New Practical Approaches to Chemotherapy-Induced Neuropathic Pain: Prevention, Assessment, and Treatment.

Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most disabling and demoralizing problems that arise for cancer survivors. When investigating symptoms of numbness, tingling, or pain in the extremities, it is critical to determine whether the problem is neuropathic, somatic, or mixed. If the diagnosis is CIPN, it is important to weigh the potential benefits and harms of possible treatment options, and to devise an evidence-based multimodality treatment program. Such programs may include mixtures of opioid and nonopioid adjunctive medications, based on evidence from CIPN trials, and also extrapolation from trials in patients with other neuropathic pain syndromes-although such extrapolating must be done with caution, since other syndromes sometimes respond to agents that CIPN does not respond to. Other components of a successful program might include exercise; and possibly neuromodulation via acupuncture, spinal cord electrical stimulation, or neurocutaneous stimulation. There is good randomized trial evidence that most of the anticonvulsants and tricyclic antidepressants typically prescribed for neuropathic pain have little or no effect on CIPN, but there is some evidence of efficacy for duloxetine-however, clinical practice with regard to pharmacologic treatment of CIPN often does not reflect these data. We review here the recommendations of the American Society of Clinical Oncology, as well as some new and promising approaches to neuropathy, including new neuromodulation techniques.