ASCO Issues Guidelines for Preventing and Managing Neuropathy, Fatigue, Depression and Anxiety

Breast Cancer News
July 18, 2014
Marcia Frellick
Reviewed By: 
Linda T. Vahdat, MD

The American Society of Clinical Oncology published 3 new guidelines for physicians so they may better help people prevent or manage neuropathy, fatigue, depression and anxiety. These common cancer side effects may linger long after treatment.

The guidelines are based on ASCO’s review of published research and its assessment of risks and benefits for treatments. They are the first in a planned series of guidelines for caring for people who have any type of cancer. Here’s a look at each side effect and the new guideline for each:


Neuropathy occurs when nerves that carry information between the brain and spinal cord are damaged. You may feel muscle weakness, tingling, pain and numbness, especially in your hands and feet. It may be caused by certain types of chemotherapy or high doses of chemotherapy.

There are currently no recommended medicines to prevent or reverse neuropathy. Some relieve pain, but not numbness.

If neuropathy is related to chemotherapy, ASCO recommends providers prescribe the antidepressant duloxetine (Cymbalta) to help relieve pain. The study notes duloxetine may not be as effective when the pain comes from taking paclitaxel (Taxol), a common chemotherapy for breast cancer, but that larger studies will need to confirm this. Your doctor may want to consider other medicines depending on your specific needs and the cause of your neuropathy. The guidelines did not specify whether duloxetine is more effective for certain ages, subtypes, or stages of cancer.


Fatigue is more than the tiredness caused by everyday life stresses. Cancer-related fatigue is a constant feeling of physical or mental exhaustion that makes it hard to function and doesn’t improve with rest. Many factors can cause it, including the cancer itself, the treatment or emotional stress.

ASCO says healthcare providers should assess your level of fatigue when you are diagnosed as part of screening before treatment starts. Providers should evaluate it every year throughout treatment and recovery, to watch for changes and give advice. Other recommendations in the guideline suggest that your doctor:

  • Identify whether fatigue is caused by a medicine or treatment you have had. In some cases, these medicines can be changed to lessen fatigue
  • Offer you education materials about how to cope with fatigue using physical activity or complementary therapies
  • Treat other factors that may lead to fatigue, such as depression, pain, or low blood counts

This guideline is geared toward adults with early-stage cancer who have completed their first treatment, for example people treated for breast cancer who are now taking hormonal therapy such as tamoxifen.

Depression and Anxiety

Depression is ongoing sadness and lack of interest in doing things that usually bring you pleasure that continues for 2 or more weeks, makes it hard to keep up with daily activities and affects your relationships. Anxiety makes you feel nervous, worried or overwhelmed. While you might expect anxiety after a cancer diagnosis, the condition may need attention if it continues for a long time.

Depression and anxiety may be caused by factors including body image, ability to have children or sexual side effects.

ASCO says your doctor should check for these conditions when you are first diagnosed and regularly during and after treatment. They also include that your doctor:

  • Find out if either is caused by a medicine you currently take that can be changed or avoided
  • Offer you prescription antidepressants or anti-anxiety medicines if medically necessary, and follow-up every 8 weeks to see if the medicine is working and how you feel
  • Refer you to a talk therapist or psychiatrist if medicine is not an option or doesn’t help
  • Talk with you to find out if prescription medicines are working, and offer nonmedical alternatives if they aren’t

This guideline applies to people 18 or older who have any kind or stage of cancer, and who receive any kind of anticancer treatment.

What This Means for You

It may be surprising when side effects linger long after treatment. These guidelines will help you and your healthcare team know what to expect and how to cope.

Because of these guidelines, your provider may ask you more regularly about how you are feeling emotionally and physically, how easily you are able to perform daily tasks and how you feel about your relationships with others. This will help them watch for changes in fatigue, depression and anxiety.

Keep in mind these are guidelines, rather than rules, for doctors. It’s important to discuss concerns with your care team as soon as they come up.

Andersen, B, DeRubeis, R, Berman, B, et al.  Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer: An American Society of Clinical Oncology Guideline Adaptation. (April 2014). DOI: 10.1200/JCO.2013.52.4611

Bower, J, Bak, K, Berger, A, et al.  Screening, Assessment, and Management of Fatigue in Adult Survivors of Cancer: An American Society of Clinical Oncology Clinical Practice Guideline Adaptation. (April 2014). DOI: 10.1200/JCO.2013.53.4495

Hershman, D, Lacchetti, C, Dworkin, R, et al.  Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. (April 2014). DOI: 10.1200/JCO.2013.54.0914

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