The treatment paradigm for colorectal cancer (CRC) in both the adjuvant and metastatic settings includes the use of oxaliplatin in combination with fluorouracil and folinic acid (FOLFOX).1 It is well known that one of the most troubling side effects associated with oxaliplatin is peripheral neuropathy. Chemotherapy-induced peripheral neuropathy (CIPN) associated with oxaliplatin can be acute or chronic. Acute CIPN can have an immediate onset during the oxaliplatin infusion or can occur hours to days later. Typically it will resolve between cycles of chemotherapy treatment. Chronic CIPN has a more gradual onset, associated with cumulative doses of oxaliplatin, it can be persistent between treatments without resolution and can intensify with subsequent cycles of therapy.
Tofthagen and colleagues explored the characteristics of peripheral neuropathy in 33 CRC patients undergoing chemotherapy with oxaliplatin. Their descriptive research sought to investigate the prevalence of neuropathic symptoms in this patient population.2
Patients were accrued from a large NCI-designated comprehensive cancer center in west central Florida and a medical oncology private practice within the same geographic area. The researchers used the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool (CIPNAT). This tool contains items relating to symptom experience and interference. The symptom experience scale measured nine neuropathic symptoms; participants were asked to rate these symptoms on a 0-10 scale in terms of intensity, distress and frequency. These symptoms consisted of: cold sensitivity, tingling hands, numbness in hands, tingling feet, muscle weakness, numbness in feet, muscle or joint aches, trouble with balance and nerve pain. The interference scale measured 14 items or activities in terms of the degree to which they interfere with the patient’s ability to perform these activities, also using a 0-10 rating scale. These activities included: dressing, walking, picking up objects, holding onto objects, driving, working, participating in hobbies or leisure activities, exercising, sexual activity, sleeping, relationships with others, writing, household chores and enjoyment of life. 2
All participants reported experiencing at least one of the nine symptoms following initiation of chemotherapy with oxaliplatin. On average participants experienced 4.6 neuropathic symptoms. The top three symptoms realized were cold sensitivity, tingling in the hands and numbness in the hands. The hands (n = 25), throat (n = 15), mouth (n = 12) and jaw (n =8) were the most common locations of cold sensitivity. Nerve pain developed in 10 (30%) participants and was often described as burning, shooting or sharp. The mean severity of symptoms was 4.6, with the mean distress and frequency at 3.8 and 5.5 respectively on the 0-10 scale. Participants noted a mean interference in 5.2 of 14 activities. Activities most commonly interfered with enjoyment of life, sleep and hobbies.
The FDA approval for oxaliplatin in 2002 was indicated for treatment of metastatic CRC, it then was approved for use in the adjuvant setting in 2005. This subsequent approval has broadened the scope of use and potential impact of toxicities. Oxaliplatin is not the first chemotherapeutic agent carrying with it CIPN. Nonetheless, there has been little advancement in the prevention and management of such effects. Albeit a small number of participants evaluated, the work of Tofthagen et al, reveals the critical impact CIPN has on the quality of life of CRC patients receiving oxaliplatin therapy. It is imperative that oncology nurses thoroughly evaluate the grade of severity of CIPN from initiation of therapy and throughout in order to communicate with the medical oncologist the patient experience and proactively institute the safeguards necessary to prevent disabling sequelae. Further research on prevention and management of CIPN is desperately needed in order to overt suboptimal treatment outcomes.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) Colon Cancer v 3.1011. Retrieved from: http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf (Free registration required.)
- Tofthagen, C, McAllister, RD, & McMillan, SC. Peripheral neuropathy in patients with colorectal cancer receiving oxaliplatin. Clin J Oncol Nurse 2011; 15:182-188.doi: 10.118811.CJON.182-188 Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/21444285