New Recommendations for Preventing and Managing Neuropathy, Fatigue, Depression, and Anxiety

April 15, 2014
Amber Bauer, ASCO staff

Many people are prepared to experience side effects while they are going through cancer treatment. However, it is often surprising to cancer survivors that some side effects may linger after treatment has finished. Some of these side effects go away over time, but others require lifelong management.

Relieving side effects, both during and after treatment, is an important priority for your health care team. To help doctors better prevent and manage peripheral neuropathy, fatigue, depression, and anxiety, the American Society of Clinical Oncology (ASCO) has just released three new clinical practice guidelines. Clinical practice guidelines are recommendations created to help improve patient care. They are based on a thorough review of the research and an assessment of the benefits and risks of the possible care options.

Peripheral neuropathy

Peripheral neuropathy is a type of nerve damage that can cause numbness, tingling, pain, muscle weakness, and other changes. It develops when the nerves that carry information back and forth between the brain and spinal cord are damaged.

About 30% to 40% of people with cancer develop peripheral neuropathy as a result of specific types of chemotherapy, particularly in high doses. Unfortunately, there is no good evidence that any medications, vitamins, or supplements can help prevent neuropathy caused by chemotherapy. Still, if neuropathy is caught early enough, your doctor can switch to another drug that doesn’t have neuropathy as a side effect, reducing the risk of permanent nerve damage.

Although there are no medications that are able to reverse neuropathy, there are a number that may help relieve pain. However, they do not relieve numbness. For neuropathy related to chemotherapy, ASCO recommends the antidepressant duloxetine (Cymbalta). Other medications may be considered depending on your specific situation and the cause of your neuropathy.

“Some of the drugs used for prevention or treatment of neuropathy may cause side effects or interfere with other drugs,” said Gary Lyman, MD, MPH, co-chair of the ASCO Survivorship Guidelines Advisory Group.  “We want to be clear that if there is no evidence of benefit from those drugs, it’s probably best not to take them.”


Fatigue caused by cancer treatment is different from feeling tired because you stayed up too late. It is a persistent feeling of physical, emotional, or mental exhaustion that interferes with your usual functioning and doesn’t improve with rest. Most people receiving cancer treatment experience fatigue, and approximately one-third of cancer survivors have fatigue that lasts for years after finishing treatment.

“Fatigue is an extremely common symptom in patients with cancer,” said Smita Bhatia, MD, MPH, co-chair of the ASCO Survivorship Guidelines Advisory Group. “We hope that this guideline will help ensure that fatigue screening and management are incorporated in the care of every patient and survivor.”

ASCO now recommends that people should have their level of fatigue evaluated when they are first diagnosed with cancer. This evaluation is part of a comprehensive screening called distress screening that evaluates your emotional health and quality of life. Health care providers should perform this evaluation every year and any time there are symptoms of fatigue throughout treatment and into recovery.

 If fatigue becomes an issue, there are a number of strategies to help manage it, including physical activity, cognitive and behavioral therapies, psycho-educational therapies, yoga, acupuncture, massage, and music therapy.

Depression and Anxiety

Depression begins with feeling down or sad, having little interest in or receiving little pleasure from doing the things you once enjoyed, and feeling hopeless. While these feelings can be a common reaction to a cancer diagnosis and the challenges of treatment, they become an issue when they continue for two or more weeks and negatively affect your daily activities or relationships.

Anxiety, on the other hand, makes you feel nervous, on edge, worried, or overwhelmed a lot of the time. Anxiety is a normal response to anything your body perceives as a threat, but intense anxiety for a long time is a disorder that may interfere with your daily activities and relationships. Many people with cancer experience symptoms of anxiety, with fears triggered by the uncertainties of a cancer diagnosis.

“Doctors sometimes don’t give these symptoms much attention because they think it’s normal that patients are a little anxious or depressed about their disease,” said Dr. Lyman. “But it’s important to keep an eye on the symptoms and step in when they start to interfere with a person’s life.”

ASCO recommends you receive an evaluation for depression and anxiety when you are first diagnosed with cancer and on a regular schedule throughout treatment and recovery. During this evaluation your doctor or another member of the health care team will ask you about any symptoms of depression and anxiety you may have and how often you have experienced them. Based on your answers, your doctor may refer you to supportive care services available at the hospital or cancer center where you receive treatment, group therapy, or a mental health professional, such as a licensed counselor, psychologist, or psychiatrist.

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