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Peripheral Neuropathy Tool

This tool is for the purpose of facilitating the detection of peripheral neuropathy. Please utilize the assessment questions during patient discussions and consider the suggested intervention instructions to help manage your patients.

Click Here when Beginning a Patient Discussion


Does the patient have tingling/burning/numbness/pain in their hands/fingers?

Yes No

If yes, please rate the severity on a scale of 1-10.

Does the patient have tingling/burning/numbness/pain in their feet/toes?

Yes No

If yes, please rate the severity on a scale of 1-10.

Does the patient have an inability to detect temperature changes in regards to their hands or feet (ex. cannot feel temperature of water while washing dishes)?

Yes No

If yes, please rate the severity on a scale of 1-10.

Does the patient experience hypersensitivity or pain to hot/cold temperatures?

Yes No

If yes, please rate the severity on a scale of 1-10.

Does the patient have difficulty or loss of fine motor function?

Yes No

If yes, please rate the severity on a scale of 1-10.

Is the patient experiencing any problems with completing activities of daily living?

Yes No

If yes, please rate the severity on a scale of 1-10.

Has hospitalization or urgent intervention been required for any of the above symptoms?

Yes No

Has the patient been previously treated with chemotherapy(platinums, taxanes, vinca alkaloids, proteosome inhibitors, brentuximab vedotin, etc)?

Yes No

Has the patient previously been diagnosed with peripheral neuropathy from any cause?

Yes No

Is the patient > 65 years old?

Yes No

Does the patient have comorbid health conditions of diabetes, HIV, excess alcohol consumption, smoking, increased BMI, or decreased creatinine clearance?

Yes No

Based on these factor(s):

Please click on the dropdown menu to select the grade best matching the patient's degree of adverse event

Based on the responses, possible grade is suggested


Note: Patient may be at an increased risk of developing peripheral neuropathy and should be monitored for the development and early identification of peripheral neuropathy.

Please fill-in reason for change in suggested grade if applicable
Report summary:

Reference:
1. National Cancer Institute. Common Toxicity Criteria version 5.0. Bethesda, MD: National Cancer Institute; 2017.
2. Smith EML, Knoerl R, Yang JJ, Kanzawa-Lee G, Lee D, Bridges CM. In Search of a Gold Standard Patient-Reported Outcome Measure for Use in Chemotherapy- Induced Peripheral Neuropathy Clinical Trials. Cancer Control. 2018;25(1):1073274818756608. doi:10.1177/1073274818756608
3. Bulls HW, Hoogland AI, Kennedy B, James BW, Arboleda BL, Apte S, Chon HS, Small BJ, Gonzalez BD, Jim HSL. A longitudinal examination of associations between age and chemotherapy-induced peripheral neuropathy in patients with gynecologic cancer. Gynecol Oncol. 2018
4. ark SB, Kwok JB, Asher R, Lee CK, Beale P, Selle F, Friedlander M. Clinical and genetic predictors of paclitaxel neurotoxicity based on patient- versus clinician-reported incidence and severity of neurotoxicity in the ICON7 trial. Ann Oncol. 2017;28(11):2733-2740.
5. Sanchez-Barroso L, Apellaniz-Ruiz M, Gutierrez-Gutierrez G, Santos M, Roldan-Romero JM, Curras M, Remacha L, Calsina B, Calvo I, Sereno M, Merino M, et al. Concomitant Medications and Risk of Chemotherapy-Induced Peripheral Neuropathy. Oncologist. 2018
6. Dimopoulos MA, Mateos MV, Richardson PG, Schlag R, Khuageva NK, Shpilberg O, Kropff M, Spicka I, Palumbo A, Wu KL, Esseltine DL, et al. Risk factors for, and reversibility of, peripheral neuropathy associated with bortezomib-melphalan-prednisone in newly diagnosed patients with multiple myeloma: subanalysis of the phase 3 VISTA study. Eur J Haematol. 2011;86(1):23-31.
7. Incidence, prevalence, and predictors of chemotherapy-induced peripheral neuropathy: A systematic review and meta-analysis. Seretny M, Currie GL, Sena ES, Ramnarine S, Grant R, MacLeod MR, Colvin LA, Fallon M Pain. 2014 Dec; 155(12):2461-2470.
8. Colvin LA. Chemotherapy-induced peripheral neuropathy: where are we now?. Pain. 2019;160 Suppl 1(Suppl 1):S1-S10. doi:10.1097/j.pain.0000000000001540.