Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers

Publication Date: July 14, 2020
Last Updated: January 19, 2024

Prevention

Prevention of chemotherapy-induced peripheral neuropathy

Recommendation 1.1

Clinicians should assess the risks and benefits of agents known to cause CIPN among patients with underlying neuropathy and with conditions that predispose to neuropathy such as diabetes and/or a family or personal history of hereditary neuropathy. ( IC , H , H , W )
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Recommendation 1.2

Clinicians should NOT offer, and should discourage use of, acetyl-L-carnitine for the prevention of CIPN in cancer patients. ( EB , I , B , S )
3336

Recommendation 1.3

Outside the context of a clinical trial, no recommendations can be made on the use of the following interventions for the prevention of CIPN:
  • Acupuncture
  • Cryotherapy
  • Compression therapy
  • Exercise therapy
  • Ganglioside-monosialic acid (GM-1)
(, , , W )
Note: While preliminary evidence suggests a potential for benefit from these interventions, larger sample-sized definitive studies are needed to confirm efficacy and clarify risks.
(No recommendation)
3336

Recommendation 1.4

Clinicians should NOT offer the following agents for the prevention of CIPN to cancer patients undergoing treatment with neurotoxic agents:
  • All-trans retinoic acid
  • Amifostine
  • Amitriptyline
  • Calcium magnesium
  • Calmangafodipir
  • Cannabinoids
  • Carbamazepine
  • L-carnosine
  • Diethyldithio-carbamate (DDTC)
  • Gabapentin/pregabalin
  • Glutamate
  • Glutathione (GSH) for patients receiving paclitaxel/carboplatin chemotherapy
  • Goshajinkigan (GJG)
  • Metformin
  • Minocycline
  • N-acetylcysteine
  • Nimodipine
  • Omega-3 fatty acids
  • Org 2766
  • Oxcarbazepine
  • rhuLIF
  • Venlafaxine
  • Vitamin B
  • Vitamin E
(EB, NB, M, I)
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Treatment

Treatment of chemotherapy-induced peripheral neuropathy that develops while patients are receiving neurotoxic chemotherapy

Recommendation 2.1

Clinicians should assess, and discuss with patients, the appropriateness of dose delaying, dose reduction or stopping chemotherapy (or substituting with agents that do not cause CIPN) in patients who develop intolerable neuropathy and/or functional nerve impairment. ( IC , H , H , W )
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Treatment of chemotherapy-induced peripheral neuropathy for patients who have completed neurotoxic chemotherapy

Recommendation 3.1

For cancer patients experiencing painful CIPN, clinicians may offer duloxetine. ( EB , L , H , M )
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Recommendation 3.2

Outside the context of a clinical trial, no recommendations can be made on the use of the following interventions for the treatment of CIPN:
  • Exercise therapy
  • Acupuncture
  • Scrambler therapy
  • Gabapentin/pregabalin
  • Topical gel treatment containing baclofen, amitriptyline HCL, plus/minus ketamine
  • Tricyclic antidepressants
  • Oral cannabinoids
(, , , W )
Note: While recent preliminary evidence suggests a potential for benefit from exercise, acupuncture, and scrambler therapy, larger sample-sized definitive studies are needed to confirm efficacy and clarify risks.
(No recommendation)
3336

Recommendation Grading

Overview

Title

Prevention And Management Of Chemotherapy-Induced Peripheral Neuropathy In Survivors Of Adult Cancers

Authoring Organization

American Society of Clinical Oncology

Publication Month/Year

July 14, 2020

Last Updated Month/Year

October 1, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To update the ASCO guideline on the recommended prevention and treatment approaches in the management of chemotherapy-induced peripheral neuropathy (CIPN) in adult cancer survivors.

Target Patient Population

Adult cancer survivors with, or at risk for developing, chemotherapy-induced neuropathies

Target Provider Population

Health care practitioners who provide care to cancer survivors

PICO Questions

  1. What are the recommended prevention approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors?

  2. What are the recommended treatment approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Long term care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management, Prevention

Keywords

chemotherapy, acute inflammatory demyelinating polyneuropathy (AIDP), cancer survivors, cancer pain, chemotherapy-induced neuropathies

Source Citation

DOI: 10.1200/JCO.20.01399 Journal of Clinical Oncology 38, no. 28 (October 01, 2020) 3325-3348.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
45
Literature Search Start Date
January 1, 2013
Literature Search End Date
August 28, 2019
Description of External Review Process
ASCO has a rigorous review process for guidelines. After the draft has been approved by the Expert Panel, the guideline is independently reviewed and approved by the Clinical Practice Guideline Oversight Committee (CPGC). Select members of the CPGC are asked to critically review the guideline prior to the next scheduled CPGC meeting. The CPGC members then present the results of their reviews to the full committee, discuss the review with the full committee, and the CPGC votes on whether to approve the guideline (with recusals from members who have relationships with affected companies). Approved ASCO Guidelines are then submitted to the Society’s journal for consideration of publication.
Description of Public Comment Process
ASCO Guidelines are available for open comment for a 2 to 3‐week period. Guideline recommendations available for open comment are posted on asco.org/open‐comment‐guidelines. Prospective reviewers must contact ASCO to request to review the draft guideline recommendations and are required to sign a non‐disclosure and confidentiality agreement before receiving the draft guideline recommendations. Reviewers must identify themselves by name and affiliation; anonymous comments will not be accepted. Guidelines staff review and summarize comments and bring relevant comments to the Expert Panel Co‐ chairs, and to the entire panel if necessary. Any changes made from the open comment process will be reviewed by the entire panel prior to CPGC approval. Comments are advisory only and ASCO is not bound to make any changes based on feedback from open comment. ASCO does not respond to reviewers or post responses to comments; however, major edits to the draft will be reflected in the open comment discussion.
Specialties Involved
Family Medicine, Geriatric Medicine, Internal Medicine General, Oncology, Pain Medicine, Post Acute And Long Term Care
Description of Systematic Review
The Protocol specifies the purpose of the guideline product, target patient population, clinical outcomes of interest, key features of the systematic literature review, and a proposed timeline for completion. ASCO staff, the Expert Panel Co‐Chairs, and possibly other panel members selected by the Co‐Chairs (the Expert Panel Steering Committee), will typically draft the protocol for full panel review. A standard protocol worksheet is used for consistency. Once the Co‐Chairs have approved a first draft of the Protocol, the Protocol will be shared with the full Expert Panel. At the discretion of the Guidelines Director, the CPGC leadership and/or the CPGC Methodology Subcommittee may review the Protocol to make suggestions for revision intended to clarify aspects of the plan for developing the guideline. These suggestions are sent to the Expert Panel Co‐Chairs. Work on the systematic literature review can proceed upon the sign‐off of the Protocol by the Expert Panel.
List of Questions
What are the recommended (1) prevention and (2) treatment approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors?
Description of Study Criteria
Refer to supplement
Description of Search Strategy
Upon approval of the Protocol, a systematic review of the medical literature is conducted. ASCO staff use the information entered into the Protocol, including the clinical questions, inclusion/exclusion criteria for qualified studies, search terms/phrases, and range of study dates, to perform the systematic review. Literature searches of selected databases, including The Cochrane Library and Medline (via PubMed) are performed. Working with the Expert Panel, ASCO staff complete screening of the abstracts and full text articles to determine eligibility for inclusion in the systematic review of the evidence. Unpublished data from meeting abstracts are not generally used as part of normal ASCO guideline development (“Meeting Data”). However, abstract data from reputable scientific meetings and congresses may be included on a case‐by‐case basis after review by the CPGC leadership. Expert Panels should present a rationale to support integration of abstract data into a guideline. The CPGC leadership will consider the following inclusion criteria for the unpublished scientific meeting data: 1) whether the data were independently peer reviewed in connection with a reputable scientific meeting or congress; 2) the potential clinical impact of the unpublished data; 3) the methodological quality and validity of the associated study; 3) the potential harms of not including the data; and 4) the availability of other published data to inform the guideline recommendations.
Description of Study Selection
Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplement.
Description of Evidence Analysis Methods
ASCO guideline recommendations are crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology. ASCO adopted a five‐step approach to carry out quality appraisal, strength of evidence ratings and strength of recommendations ratings. The ASCO approach was primarily adapted from those developed by the AHRQ,, USPSTF, and GRADE, however with the validation of the GRADE methodology, the sole use of GRADE is being evaluated by the Clinical Practice Guidelines Committee.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect. Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect. Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect. Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
ASCO uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations. Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice. Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field). Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
Yes
Company/Author Disclosures
ASCO provides funding for Guideline Development
Percentage of Authors Reporting COI
100