As many as 50% of patients receiving taxane chemotherapy have reported experiencing peripheral neuropathy (PN) or nail changes during treatment. Both are potentially dose-limiting adverse events: nail changes can lead to infections; PN affects patients’ ability to perform activities of daily living and results in sensory impairments such as loss of balance, muscle weakness, and numbness that can increase patients’ risk for falls.
In their article in the October 2019 issue of the Clinical Journal of Oncology Nursing, Peyton and Fischer-Cartlidge discussed the research supporting cryotherapy-based interventions that may reduce the severity or incidence of PN or nail changes from taxane chemotherapy.
Taxanes’ Extremity-Related Side Effects
Researchers don’t know exactly why taxanes—which include paclitaxel, docetaxel, and cabazitaxel—cause nail changes or PN, Peyton and Fischer-Cartlidge said, although various hypotheses have been presented. The highest incidence of nail changes is seen with docetaxel, whereas paclitaxel is associated with the highest rates of PN. Because no pharmacologic treatments are available for either condition, management is usually done with treatment delays or dose reductions of the taxane drug.
Cryotherapy as a Prevention Strategy
Using cold to vasoconstrict circulation to the extremities also reduces the tissues’ exposure to the cytotoxic effects of chemotherapy, Peyton and Fischer-Cartlidge explained. The intervention has shown success for oral mucositis and alopecia, although it is contraindicated for certain patient groups, including those with:
- Raynaud disease
- Vascular impairments (e.g., peripheral vascular disease)
- Cold hypersensitivity from oxaliplatin treatment
Peyton and Fischer-Cartlidge conducted a literature search to investigate the evidence for cryotherapy, how the intervention was administered, and the nursing considerations for delivering the therapy. Five articles for nail changes and five articles for PN met their inclusion criteria.
What the Evidence Says for Nail Changes
All of the articles reported on cohort studies, and the primary populations were patients with breast or prostate cancer. They had the following commonalities:
- Patients were receiving docetaxel, although one study also included paclitaxel.
- Cryotherapy was delivered with Elasto-Gel™ frozen gloves or socks.
- Patients wore the socks or gloves for 15 minutes before, during, and for 15 minutes after their taxane infusion.
- The researchers used the Common Terminology Criteria for Adverse Events to grade the onycholysis severity.
In general across the studies, the gloves and socks were frozen at various ranges spanning –25°C to –30°C, –18°C to –20°C, or –4°C to –10°C. The researchers changed patients’ gloves and socks every 20–45 minutes as they warmed to keep a consistently cold temperature.
One study reported a reduction in nail changes from 51% to 11% and reduced severity in the cooled extremities. Several of the studies had high attrition rates because of cold intolerance, but those who completed the intervention reported satisfaction rates ranging from 58%–86%.
What the Evidence Says for PN
The five articles reporting investigations of cryotherapy for PN had fewer commonalities than the research for nail changes:
- Four discussed patients with breast cancer, and one used patients with gynecologic cancers.
- Four involved treatment with paclitaxel, but one used docetaxel.
- Four used gloves or socks frozen at various ranges down to –30°C ,whereas one used a continuous-flow hypothermia boot set at a warm 22°C.
Like the nail toxicity studies, gloves and socks were changed every 45–60 minutes to ensure a consistently cold temperature. Attrition rates were lower in the PN studies and ranged from 0%–30%.
All of the studies reported decreased PN incidence in those receiving the cryotherapy intervention, although some of the differences were not statistically significant.
What This Means for Oncology Nurses
Although the overall findings about the benefit of extremity cooling were mixed, Peyton and Fischer-Cartlidge pointed to several study limitations as possible rationale instead of the lack of efficacy of the intervention itself. Many had small sample sizes, lack of power analyses, high attrition rates, incomparable treatment regimens, and limited post-treatment follow-up.
The authors concluded that their “literature synthesis reveals early evidence for cryotherapy in the prevention or reduction of nail toxicity and PN,” although larger studies are needed. While those additional studies are conducted, they recommended that clinicians weigh extremity cooling’s low risk against the potential harms of dose-limiting toxicities and may wish to consider it in certain appropriate patients.
For more information about the use of cryotherapy extremity cooling in patients receiving taxane chemotherapy and the opportunity to earn 0.5 contact hours of nursing continuing professional development, free for ONS members, refer to the full article by Peyton and Fischer-Cartlidge.
Questions regarding the information presented in this article should be directed to the Clinical Journal of Oncology Nursing editor at CJONEditor@ons.org.