Cancer Treatment And Neuropathy

Today's post from cancerfightersthrive.com (see link below) is specifically directed at patients receiving chemotherapy treatment for their cancer and discusses the ensuing neuropathic problems that many of these patients end up having. However, remove all references to cancer from the article and you have a standard description of nerve damage which can happen to everybody and from a multitude of other causes. For that reason, this article is useful to cancer patients but also for anyone else who is suffering from neuropathy. That's the problem with this disease:- both doctors and experts tend to concentrate too much on the cause, when in fact if you already have neuropathy, you need to be concentrating on treating and reducing the symptoms. Contrary to what this article suggests, in the vast majority of cases, nerve damage can't be reversed and won't go away just because a particular cause has been stopped or removed. It's a cruel disease, with over 100 causes and over 100 different forms - the medical emphasis should be more on treating the patient's discomfort and less on addressing the cause (a bit like shutting the stable door after the horse has bolted!). That said, if the cause is something like cancer then treating that particular cause naturally needs to be ongoing but unfortunately, curing the cancer is unlikely to cure the nerve damage from the cancer treatment.

Burning, Tingling Pain? It Could Be Peripheral Neuropathy 
By Rachael Bieschke 2018

If you've experienced these symptoms after chemo, here’s what you should know about the condition.

Receiving chemotherapy for cancer treatment can lead to a number of unexpected side effects, including damage to the nerves located outside your brain and spinal cord, known as your peripheral nerves. Peripheral neuropathy, which describes nerve damage that’s often felt in your extremities, including your hands, feet, legs and arms, may be caused by a number of factors, from diabetes to alcohol abuse, but it’s also a common side effect of chemotherapy.

“Most cancer chemotherapies can cause peripheral neuropathy,” explains Glynis Vashi, M.D., chief of medicine and lead physician at Cancer Treatment Centers of America® (CTCA) in Suburban Chicago. “Especially the taxanes,” which may include such chemotherapy drugs as paclitaxel (Taxol®), docetaxel (Taxotere®) and cabazitaxel (Jevtana®). Platinum drugs, epothilones, plant alkaloids and thalidomide (Thalomid®) are examples of additional chemotherapy drugs that are frequently linked to peripheral neuropathy, according to the American Cancer Society (ACS).

What Are the Signs and Symptoms of Peripheral Neuropathy?

Pain, burning, numbness and tingling in the areas where your nerves are damaged are the most common symptoms of peripheral neuropathy. The severity varies from person to person, ranging from mild to debilitating.

“It starts out with pain,” Dr. Vashi says. “Your sensory nerves receive all the sensory stimuli, so usually the pain is a burning kind of pain. Then as it gets more severe the pain can ascend more proximally toward the body, and the most severe form is accompanied by muscle weakness.”

So while the pain may initially only be felt in your toes or fingers, it can progress, moving into your feet, ankles and legs or hands and arms. In the most severe cases, you may have severe pain and difficulty walking or carrying out daily activities, such as buttoning a shirt or writing.

Meredith Boudreau, PT, DPT, physical therapist at CTCA® in Suburban Chicago, notes that there are a variety of symptoms that can occur, but many patients describe peripheral neuropathy as a feeling of “walking on gravel” and says sometimes people also have a sensitivity to temperatures, such as cold or heat. “There’s a wide range on severity of symptoms, some people experience only slight numbness while others can barely feel anything, which can lead to trouble with balance,” she says. ACS lists additional symptoms, including:

Loss of feeling, including less ability to sense pressure, touch and temperatures
Trouble picking things up or holding things
Difficulty walking
Sensitivity to touch or pressure

Less common symptoms may include:

Shrinking muscles
Trouble swallowing
Constipation
Trouble passing urine
Changes in blood pressure
Decreased or no reflexes

Is It Possible to Prevent Peripheral Neuropathy?

Research is ongoing looking into possible tools to prevent chemotherapy-induced peripheral neuropathy (CIPN), but so far results have been mixed. More research is needed, but depending on the type of chemotherapy, the following nutraceuticals have shown some evidence that they could have a protective effect on peripheral neuropathy:

Vitamin E
Glutathione
Vitamin B6
Omega-3 fats

However, according to a review in Critical Reviews in Food Science and Nutrition, “Currently no agent has shown solid beneficial evidence to be recommended for the treatment or prophylaxis of CIPN.” As such, typically when peripheral neuropathy occurs during chemotherapy treatment it’s dealt with by altering the treatment.

“Most oncologists, if the neuropathy seems to be getting more debilitating, would decrease the dose of chemotherapy or stop the therapy,” Dr. Vashi says. Sometimes the chemotherapy would then be restarted once the neuropathy has a chance to subside. Because peripheral neuropathy can also be caused by factors other than cancer treatment, it’s important to address these as well. Dr. Vashi adds:

“We don’t see the patients until they’re having chemotherapy and develop the neuropathy, but in general practice we would want to make sure patients deal with other causes of neuropathy such as poor dietary choices, abusing alcohol, diabetes or the use of certain medications. All of these can cause or add to neuropathy even before the cancer treatment. That way we can help them to start at a better place.”

Treatment Options for Peripheral Neuropathy

Treatments depend on your particular symptoms and their severity. In the mild forms, you can use over-the-counter medications for pain relief. If the pain is severe, prescription pain relievers are the next step. From there, there are specific medications available to treat neuropathy, such as gabapentin (Neurontin®) and antidepressants may also be offered.

“Antidepressants may help increase a patient’s tolerance to pain,” Dr. Vashi says. “When patients are depressed, their pain tolerance is decreased and symptoms are exaggerated.” She also notes that vitamins and nutritional supplements, including vitamin B12 and folate, can be helpful, and for patients who are having trouble walking, physical therapy is recommended.

“If the patient cannot walk and it’s accompanied by muscle weakness, we use physical therapy to help. To help people walk, you can also use specialized footwear,” she says. Boudreau, the physical therapist, often works with patients on balance exercises and grip-strengthening activities, while doing sensory exercises to help patients learn to live with the condition.

Topical neuropathy creams are also available, which may work by temporarily numbing the pain, and there’s also an electrical stimulation unit that helps recreate normal nerve signaling. “It won’t cure the condition,” Boudreau says, “but patients have expressed reduced pain and symptoms with use of electric stimulation.” The prescription-based device is designed to be used at home two to three times a day and can also be administered by a physical therapist. Some people also find relief using acupuncture and essential oils, including aromatherapy massage.

Learning to Live With Peripheral Neuropathy

For some, peripheral neuropathy resolves once chemotherapy is complete. For others, symptoms may persist for years after. “As long as the treatment is ongoing, the neuropathy will be there,” Dr. Vashi says, which is why taking steps to live safely with the condition is so important. “Some people can’t feel the ground, which can result in falls, so education helps patients to know what to expect from having it.”

Boudreau also recommends taking precautions, especially with numbness and pain. “Get your skin checked often and wear proper footwear,” such as closed-toe shoes, to avoid injuries, she says. You may also want to wear gloves to protect your hands and take extra precautions to avoid being harmed by extreme temperatures, such as setting your water heater to a safe temperature to avoid scalding.

If you’re having trouble with muscle weakness, you may need to use the support of a cane or walker, and installing handrails in your home can help you avoid falls. If the symptoms of peripheral neuropathy are persistent and significantly interfering with your quality of life, be sure to let your health care providers know so they can create a treatment plan that addresses your individual needs and provides adequate relief.

http://www.cancerfightersthrive.com/burning-tingling-pain-peripheral-neuropathy/

Cancer Treatment and Neuropathy

Unfortunately, more and more people living with HIV are being confronted by various forms of cancer. This may be due to the fact that many more people are surviving and living longer with the virus and are therefore meeting diseases more associated with older patients. The point is that cancer treatment is also a well-known cause of neuropathy. The chemotherapy is the culprit though by no means everybody who undergoes chemo also contracts neuropathy as a result. That said, it will be difficult for doctors with an HIV and cancer patient to establish the cause of the nerve damage - it could be the virus itself, or the HIV medication, or the chemotherapy, or a host of other reasons.
Today's article from the NCI Cancer Bulletin of cancer.gov (see link below) is written by Brittany Moya del Pino (an article writer specialising in cancer discussions). It will be familiar to everybody already suffering from neuropathic problems but looks at it from a slightly different angle to those you may be used to on this blog.

Chemotherapy-induced Peripheral Neuropathy
by Brittany Moya del Pino

It usually starts in the hands and/or feet and creeps up the arms and legs. Sometimes it feels like a tingling or numbness. Other times, it’s more of a shooting and/or burning pain or sensitivity to temperature. It can include sharp, stabbing pain, and it can make it difficult to perform normal day-to-day tasks like buttoning a shirt, sorting coins in a purse, or walking. An estimated 30 to 40 percent of cancer patients treated with chemotherapy experience these symptoms, a condition called chemotherapy-induced peripheral neuropathy (CIPN).

CIPN is one of the most common reasons that cancer patients stop their treatment early. For some people, the symptoms can be mitigated by lowering the dose of chemotherapy or temporarily stopping it, which diminishes the pain within a few weeks. But, for other patients, the symptoms last beyond their chemotherapy for months, years, or even indefinitely.

“Peripheral neuropathy can be an incredibly debilitating side effect,” explained Dr. Ann O’Mara, head of NCI’s Palliative Care Program in the Division of Cancer Prevention. “We can’t predict who will come down with it or to what degree they will get it. So there are a lot of questions around this issue, in terms of preventing and treating it.”

Outside of clinical trials, CIPN symptoms are commonly managed in a manner similar to other types of nerve pain—that is, with a combination of physical therapy, complementary therapies such as massage and acupuncture, and medications that can include steroids, antidepressants, anti-epileptic drugs, and opioids for severe pain. But these therapies have not demonstrated true efficacy for CIPN, and virtually all of the drugs to treat peripheral neuropathy carry side effects of their own.

Life with Neuropathy

Cynthia Chauhan is a patient advocate who is very active in the cancer community. She participates with several boards and committees that advise NCI-sponsored clinical trial groups, including the North Central Cancer Treatment Group and the Southwest Oncology Group, and she is co-chair of the Patient Advocate Working Group for the Translational Breast Cancer Research Consortium. She is also very familiar with the burden of peripheral neuropathy and the shortcomings of current treatments.

A two-time cancer survivor, Ms. Chauhan lives with peripheral neuropathy that arose spontaneously—called idiopathic neuropathy—nearly 15 years ago. Her symptoms include shooting pains, fiery numbness, and tingling in her hands and feet, as well as a lack of sensitivity to temperatures. Her mother developed chronic CIPN during her treatment for stage IV ovarian cancer and, because of the pain, has terrible difficulty sleeping. “But without the drugs that caused her neuropathy, she would not have survived,” Ms. Chauhan said. “So she uses that knowledge to balance the negative aspects.

“I’m an optimist by nature,” Ms. Chauhan continued. “I like to focus on what I have, rather than what I don’t have, and I can still walk and use my hands—I’m an artist, so my hands are important to me. That I can still use them is very positive.”

She has tried several medications for her neuropathy, and all of the systemic drugs caused unbearable side effects. Today she manages her pain with Lidoderm patches and the practice of guided imagery and meditation, which she says function mostly as distractions for the pain. “Nothing ever stops it. It’s a 24-7 issue with me. I know that drugs work for some people, and if you can find effective medications under the care of a really knowledgeable physician, that’s great,” she said. “But more basic and translational research is critical for those of us who are living with the condition.”

Understanding the Pain

NCI’s Symptom Management and Health-related Quality of Life Steering Committee, of which Ms. Chauhan is a member, met in Rockville, MD, last year to discuss these issues. This steering committee is one of several that advise NCI as it works to improve the efficiency of clinical trials so that proposed treatment hypotheses can be translated more quickly into new screening, treatment, and prevention options for patients.

What actually causes CIPN, on the cellular and tissue level, is still largely a matter of speculation. There is evidence that nerves can become sensitized because the concentration of salts in the fluid surrounding them changes, or because the channels that use these salts to trigger nerve impulses become dysfunctional. These or other changes may actually damage the structure of nerves.

Because the underlying etiology may vary according to the chemotherapy agent and from patient to patient, more research with animal models is needed, in addition to clinical trials, to try to define the causes of CIPN and identify means to prevent or alleviate it, said Dr. Charles Loprinzi, the Regis Professor of Breast Cancer Research at the Mayo Clinic in Rochester, MN, who chaired the steering committee meeting.

“We need a multi-pronged approach,” he explained. “If we can better understand what causes CIPN in animals and which antidotes might be helpful for preventing and treating it, that doesn’t necessarily mean that [the antidotes] will be exactly the same in humans, but it will allow us the opportunity to screen promising compounds. Ones that successfully alleviate the symptom profiles in animals can be advanced to clinical trials in humans.”

Getting the Right Measures

“I’ve been very lucky not to develop this before now, actually…It’s likely just a side effect of the chemotherapy treatment that I’ve been receiving for the past 10 weeks (Taxol). And that’s why we’re taking a break from chemo this week,” Dr. Susan Niebur wrote in 2007 of her experience with peripheral neuropathy on her blog Toddler Planet, where she documents her experience as a mother and survivor of inflammatory breast cancer.

“Hopefully the week off will allow my system some time to recover and the pain to diminish. Already, my legs are responding more to me (no more wheelchair!) and I can feel my left foot. My right foot and leg, up to the knee, is still tingling and painful to the touch, but I hope that will also resolve in the next few days.” More than 2 years after finishing her chemotherapy, Dr. Niebur still has some residual neuropathy in her right foot and occasionally in her hand, but she wrote in an e-mail that it’s primarily a numbness now, “and a bother more than anything else.”

Patient-reported outcomes (PROs) during and after chemotherapy, such as those Dr. Niebur described, will be an important part of future research on CIPN. A tool that was developed by NCI and that is routinely used to record adverse effects from cancer treatment in clinical trials, the CTCAE, “is not adequate to help us fully understand this condition,” said Dr. Loprinzi. “As opposed to having a health care provider summarize the symptoms of a patient, it is much preferred to have patients more directly record their symptoms.”

PROs commonly include substantially more detailed and accurate information for a variety of symptoms. The steering committee identified several tools, including a 20-item patient questionnaire called the EORTC-QLQ-CIPN20, which appear to better capture this level of information.

Clinical Research Ahead

Several new agents have shown positive effects in pilot studies in patients with CIPN or neuropathy related to diabetes or HIV, and the steering committee has recommended that some of the more promising of these be pursued in larger placebo-controlled randomized clinical trials. Some of these trials are already enrolling patients, while others are still in the planning stages. More information about these trials can be found on NCI’s Web site.

For treating the pain associated with CIPN, agents that appear promising include the antidepressants duloxetine and venlafaxine, which are both serotonin/norepinephrine-reuptake inhibitors. Another promising agent is a topical compound of the muscle-relaxant baclofen, the antidepressant amitriptyline, and the analgesic ketamine.

For preventing the onset of CIPN, the committee recommended further clinical testing of intravenous calcium and magnesium, which reduced CIPN symptoms by approximately half compared with a placebo in one trial involving patients receiving oxaliplatin; a peptide called glutathione, which is thought to bind to heavy metals and has shown promise in small trials in patients who are treated with platinum chemotherapies; acetyl-L-carnitine, a substance that was effective in animal models and in patients with diabetes and HIV; and the antioxidant alpha-lipoic acid.

Pharmacogenomic studies will also, it is hoped, help guide the identification of patients who are more or less likely to develop CIPN. One such study is being planned at the Mayo Clinic to determine how a variation in genes that control taxane and carboplatin metabolism may affect a person’s risk of getting CIPN.

“I’m a relatively conservative person, in terms of how I practice medicine and research,” said Dr. Loprinzi. “But I’m excited about this area. We’re just starting to tap it. Over the next few years, as study results become apparent, I’m reasonably confident that one or two, or possibly more, of these agents will be shown to be beneficial for patients.”

http://www.cancer.gov/aboutnci/ncicancerbulletin/archive/2010/022310/page6