Peripheral neuropathy

Cancer and its treatment can sometimes damage nerves around the body. This is known as peripheral neuropathy. It can happen for a number of reasons. For example:

  • it can be a side effect of some anti-cancer drugs
  • a tumour may be pressing on a nerve close by
  • surgery or radiotherapy may sometimes damage nerves.

If you have peripheral neuropathy, your symptoms will vary depending on the nerves affected. You may experience pain, sensitivity, numbness, or weakness. This is often in the hands, feet, or lower legs. The nerves controlling digestion and blood pressure can also be affected, so you may have constipation, dizziness or other symptoms.

If you’re being treated with drugs that are known to cause peripheral neuropathy, your doctor will monitor you for symptoms before each treatment. The earlier that nerve damage is found, the better. So it’s important to tell your doctor about any new symptoms. In some cases you may need to stop treatment to prevent symptoms from getting worse. Your doctor or nurse can give you advice on other things you can do to manage your symptoms.

What is peripheral neuropathy?

Peripheral neuropathy (also called neuropathy) is a term used to describe damage to nerves that are outside the brain and spinal cord (peripheral nerves).

Peripheral neuropathy is not one specific disease. Many different conditions that can damage the peripheral nerves can cause it. This information is about cancer-related causes of peripheral neuropathy, which mainly involves neuropathy caused by anti-cancer drugs.


The nervous system

The nervous system consists of the brain, the spinal cord and a network of nerves threaded throughout the body. It has two main parts:

  • the central nervous system (CNS), which is made up of the brain and spinal cord
  • the peripheral nervous system (PNS), which is made up of nerves that carry messages between the brain, the spinal cord and the rest of the body.

Nerves carry impulses back and forth between the body and the brain. They are made up of nerve cells called neurons. Some neurons are very small, but others can be up to one metre (three feet) long. When a nerve ending is stimulated - for example, by heat, touch or vibration – it creates a tiny electrical pulse. This sends a signal along the nerve cell.

When it reaches the end of the cell, the signal triggers the release of chemicals. These carry the signal to the next nerve cell. In this way, messages can be sent from nerves anywhere in the body to the spinal cord and then up to the brain.

There are different types of nerves:

  • Motor nerves - These carry messages from the brain to the muscles. When a muscle receives a message, it reacts with a movement. Messages can be sent from the brain to any part of the body.
  • Sensory nerves - These carry messages from the body to the brain. These nerves have endings (receptors) that are sensitive to sensations such as pain, temperature, touch and vibration. They enable us to feel different sensations. Although we are not aware of it, our brain is constantly receiving messages from sensory nerves throughout our body. These messages tell our brain where each part of our body is and are important for balance, coordination and walking.
  • Autonomic nerves - These carry messages back and forth between internal organs and the brain. They control the actions of muscles that aren’t under our voluntary control. They are responsible for maintaining our blood pressure and heart rate.

Autonomic nerves also control both the rate that food passes through our digestive tract (stomach and bowel) and how the bladder works.


Causes of peripheral neuropathy

There are several ways that cancer and its treatments can cause peripheral neuropathy: 

  • Some anti-cancer drugs can cause nerve damage. This is the most common cause of peripheral neuropathy in people with cancer.
  • Cancer can cause peripheral neuropathy in one area of the body if the tumour is growing close to a nerve and presses on it.
  • Surgery may damage nerves and cause symptoms in the affected area - for example, numbness or tingling and pain in the arm after breast cancer surgery.
  • Rarely, radiotherapy may damage nerves within the treated area, causing symptoms such as numbness and weakness. These may develop months or years after treatment.
  • Occasionally in some types of cancer, the body makes substances that damage peripheral nerves. This is called paraneoplastic peripheral neuropathy. It most commonly occurs in people with lung cancer, myeloma or lymphoma.


Symptoms of peripheral neuropathy

The symptoms of peripheral neuropathy vary depending on which nerves are affected. Anti-cancer drugs that cause nerve damage are most likely to affect sensory nerves, but some can also affect the motor nerves and the autonomic nerves.

Peripheral neuropathy often affects the hands, feet and lower legs. This is because the longer a nerve is, the more vulnerable it is to injury. Nerves going to the hands, feet and lower legs are some of the longest in the body.

Symptoms of peripheral neuropathy are usually mild to begin with and gradually get worse.

A change in sensation

You may have a feeling of heaviness, burning or pins and needles in the affected area. Alternatively, you may notice unusual sensations, such as a feeling of warmth or burning when touching something cold.

Increased sensitivity

You may find that even the lightest touch or pressure in the affected area feels uncomfortable or painful.

Pain

This can be mild or more severe. The pain may be felt as sharp and stabbing or as a burning sensation, or it may feel like minor electric shocks. There are treatments to help relieve pain.

Numbness

There may be a loss of sensitivity or feeling in the affected area. Often the feet and fingertips are the first places to be affected.

Muscle weakness

A muscle may lose strength if it isn’t being stimulated by a nerve. Depending on which muscles are affected, this may make it difficult to walk, climb stairs or do other tasks.

Difficulty buttoning clothes or picking up small objects

If the nerve endings in the fingers are affected, you may not be able to do ‘fiddly’ tasks, such as fastening small buttons or tying shoelaces.

Difficulty with balance, walking and coordination

You may find that you stumble or trip when walking; uneven surfaces may be particularly difficult. You may feel clumsy at times or you may feel that your body isn't doing what you want it to. Your sense of where things are around you may become less certain.

Constipation and feeling bloated

This can happen when the nerves that control the rate that food passes through the bowel (autonomic nerves) are affected. Let your doctor or nurse know if you're having these problems.

Feeling light-headed or dizzy when you sit up or stand up

These symptoms are sometimes caused by a sudden drop in your blood pressure, known as postural hypotension. This can happen when the nerves that control blood pressure and heart rate (autonomic nerves) are damaged. Your doctor can see if this is the cause of your symptoms by checking your blood pressure when you're lying down and standing up.


Anti-cancer drugs and peripheral neuropathy

There are many different anti-cancer drugs. The types that most frequently cause peripheral neuropathy are: 

  • Vinca alkaloids, which include vinblastine (Velbe®), vincristine (Oncovin®), vinorelbine (Navelbine®) and vindesine (Eldisine®). Vincristine is the most likely one of these drugs to cause peripheral neuropathy. 
  • The platinum based drugs cisplatin, oxaliplatin and carboplatin. 
  • The taxanes docetaxel (Taxotere®) and paclitaxel (Taxol®). 

Other anti-cancer drugs that may cause peripheral neuropathy include thalidomide, bortezomib (Velcade®) and interferon alpha.

Are some people more at risk of peripheral neuropathy when having these drugs than others?

You may be at a higher risk if you:

  • are having more than one type of drug or treatment that can cause nerve damage
  • have had previous anti-cancer drugs that can cause peripheral neuropathy
  • have diabetes
  • have low levels of certain minerals and vitamins, such as vitamin E and B – this may be because of your diet, how much alcohol you drink or another reason.

What can I do to reduce my risk?

If you think your diet may be low in vitamins or minerals, or if you're concerned that you drink a lot of alcohol, talk to your doctor about whether you should take vitamin supplements. The supplements may help prevent or reduce nerve damage. It's important not to take high doses of vitamins or minerals without your doctor's knowledge, in case this interferes with how well your treatment works.

If you already have peripheral neuropathy and need to have anti-cancer treatment, there are a large number of anti-cancer drugs that don't cause or aggravate peripheral neuropathy. Your doctor can discuss the possible options with you.


Assessment

If you're being given a drug that can cause peripheral neuropathy, your doctor will monitor you for signs of nerve damage before each treatment. Symptoms are often mild to begin with and gradually become more severe.

The earlier that nerve damage is detected, the better; so it's important to tell your doctor if you notice any new symptoms that may be caused by the treatment or if your symptoms are getting worse.

If an anti-cancer drug is causing peripheral neuropathy, your doctor will assess how much your nerves are affected. This information helps them decide whether to continue your treatment, reduce the dose or stop the drug.

There are various ways your doctor may assess your symptoms:

  • Finding out how your symptoms are affecting your daily activities.
  • Establishing your ability to sense where parts of your body are when your eyes are closed.
  • Checking whether the reflexes in your ankles, knees and wrists are working. Everyone has points on their body that, if hit gently with a rubber hammer, will normally respond with an automatic (reflex) movement.
  • Testing for numbness or loss of sensation (pinprick test). This test measures whether you have lost any feeling in particular areas of your body such as your feet, lower legs and hands. You will be asked to say if you can feel a pin gently touching your skin in the areas of your body that may be affected by nerve damage.
  • Assessing your balance and coordination – for example, by asking you to walk in a straight line.

Checking your blood pressure when you're lying down and then when you're standing up. This tells your doctor whether feeling dizzy and lightheaded when you stand up is caused by a sudden fall in your blood pressure (postural hypotension). These symptoms can be caused by damage to the autonomic nerves.

Other more specialised tests are also sometimes done:

Nerve conduction studies

These assess the number of nerve cells that are working and test the speed that your nerves send messages (an impulse).

Electromyography (EMG)

This records the response of the nerve or muscle to an electrical impulse.


Management of peripheral neuropathy

There isn't a treatment to prevent or reverse nerve damage caused by anti-cancer drugs. Studies are looking at various drug treatments to see if they can help protect against nerve damage during anti-cancer treatment. There are also studies looking into whether any treatments can reverse nerve damage that has occurred. At the moment, however, there isn’t enough evidence that any of these drugs work.

The most effective treatment for peripheral neuropathy is to prevent further damage to the nerves. Sometimes it can help to lower the dose of the drug that is causing the problem. If your symptoms continue to get worse, your doctors may have to stop the treatment.

For most people, symptoms gradually improve once the drug is stopped, but they can sometimes continue to get worse for a few weeks. This is known as coasting.

Stopping treatment because of symptoms can be very difficult for some people to accept, especially if the treatment is working well. Your doctors will usually discuss with you whether another type of anti-cancer drug can be given instead. Alternatively, some other kind of treatment such as radiotherapy may be suggested. It is extremely important not to stop treatment without talking to your cancer specialist first.

Most people find that their symptoms gradually improve with time as the nerves slowly recover. This may take several months or more. For some people, nerve damage will be permanent. In this situation, however, many people find that their symptoms become less troublesome over time, as they adapt and find ways of coping with the changes.

Treating pain

If you have nerve pain, sometimes called neuropathic pain, this can be managed in a number of ways:

Drugs

Some types of drugs can alter nerve impulses and help relieve nerve pain. Gabapentin (Neurontin®) and pregabalin (Lyrica®) are drugs that work in this way. They are also anticonvulsants (drugs used to treat epilepsy). Other anticonvulsants and antidepressants are also used to treat nerve pain. If your doctor suggests an antidepressant drug, such as amitriptyline, this is because of the way it acts on nerves, not because they think that the pain is just in your mind. Drugs such as morphine can also sometimes help.

Transcutaneous electrical nerve stimulation (TENS)

This may help reduce pain. TENS uses pads, which are put on to the skin, that give off small electrical pulses. This causes a tingling sensation, which aims to stimulate nerves close to the painful area. It's thought that this may work by blocking pain messages from being carried along the nerves to the brain. TENS is unlikely to cause any side effects. Physiotherapists or pain teams can advise you on whether TENS is suitable for you and how to use it. They may be able to loan you a TENS machine on a short-term basis so that you can find out if it’s helpful.

Acupuncture

Very fine needles are placed through the skin at particular points. It isn’t clear exactly how this works, but it may help block pain messages from being sent to the brain.

Psychological support

This may help reduce the anxiety, tension and fear caused by the pain, and support can make it feel more bearable. Psychological support can be offered by psychotherapists, counsellors and some pain teams.

Pain teams

Many hospitals have pain teams that have specialist doctors and nurses who advise on all aspects of pain control. Your GP or hospital doctor can refer you to a pain team if your pain is troublesome.

Other types of help

If your symptoms are mild, you may not need any additional help in managing them. However, if you have more troublesome symptoms, support is available to help you cope with them.

Physiotherapy

A physiotherapist will be able to offer treatment and advice if you're having problems with coordination, muscle weakness, balance or walking.

Occupational therapy

If you're having difficulty carrying out daily tasks because of peripheral neuropathy, you can ask to be referred to an occupational therapist. They can assess your needs and recommend appropriate aids and equipment to help you. There are organisations that provide equipment for people who need help with daily tasks (see below).

Benefits and financial help

If symptoms continue for more than six months and cause you difficulty in walking or carrying out daily activities, you may be entitled to financial help. You may be able to claim Disability Living Allowance if you're younger than 65 or Attendance Allowance if you're older than 65.

For more details on benefits and financial support, look at our financial issues section or talk to us.


Things you can do

Protect your hands and feet

If your hands or feet are affected, it's important to protect them as much as possible:

  • Keep them warm by wearing gloves and warm socks in cold weather.
  • Wear gloves when working with your hands – for example, when gardening or washing up.
  • Use potholders and take care to avoid burning your hands when cooking.
  • Wear well-fitting shoes or boots.
  • Avoid walking around barefoot and check your feet regularly for any problems.
  • Test the temperature of water with your elbow to make sure it isn’t too hot before baths, showers or doing the washing-up. Turn the temperature control (thermostat) to a lower setting for hot water, or have a temperature control fitted.

If your balance, coordination or walking are affected

If your balance, coordination or walking are affected, you may be more at risk of accidents and falls:

  • Make sure rooms are well lit and always put a light on if you get up during the night.
  • Keep areas that you walk through (such as halls) free of clutter and make sure there aren’t things (such as loose rugs) that you could trip over.
  • Get advice from a physiotherapist about walking aids if your balance is affected.

Feeling lightheaded or dizzy

If you feel lightheaded or dizzy when you stand up, because of problems with your blood pressure (postural hypertension), your GP can give you advice. The following suggestions may also help:

  • Ask your GP to prescribe you support stockings to wear during the day. These improve circulation and can help your symptoms.
  • Do leg exercises, such as moving your feet up and down at the ankle and some gentle marching on the spot, before you stand up.
  • Stand up more slowly, as this gives your body more time to adjust to the change in position.
  • Drink plenty of fluids. Being dehydrated can make your symptoms worse.
  • If you begin to feel lightheaded or dizzy, stop what you're doing and sit down, or lie down if possible. Drink some water.
  • Try to think if there's anything that's triggered your symptoms that you could avoid.
  • Follow the advice in the previous section to try to make sure there's less risk of hurting yourself if you do fall.

Problems with constipation

If you're having problems with constipation, ask your doctor or a dietitian for advice. There are also things you can do to help your symptoms:

  • Take laxatives or other treatment prescribed by your doctor.
  • Drink at least two litres (three and a half pints) of fluid a day.
  • Eat more fruit and vegetables, and include more fibre in your diet.
  • Try to keep active or exercise regularly. Even short walks can make a difference.


Your feelings

How peripheral neuropathy affects each person, and how much practical and emotional support is needed to cope with it, varies from person to person. You may find that your life is not affected very much, or you may have many more challenges and difficulties to cope with.

It's natural to feel isolated and frustrated if your symptoms are severe and causing changes to your lifestyle. You may feel angry, resentful or anxious. These are all normal reactions and part of the process many people go through in trying to come to terms with side effects caused by their treatment.


Back to Other side effects

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