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NCCN Cancer Survivorship Guidelines Expanded to Address Two Common Conditions

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Key Points

  • The NCCN Survivorship Guidelines include a new section on cancer-associated cognitive impairment and an expanded adult cancer pain section that more fully addresses chemotherapy-induced peripheral neuropathy.
  • Current management strategies for cognitive impairment are patient-centered, supportive, and nonspecific.
  • Treatment for peripheral neuropathy includes antidepressants and anticonvulsants, with low-dose opioids and topical agents used as intervention, if necessary.

The National Comprehensive Cancer Network (NCCN) has expanded its Survivorship Guidelines to include a section on cancer-associated cognitive impairment, and to include chemotherapy-induced peripheral neuropathy as a component of the Adult Cancer Pain section.

The inaugural guidelines for cognitive impairment were presented at the NCCN 19th Annual Conference by Elizabeth Kvale, MD, of the University of Alabama at Birmingham Comprehensive Cancer Center, while Susan G. Urba, MD, of the University of Michigan Comprehensive Cancer Center, described the new section on peripheral neuropathy.

Dr. Kvale told The ASCO Post, “Chemotherapy-associated cognitive impairment is a common experience for cancer survivors and it has been underrecognized. The guidelines are an important validation of our patients’ symptomatic experience, and they will allow clinicians to take a structured approach to evaluating it and to supporting patients who have this problem.”

Cognitive Impairment

The NCCN Cognitive Function Guideline for Cancer Survivors acknowledges that although patient-reported cognitive dysfunction is associated with cancer treatment and is modestly correlated with testing, there is limited evidence to guide management, especially for cancers other than those of the breast, Dr. Kvale said.

Neuropsychogical testing can help “sort out” the condition, she noted, especially in elderly patients who may have dementia. Neuroimaging, on the other hand, is generally not helpful, but an expanding evidence-base is now suggesting that structural and functional changes underlie the experience, she added.

Patients who present with symptoms of cognitive impairment should also be screened for potentially reversible contributing factors, especially depression. Currently, there is no effective brief screening tool, and available instruments lack adequate sensitivity for subtle declines in cognitive performance.

“Current management strategies are patient-centered, supportive, and nonspecific,” Dr. Kvale said. “Reassurance and watchful waiting are not inappropriate, because many issues resolve on their own.”

Chemotherapy-Induced Peripheral Neuropathy

Perhaps, at this point in time, more can be offered to the 20% to 40% of patients suffering from peripheral neuropathy. The development of neuropathy is a key reason for premature discontinuation of treatment, and for a sizable proportion of patients neuropathic pain persists indefinitely.

“Peripheral neuropathy has been part of the cancer pain guidelines for years, but we are now focusing more on the long-term cancer survivor, who can have late effects of treatment,” Dr. Urba said.

The first line of treatment is antidepressants (especially duloxetine) and anticonvulsants (gabapentin and pregabalin), which are often effective on their own but can be combined with opioids when pain is more resistant, Dr. Urba said.

If opioids are necessary, the lowest dose should be used, and for long-term use clinicians may want to consider establishing a pain treatment agreement, she said. Having patients on opioids can be “tricky,” she indicated. “Clinicians don’t worry about a patient being on gabapentin for years, but they can be uncomfortable prescribing opioids long-term.”

Other interventions recommended by the NCCN include topical agents (usually best when combined with an opioid, antidepressant, and/or anticonvulsant). These include the 5% lidocaine patch, diclofenac gel 1%, and corticosteroids in acute crises.

The psychosocial support of patients left with peripheral neuropathy is important, Dr. Urba emphasized. “They may be on lifelong medication, and they should learn coping skills,” she said. Because of the multidimensional nature of treatment-induced neuropathy, she recommended a “team effort” in order to truly impact this symptom.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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