle Gregory: Great. This is definitely an important guideline for patients. So thank you so much for sharing your expertise today, Dr. Loprinzi, and for taking the time. It was such a pleasure having you.

Dr. Loprinzi: My pleasure.

ASCO: Thank you Dr. Loprinzi. If this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.

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