Cancer care

Australian consensus achieved on CIPN clinical pathway

Implementation of a new clinical practice pathway for the assessment and management of chemotherapy-induced peripheral neuropathy (CIPN) is expected to improve outcomes for Australian patients.

The CIPN clinical pathway, developed through a consensus process including medical oncologists, neurologists, nurses, allied health professionals and specialised CIPN researchers, highlights the critical importance of a multidisciplinary team.

However initial consensus was difficult to achieve on some items and there was also concern about the feasibility of the pathway especially relating to access to neurologists, an article in Supportive Care in Cancer said.

“A common theme reported by respondents was potential difficulties with incorporating neurology services into CIPN management, including that “timely access to neurology and NCS is a barrier at some sites”, “routine neurology review may not be helpful, or be feasible, particularly in busy clinics”, and that in rural areas “patients do not have access to publicly available neurologists or specialised allied health professionals”.”

The process achieved consensus on the pretreatment review of patients which should include patient education about CIPN (100%), a medical history to identify potential CIPN risk factors (98.5%), and patients with preexisting neuropathy or at high-risk for CIPN should be considered for pretreatment neurological assessment or closer monitoring (94.2%).

There was also a high level of consensus that screening and assessment for CIPN should occur at every treatment cycle (94.2%), at follow-up visits after treatment has finished (97.0%), and that patients with CIPN should be followed up with longer assessment tools to assess symptoms and impact on daily function (94.2%).

However there was less agreement on screening and assessment options (75.7%), whether a short patient-reported questionnaire was appropriate (72.5%) and which staff members should be responsible for CIPN screening (52.9%).

Regarding CIPN management and referral, participants agreed that symptoms including neuropathic pain, balance impairment, and sleep disturbances, may warrant closer monitoring, additional investigation and referral to other healthcare providers (98.5%).

Duloxetine was the only medication specifically mentioned as treatment for painful CIPN or “other medications as per 2020 ASCO guidelines“.

Participants agreed patients should be encouraged to stay physically active (98.5%), that patient education should include foot care and safety measures to reduce the risk of falls and thermal injury (98.5%).

Consensus was also achieved that patients with worsening or prolonged CIPN symptoms should be referred to a neurology service (86.4%).

The authors, led by Dr David Mizrahi from The Daffodil Centre, said the best practice timing, frequency, and responsibility for CIPN screening were not well established.

“Our results highlighted support for enhanced CIPN management in clinical practice to assist teams across different health services to identify CIPN symptoms, aid decision-making, and reduce morbidity from CIPN, as well as identify focus areas for future implementation strategies,” they said.

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