Foot Care in Oncology: The Cancer Patient From Ankle to Toe

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Mischa P. M. Nagel

David J. Kopsky, MD

Fiona Damstra, MD

Mario E. Lacouture, MD

Barrie Cassileth, MS, PhD

Systematic and evidence-based foot care in oncology commands attention, given the wide range of agents resulting in adverse events that affect the feet. Moreover, complications may develop at a faster pace in cancer patients in the setting of immunosuppression and comorbidities.

—Mischa P. M. Nagel, David J. Kopsky, MD, Fiona Damstra, MD, Mario E. Lacouture, MD, and Barrie Cassileth, MS, PhD

There is as yet no clinical or research focus on foot complications that result from cancer therapies. Foot conditions, however, are common and have a considerable negative impact on patients’ ambulation, quality of life, and consistent dosing of antineoplastic agents.1-4 There are currently no guidelines in the United States for screening or care of cancer treatment–related foot events. This is in contrast with foot care protocols for patients with diabetes and arthritis, where podiatric care is a critical component of disease control.

Systematic and evidence-based foot care in oncology commands attention, given the wide range of agents resulting in adverse events that affect the feet. Moreover, complications may develop at a faster pace in cancer patients in the setting of immunosuppression and comorbidities. Given the serious impact and potential development of complications, patients and health-care providers must be informed as to how to prevent and address these untoward events. The oncology team and caregivers need oncology-specific guidelines.

“Dermatologic toxicities are diverse and can have an enormous impact on the cutaneous health of patients, overall costs of treatment, health-care–related quality of life, and consistent anticancer therapy.”5 Some of the most common complications resulting from cancer treatments include:

  • Chemotherapy-induced peripheral neuropathy
  • Hand-foot syndrome (resulting from cytotoxic agents)
  • Hand-foot skin reaction (resulting from targeted therapies)
  • Paronychia and onycholysis
  • Edema, lymphedema
  • Skin and soft-tissue infections

These events may impede a patient’s ability to use footwear, bear weight, ambulate, or perform activities of daily living.2

Awareness of Foot Complications

Preventive evaluation and management strategies, such as those performed during de rigueur dental evaluations prior to head and neck radiotherapy or stem cell transplants, serve as a model for the podiatric evaluation of patients receiving agents that result in foot-related adverse events. Most patients, caregivers, podiatrists, other foot-care therapists, and oncology professionals are not aware that cancer treatments may cause foot events.

On the other hand, podiatrists and other foot-care workers may not be aware of the complications that their treatments can induce during or after cancer treatment. Medical professionals, patients, and caregivers should be aware of potential foot complications and how to prevent and treat them.

International Developments

In 2012, the Netherlands “medical foot” academy developed an educational program for foot therapists, who are analogous to podiatrists in the United States. The main goal of the program was to encourage awareness of potential complications and screening, providing appropriate guidance to patients and keeping the feet of cancer patients in optimal condition during and after treatment. This effort also aimed to stimulate communication between foot therapists and oncology professionals. In 2015, at the Dutch Foot College, under the guidance of  Mario E. Lacouture, MD, training was provided to foot therapists concerning relevant complications.

This training will enable foot therapists to properly screen feet before, during, and after cancer treatment. They will learn to recognize complications and to discuss problems with oncology team members. To ensure patient safety, foot therapists will ask and receive permission from treating oncologists prior to treatment.

The need for proper training was evident in the results of a 2013 Dutch survey published in the Dutch publication The Medical Foot. A total of 765 foot therapists responded, indicating that 80% work with cancer patients while they are receiving treatment, 80% of the therapists had little or no knowledge of cancer or complications of cancer treatment, and only 10% received information about cancer during foot therapy training. This survey also revealed a complete absence of communication between foot therapists and members of an oncology team.

In 2014, an education initiative in the Netherlands led to the successful training of 200 foot therapists who now specialize in cancer patient foot care. A survey of this group revealed that 33% now work with patients referred by oncology team members (previously 0%), 70% of foot therapists now work as part of the oncology team, and 70% work with written approval. Unfortunately, 30% of trained foot therapists do not get a response to their treatment request from the oncology team, and the patient, therefore, does not receive foot care.

However, two-thirds of Dutch oncology departments offer foot therapists a 2-day observation of inpatient and outpatient care. Many oncology team members acknowledge foot care as an added value to their specialty. To date, two hospitals in the Netherlands have employed trained foot therapists. In June 2015, a newly established association of oncology foot therapists was welcomed as a member of the Dutch Association for Oncology ( This umbrella association covers all cancer professionals striving for optimal cancer care in the Netherlands.


In 2014, guidelines were developed for foot therapists on safe foot care for cancer patients in the Netherlands. After questioning several national European cancer foundations, it appeared that no such guidelines existed previously.

In 2015, a second version was published. The need for guidelines is clear, and hopefully they will be further developed by the newly established international foundation for oncology foot care ( ■

Disclosure: Mr. Nagel is owner and Director of Supplement BV/Medical Foot and Director of Van Dooren Advice, Amsterdam. Drs. Kopsky, Damstra, Lacouture, and Cassileth reported no potential conflicts of interest.


1. Miller KK, Gorcey L, McLellan BN: Chemotherapy-induced hand-foot syndrome and nail changes: A review of clinical presentation, etiology, pathogenesis, and management. J Am Acad Dermatol 71:787-794, 2014.

2. McLellan B, Ciardiello F, Lacouture ME, et al: Regorafenib-associated hand-foot skin reaction: Practical advice on diagnosis, prevention, and management. Ann Oncol 26:2017-2026, 2015.

3. Macdonald JB, Macdonald B, Golitz LE, et al: Cutaneous adverse effects of targeted therapies: Part I: Inhibitors of the cellular membrane. J Am Acad Dermatol 72:203-218, quiz 219-220, 2015.

4. Gomez P, Lacouture ME: Clinical presentation and management of hand-foot skin reaction associated with sorafenib in combination with cytotoxic chemotherapy: Experience in breast cancer. Oncologist 16:1508-1519, 2011.

5. Lacouture ME: Dermatologic Principles and Practice in Oncology: Conditions of the Skin, Hair, and Nails in Cancer Patients. Hoboken, NJ, Wiley-Blackwell, 2014.

Suggested Reading

Capriotti K, Capriotti JA, Lessin S, et al: The risk of nail changes with taxane chemotherapy: A systematic review of the literature and meta-analysis. Br J Dermatol 173:842-845, 2015.

Dranitsaris G, Vincent MD, Yu J, et al: Development and validation of a prediction index for hand-foot skin reaction in cancer patients receiving sorafenib. Ann Oncol 23:2103-2108, 2012.

Lacouture ME, Reilly LM, Gerami P, et al: Hand foot skin reaction in cancer patients treated with the multikinase inhibitors sorafenib and sunitinib. Ann Oncol 19:1955-1961, 2008.

Park HJ: Chemotherapy induced peripheral neuropathic pain. Korean J Anesthesiol 67:4-7, 2014.

Piano V, Schalkwijk A, Burgers J, et al: Guidelines for neuropathic pain management in patients with cancer: A European survey and comparison. Pain Pract 13:349-357, 2013.

von Moos R, Thuerlimann BJ, Aapro M, et al: Pegylated liposomal doxorubicin-associated hand-foot syndrome: Recommendations of an international panel of experts. Eur J Cancer 44:781-790, 2008.

Mr. Nagel is Director, Supplement BV/Medical Foot, Van Dooren Advice, Amsterdam. Dr. Kopsky is Director of Clinical Operations at the Institute for Neuropathic Pain, Amsterdam. Dr. Damstra is is a rehabilitation physician at the Jan van Breemen Institute, Amsterdam. Dr. Lacouture is Associate Member in the Division of Dermatology, Department of Medicine, at Memorial Sloan Kettering Cancer Center, New York. Dr. Cassileth is Chief of the Integrative Medicine Service and Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan Kettering Cancer Center, New York.



Integrative Oncology is guest edited by Barrie R. Cassileth, MS, PhD, Chief of the Integrative Medicine Service and Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan Kettering Cancer Center, New York.

The Integrative Medicine Service at Memorial Sloan Kettering Cancer Center developed and maintains a free website—About Herbs (—that provides objective and unbiased information about herbs, vitamins, minerals, and other dietary supplements, and unproved anticancer treatments. Each of the close to 300 and growing number of entries offers health-care professional and patient versions, and entries are regularly updated with the latest research findings.

In addition, the About Herbs app, Memorial Sloan Kettering Cancer Center’s very first mobile application, can be downloaded at The app is compatible with iPad, iPhone, and iPod Touch devices.