Prayuenyong, Pattarawadee
(2021)
Vestibulotoxicity and balance problems associated with cisplatin chemotherapy in adult cancer survivors.
PhD thesis, University of Nottingham.
Abstract
Introduction and aims
Cisplatin is an effective chemotherapeutic agent, but it has common side effects of ototoxicity and peripheral neuropathy which could potentially lead to balance problems. While cisplatin cochleotoxicity (causing hearing loss or tinnitus) is well documented, vestibulotoxicity (causing balance problems) is still unclear in literature. This thesis aimed to examine vestibular dysfunction and balance problems associated with cisplatin chemotherapy in adult cancer survivors to determine the epidemiology and impact of the problems. The project consists of 4 original research studies to evaluate the problems from patients and healthcare professional perspectives. Specific objectives of the studies were
I. To examine current evidence and identify research gaps on vestibulotoxicity associated with cisplatin chemotherapy
II. To explore knowledge, experiences, and opinions of audiovestibular professionals about cisplatin vestibulotoxicity
III. To assess the vestibular function and balance problems in adult cancer survivors who had completed cisplatin chemotherapy treatment
IV. To explore the lived experience and attitudes towards balance problems in adult cancer survivors who had completed cisplatin chemotherapy treatment
Methods
Scoping review: Research studies that mentioned vestibulotoxicity of cisplatin chemotherapy was identified through systematic literature search. Two researchers independently assessed and extracted data. Research findings were summarized narratively and research gaps were identified.
Online survey: A questionnaire was developed to answer the specific research questions. Ninety-three clinicians working in the audiovestibular field participated in the online survey. Descriptive statistical analysis was conducted.
Cross-sectional study: Sixty-five cancer survivors who had completed cisplatin treatment were recruited. The video Head Impulse Test (vHIT) of all semicircular canals was performed. Patient-reported balance symptoms were evaluated by a semi-structured clinical interview. Patients underwent bedside clinical tests including Dynamic Visual Acuity (DVA) test, Modified Clinical Testing of Sensory Interaction and Balance (CTSIB-m), and vibration sense testing to detect peripheral neuropathy. Descriptive and logistic regression statistical analyses were conducted.
Interview study: Nine cancer survivors who had balance problems after chemotherapy treatment were interviewed. The interviews were transcribed, and analysed using inductive thematic analysis.
Results
Scoping review: Testing for cisplatin vestibulotoxicity predominately featured functional evaluation of the horizontal semicircular canal using the caloric and rotational tests. The rate of abnormal vestibular function test results after cisplatin treatment varied from 0 to 50%. The results of objective testing did not always correspond to patient symptoms.
Online survey: Most of the audiovestibular professionals (87%) were aware of potential vestibulotoxicity associated with cisplatin chemotherapy, and some (31%) had seen patients with the condition. Forty percent of them were confident in making the diagnosis and in managing the patient in this situation.
Cross-sectional study: All patients had normal vHIT results in all semicircular canals. Eleven out of sixty-five patients (17%) reported some balance symptoms after cisplatin therapy, including vertigo, dizziness, unsteadiness and falls. Vertigo was the most common balance symptom, reported by six patients (9.2%), and the clinical histories of these patients were consistent with benign paroxysmal positional vertigo (BPPV). Three patients (5%) had abnormal results of the CTSIB-m test, and they were the same patients that reported falls. Those who have noticeable hearing loss and peripheral neuropathy are more likely to have balance problems. Balance problems mainly affect quality of life of cancer survivors in the physical domain.
Interview study: The themes included impact, coping strategies, experience through cancer journey, and opinions about investigation and management. Balance problems have an impact on physical and emotional aspects of life for cancer survivors with most participants rating low perceived handicap. These participants coped with balance symptoms using different strategies such as optimisation, lifestyle modification, or activity restriction. Positive attitudes along cancer journey have been described by most participants which demonstrate the ability of cancer survivors to turn around negative life experiences. Most participants did not say they needed help regarding balance problems. The concept of further investigation and management was generally acceptable but may not be needed for some individuals.
Conclusion
There is no definite vestibular dysfunction detected by video Head Impulse Test in cancer survivors who received cisplatin treatment. Vertigo triggered by BPPV is relatively prevalent in this group of patients and warrants further elucidation. Balance symptoms should not be overlooked and potentially affect one in six cancer survivors who received cisplatin. It is also important to identify the minority of cancer survivors who are significantly impacted with balance problems, and to offer appropriate physical and psychological support. Various research opportunities of both scientific and clinical value regarding the topic warrant more attention such as cancer survivor care and the better understanding of mechanisms of cisplatin ototoxicity.
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