The potential of podiatrists in Chemotherapy Induced Peripheral Neuropathy (Part One)

The turning point that led to my research

I remember this patient having a neurovascular assessment. I said, “So how long have you had diabetes for? ” And they said, “No, I don’t have diabetes.” At that moment, I was like, “Oh, okay, so no diabetes, yet this is pronounced neuropathy?”

I began delving a bit deeper to ask the patient, “So what do you think has caused this neuropathy?” They started talking about their cancer treatment, which was a gap in my knowledge at that time. After talking to some other new grads at that time – they also felt like the key factor we always think about is diabetes when it comes to peripheral neuropathy. This is fairly understandable, given chemotherapy is usually just mentioned in passing when we are doing podiatry study. It may be along the lines of ‘Chemotherapy can also cause neuropathy.’

I also have a personal history of cancer in my family – my very lovely close Aunt passed away from breast cancer. I remember her telling me that she couldn’t feel her hands and she couldn’t feel her feet. At that time, I was not a podiatrist. Yet that history gave me a little more push when the time did arrive to look at this subject in more detail.

Finally, this project is very clinically relevant. As podiatrists we see a lot of people who are either going through chemotherapy or who are cancer survivors. Often, we know that they have neuropathy. If we can do so well in the field of diabetes and neuropathy, why can’t we do similar for our cancer patients?

This is what sparked my attention and my real interest in this field.

The start of my PhD and advocacy

When I started my PhD project, my idea was two-fold.

First of all, it was to create advocacy for cancer patients and cancer survivors who are going through this challenge – day in, day out. Yet also I wanted to advocate for the podiatry profession. By definition, we are the lower limb specialists, and we have the scope of practice to assess, diagnose, and manage conditions that are related to lower limbs.

In realising that we as podiatrists are not at the forefront of this issue – that is, frequently working with patients who have chemotherapy related peripheral neuropathy – I thought that we can do better.

Establishing the need for podiatric intervention

Studies have been done in cancer survivors up to 13 years after they ceased their chemotherapy. Their neuropathy presents often with sensory symptoms. If we talk about feet in this context, we call it ‘Chemotherapy Induced Peripheral Neuropathy’ or CIPN, mainly presenting  as a sensory neuropathy.

These people will have symptoms of numbness, tingling, and shooting sharp pains in their feet mainly. And a lot of the studies have shown that the symptoms in the hands actually start resolving after a while, but in the feet, they tend to persist. Tingling and numbness are the most common symptoms that have been reported in this context. Yet more research is  needed on motor symptoms, by which I mean both fine and gross motor symptoms.

In gross motor, it can be balance, walking, stair negotiation, for example. We all know that when balance is impacted, there’s a greater risk of falls. Given a lot of cancer survivors are elderly as well, they have that extra risk of that falls following that neuropathy.

If we then talk about the fine motor skills being impacted up to 13 years after chemotherapy, patients can have issues with, say, motor dexterity – holding objects, tying shoelaces, for example, or doing buttons, writing, or typing. The tasks that we take for granted into our day-to-day life become more difficult and challenging for our cancer survivors.

I realise that, being podiatrists, we can’t intervene in the upper extremities and hands, but we definitely can help with things that are related to lower limbs. We can provide resources and education around how to help with, say, for example, simple things – like using a shoe horn or having Velcro shoes.

Education is everything – and podiatrists can do this

When it comes to helping people with CIPN, the answer largely lies in education. Being a lecturer at university as well, I always say to my students, “The best thing you can do is provide good education.” That’s always the start of treatment, I would say.

I do believe that there is a lot of room for improvement in cancer, neuropathy and podiatry intervention, definitely – through the power of education. If the patient can learn how to do certain things or manage their own symptoms, why wouldn’t we be sharing that information?

Updated guidelines are required

Overall, CIPN is an area of very active research but then looking at podiatry’s involvement in it, unfortunately, none of the current guidelines incorporate podiatry as a part of CIPN diagnosis, assessment or treatment.

There are four guidelines that I have come across during my PhD journey, and some of them do mention the role of allied health. Physiotherapy is very commonly mentioned, speech, occupational therapy is very commonly mentioned and exercise physiology is mentioned. Yet only one guideline just barely mentions podiatry. They are cancer oncology guidelines mainly.

That was a little bit of a saddening moment for me. I’m like, “Oh, we podiatrists can do this – and we do this day in and day out.”

We do neurovascular assessments often on more than five or six patients a day because of the diabetes-related factors. And we know that the assessment that we do is validated for diabetes.

Delphi study insights and the disparity shown

We conducted a Delphi study of podiatrists in 2023 – given the current lack of guidelines to manage chemotherapy-induced neuropathy. We believed the starting point was to talk to podiatrists and see how they are managing clients presenting with CIPN.

With regards to the Delphi we did, we asked our podiatrists, ‘how many patients are you actually seeing that present with CIPN?’ Most of the podiatrists have only seen between zero and five patients with CIPN in the last three months. Then we asked them, ‘where are these referrals coming from when you are seeing people with CIPN?’

Most of these referrals come from GPs, through chronic disease management plans. The next referral stream on the list was self-referred. We also realised that patients are a little bit more aware of their foot problems, so they are seeking podiatry help. And then some oncology referrals were noted. Yet very little came through from nurse practitioners. That’s who I believe the target audience is for podiatrists – nurse practitioners in the oncology world.

The nurse practitioner connection needs exploring

Nurse practitioners are often looking after patients with cancer on a more regular basis – given oncologists obviously are very busy people. The oncologist’s key goal is survival for that patient – which is understandable, completely fair. Whereas the nurse practitioners are the ones that look after and manage all the side effects around chemotherapy and cancer treatment.

If nurse practitioners are not aware of the role of podiatry, they’re not going to recommend it. That’s where the education and awareness gap exists. Yes, people are made aware of CIPN and its implications because that’s a very, very pronounced side effect of chemotherapy. Yet I feel they may not often be how to manage CIPN. This part needs a bit more attention, research, and maybe advocacy from our end – for nurse practitioners, oncologists, GPs and patients alike.

If I could, I would spread awareness of the role of podiatry as much as much as I can in the cancer world – starting with educational resources. This might include pamphlets or charts in oncology centres. Or even simple patient-facing brochures to say, ‘Are you experiencing these symptoms? Your local podiatrist can help.’ This would be a good starting point.

Where the podiatrist comes in

If we were to put a podiatrist within the care of the person either going through chemotherapy or who has had chemotherapy before, we can help to diagnose CIPN. We can be the first ones to see that the patient has neuropathy following chemotherapy, or we can be the ones that do the baseline assessments.

We can assess a person before they start chemotherapy. The research tells us that somebody with a pre-established neuropathy is at increased risk of CIPN as well. If patients were to get the baseline neuropathy assessments done through a podiatrist – perhaps the patient even has a neuropathy, either from diabetes or various other causes – then we can write this letter to an oncologist. In it we can say: “This person already has established diagnosis of neuropathy. You might want to consider their treatment options because they might be at increased risk of CIPN as well.”

Podiatrists can play a very important role in prevention – but also to diagnose CIPN and assess it properly, because we are already doing these assessments for diabetes. Nothing is out of the scope of our practice here.

Looking at the research that I’m doing now, there are simple things we do as podiatrists [which could make a difference]. Say for example, using monofilament – the little fishing line we use to check the sensation in the feet or the vibration sensation of the feet or the tendon reflexes – all of which will be reduced or diminished because of CIPN. [As podiatrists] we already do these assessments, which have shown some promise in diagnosing CIPN as well.

The treatment for CIPN is very much within a podiatrist’s scope. The common manifestation of symptoms in the lower limbs is reduced walking, change in gait, balance, sensory symptoms, all of which we already very confidently manage in different settings.

We know that [as podiatrists] we can provide very good, wonderful footwear education that can reduce falls. We know that we can provide exercises that can reduce falls. We also know that we can recommend pain interventions to help with pain related symptoms. Some podiatrists have done extra training to do dry needling, for example, which can help with the numbness and tingling aspect of it. The evidence behind it appears very mild at the moment, it’s not strong – but there is some promise there.