Cancer and Neuropathy

Andrew Schorr:

All right. Well, let's ask the expert. Dr. Oh, so help us understand that. With these sorts of problems how can you help? And what are these, you know, she mentioned some of these modalities. Tell us maybe some of the things you recommended in Janice's case and also how there may be other approaches for other people.

Dr. Oh:

So there are several different approaches. One would be medications. Another approach would be supplementation with nutrients. And the third one is behavioral changes that can help with the symptoms. So she was mentioning about the behavioral changes. With chemotherapy, particularly the type that she has received, there are two issues. One, being sensitive to cold objects, and as she said tap water was cold for her. And by trying to avoid the nerves from becoming cold helps, so the socks and the gloves can help. And also the fact that by stimulating the pressure nerves, and with this chemo the pressure nerves are not really affected, we will keep her brain distracted from the pain information that's coming from touching cold objects. So that's one thing that can be done for the patient is to try to keep [hands and feet] warm during the night, and during the day also if the day is cold.

The other one is try to prevent the neuropathy from coming if we know that the patient is at a higher risk. And that we can do with two food supplements are available that in theory can help. One a glutamine, which I personally am a little bit reluctant to use. We feel that we need a little bit more research to prove the safety because glutamine, in theory, could make the cancer cells to grow faster even though clinical studies didn't show that.

But the other one is [L-acetyl] carnitine, which is a product that our body produces but the chemotherapy makes you loose it in the urine. And the carnitine is needed to increase a product [nerve growth factor] in our body that helps heal the nerves, so it can be given with the chemotherapy to try to prevent the neuropathy. Once you already have the symptoms, then it depends on the symptoms what kind of medication we will give.

Andrew Schorr:

Now, what about exercise? I'm not clear whether exercise is a good thing or not.

Dr. Oh:

I have not seen any good studies showing a proven benefit from exercise to treat neuropathy yet. [It does help you cope better with the effects of neuropathy]

Andrew Schorr:

There are health benefits, of course.

Dr. Oh:

Sure.

Andrew Schorr:

But the question is will the exercise reduce the neuropathy.

Now, what about this whole area, and you touched on it there, of complementary and alternative medicine, and I know of course there is a center for that at M. D. Anderson as well. So there is still research going on, vitamins, you know, all sorts of things we wonder can they make a difference.

Dr. Oh:

Yeah. There are a lot of products in natural and complementary medicines that seems to show some, how can I say it, some hope. Not many of them were studied very well. If you have severe pain, sometimes I recommend patients to get acupuncture that may have less side effects than some of our pain medications.

For natural products there are some products that have been looked into that I reserve for the later use [after I have exhausted other options] like vitamin E, which seems to show some benefits, however there is some other studies that show that high dose vitamin E can have other complications for your body, so I try to stay away from them. Vitamin B, there is some controversial literature on that. And I think the one that has been studied the most in many different diseases and shows very minimal side effects and benefits in all different areas has been the L acetyl carnitine which also helps prevent hepatotoxicity from the chemotherapy, helps with your fatigue level, and can help with the memory and the neuropathy that you feel.

Andrew Schorr:

I was reading an article that quoted Dr. Dougherty, who is in research there in the lab, related to these effects of neuropathy and pain, etc., and he was mentioning there that he said to decrease symptoms patients are asked to eliminate smoking and alcohol and exposure to insecticides. Tell us about that. What's the tie there?

Dr. Oh:

To be honest I don't know the exact, direct tie between the smoking and alcohol [and neuropathy]. Obviously we know that the alcohol by itself can cause neuropathy if you drink for a long period of time. And also usually your diet tends to change if you drink a lot of alcohol, so there are mechanisms also in the liver, because you shift how your liver works, and both glutamine and carnitine are produced in the liver. So there may be some effect there, but I am not very aware of direct effect. And insecticide by itself can also cause damage to your nerves so you don't want to add [further damage] into that.

Andrew Schorr:

And smoking of course is not good for your circulation or nerves either.

Dr. Oh:

Your circulation and the amount of oxygen that will be reaching your nerves is reduced [when you are already have lower levels of the enzymes that help produce energy at all different levels].

Andrew Schorr:

What about what you eat? So we hear a lot about antioxidant vegetables. Any knowledge there that that can make a difference, that we should eat a certain diet if we are experiencing neuropathy?

Dr. Oh:

Well, I haven't found any specific diet that is really helpful. So far the research has been more in using specific products that are nutritional supplements, but usually the diet does not provide enough quantity to overcome the deficit.

Andrew Schorr:

Dr. Oh, one of the things we wonder about is is this a one way trip. So if somebody has nerve damage from the cancer fighting drugs, can after the therapy, can these nerves, and I know nerves don't change rapidly, can they recover, or are we stuck with what we get?

Dr. Oh:

Well, it depends really from the, for example, from the drug that you take. In the case of Miss Swain, for example she took oxaliplatin. Most of the patients who receive oxaliplatin, their neuropathy is very short lived. It gets better within weeks from the chemotherapy. But in her case with the diabetes and the fact that she felt the more severe symptoms a little bit later in the chemo, that was a way that we knew she was going to have the type of damage that either lasts for several years or may last forever.

Overall most patients who get neuropathy, even without treatment, they improve somewhat in their symptoms. The body recovers somewhat. But usually there is not 100 percent recovery. If you did not recover by six months, that usually means you are going to stay with that neuropathy for a long time.

Andrew Schorr:

What I have always been told, though, is that's where communication is so important. So if people are experiencing the very early signs of neuropathy, you and the healthcare team want to hear about it right away.

Dr. Oh:

Absolutely.

Andrew Schorr:

Okay. Janice, let's gets some practical advice for you. So first of all, what's been working for you, and have you seen an improvement over time?

Janice:

I have seen an improvement. My hands are better. I still feel a little numbness to the tips, but not nearly as bad as it was during the chemotherapy and right after. My feet, I still they still hurt at night, and basically when I take my shoes off I feel like there is a piece of cardboard that is just totally attached to the bottom of my feet. That's the best way to explain it. And then I have, I still have pain in my feet. I tried to reduce the Neurontin medication that I'm on and noticed that it was just unbearable at night really to be able to sleep or have any kind of relaxing night whatsoever.

Andrew Schorr:

So medicine then, having the right dosage has helped?

Janice:

Absolutely.

Andrew Schorr:

So Janice, you know, we have all gone through you and I and so many people listening have gone through state of the art cancer care, and we are going on with our lives and doing pretty well. That's really what it's about, isn't it? It's fighting the cancer. We wish we had perfect treatment modalities where there was no price to pay, no side effects to beat the cancer, but when you look back on this, how would you say it? I mean, nobody wants neuropathy, and you certainly didn't want it with your diabetes or even to have diabetes, but how is it compared to the alternative?

Janice:

Oh, I would go through it again and risk any symptoms to go through the possibilities of the chemotherapy helping. That's a risk we have to take, and we can, you know, I think all of us can deal with the side effects if we have a good doctor that's cheering us on and saying we are going to get better, or we are just going to deal with this and get through life and just take a positive attitude.

Andrew Schorr:

And Dr. Oh is that partner for you?

Janice:

Absolutely, he is. He has been a great doctor.

Andrew Schorr:

Dr. Oh, now standing beside you there not only are great folks in the clinic but also as I mentioned a lot of research going on at M. D. Anderson. Nobody is satisfied with where we are now with neuropathy. Certainly there has been help, and you are on the forefront of that, but when you have conversations with folks in the lab and knowing the progress that has come out of M. D. Anderson in so many areas, are you confident that we will be able to do better?

Dr. Oh:

I am confident we will be able to do better. It's going to take time, and I think the biggest challenge in this one area is that we are doing progress in the lab and the research, but we have not been doing a lot of progress in communicating these advances to the primary care doctors in the community. Many times patients have to follow with them [primary care physicians in the community], so that's where lately I have been putting my focus on. I need to know where the other doctors stand in their knowledge and how can I help them to be able to provide better care. We have close to 13 million survivors now, and the comprehensive cancer centers cannot not handle all of them. We need to help the community doctors to be able to help the survivors.

Andrew Schorr:

Right. Well, I am all about that too, and so I am delighted that we can be doing this program on the Internet. So wherever you may be, whether you are an M. D. Anderson patient or not, this is an important discussion with your doctor or your healthcare team, wherever they may be, alerting them that you are experiencing what we have described as some neuropathy and asking questions. Are there things we can do? Hey, I heard about this, I heard about that. Ask questions. And if you are not getting good answers, then seek another opinion as well, whether it's at M. D. Anderson or another major cancer center. And for the folks who go to M. D. Anderson, they are blessed if they get to have a partner like you, Dr. Jeong Oh. Thank you so much for being with us, Dr. Oh.

Dr. Oh:

Thank you very much. I really appreciate the opportunity to be able to bring more information to the patients and survivors.

Andrew Schorr:

Well, thank you. All the best. And, Janice, all the best to you. Now, is there anything you want to say to Dr. Oh while we have got you in a public forum here?

Janice:

Oh, just many thanks. He came in at a time that I needed him, and for other, you know, for other reasons, for my diabetes, and then the other side effects occurred, and he was able to help me through all of that, and I certainly appreciate it.

Andrew Schorr:

Well, all the best. And I am delighted with the people I have on Patient Power and to see this partnership between patients who are very involved in their care and practitioners who really want to help and bring state of the art approaches to help them get better. So it's really thrilling for me.

I want to mention what our next program is about. We will be doing a broadcast on September 16th on advances in the treatment of testicular cancer, and our expert will be Dr. Lance Pagliaro, and he will talk to us about testicular cancer. Of course there are famous people like Lance Armstrong who have been treated successfully for it. We are going to hear the latest in that next program.

This is what we do on Patient Power with M. D. Anderson every two weeks connecting with leading experts and inspiring patients like Janice Swain today. We like to say that knowledge can be the best medicine of all. I am Andrew Schorr. You have been listening to Patient Power brought to you by M. D. Anderson Cancer Center. Thanks for joining us.

Please remember the opinions expressed on Patient Power are not necessarily the views of M. D. Anderson Cancer Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you'll get care that's most appropriate for you.

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