Screening for ChemotherapyInduced Peripheral Neuropathy Elizabeth - PowerPoint PPT Presentation

Screening for Chemotherapy‐Induced Peripheral Neuropathy Elizabeth McGrath DNP, APRN, AGACNP‐BC, AOCNP, ACHPN Lara Ronan MD Victoria Lawson MD Lynsey Teulings MS, APRN Michaela Rowland MS, APRN, AOCNP

CIPN Defined as the presence of signs or symptoms of peripheral nerve dysfunction, as a consequence of damage to the peripheral or autonomic nervous system caused by chemotherapeutic agents

Background • CIPN is a common treatment‐related side effect • It has the potential to result in chemotherapy dose reductions and/or early discontinuation. • The overall incidence of CIPN is ~38% in patients treated with multiple agents • The proportion of cancer patients who experience neuropathic pain at some point in their survivorship ranges from 40% to 70% • This percentage varies depending on regimens, duration of exposure and assessment methods.

Background • Chemotherapy combinations with higher incidences include those that involve platinum drugs, vinca alkaloids, bortezomib and/or taxanes • May begin weeks to months after initiation of therapy • Often presents with a sensory neuropathy, including paresthesia's and pain • Symptoms may resolve after completion of treatment but are often only partially reversible, and can remain for years

Background • Research demonstrates learning about CIPN before chemotherapy was associated with a lower chance of severe CIPN • Having healthcare providers ask about symptoms was linked with a greater chance of moderate vs severe CIPN (28% vs 17%) • Due to lack of evidence for effective management of CIPN, regular assessment of neurological function is recommended. However no standardized measurement for CIPN exists and general agreement regarding the best way to assess and grade CIPN has not yet been reached

CIPN American Society of Clinical Oncology (ASCO) guidelines for the Prevention and Management of CIPN • There are no established agents recommended for the prevention of CIPN in cancer patients undergoing treatment with neurotoxic agents. • This is based on the paucity of high‐quality, consistent evidence and a balance of benefits versus harms.

CIPN Due to the lack of evidence for effective management of neurotoxicity, regular assessment of neurological function is recommended for patients receiving neurotoxic agents

CIPN Process Improvement OBJECTIVES Phase 1 Aim of the project was to evaluate the feasibility of integration of EBP assessment of CIPN into practice, and implement strategies to improve compliance with acceptable practice

Quality Improvement

CIPN Process Improvement Goals • Develop and pilot a standardized process to identify cancer patients at risk for CIPN • APRN conduct initial education session to include discussion of the potential for CIPN • Conduct regular assessment & re‐assessment utilizing an evidenced‐ based assessment tool

Initial audit of 20 charts was done to investigate occurrence of discussion of CIPN by providers before and during chemotherapy INITIAL DISCUSSION OF CIPN 20 6 NP MD

Initial audit of 20 charts was done to investigate occurrence of discussion of CIPN by providers before and during chemotherapy

CIPN A literature search was done to select an evidenced based screening tool

EORTC QOL- CIPN 20 During the past week : Not at A Quite All Little a Bit 45 Did you have difficulty climbing stairs or getting up out of a chair because of weakness in your legs? 1 2 3 46 Were you dizzy when standing up from a sitting or lying position? 1 2 3 47 Did you have blurred vision? 1 2 3 48 Did you have difficulty hearing? 1 2 3 Please answer the following question only if you drive a car 49 Did you have difficulty using the pedals? 1 2 3 Please answer the following question only if you are a man 50 Did you have difficulty getting or maintaining an erection? 1 2 3 Please indicate how long it took you to fill out this questionnaire ___________Minutes

CIPN CTCAE Grading

CIPN • Initially data was collected on patients diagnosed with breast cancer • Subsequently expanded to include colon and head and neck cancer patients • Goal: to screen patients prior to treatment, mid‐cycle and post‐ treatment

REDCap Motor Score Total Missing Min Max Mean St Sum Percentile (N) Dev 0.5 0.10 0.25 0.50 0.75 0.90 0.95 0 36 (0.0%) 6.0 16.0 9.08 1.7 327 8.0 8.0 8.0 8.5 10.0 10.5 12.25 8 Sensory Score Total Missing Min Max Mean St Sum Percentile (N) Dev 0.5 0.10 0.25 0.50 0.75 0.90 0.95 Data 0 36 (0.0%) 8.0 15.0 10.3 1.78 373 8.75 9.0 9.0 10.0 11.0 13.0 13.2 collection instrument Autonomic Score Total Missing Min Max Mean St Sum Percentile (N) Dev 0.5 0.10 0.25 0.50 0.75 0.90 0.95 0 36 (0.0%) 0.0 6.0 2.53 1.06 91 2.0 2.0 2.0 2.0 3.0 4.0 4.25 Please indicate how long it took you to complete the questionnaire (minutes) Total Missing Min Max Mean St Sum Percentile (N) Dev 0.5 0.10 0.25 0.50 0.75 0.90 0.95 20 16 (55.6%) 1.0 5.0 2.63 0.96 42.0 1.75 2.00 2.00 2.50 3.00 3.50 4.25

CIPN Results • The patient time to complete survey is brief: 2‐5 minutes • Only one patient refused to complete the survey • APRN’s felt screening for CIPN did not significantly interrupt the flow of care

CIPN Results • Before chemotherapy (25, 69.4%) • Mid‐regimen (8, 22.2%) • After Chemotherapy (3, 8.3%)

CIPN Conclusions The project demonstrates screening for CIPN can be easily accomplished by APRN’s in the routine care of patients receiving chemotherapy

CIPN Phase 2 • Educate APRN staff and expand screening to include assessment of all patients at risk of CIPN • Expand assessment of chemotherapy‐induced peripheral neuropathy (CIPN) using a combination of subjective and objective measures (TNS Score) • Develop CIPN patient education material • Develop a process to ensure screening is done at the proper intervals • Link CIPN screening to the computerized chemotherapy order set to ensure screening • Develop a process for referral to specialty care when clinically significant CIPN is identified

CIPN References Common Terminology Criteria for Adverse Events (CTCAE), Version 4.0, June 2010, National Institutes of Health, National Cancer Institute. Available at: http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010‐06‐14_QuickReference_5x7.pdf (Accessed March 21, 2017) Lavoie Smith, E.M., Barton, D.L., Qin, R. et al. Qual Life Res (2013) 22: 2787. doi:10.1007/s11136‐013‐0379‐8 Postma, T. J., Aaronson, N. K., Heimans, J. J., Muller, M. J., Hildebrand, J. G., Delattre, J. Y., . . . Lucey, R. (2005). The development of an EORTC quality of life questionnaire to assess chemotherapy‐induced peripheral neuropathy: The QLQ‐CIPN20. European Journal of Cancer, 41(8), 1135‐1139. doi:http://dx.doi.org.dartmouth.idm.oclc.org/10.1016/j.ejca.2005.02.012 Smith, M.L., White, C. B., Railey, E., Bellucci, R. and Thompson, C. Do informed patients have different CIPN outcomes? Results of a research advocacy network survey. Journal of Clinical Oncology 2016 34:7_suppl, 60‐60 Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880‐7