I finished chemotherapy 3 months ago and am struggling with numbness and tingling in my feet. I’ve been tripping more than usual, and fell down on my driveway last week during a rainstorm. Fortunately, I only bruised my hip, but I’m worried that I may break a bone next time. My doctor says I have neuropathy from the chemotherapy. Will it get better? Is there anything I can do to improve my balance?
The problem you are describing is called chemotherapy-induced peripheral neuropathy (CIPN). It is very common among cancer survivors. The problem happens in the nerves in our body (the peripheral nervous system), outside of our brain and spinal cord (the central nervous system).
To some degree, neuropathy affects between 30% and 40% of cancer survivors who receive chemotherapy. It is believed to be a side effect of some chemotherapies. The chemotherapies most often associated with CIPN are:
- Platinum-based drugs: Platinol (cisplatin), Paraplatin (carboplatin), Eloxatin (oxaliplatin)
- Taxanes: Taxol (paclitaxel), Taxotere (docetaxel), Jevtana (cabazitaxel)
- Epothilone: Ixempra (ixabepilone)
- Other mitotic inhibitor: Halaven (eribulin)
- Vinca alkaloids: Oncovin (vincristine), Velban (vinblastine), Navelbine (vinorelbine), Etopophos (etoposide)
- Immunomodulators: Thalomid (thalidomide), Revlimid (lenalidomide), Pomalyst (pomalidomide)
- Proteasome inhibitors: Velcade (bortezomib), Kyprolis (carfilzomib)
The Symptoms of CIPN
Mild to moderate numbness, tingling, and pain in the hands and feet are common in CIPN. The pain is often described as burning, stabbing, throbbing, shooting, or electric. Itching can also be related. Difficulty in feeling vibrations, or difficulty in telling the position of a body part without looking at it can also occur.
With platinum-based drugs, the symptoms can occur after long-term therapy and may develop several weeks after the last chemotherapy dose. Muscle weakness sometimes occurs at the far ends of the limbs, such as the ankles, feet, toes, hands, or fingers. A reduced or absent Achilles tendon reflex sometimes also happens.
Sometimes, CIPN involves the autonomic nervous system. This can cause digestion issues, constipation, diarrhea, nausea, or vomiting. Blood pressure and heart rate can also be affected, causing dizziness when getting up, or abnormal heart rhythms.
Sometimes the peripheral nerves may be able to repair themselves, and the symptoms are often relieved over time. This repair process, however, is slow. If the damage is too severe, the symptoms may persist and not go away.
Who Is at Risk?
The factors that predict who is at risk for severe or persistent CIPN are not completely clear. However, the risk for CIPN and for more severe symptoms is linked to higher-dose chemotherapy, and/or higher total doses of chemotherapy.
Certain people may be at higher risk for CIPN, including people who already have neuropathies, or those who have diabetes, autoimmune disorders, digestive disorders, malabsorption disorders, or those who drink alcohol excessively. Symptoms such as CIPN can also be caused by a cancer that is progressing or spreading.
Because the causes for neuropathies can be other than CIPN, it is important to find out what is the cause.
The first step in recognizing neuropathy is to talk with your oncology team. You can discuss your symptoms, including the onset, location, and how they have changed over time.
Your oncology team may also review any preexisting medical conditions that can cause similar symptoms.
Your oncology team may also order lab tests to look for metabolic problems and nutritional deficiencies. They may also explore whether the cancer is progressing, and review and adjust your chemotherapy regimen as needed.
Some patients will also have neurodiagnostic tests, such as electromyography, nerve conduction studies, and quantitative sensory tests.
Medications are available to reduce the pain and sensory symptoms related to CIPN. There is good evidence showing the benefits of Cymbalta (duloxetine). Doctors often try other medications that are helpful for other neuropathies, but good evidence for these helping in CIPN is not yet available. A physician may try treatments such as:
- Patches or numbing cream, such as lidocaine patches or capsaicin cream, which can be applied to smaller painful areas
- Small doses of antidepressants, such as Pamelor (nortriptyline), Elavil (amitriptline), Effexor (venlafaxine), or Cymbalta (duloxetine)
- Antiseizure medicines, including Neurontin (gabapentin) and Lyrica (pregabalin), used to help other types of nerve pain
- Opioids may be tried if the pain is severe and chronic
It may take more than one try to find out what works best for you.
Your oncology team may refer you to a physiatrist (a doctor who specializes in rehabilitation), a physical therapist, or an occupational therapist for evaluation and treatment. The physiatrist may do some imaging, lab and/or neurodiagnostic tests, as well as bracing and certain injections. The physiatrist may also identify and treat other pain causes that affect your mobility and quality of life, such as arthritic joints or bursitis.
A physical therapist can help survivors with CIPN to improve balance, gait, and coordination. An occupational therapist can help survivors with fine motor skills and dexterity. Occupational therapists can visit your home to help you with walking or getting around in your home and community safely. They may also try therapeutic modalities, such as desensitization or manual lymph drainage. They may find that using a cane or a walker may make a big difference in your steadiness. These interventions help to decrease falls and injuries, while increasing physical function, independence, and quality of life. You also can try:
- Relaxation therapy
- Guided imagery
Tips for Managing CIPN to Help You Take Charge of Your Health and Safety:
- Taking medicines as prescribed by your doctor. Most as-needed pain medicines work best if they are taken before the pain gets bad
- If constipation is a problem, follow your doctor’s recommendations about laxatives, other medications, and exercise. Drink plenty of water and eat fruits, vegetables, and whole grains to get enough fiber
- Avoid things that make your CIPN worse, such as hot or cold temperatures, snug clothes, and tight shoes
- Stop drinking alcohol; it can cause neuropathy and make CIPN worse
- If you have diabetes, work to control your blood sugar. High blood sugar levels can also cause neuropathy
- If you have decreased sensation in your hands, be very careful when using knives, scissors, and other sharp objects. Use them only when you can give your full attention to your task. Protect your hands by wearing gloves when you clean, work outdoors, or do repairs
- Set hot water heater thermostats between 105°F and 120°F to reduce risk of accidental scalding. Check bath water with a thermometer, and use gloves when handling hot dishes or pans
- Protect yourself from cold weather and frostbite. Keep your hands and feet warm and well covered. For example, consider keeping a pair of gloves in your car. Avoid extreme temperatures
- Use night-lights or flashlights when walking around in the dark
- Make sure to take care of your feet. Look at them once a day to see if you have any injuries or open sores. Use a mirror, or have someone else look at the areas of your feet that you cannot easily see, such as the soles or back of the heel. Always wear shoes that cover your whole foot when walking, even at home. Talk to your doctor about special shoes
- Be sure that you have ways to support yourself if you have problems with stumbling while walking. Handrails in hallways and bathrooms may help you keep your balance
- If you often get dizzy when getting up, rise slowly, and then give your body a little extra time to adjust before standing. Then again give your body extra time to adjust before walking
- Give yourself extra time to do things, and ask for help with difficult things
- Talk to your oncology team or primary care physician about the problems you are having. They may be able to treat your symptoms and reduce the risk for CIPN worsening, or help you to improve your physical function