Cancer Related Cognitive Impairment
Mild cognitive impairment (also known as "chemo brain" or "chemo for") is common among individuals being treated for cancer. Recent reports suggest that up to 75% of cancer patients may experience subtle cognitive changes that make day-to-day management of work and family responsibilities very difficult. Domains affected by neurocognitive dysfunction include:
Fortunately, baseline assessments and evidence-based treatments are available to improve cognitive function.
To schedule a cognitive impairment assessment please call or email:
Neurocognitive dysfunction (AKA “chemo brain”, “chemo fog”), resulting from cancer treatment, is now a recognized biomarker reflecting treatment effects, disease status, and psychological well-being (1).
Recent reports suggest that up to 75% of cancer patients may experience subtle cognitive changes that make day-to-day management of work and family responsibilities very difficult (2,3). Moreover, debilitating neurocognitive dysfunctions are reported by 15% to 50% of cancer patients treated with chemotherapy (4-8).
Domains disrupted by neurocognitive dysfunction include (9,10):
Etiology of Disease
Functional MRI studies have documented that cerebral functional and structural changes correlate with complaints regarding impaired cognition and performance, and these alterations persist over time (11).
There are multiple hypotheses for brain changes that underlie neurocognitive impairment, resulting from cancer treatment including disruption of hippocampal cell proliferation and neurogenesis (11), chronic inflammation (12,13), oxidative stress (12), white matter disruption (14,15), changes in cerebral blood flow, and metabolism (16). For instance, treatment with tamoxifen has been associated with functional declines in verbal learning, memory, and executive function, when compared with treatment using exemestane.
The biologic basis for tamoxifen related neurocognitive dysfunction may be associated to estrogen receptors in the hippocampus and prefrontal cortex that initiate intracellular signal transduction pathways and induce spinogenesis and synaptogenesis (17).
Additional factors currently being studied include age, hormonal status, baseline cognitive performance, educational level, genetic predisposition, depression, anxiety, fatigue, pain, anemia, time since treatment, and dietary factors (11).
More than thirty diagnostics are currently suggested to improve pathogenic understanding of neurocognitive impairment (1). While these diagnostics may provide further insight into the etiology of an individual’s neurocognitive impairment, NCCN guidelines state these tests are not warranted without first deploying a neuropsychological evaluation (18).
TREATMENT (follows NCCN Guidelines
Neurocognitive impairment, related to cancer treatment, is a rapidly evolving field of medical science. A review of the literature reveals four evidence-based, non-invasive, low-cost interventions that can improve cognitive function and quality of life.
A randomized controlled trial assessing the efficacy of modafinil for fatigue and cognitive function in breast cancer survivors found significantly greater improvement in memory and attention among patients receiving modafinil than in a placebo group (18). Additionally, donepezil was found to enhance memory performance and partially reverse the hypometabolism induced by chemotherapy (19). Although a feasibility study of donepezil in breast cancer survivors showed improvement in objective neurocognitive function, more research is necessary (20).
Physical Activity & Exercise
There is a plethora of research demonstrating the benefits of exercise for improved cognitive function. Animal and human studies support the use of exercise for chemotherapy-related neurocognitive function. Studies with cancer patients have documented neurocognitive improvements of exercise, including Qigong, Yoga, Tai Chi, physical fitness, and resistance training (22-23).
Cognitive Behavioral Therapy (CBT)
Neurocognitive changes frequently occur with anxiety, depression, fatigue, and sleep disturbances (24,25,26,27). CBT addresses the psychological response to neurocognitive change rather than the cause of neurologic injury (28). Memory and adaptation training (MAAT) is a form of CBT developed for patients with cancer (28). MAAT aims to build adaptive skills and reduce the disparity between cognitive demand and perceived ability to cope with cognitive demands (29-33). Improvements in cognitive performance have also been noted with compensatory (34) and computer based (35) cognitive training. Sustained performance improvements has been demonstrated months after CBT (36,37).
Based on a thorough review of the literature, we have developed an evidence-based strategy to address cancer treatment related cognitive impairment:
Patient is assigned to health counselor at time of diagnosis or prior to treatment
Clinical psychologist conducts baseline cognitive assessment
Patient is offered to enroll in an exercise program, behavioral therapy, and community support programs
Follow-up assessments are scheduled mid-way through treatment, post treatment, and at six month intervals until patient returns to baseline, enhances from baseline, or measurements suggest further evaluations are needed by a clinical neurologist.
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