More Than Chemo Brain: Several Factors Contribute to Cognitive Decline After Cancer

Started by LisaE, January 20, 2016
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LisaE

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558 Posts
Posted on
January 20, 2016
Though patients and survivors often complain of chemo brain during and after treatment for cancer, a growing body of research shows that there are multiple causes behind the cognitive decline many survivors experience.

Whatever the culprits, cognitive complaints persist for many cancer survivors long after their active treatment has ended, and there is increasing evidence to back this up, said Tim Ahles, in his presentation at the inaugural 2016 Cancer Survivorship Symposium.

Ahles, a behavioral psychologist at Memorial Sloan Kettering Cancer Center, noted that most of the research on the cognitive impact of cancer treatments has been done in breast cancer, with at least 20 longitudinal studies devoted to cognitive functioning in this population.

While almost everyone reports some temporary issues with cognitive function during their chemotherapy treatment, Ahles estimates that for about 15 to 20 percent of survivors, this condition may persist one or two years — for some even longer — though the research varies, with some studies finding no evidence of impairment and others reporting as much as 60 percent.

Advanced imaging techniques and animal studies have enabled researchers to better elucidate how exposure to chemotherapy can impact the brain, Ahles explained, and researchers theorize that the mechanisms may be a kind of “accelerated aging” that results in DNA damage, inflammation and increased oxidative stress, among other effects.

“If you think about it, what does chemotherapy do? What does radiation do? These affect all of these systems as well. There may be this complex interaction between specific effects of our cancer treatments and the impact on the underlying biology of aging.”

Among cancer survivors, we in the research community have traditionally called it ‘chemo brain,’ added Ahles. “Many of us started in this area believing that chemotherapy was the primary cause, but as it turns out, there’s growing evidence that endocrine therapies may also impact cognitive function … also hormone ablation therapy. Testosterone and estrogen are important in maintaining cognitive function, particularly working memory.”

Drawing a typical example of a woman with breast cancer, Ahles said, “she will have had one or maybe multiple surgeries with general anesthesia, chemotherapy, radiation, endocrine therapy — we really are studying that whole package of treatments.”

The most common cognitive issues individuals report after cancer treatment include problems with memory, concentration, and executive function, which for patients often translates into worry that they can’t multitask anymore and need to start over when they are interrupted or get distracted, explained Ahles.

Other frequent complaints, he said, involve a reduction in the ability to learn new material and reading comprehension, for example, survivors say they need to read articles two or three times to understand them. They may also report trouble working with numbers, for example, figuring out the tip at a restaurant. “People often tell me they feel like they’re in ‘a bit of a fog.’ “It’s not that they can’t learn; it just takes more effort and more time.”

Ahles stressed that when a survivor reports any loss of cognitive function, clinicians need to rule out other, potentially treatable, causes, such as sleep disorders (insomnia, sleep apnea), depression, anxiety, stress, pain (and any associated pain/sedating medications), as well as other comorbid conditions which can affect memory and cognition.

Certain genetic and other factors can make a patient more susceptible to cognitive impairment after treatment. Older age and a lower level of cognitive reserve, which Ahles explained involves not only IQ, but education, occupation, and cognitively-stimulating hobbies, can predict cognitive decline. Presence of the gene ApoE4 increases risk of Alzheimer’s disease, and, “it turns out if you’re E4 positive, you have an increased risk for cognitive decline secondary to any insult to the brain,” Ahles explained.

Moreover, although cancer treatment’s negative impacts on cognitive functioning have been studied predominantly in breast cancer, they have been reported in other settings as well, including adult survivors of childhood blood cancers.

What can be done?

“Unfortunately, we don’t have great treatments at this point,” Ahles told his audience, although a lot of work is being done.

In the area of pharmacologic interventions, he said, most are some variant of psychostimulants, for example, Ritalin (methylphenidate), Provigil (modafinil) and Aracept (donepezil). Ahles said that for some people, these agents can be very helpful, and from a clinical point of view, it can be determined within a very short period of time whether they are going to help or whether the individual’s quality of life is impacted by any side effects of taking them.

Preliminary research is under way in the area of cognitive rehabilitation in breast cancer survivors, Ahles said, including interventions aimed at memory and attention training delivered by rehabilitation psychologists or occupational therapists.

Investigators are also looking at the use of technology, including the effectiveness of computer-based interventions.

Ahles also pointed to evidence that exercise slows cognitive changes associated with aging:

“This makes a lot of sense. If you look at the literature on aging, probably the best thing one can do in terms of trying to slow cognitive aging is to exercise regularly. There are multiple side effects of cancer treatment, and exercise has an impact on multiple biologic systems, which may be why it works so well.”

Ahles said that as we await the results of ongoing studies looking at the role of exercise, it’s important to acknowledge that neurocognitive effects of cancer treatment can persist for a significant subgroup of survivors.

“The risk for cognitive problems is likely an interaction of various vulnerability factors, including age, cognitive reserve, genetics, lifestyle, environmental exposures — and our specific treatments.”

“It’s a very complicated interaction that we see, and obviously much more work on interventions is needed.”
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Cyndi

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Posted on
January 20, 2016
My husband has acromegaly. Had 2 pituitary surgeries. Last one removed pituitary. Then had radiation. His personality has changed and is now impatient, fussy, OCD and forgetful. It has been 2 yrs since the surgeries and radiation. And he continues to get worse. Help! Been to psychiatrist who said get on Prozac, made him more forgetting. He stopped taking it.
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Gabbymac

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Posted on
January 24, 2016
Post Breast Cancer (7.5 years), I've had several issues with cognitive function, memory, anxiety, depression, energy, focus, etc. but it's been difficult to describe and have someone believe/understand. Sometimes it looks like normal post menopausal (early due to chemo), or aging issues (53). It's hard to see the big picture at times, but when I step back and look, the before and after "me" are very different. It feels like I've been on a run away treadmill trying to get back to normal. I have about 15 years to work before retirement, so I am interested in getting some of these issues addressed. I'll take this article to my new doctor. Thanks for putting it all together.
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Joni

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Posted on
January 24, 2016
I had diffuse large b-cell lymphoma in 2010. I had R-chop chemo and radiation to my neck. 5 years later I am suffering cognitive behavioral changes: brain atrophy, complete loss of smell and taste, short-term memory issues and sudden sensorineural hearing loss. Oncologist is saying my problems are not due to treatment, although Stanford neurologist is saying my brain atrophy is due to radiation. Interested in hearing from others who have experienced any of these symptoms after chemo/radiation. Thanks.
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Suemcl

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Posted on
January 24, 2016
So glad to see this article and discussion. I was diagnosed in 2005 with non-Hodgkin lymphoma. Had the typical Chop, radiation. It came back in 2008', then it was Chop with Rituxan. Came back yet again in 2013, chemo with Trianda(?) and Rituxan. I've had issues since day one. Initially, panic attacks that kept me in the fetal position in bed for three weeks, and at night I had to walk the floor, counting backwards from 200 repeatedly until the attacks went away. My cancer is indolent, so no cure, and the typical regiment is watch and wait--it makes me crazy. I saw a doctor for months whose specialty was chemo brain, he had wonderful advice, but I'm sorry to say I can't remember any of it any longer. I'm now 67, and probably some of the cognitive deterioration is from age, but it's been a rough ride since 2005. Ritalin has helped me keep focus, but it wears off quickly. I also take Wellbutrin for depression, and alprazolam for anxiety. I wish I could be my old self again. My husband tells me I seem to enjoy being angry all the time. I don't--but I don't know how to be anything but angry. I sure hope they find something before my life is over. I don't want to leave this earth as an angry old woman.
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lkmystique

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Posted on
January 25, 2016
I had rectal cancer with three years of treatments and radiation. It will be a year February 25th since my last radiation treatment. I still have chemo brain and wonder if it will go away or if I will have problems forever with memory loss. It's really scary to all of a sudden not remember what you're going to say or what you got up to do. When I first mentioned it to my oncology nurse she said oh it's chemo brain. I laughed and she said no, that's real. I'm hoping at some point I will finally not be so forgetful. If anyone has actually recovered from chemo brain and reads this article please give us a little hope!
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LisaLisa

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Posted on
February 09, 2016
I was diagnosed with inoperable stage 3 esophageal cancer with mets to the lymph nodes. I was on a Phase II Clinical Trial through the National Cancer Institute and received the experimental treatment. I had 3 types of chemo at the same time as radiation. I was diagnosed in Oct. 01, and did not finish treatment till the end of '02. The tumor was right at the cervical esophagus and was growing into the trachea. I had the radiation from my chin down to my chest and each underarm. The "chemo brain" was bad, but I find it is getting worse, I cannot remember things. I don't even read books anymore as I have to go back and reread chapters because I forget. I had finished a book recently and the next day had to read the end again as I could not remember how it ended! People say, "Oh it's age also", I'm 57...I don't think my memory should be that bad at my age. I just printed this article and am taking to my oncologist as I have told him repeatedly about all my issues; neuropathy, the can't remembering anything. I have to go for an endoscopy every year and I have difficulty swallowing due to the radiation to my throat and the scar tissue.
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LisaLisa

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Posted on
February 09, 2016
I was diagnosed with inoperable stage 3 esophageal cancer with mets to the lymph nodes. I was on a Phase II Clinical Trial through the National Cancer Institute and received the experimental treatment. I had 3 types of chemo at the same time as radiation. I was diagnosed in Oct. 01, and did not finish treatment till the end of '02. The tumor was right at the cervical esophagus and was growing into the trachea. I had the radiation from my chin down to my chest and each underarm. The "chemo brain" was bad, but I find it is getting worse, I cannot remember things. I don't even read books anymore as I have to go back and reread chapters because I forget. I had finished a book recently and the next day had to read the end again as I could not remember how it ended! People say, "Oh it's age also", I'm 57...I don't think my memory should be that bad at my age. I just printed this article and am taking to my oncologist as I have told him repeatedly about all my issues; neuropathy, the can't remembering anything. I have to go for an endoscopy every year and I have difficulty swallowing due to the radiation to my throat and the scar tissue.
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Joni

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Posted on
February 15, 2016
This is a follow-up to my earlier post regarding cognitive changes that I am experiencing after cancer treatment. I do have brain atrophy and consensus of Stanford neurologists is that it is probably due to radiation. No one can tell me if the atrophy will get worse, but I have been advised that I should do the following to protect my memory and cognition: Aerobic exercise, 30 minutes per session, 5 sessions per week Get restful sleep Reduce stress and anxiety. Consider yoga, meditation, mindfulness, deep breathing, guided imagery, exercise. I have started this regime and if nothing else it has helped me mentally cope with the cognitive changes that I am experiencing.
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Will2

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Posted on
May 30, 2016
Even a minor case of Chemobrain is a nuisance. I was, just now over my morning bowl of cereal, reading the May 2016 "Cure" article on Chemobrain and Cognitive Training. While eating and reading, my wife asked why I had taken a new stick of butter from the refrigerator for the dish on the counter, not the partial stick of butter we brought back from last week's vacation in a time-share cabin. The habit of many years (using the new butter) was stronger than the memory of a half-stick of left-over butter in the storage container (both in the 'fridge). I replied to her: "Habit". She said "Not thinking". While mild, this shows the (fortunately mild... in this case, anyway) frustration which can arise from Chemobrain. I could have said "Chemobrain" when my wife asked why I chose the new, not the left-over, but 1) I didn't think of it, and 2) she gets really tired of hearing my "excuse" for not thinking clearly, or for not thinking as quickly as she. -- To you caregivers, I ask your continuing patience. Yes, it gets frustrating, and is tiresome. But, as patients, we often don't wish to keep 'badgering' you with the seeming excuse for our slower-reacting brains. Both you and we hope the Chemobrain will improve; but until that happens, I hope we can all (caregivers and patients) be patient and forgiving. Yes, caregivers, it's OK to encourage us patients to try to improve our thinking. But I hope you do so with gentle understanding, and patience for us patients.
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