Neuropathy During Cancer Treatment
Peripheral Neuropathy & Chemotherapy
The peripheral nervous system sends signals between the central nervous system (the brain and spinal cord) to all other parts of the body. Peripheral neuropathy happens when peripheral nerves are damaged, resulting in pain, numbness, tingling, weakness or balance problems among other symptoms. These symptoms usually develop in the legs, feet, arms or hands, but can appear anywhere in the body.
Why does peripheral neuropathy occur in cancer patients?
Cancer patients are at risk for peripheral neuropathy because of the cancer itself and related treatments.
Cancer: Depending on its location, cancer can cause neuropathy. It is possible for cancer to move into the nerves. Cancerous tumors can also press on nerves and cause damage.
Chemotherapy: Chemotherapy can also cause severe nerve damage. Approximately 30-40% of cancer patients experience some form of neuropathy during or after chemotherapy treatment. Often, the hands and feet are the most affected areas.
Other cancer treatments: Surgeries to remove tumors may cause damage to nearby nerves. Also, radiation therapy used to kill cancer cells can impact the nerves in the treatment area. Neuropathy from radiation may not occur until months or even years after treatment.
Other causes of peripheral neuropathy
Peripheral neuropathy can also result from traumatic injuries, infections, metabolic problems and exposure to toxins. One of the most common causes is diabetes. Other causes can include:
- Benign tumors
- Medications
- Alcohol use disorder
- Vitamin/nutrient deficiency
- Inflammatory and autoimmune disease
- Heredity
Peripheral neuropathy symptoms
The symptoms of peripheral neuropathy vary based on the number of nerves involved, the location of the nerves and the severity of damage. There are different types of nerves in your nervous system:
- Sensory nerves send signals to the brain that allow for taste, smell and the sensation of pain.
- Autonomic nerves regulate unconscious processes in your body such as blood pressure, digestion and body temperature.
- Motor nerves carry messages from the brain that tell your muscles to move.
Peripheral neuropathy symptoms for different nerves can include the following:
Sensory nerves
- Numbness
- Tingling
- Lack of balance
- Burning
- Buzzing sensation
- Shocking sensation
Autonomic nerves
- Intolerance of heat
- Excessive sweating
- Loss of bladder control
- Diarrhea or constipation
- Dizziness after standing up
Motor nerves
- Twitching
- Muscle cramps
- Abnormal reflexes
Peripheral neuropathy diagnosis
It is important to diagnose peripheral neuropathy accurately. Some of the following information and tests may be used to find out if you have peripheral neuropathy.
- Medical history: Your health care team will ask you a series of questions about social habits, exposure to toxins, alcohol use, medical treatments and family history of neurological conditions.
- Physical and neurological exams: The doctor will look for signs of peripheral neuropathy and test your coordination, muscle strength and reflexes.
- Blood tests: These can detect exposure to harmful chemicals/toxins and immune system problems.
- Genetic tests: These are typically performed in the form of lab tests.
- EMG (electromyogram): This is a diagnostic test that measures the health of nerves and the muscles they control.
- NCV (nerve conduction velocity): This test measures how fast an electrical impulse moves through your nerves.
- Diagnostic imaging: MRI and CT scans may reveal certain causes of neuropathy such as tumors, herniated disks and abnormalities in veins or arteries.
Stages of peripheral neuropathy
Staging is a way of classifying a condition by symptoms and how the body is affected when it is diagnosed. The stages of peripheral neuropathy are:
- Stage I: Sporadic pain and numbness
- You may notice symptoms occasionally, but not constantly. Often symptoms are easily overlooked during this stage.
- Stage II: Persistent pain and numbness
- Pain and numbness are more constant and increasingly difficult to ignore. Addressing symptoms by this stage is critical to preventing further nerve damage.
- Stage III: Debilitating pain and numbness
- The pain and numbness in stage III are so severe that activity is greatly affected. Walking will become difficult, and you may be unable to balance. Severe numbness increases risk of injuries such as cuts and burns and resulting infections can be life threatening.
- Stage IV: Complete numbness
- Walking is almost impossible due to severely damaged and deadened nerves. The risk of amputations and complications is highest at this stage.
Treating peripheral neuropathy
While it cannot be cured, there are several options to treat peripheral neuropathy and prevent it from worsening. It is important to discuss your options with your health care team.
Ways to address peripheral neuropathy include:
- Correction of the underlying cause (Examples: Stop smoking, address any vitamin deficiencies, and avoid alcohol and toxic agents)
- Medications
- Anticonvulsants: Anticonvulsants have been found effective in managing neuropathy due to their ability to block electrical signals in the nervous system.
- Antidepressants: Certain antidepressants can treat peripheral neuropathy pain. Often, antidepressants are used in combination with other methods such as anticonvulsants.
- Opioids: Opioids may be used for pain that cannot be managed with other treatments. This is generally not recommended due to limited data and the risk of dependence or addiction.
- Topical agents: These include gels, lotions and patches often available over the counter.
- Surgery: Occasionally, surgery can be performed to alleviate painful pressure on nerves.
- Plasma exchange and intravenous immunoglobulin (IVIg): Patients suffering from certain inflammatory conditions may find relief using plasma exchange or immune globulin therapy.
- Transcutaneous electrical nerve stimulation (TENS): A small unit sends low-level electrical impulses though the skin using small adhesive patches; the impulses block the sensation of pain from reaching the brain.
- Physical therapy: With the help of a physical therapist, patients can learn exercises to improve muscle strength. The physical therapist may recommend devices such as canes and walkers.
- Lifestyle modifications (Examples: Avoid alcohol, stop smoking, exercise regularly and eat a well-balanced diet that supports nerve health).
- Alternative medicine: Acupuncture and massage may help patients with peripheral neuropathy.
Peripheral neuropathy safety tips
There are several steps patients can take to limit the impact of peripheral neuropathy. These include:
- When running water, start with a cold temperature then gradually shift to warmer.
- Use gloves for protection when exposed to cold temperatures and while performing activities such as yard work.
- Wear socks.
- Inspect your hands and feet regularly for cuts and injuries.
- Do not drive a vehicle if you are unable to feel the brakes or gas pedal.
- Take steps to prevent falling, including:
- Both indoors and outdoors, wear shoes that fit properly and have a rubber sole.
- Avoid walking on surfaces that are uneven.
- Keep your living area well lit.
- If advised, use a cane or walker.
- Consider installing grab bars in the shower/bathtub and stairway railings at home.
- Keep floors clear of things that could cause you to trip such as electrical cords or rugs.
Many patients receive chemotherapy as part of their cancer treatment plan. These drugs have long shown benefits in extending patients’ lives, but they are also known for their side effects.
Chemotherapy-induced peripheral neuropathy is one of the most common side effects patients can experience. It can occur while a patient is receiving chemotherapy or after treatment is finished.
There are many approaches to managing the discomfort of peripheral neuropathy. We spoke with Salahadin Abdi, M.D., Ph.D., to learn more.
What are the symptoms of peripheral neuropathy?
Patients can feel pain, numbness and tingling in a “glove and stocking” distribution. The most severe symptoms are typically experienced on the palm-side surfaces of the hands and the bottom surfaces of the feet.
For some patients, neuropathy brings only mild discomfort, but others experience extreme changes that impact their balance, lead to trouble walking and cause sleepless nights. It negatively affects their quality of life.
What causes the pain of peripheral neuropathy?
Chemotherapy drugs work by clearing out any rapidly growing cells. Although they’re effective in wiping out cancer cells, they can also affect normal cells, which leads to side effects.
Sometimes, the central nervous system is affected. This can cause some patients to experience confusion and forgetfulness. This is known as chemobrain. Other times, the nerves in the arms, legs, feet and hands are impacted. This leads to pain and/or tingling, burning or numbness in the limbs.
There are two things happening with the chemotherapy and the nerves. First, the chemotherapy can cause structural damage to the nerves.
Secondly, it can influence how the brain registers pain. When a patient has a nerve injury in the hands, feet, arms or legs, it’s translated into signals that travel to the patient’s brain to alert it that something’s wrong. This signal is what’s perceived as pain. Unfortunately, even if the nerves are structurally OK, they may function abnormally after chemotherapy, and the brain’s perception of nerve signals in the limbs can still be altered.
How long does peripheral neuropathy last?
Some patients only experience symptoms of peripheral neuropathy for a short time while they’re receiving chemotherapy. Once the treatment stops, the nerves recover, and the neuropathy sensation goes away.
But many patients experience the feeling after they stop chemotherapy – sometimes years later.
How is peripheral neuropathy treated?
There are several medication options that can help reduce the pain and discomfort, but they can have side effects that can be just as disruptive as peripheral neuropathy.
Are there non-medication treatment options for peripheral neuropathy?
Yes. Some non-medication treatment options include acupuncture, acupressure, exercise or physical therapy intervention, neurofeedback therapy and cognitive-behavioral therapy.
Because so many patients experience peripheral neuropathy, there’s a lot of research being devoted to exploring effective treatments with fewer side effects. Three areas of alternative options include:
- Scrambler therapy – Scrambler therapy mixes up the pain signals to only permit normal, non-pain signals to be transmitted to the brain. Electrode patches are placed on the skin around the area where the patient is experiencing pain. The patches are tethered to a machine that sends electrode pulses to the area to interfere with the pain signal, which then reduces the pain sensation the patient perceives. Overall, we’ve seen a significant increase in patients’ quality of life. Patients have reported experiencing less pain, and others have also had sensation return where they had previously had numbness. MD Anderson has been pivotal in studying scrambler therapy, but it’s still not as widely available as I’d like to see.
- Neurostimulators – Neurostimulators are in the early stages of investigation. These implanted devices deliver electric signals to interfere with pain signals. Historically, implanted electrodes have been placed around the spinal cord. A newer approach implants the electrodes at the root of the nerve known as the dorsal root ganglion that branches off from the spine. There are early signs that this placement may be more beneficial for some patients, but more research is needed.
- Cryotherapy – Another treatment called cryotherapy targets the extremities of the body with cold. With this approach, patients wear devices such as bracelets and ankle cuffs or gloves and socks that are designed to continuously circulate a cooling feeling to the arms, hands, legs and feet. However, there are risks and many patients don’t find much relief with cryotherapy. Some patients are sensitive to the cold, and their symptoms get worse.
What is your advice to patients experiencing chemotherapy-induced peripheral neuropathy?
Don’t hesitate to share what you’re experiencing with your care team. MD Anderson patients should speak with their doctor about our Pain Management Center. We have a multidisciplinary team that’s devoted to making our patients as comfortable as possible.
But no matter where you’re getting your cancer treatment, it’s important to speak up about pain sooner rather than later. Don’t wait until your quality of life is really affected. Like any other disease, the earlier you start treatment, the better outcomes you’ll have.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Simple exercises may help cancer survivors struggling with peripheral neuropathy, a common cancer treatment side effect that causes muscle weakness, decreased feeling and trouble balancing.
While exercise can’t make peripheral neuropathy go away, studies show it can help minimize pain and improve strength and balance, says Whittney Thoman, an exercise physiologist at MD Anderson.
Talk to your doctor
Thoman stresses the importance of talking to your doctor before starting any new exercise program. He or she may have advice specific to your treatment or cancer.
For most cancer survivors, The American Cancer Society and the American College of Sports Medicine recommend avoiding inactivity and resuming exercise as soon as possible. Survivors should aim for 150 minutes of moderate intensity exercise or 75 minutes of vigorous intensity exercise per week. The American Cancer Society also recommends including strength-building exercises in your routine at least two days per week.
In addition, patients who are able to exercise during treatment should do so, but they may need to make adjustments.
Work with a trainer or physical therapist
Once you receive your doctor’s permission to exercise, Thoman suggests meeting with a trainer, exercise physiologist or physical therapist. This way, you can work together to establish your exercise routine and ensure that you’re doing movements correctly.
Use a stable environment
Because neuropathy affects your balance, it’s important to exercise in a stable environment where you’re less likely to fall down or drop something.
Thoman recommends using weightlifting machines. “If you use free weights, you’re more likely to drop them and injure yourself,” Thoman says.
If you want a cardiovascular workout, try a stationary bike rather than a treadmill or elliptical machine.
“Anything where your body is stable is safer,” Thoman says.
Work on balance
To help improve your balance, Thoman recommends doing exercises that will help strengthen your stabilizing muscles.
“It doesn’t have to be anything complicated,” she says. “Try standing on one foot while you brush your teeth. If you mastered that, try standing on one foot with your eyes closed.”
Be consistent
To see results, Thoman recommends completing these exercises two to three times a week.
“Consistency is very important,” she says. This will help you make a habit of exercising. And that will help improve your strength and balance so that you start to see your neuropathy symptoms lessen.
Don’t overdo it
Depending on your cancer treatment, you may need more time to rest between exercise sessions, Thoman says. Give yourself 48 to 72 hours to recover between resistance training sessions.
Following all of these steps can help you ease neuropathy symptoms.
“Exercise can’t undo neuropathy,” Thoman says. “But it can make a big difference when it comes to functionality and daily life.”
For many of our patients, peripheral neuropathy is among the unexpected side effects of cancer treatment.
It's caused by damage to your peripheral nerves -- that is, the nerves that are farther away from your brain and spinal cord. Certain complications of cancer or cancer treatments can cause or worsen neuropathy. So can some health conditions, such as diabetes, alcoholism, AIDS, hypothyroidism, rheumatoid arthritis and carpel tunnel syndrome.
We recently spoke with Julie Walker, advanced practice nurse in Neuro-Oncology, about peripheral neuropathy. Here's what she had to say.
What causes peripheral neuropathy in cancer patients?
The nerve damage that causes peripheral neuropathy may be the result of many different factors, including some chemotherapy drugs using vinca alkaloids, platinum compounds, taxanes and thalidomide.
Tumors themselves can cause nerve damage as well if they grow close to and press on the nerve.
And, patients with cancers of the nervous system -- such as brain tumors, spine tumors and skill base tumors -- are more likely to develop peripheral neuropathy due to nerve damage resulting from the tumor.
What are common peripheral neuropathy symptoms?
Symptoms depend on the type(s) and location(s) of the damaged nerves. The most common peripheral neuropathy symptoms include:
- numbness
- tingling
- shooting pain or burning, especially in your fingers or toes.
Other peripheral neuropathy symptoms include:
- loss of balance, difficulty walking or frequent falls
- clumsiness
- difficulty picking up objects or buttoning your clothes
- facial pain
- hearing loss
- loss of sensitivity to hot and cold
- stomach pain
- constipation
What can cancer patients do to relieve peripheral neuropathy?
If the neuropathy is related to something you can control, try to control the cause.
If your neuropathy is chemo-related, your oncologist can decide whether it's beneficial to reduce your chemotherapy dosage or switch to a different treatment regimen.
If it's related to diabetes, you can often slow down or stop the progression of peripheral neuropathy with better blood sugar control.
Beyond that, physical activity can help by keeping blood flowing in the affected areas. Some people also try acupuncture.
Over-the-counter pain relievers and prescription medications like carbamazepine and Lyrica may help in some cases. Non-prescription-type treatments -- such as acetyl l-carnitine, alpha lipoic acid, glutamin, calcium and magnesium -- may help, too. But more research is needed to better gauge their effectiveness. Be sure to speak with your health care provider before trying any of these.
What can cancer patients do to lower their chances of developing peripheral neuropathy?
If you have other health conditions, such as diabetes, that can make the neuropathy worse, manage them appropriately. Limit alcohol use. Maintain a well-balanced diet. And, discuss your neuropathy risks with your health care provider.
How long do peripheral neuropathy symptoms last?
Every case is different. Because neuropathy is caused by nerve damage, it depends largely on how well your nerves recover. And, that depends on the length of your treatment, extent of the damage and, in the case of chemotherapy-induced neuropathy, dosage intensity.
It's usually possible to manage peripheral neuropathy up to a certain point, but for many people, it never goes away.
As the nerves heal, some people may actually experience more tingling in the affected area. Speak with your health care provider to find out if a prescription might help relieve symptoms during this time.
People with peripheral neuropathy lose the ability to feel pain or extreme temperatures in the affected areas.
What can cancer patients with peripheral neuropathy do to avoid burning or injuring themselves?
Always wear shoes to protect your feet from an injury. Also, make sure you examine your feet every day to look for any wounds or sores that aren't healing.
Be careful when using sharp utensils or avoid them altogether. Likewise, since neuropathy typically inhibits your fine motor movements, be cautious around or avoid dangerous machinery.
Before touching water with your hands or feet, feel the water with a part of your body -- such as the underside of your forearm -- that can sense how warm it is. And, avoid using heating pads and hot water bottles.
Any other advice for cancer patients who are experiencing neuropathy?
People with neuropathy are more prone to falls because they struggle to feel the ground beneath them, especially in the dark or an enclosed space. So:
- use a nightlight
- keep clutter and throw rugs off the floor
- use handrails when taking the stairs
- put handrails in the shower
- use skid-free shower and bath mats
Neuropathy also makes the body more prone to infection since circulation is decreased and wounds don't heal as well. So it's a good idea to keep your skin moist to prevent cracking and, in turn, infection.
The most important thing you can do, though, is to speak with your health care provider as soon as you start to experience neuropathy symptoms. Together, you can hopefully find ways to manage your symptoms.