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).
The peripheral nerves can be damaged by different medical conditions, such as diabetes, injury,
infection and sometimes as a side effect of cancer treatments.
This information is about cancer-related causes of peripheral neuropathy, which mainly involves
neuropathy caused by anti-cancer drugs. For most people, the symptoms of cancer-related
peripheral neuropathy will gradually improve once their cancer treatment has finished.
We hope the information here answers your questions. If you have any further questions, you can ask your doctor or nurse at the hospital where you are having your treatment.
In this information:
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The nervous system
Causes of peripheral neuropathy
Symptoms of peripheral neuropathy
Anti-cancer drugs and peripheral neuropathy
Assessment of peripheral neuropathy
Managing peripheral neuropathy
Other types of help
Things you can do to help cope with the symptoms of peripheral neuropathy
• Your feelings
• Useful organisations
• References and thanks
The nervous system
The nervous system is made up 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 messages (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 1m (3ft)
long. When a nerve ending is stimulated – by heat, touch or vibration, for example – it creates a tiny electrical pulse. This sends a signal along the nerve cell.
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When the signal reaches the end of the cell, it 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.
• The cancer itself can cause peripheral neuropathy 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 called antibodies that damage peripheral nerves. This is called paraneoplastic peripheral neuropathy. It most commonly occurs in people with lung, ovary or breast cancer.
In
• other types of cancer, such as myeloma or lymphoma, the body produces a substance,
known as a paraprotein, that can damage the peripheral nerves.
Symptoms of peripheral neuropathy
If the peripheral nerves are damaged, the signals, or messages, they carry between the brain and the body become distorted or interrupted. This causes symptoms.
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.
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Peripheral neuropathy
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.
If you notice any of these symptoms tell your doctor or specialist nurse. The earlier that peripheral
neuropathy is diagnosed the easier it is to control and prevent further damage to your peripheral
nerves.
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 specific treatments to help relieve
nerve 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. You may feel as if you’re wearing gloves or stockings.
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. You may notice that you drop things more easily.
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Peripheral neuropathy
Tremor
You may notice a tremor in your hands that becomes more vigorous over time. It may get worse
when you are trying to use your hands.
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. It is important to let your doctor know if you are taking medication for high blood pressure or the prostate condition
benign prostatic hyperplasia (BPH), as these may need to be reduced or stopped.
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, vincristine, vinorelbine, and vindesine.
• 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
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• have diabetes
• have low levels of certain minerals and vitamins, such as vitamin E and B – this may be because of your diet, if you drink more than the recommended daily amount of alcohol or another reason.
What can I do to reduce my risk?
If you are diabetic, you should make sure that your blood sugar is controlled as well as possible.
If you think your diet may be low in vitamins or minerals, or if you’re concerned that you drink too much
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 of peripheral neuropathy
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.
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Other more specialised tests are also sometimes done:
Blood tests
You may have blood tests to look for possible causes of peripheral neuropathy, such as low levels
of vitamins and minerals, hormonal imbalances, diabetes and abnormal antibodies.
Nerve conduction tests and electromyography (EMG)
These tests record the response of a nerve or muscle to an electrical impulse. They measure the speed and strength of the messages (impulses) to the brain. The tests will be done by a neurologist (a nerve specialist), who will carefully place small metal wires (electrodes) on your
skin or small needles into a muscle. A small electrical current is then given to stimulate the nerves.
Nerve biopsy
Very occasionally, a small sample (biopsy) of one of your peripheral nerves may be taken so it can
be examined under a microscope. The biopsy is usually done under a local anaesthetic. The biopsy
will be checked for changes that could be a sign of certain types of peripheral neuropathy.
Managing peripheral neuropathy
There isn’t a treatment to prevent or reverse nerve damage caused by anti-cancer drugs. Studies are looking at different ways to 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 to accept, especially if the treatment
is working well. However, there needs to be a balance between the best chance of treating the
cancer and avoiding long-term problems due to nerve damage. 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, an amount of nerve damage will
be permanent. In this situation, however, many people find that their symptoms become less
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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
or nortriptyline, 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)
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.
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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 walking or carrying
out daily activities, you may be entitled to financial help. You may be able to claim Personal
Independence Payment (PIP) 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 to help cope with the symptoms of peripheral neuropathy
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.
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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 before you stand up, such as moving your feet up and down at the ankle and some gentle marching on the spot.
• 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, and 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.
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Useful organisations
The Neuropathy Trust www.neuinsight.com Aims to ensure that patients, family, carers and healthcare providers receive the highest possible
level of support, information and communication about peripheral neuropathy.
British Pain Society www.britishpainsociety.org Can provide a list of local pain clinics, and information on managing pain via their ‘For Patients’
section.
British Red Cross Society www.redcross.org.uk
Runs a lending service for equipment and gives practical information on nursing.
Dial UK www.scope.org.uk
A free, impartial and confidential service offering information, advice and, in some cases practical help. The service is provided by people with direct experience of disability.
Disabled Living Foundation www.dlf.org.uk Provides practical, up-to-date, unbiased information and advice on equipment to increase
independence in daily activities.
References and thanks
The information in this section has been produced in accordance with the following sources and
guidelines:
• Rutkove SB, Overview of lower extremity peripheral nerve syndromes. UpToDate online
2014. www.uptodate.com/contents/overview-of-lower-extremity-peripheral-nerve-syndromes
(accessed October 2014).
• Albers J, et al. Interventions for preventing neuropathy caused by cisplatin and related
compounds. Cochrane Database of Systematic Reviews. March 2014. www.onlinelibrary.wiley.com/doi/10.1002/14651858.CD005228.pub4/full (accessed October 2014).
• Perry M. The Chemotherapy Source Book. 5th edition. 2012. Lippincott Williams and Wilkins.
If you’d like further information on the sources we use, please feel free to contact us.
Thanks
With thanks to Dr Shirley D’Sa, Clinical Haematologist, who reviewed this information.
Thank you to all the people affected by cancer who reviewed what you’re reading and have helped
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our information to develop.
You could help us too when you join our Cancer Voices Network – find out more.
Content last reviewed: 11 November 2014
Next planned review: 2016
We make every effort to ensure that the information we provide is accurate and up-to-date but it should not be relied
upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan
does not accept liability in relation to the use of any information contained in this publication or third party information or
websites included or referred to in it.
Macmillan Cancer Support, registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of
Man (604). A company limited by guarantee, registered in England and Wales company number 2400969. Isle of Man
company number 4694F. Registered office: 89 Albert Embankment, London SE1 7UQ.
For cancer support every step of the way, call Macmillan free on 0808 808 00 00 (Mon-Fri, 9am-8pm) or visit
macmillan.org.uk
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