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CME – CIPN: A Guide for Prevention & Management

CME – CIPN: A Guide for Prevention & Management
Author Information (click to view)

Dawn L. Hershman, MD, MS

Associate Professor of Medicine and Epidemiology
Leader, Breast Cancer Program
Herbert Irving Comprehensive Cancer Center
Columbia University

Dawn L. Hershman, MD, MS, has indicated to Physician’s Weekly that she has or has had no financial interests to report.

Figure 1 (click to view)
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Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Cite key recommendations made in the American Society of Clinical Oncology’s clinical practice guideline on the prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers;
  2. Explain the need for more, higher-quality trials focused on the prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwmay5.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Keith D’Oria- Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dawn L. Hershman, MD, MS
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Dawn L. Hershman, MD, MS (click to view)

Dawn L. Hershman, MD, MS

Associate Professor of Medicine and Epidemiology
Leader, Breast Cancer Program
Herbert Irving Comprehensive Cancer Center
Columbia University

Dawn L. Hershman, MD, MS, has indicated to Physician’s Weekly that she has or has had no financial interests to report.

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The American Society of Clinical Oncology has released a guideline for preventing and managing chemotherapy-induced peripheral neuropathy (CIPN) among adult cancer survivors. Although there is no panacea for managing CIPN, it is critical that clinicians address these issues when they emerge.

Chemotherapy-induced peripheral neuropathy (CIPN) is a common treatment-related adverse effect that can significantly affect long-term quality of life and interfere with cancer treatments. The pain can lead to reductions in chemotherapy doses and early discontinuation of the therapy. Studies estimate that about 38% of patients who are treated with multiple agents will develop CIPN, but this rate varies depending on the types of chemotherapy regimens used, duration of exposure to these agents, and how patients are assessed.

“CIPN is an important issue, especially within the context of the most commonly used chemotherapy regimens,” says Dawn L. Hershman, MD, MS. “Many of the drugs that have been evaluated for treating and preventing CIPN are agents that have documented efficacy for other common neuropathies. CIPN, however, is more difficult to manage than other neuropathies because there is greater variability in its pathophysiology and associated symptoms.”

A New Guideline

In 2014, the American Society of Clinical Oncology (ASCO) released a systematic review and evidence-based guideline on the management of CIPN in adult cancer survivors. The ASCO writing panel that developed the guideline systematically reviewed randomized controlled trials (RCTs) from the literature on managing CIPN, compared outcomes among trials, and provided guidance on the effectiveness of prevention and treatment options for CIPN in adults with a history of cancer. Primary outcomes included incidence and severity of neuropathy as measured by neurophysiologic changes, patient-reported outcomes, and quality of life.

CIPN-Prevention-Management-Callout

For the analysis, 48 RCTs met the eligibility criteria and comprised the evidentiary basis for the recommendations. “We studied many agents that have been used for CIPN, but few actually worked,” explains Dr. Hershman, who co-chaired the ASCO writing group that developed the guideline. “Overall, clinical trials tended to be small and many had insufficient sample sizes to detect any important differences in outcomes.” Primary outcomes varied across trials, and in most cases, studies were not directly comparable because of different outcomes, measurements, and instruments used at different time points.

Prevention & Treatment

On the basis of a paucity of high-quality evidence, the ASCO guidelines note that no agents are recommended for the prevention of CIPN (Table 1). “To treat existing CIPN, the best available data support a moderate recommendation for using duloxetine, but we still need more research on use of this drug for CIPN,” Dr. Hershman says (Table 2). Trials were inconclusive regarding tricyclic antidepressants, gabapentin, and a compounded topical gel containing a variety of active ingredients. ASCO reported that these agents may be offered—on the basis of data supporting their utility in other neuropathic pain conditions—given the limited options available to treat CIPN. The guideline panel noted that further research on these agents is warranted.

“Overall, the literature has shown that we lack effective therapies to treat cancer survivors suffering from CIPN,” says Dr. Hershman. “Some are promising or somewhat effective, but the benefits achieved with the currently available agents are small. These findings should serve as a call to action to conduct more research to explore the biologic drivers of CIPN so that we can better understand its pathogenesis. As we increase our understanding, we can use those lessons to help us develop new treatments.” Dr. Hershman adds that more data on the agents currently being used to treat CIPN are needed. Many of the studies reviewed did not consistently report adverse effects, an important missing component for helping make informed decisions about managing CIPN.

Looking Ahead

According to Dr. Hershman, there is an opportunity to decrease the incidence of CIPN if it is reported and recognized early. “We need to define the predictors of CIPN so that we can identify patients who may be at risk,” she says. “Clinicians are lacking a comprehensive and standardized approach to assessing CIPN, but this is vital to ensuring that we get reliable and valid data that can, in turn, enable us to better recognize, understand, and respond to CIPN.”

ASCO recommends that physicians should initiate discussions on the potential for CIPN when managing adult cancer survivors. It notes that patients may feel overwhelmed by their cancer diagnosis and treatment regimen; may not want to burden their healthcare providers with additional concerns; and may think that early CIPN symptoms are imaginary. “Clinicians need to address the intensity and symptoms of CIPN and treat patients empirically with what is available,” Dr. Hershman says. “There are some cases in which CIPN must be tolerated because of our limited treatment choices. However, there are other instances in which early recognition and intervention can guide changes in treatment regimens so that this adverse effect can be avoided.”

Readings & Resources (click to view)

Hershman DL, Lacchetti C, Dworkin RH, et al. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Onc. 2014 Apr 14 [Epub ahead of print]. Available at: http://jco.ascopubs.org/content/early/2014/04/09/JCO.2013.54.0914.full.pdf+html.

Cavaletti G, Frigeni B, Lanzani F, et al. Chemotherapy-induced peripheral neurotoxicity assessment: a critical revision of the currently available tools. Eur J Cancer. 2010;46:479-494.

Pachman DR, Barton DL, Watson JC, et al. Chemotherapy-induced peripheral neuropathy: prevention and treatment. Clin Pharmacol Ther. 2011;90:377-387.

Argyriou AA, Bruna J, Marmiroli P, et al. Chemotherapy-induced peripheral neurotoxicity (CIPN): an update. Crit Rev Oncol Hematol. 2012;82:51-77.

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