The project, which was part-funded by an SHP Implementation Science pilot grant, has proven that better screening of patients for early signs of Chemotherapy-Induced Peripheral Neuropathy (CIPN) can be routinely performed in clinical practice.

Now the researchers are investigating how to combine the early screening with better treatment for patients suffering CIPN and overcome the practical barriers to the wider implementation of the improved clinical pathway in New South Wales.

University of Sydney Associate Professor Susanna Park and medical oncologist at Chris O’Brien Lifehouse, Associate Professor Peter Grimison, began the project because CIPN is under-recognised and under-treated.

“There hasn’t really been a guide as to how to ask patients about symptoms of CIPN and there is a huge amount of variability as to whether and how clinicians were screening for it,” said Park.

“We thought that if we could standardise the way that screening was done – in particular using validated patient reported outcome measures which have been shown to pick up early signs of neurotoxicity – we could identify patients suffering CIPN earlier and achieve better clinical outcomes.”

CIPN happens when the nerves which are located outside of the brain and spinal cord are damaged as a side effect of cancer chemotherapy. While no two cases are exactly the same, the nerve damage typically causes pain, tingling or numbness in the hands and feet.

Other symptoms may include muscle weakness, dizziness, balance problems, ringing in the ears, hearing loss and constipation. While the symptoms often abate over time, they can be permanent and greatly affect a patient’s quality of life.

CIPN can be reduced or stopped if it is identified early, and the chemotherapy dosage is reduced or given a greater intervals to allow the nerves time to recover.

Symptoms can also be managed by a variety of means including pain killers, exercise, physiotherapy, occupational therapy and podiatry, providing the CIPN is detected early.

“We are now aware that the proportion of chemo patients suffering from lasting neuropathy is dramatically higher than we thought even ten years ago,” said Park. “It is experienced by probably 30 percent of people who receive chemotherapy, but it's really undertreated.”

Research into the implementation of enhanced screening for CIPN involved oncology clinicians at Chris O’Brien Lifehouse, which is part of Sydney Local Health District, and Prince of Wales Hospital in the South Eastern Sydney Local Health District.

“I think the clinicians believed they were already doing a good enough job of screening for neurotoxicity,” said Grimison. “So, implementing the enhanced screening at the two test sites has been a big cultural change and a big technical challenge as well.

“The easiest way to screen the patient is to give them a paper questionnaire. But the problem with that is that someone has to remember to give the questionnaire, which is more difficult than you would think. And then someone has to look at the questionnaire and enter the data into some sort of record where we can see it.

“So, we wanted a sophisticated electronic solution, where people could answer the questions in their phones while in the waiting room or at home – and then the information could go into database where people can see it.”

As a result of the project, the screening has been implemented into routine clinical workflows and results are incorporated into the hospitals’ Electronic Medical Records systems, ensuring that patient CIPN information is routinely available to clinicians. 

Associate Professor Park says the research identified the need to develop a clinical pathway with standardised suggestions as to what should happen if the screening identified a patient at risk of CIPN.

“Some people questioned the purpose of identifying CIPN early, given that we don’t currently have a drug or similar that that can reduce the toxicity,” she said.  “But we felt strongly that there is a real benefit to these patients because there are clinical interventions that can improve their quality of life, even while we continue to research for cures or strategies to prevent the nerve damage.”

Oncologists, neurologists, nurses, allied health clinicians and consumers were consulted to develop a consensus on key elements of the clinical pathway.

“Our pathway identifies the circumstances in which you refer people to neurology for further investigation of unusual symptoms,” said Park. “It also looks at pain and the drugs that can be used to relieve that. So, it's basically about getting the specialties together to better address CIPN.”

As a result of their Sydney Health Partners project, Park and Grimison subsequently received a grant from the Avant Foundation, in collaboration colleagues including Professor David Goldstein, to support continued development of the new CIPN clinical pathway.

This month they also received a larger grant from the Medical Research Future Fund, allowing them to test the implementation the clinical pathway, extending it to St George Hospital and the Mater Hospital Sydney, as well and Chris O’Brien Lighthouse and Prince of Wales Hospital.

“We are tailoring the clinical pathway it to take account of the differing circumstances in these hospitals,” said Park. “That’s the trick with implementation – it’s so much more difficult than you think. Even just the differences in systems between two hospitals in the same health district or the way things are done by two clinicians. So, there’s no one size fits all solution, which is why you just have to build relationships with the clinicians at each site, get nurses on board and more organically bring it together.”

Associate Professor Grimison says the research team has learned that if there is not buy-in from senior staff the new intervention “just won’t happen.”

“I’ve been a medical oncologist for long enough to understand how much effort it takes to implement something new. If the leaders are not interested and the clinicians are busy then there’s not really any motivation to do it,” he said.

Associate Professor Park says it is incumbent upon researchers to think not just about the outcome, but also about the best way to get to that outcome.

“I think it’s evident to us now that we need to think more critically,” she said. “When we propose enhanced screening, for example, we should ask ourselves who is going to do that. How are they going to be compensated? How can we make it happen without adding a burden to frontline nursing staff who already have a list of tasks beyond what they might be able to do?”