Neuropathy

Neuropathy is pain or discomfort caused by damage to nerves that control movement and sensations in the arms and legs. Some breast cancer treatments can cause neuropathy.

What does neuropathy feel like?

Signs and symptoms of neuropathy include numbness, pain, burning, tingling, or loss of feeling in your hands or feet. Symptoms might feel mild or severe and can vary from person to person. If you have neuropathy, you may:

• Feel sharp or shooting pain that comes or goes
• Have persistent pain that interferes with your day-to-day life
• Feel a pins-and-needles sensation, itching, or weakness
• Have trouble picking up tiny objects
• Feel more sensitive to cold or heat
• Hear ringing in your ears
• Have trouble with balance
• Trip while walking
• Be constipated or have other difficulty with bowel movements, your bladder, or digestion

If you notice signs of neuropathy, it’s important to let your care team know. While some cancer treatments can cause these symptoms, other things can cause these symptoms too, such as:

• Surgery
• Radiation therapy
• Diabetes
• Tumors pressing on nerves

It can be helpful to keep a symptom journal. Write down:

• Which part of the body is affected
• When you have symptoms
• What the symptoms feel like
• How intense they are
• What makes symptoms worse
• How long you've had each symptom
• If they come and go or are persistent

Try to be as specific as possible when writing down this information. You can also rate symptoms on a scale of 1 (not at all uncomfortable) to 10 (the most uncomfortable you have ever been).

If you're having difficulty with symptoms of neuropathy, it's important to let your healthcare providers know how much it impacts your life. Take your symptom journal with you to medical appointments and share the information with your team.

What causes neuropathy?

Some — but not all — chemotherapies, targeted therapies, and immunotherapies can cause neuropathy. Because chemotherapy medicines travel throughout the body, they can reach the peripheral nerves (nerves that control sensations and motion in the arms, legs, hands, and feet) and damage them. Your care team may use the term “chemotherapy-induced peripheral neuropathy,” or CIPN.

Certain chemotherapy medicines are more commonly linked to neuropathy:

• Platinum chemotherapies, such as carboplatin (Paraplatin) and cisplatin (Platinol)
• Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)

The targeted therapy ado-trastuzumab (Kadcyla), approved to treat HER-2 positive breast cancer, can also cause neuropathy.

Neuropathy can also be a side effect of the immunotherapy pembrolizumab (Keytruda) in combination with chemotherapy.

Just taking these medicines does not mean you will develop neuropathy. Higher doses and longer treatment increase the risk. Other risk factors for neuropathy include a personal history of diabetes, an autoimmune disease, or drinking too much alcohol.

Reducing the risk of neuropathy

Research shows that having a vitamin D deficiency before starting treatment with paclitaxel and other therapies can increase the risk of developing neuropathy. While vitamin D supplements can help, taking too much vitamin D can be harmful. Before starting breast cancer treatment, ask your healthcare team about having your vitamin D levels checked, and follow their recommendations on how much vitamin D you should take.

There is also evidence that cryotherapy may help to reduce the risk of neuropathy during treatment. Cryotherapy exposes the body to very cold temperatures for a short time. There are different approaches to cryotherapy during chemotherapy treatment, including:

• Wearing cold gloves and socks or boots (ask your care team where these are available to purchase)
• Holding bags of frozen vegetables or crushed ice in your hands and positioning them on or around the feet; this is a less expensive alternative

How long will neuropathy last?

If neuropathy develops, it can start within about six months of undergoing a treatment that causes it. The symptoms often go away completely after you finish treatment.

Neuropathy can either be short-term or long-lasting. In some cases, neuropathy can remain long after treatment is over.

How can I manage neuropathy?

If the neuropathy is caused by chemotherapy, your healthcare team may decide to switch you to a different chemotherapy medicine, use smaller doses, or change the timing of your treatments. In some cases, you and your care team may decide to have you take a break from treatment so you can get relief from symptoms and to prevent long-term nerve damage.

Your team may also suggest treatment for the pain or discomfort caused by neuropathy. These may include:

• Pain medicines (over-the-counter product or prescription)
• Steroids for initial relief from symptoms
• Creams and lotions that have a numbing effect
• Taking vitamin B6
• In some cases, antidepressants or anti-seizure medicines for nerve-related pain

You can also change some things in your daily life to reduce pain from neuropathy. Here are some tips:

• Avoid tight-fitting clothes.
• Wear comfortable shoes or talk with your care team about special therapeutic shoes.
• Take care of your feet to prevent sores. Check your feet every day and keep them clean.
• Keep your hands and feet warm between treatment sessions. (During chemotherapy sessions, you may choose to use cryotherapy, or cold therapy.)
• If you have numbness and tingling in your hands, be careful using scissors and knives.
• If neuropathy is happening in your legs and feet, use handrails to help with balance.
• Avoid standing or walking for long periods.
• Clear clutter and loose rugs in your home to avoid falling.

Researchers are trying to find additional ways to manage neuropathy and looking at how to prevent neuropathy from occurring in the first place. If neuropathy is severe and interferes with your physical abilities, you may be referred to a physical or occupational therapist to help you regain strength and function.

Neuropathy and metastatic breast cancer treatment

Unlike treatment for early-stage breast cancer, metastatic breast cancer (MBC) treatment is ongoing. The risk of neuropathy increases with higher doses and longer-term use of certain treatments.

Chemotherapy, especially long-term chemotherapy regimens used in metastatic breast cancer, can cause neuropathy. The platinum and taxane chemotherapies mentioned above, approved to treat all stages of breast cancer, are more likely to cause neuropathy than other chemotherapy medicines.

Additional chemotherapy medicines, only approved to treat MBC, can cause neuropathy:

• Microtubule inhibitors, such as eribulin (Halaven), vinorelbine (Navelbine), and vincristine (Oncovin, Vincasar PES, Vincrex)
• Abraxane, the brand name for a form of paclitaxel

There are also some targeted therapies only approved to treat MBC that can cause neuropathy:

• Trastuzumab deruxtecan (Enhertu) and margetuximab (Margenza), approved to treat HER2-positive MBC
• Sacituzumab govitecan (Trodelvy), approved to treat triple-negative MBC

If the neuropathy is caused by a specific treatment, there are options for reducing the symptoms. Your care team may decide to:

• Recommend vitamin B6
• Switch you to a different treatment
• Use smaller doses
• Change the timing of your treatments
• Have you take a short treatment break
• Prescribe medicines used to treat neuropathy from diabetes, such as gabapentin (Neurontin) or pregabalin (Lyrica)

You can also try the tips listed above, such as avoiding tight clothes, keeping your hands and feet warm, or wearing comfortable shoes.

Having your care team lower the dose or change the timing of a treatment to reduce side effects can trigger feelings of uncertainty about whether the treatment will be effective. But most treatments have recommendations built in to lower the dose or change the timing of the medicine if side effects are a concern.

Talk with your care team about how they will monitor the impact of any changes to your treatment to make sure it's the most effective that it can be. Although one goal of your treatment is to keep the cancer under control for as long as possible, a second, equally important goal is to allow the best quality of life possible. You and your care team will decide together whether continuing with a certain treatment is right for you.