SCREENING TOOLS TO DETECT NEUROPATHIC PAIN RELATED TO CHEMOTHERAPY

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ASSESSING THE SEVERITY OF NEUROPATHY IN CIPN

Purpose of assessment:
Determine levels of impairment that patients experience in activities of daily living to guide decision-making about continuing chemotherapy, reducing doses or withdrawing cytotoxic drugs.
For additional information about the tools below, see interview.


WORLD HEALTH ORGANIZATION (WHO) COMMON TOXICITY CRITERIA FOR PERIPHERAL NEUROPATHY
This 4-point scale rates the severity of sensory and motor symptoms. Patients with a score of 0 have no neuropathy and patients with a score of 4 have severely debilitating symptoms of paralysis.
Available online at: http://www.fda.gov/cder/cancer/toxicityframe.htm




NATIONAL CANCER INSTITUTE (NCI) COMMON TOXICITY CRITERIA
This tool assesses sensory and motor function on a grading scale from 0 to 4.
  • Grade 1: Asymptomatic
  • Grade 2: Some sensory alteration or weakness
  • Grade 3: Interfering with activities of daily living
  • Grade 4: Life threatening and disabling (paralysis).
Available online at: http://www.fda.gov/cder/cancer/toxicityframe.htm
and http://ctep.cancer.gov/reporting/ctc.html




EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) GRADING SCALE FOR CIPN
This scale assesses sensory and motor function on a grading scale from 0 to 4.
Available online at: http://ecog.dfci.harvard.edu/general/common_tox.html
Original reference:
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5(6): 649-655.




TOTAL NEUROPATHY SCORE (TNS)
A composite score (0-32 points) combining subjective sensory symptoms, subjective report of symptoms and amount of difficulty with daily activities, deep tendon reflexes, pin sensation, ability to feel vibration and nerve conduction testing of sural and peroneal nerves.
  • Assesses subjective and objective aspects of peripheral nerve function
  • Assesses presence, characteristics, and location of symptoms, as well as physical findings
  • Each item scored by doctor or nurse on 0-4 scale.
Original reference: Cornblath DR, Chaudhry V, Carter K, Lee D, Seysedadr M, Miernicki M, Joh T. Total neuropathy score: validation and reliability study. Neurology 1999; 53(8): 1660-1664.





ASSESSING PAIN IN CIPN

To-date, there is no validated pain scale that measures the intensity and severity of neuropathic pain associated with chemotherapy [for further discussion, see interview].
Clinical and research tools to assess and measure the intensity and quality of neuropathic pain include:


BRIEF PAIN INVENTORY (BPI)
The BPI is a well-validated instrument that consists of 15 items asking the patient about average pain, worst pain in the past week, whether the patient has received relief from pain treatment and whether pain has interfered with daily activities.
Online version and user's guide available at: http://www.mdanderson.org/departments/PRG/



NEUROPATHIC PAIN SCALE (NPS)
The NPS is a self-report scale for measuring neuropathic pain. It consists of 12 distinct questions, which ask about the intensity and quality of the patient's pain. In validation studies, it has been found to have a good predictive power in discriminating between subgroups of patients with neuropathic pain. The brevity of the NPS makes it useful in clinical and research settings in which assessment burden is a significant issue.
Available online at: http://www.mapi-research.fr/t_03_serv_dist_Cduse_nps.htm
Original reference:
Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale. Neurology 1997; 48(2): 332-338.



PAIN QUALITY ASSESSMENT SCALE (PQAS)
The PQAS is a 20-item measure developed to quantify the quality and intensity of neuropathic pain. It was derived from the Neuropathic Pain Scale (NPS) in 2006 and includes pain descriptors common to people with neuropathic and other chronic pain conditions not included on the NPS. The specific items added assess tender, numb, electrical, tingling, radiating, throbbing, aching, shooting, cramping, and heavy pain qualities.
Available online at: http://www.mapi-research.fr/t_03_serv_dist_Cduse_pqas.htm
Original reference: Jensen MP, Gammaitoni AR, Olaleye DO, Oleka N, Nalamachu SR, Galer BS. The pain quality assessment scale: assessment of pain quality in carpal tunnel syndrome. J Pain 2006; 7(11): 823-832.





ASSESSING QUALITY-OF-LIFE IN CIPN


FUNCTIONAL ASSESSMENT OF CANCER THERAPY (FACT)-Taxane
A questionnaire to assess quality of life of patients being treated with taxanes. Measures emotional well-being, functional well-being, physical well-being, social/family well-being and severity of symptoms specific to taxane therapy.
Available online at: http://www.facit.org Translated in 22 languages in addition to English.
Original reference:
Cella D, Peterman A, Hudgens S, Webster K, Socinski MA. Measuring the side effects of taxane therapy in oncology: the Functional Assessment of Cancer Therapy-Taxane (FACT-Taxane). Cancer 2003; 98(4): 822-831.



FUNCTIONAL ASSESSMENT OF CANCER THERAPY/ GYNECOLOGIC ONCOLOGY GROUP NEUROTOXICITY (FACT/GOG-Ntx)
A questionnaire to assess physical, social, emotional and functional well-being in relation to neuropathy in women with ovarian cancer.
Available online at: http:www.facit.org Translated in 41 languages in addition to English.
Original reference: Calhoun EA, Welshman EE, Chang CH, Lurain JR, Fishman DA, Hunt TL, Cella D. Psychometric evaluation of the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (Fact/GOG-Ntx) questionnaire for patients receiving systemic chemotherapy. Int J Gynecol Cancer 2003; 13(6): 741-748.



EUROPEAN ORGANIZATION FOR RESEARCH AND TREATMENT OF CANCER (EORTC) QUALITY OF LIFE QUESTIONNAIRE (QLQ)
A patient self-report questionnaire assessing chemotherapy-induced peripheral neuropathy (the QLQ-CIPN20) is in development in the Netherlands, UK, France and Belgium. The completed instrument will be a patient-based measure of CIPN intended to be practical and psychometrically sound.
Original reference: Postma TJ, Aaronson NK, Heimans JJ, et al. [EORTC Quality of Life Group] The development of an EORTC quality of life questionnaire to assess chemotherapy-induced peripheral neuropathy: the QLQ-CIPN20. Eur J Cancer2005; 41(8): 1135-1139. [see abstract]





Antineoplastic agent bortezomib produces numbness, tingling and pain

Bortezomib, a newly developed proteosome inhibitor shows promising antineoplastic effects against a variety of cancers. It is used in the treatment of multiple myeloma that has relapsed after initial therapy. Neuropathic pain is emerging as a major complication of bortezomib.

A recent study shows that patients with bortezomib-induced neuropathic pain have significantly elevated touch detection threshold, impaired sharpness detection, and elevated thresholds for the detection of skin warming and heat pain. Patients also had increased reports of cold pain.

In spite of powerful analgesic regimens, most patients achieved only modest levels of pain relief, underscoring the refractory nature of pain induced by the chemotherapy drug bortezomib. Pain was accompanied by dysfunction in all fiber types in sensory nerves.


Reference
Cata JP, Weng HR, Burton AW, Villareal H, Giralt S, Dougherty PM. Quantitative sensory findings in patients with bortezomib-induced pain. J Pain 2007;8(4):296-306.





ONLINE RESOURCES ABOUT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY

Mehr JK, Ellison NM. Chemotherapy associated peripheral neuropathy. Fast Fact and Concept #197. February 2008. End-of-Life/Palliative Education Resource Center.
Online at: http://www.eperc.mcw.edu/fastFact/ff_197.htm

Hawley P. Non-tricyclic antidepressants for neuropathic pain. Fast Fact and Concept #187. September 2007. End-of-Life/Palliative Education Resource Center.
Online at: http://www.eperc.mcw.edu/fastFact/ff_187.htm

Weissman DE. Palliative chemotherapy. Fast Fact and Concept #14; 2nd edition, July 2005. End-of-Life Palliative Education Resource Center.
Online at: http://www.eperc.mcw.edu/fastFact/ff_014.htm