Perspective
Yes, Virginia, Chemo Brain is Real Joyce O. Hislop Clinical Breast Cancer, Vol. 15, No. 2, 87-9 ª 2015 Elsevier Inc. All rights reserved.
Introduction Twenty years ago, while interviewing a newly assigned patient on our hospital’s oncology unit, she apologized to me for “being stupid.” Startled at this self-deprecating response to a medical history question I had just asked, I put down my pen and met her eyes. “What makes you think you’re stupid?” Embarrassed, she blushed with her answer. “Ever since getting chemo, I feel like I’m forgetting everything. I never used to be like that. Now I can’t remember names of people or things. At work I can’t find the right words or write the drafts I’ve been doing for years . or spell or type. I’m sure I (appear) as though I’m not educated.” This was my first introduction to “chemo brain,” also described as “brain fog.” What we know currently is that this phenomenon is a toxicity of the nervous system causing cognitive impairment in verbal ability, visuospatial ability, problem solving, and affecting concentration and memory. Until around 1995, medical practitioners referred a patients’ concern with these symptoms to the commonly known chemotherapy side effects such as anemia, fatigue, depression, and hormonal changes. Primarily it was breast cancer patients who voiced concerns: studies during early acknowledgment of this phenomenon were noted only as a supplement to pharmaceutical clinical study and not specifically addressed. However, research now indicates that men with prostate cancer and subsequent treatment with hormonal therapy, such as leuprolide and goserelin, can be at risk for cognitive side effects, particularly memory maintenance. Tamoxifen, an oral drug long used to inhibit estrogen in hormone receptorpositive breast cancer, might cause neurological function changes such as concentration and planning ability.1-3 Besides chemotherapy and radiation, immunotherapy (interleukin-1 and interleukin-6) can generate increased inflammation and fatigue, both thought to contribute to cognitive dysfunction.3
Copycat Side Effects: Is It Really Chemo Brain? The complaints of a patient who believe they are experiencing chemo brain mimic some common noncancer syndromes such as Hematology-Oncology Association, Lehigh Valley Physicians Group, Allentown, PA Submitted: Jul 12, 2014; Accepted: Sep 17, 2014; Epub: Oct 7, 2014 Address for correspondence: Joyce O. Hislop, RN, AD, Hematology-Oncology Association, Lehigh Valley Physicians Group, Allentown, PA E-mail contact: [email protected]
1526-8209/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clbc.2014.09.004
cognitive dysfunction, anemia, hormonal changes, psychosocial distress, vasomotor symptoms, nutritional deficit, insomnia, and fatigue.4,5 Patients report memory lapse, poor concentration, problems with finding the right word, multitasking, and slower ability to think and process; for example, learning something new takes longer than before chemotherapy. Prolonged survival and increased life span has indicated that a breast cancer survivor’s physical condition might diminish faster than their peers: it has been suggested that managing them in a multidisciplinary approach,5 as with a geriatric population, might clarify a nonpharmacological cause of cognitive change, versus, for example, a diagnosis of chemo brain. Science needed a definitive assessment. Research scientists have found, using imaging, that after chemotherapy, there were a diminished number of the cells producing myelin, the insulation surrounding and protecting the nervous system. The reduced cells increased vulnerability to nervous system toxicity and cognitive dysfunction symptoms.6 Dr Tim A. Ahles, lead researcher at the Neurocognitive Laboratory at Memorial Sloan-Kettering Cancer Center, has addressed the prevalence of longer survivor length after diagnosis and treatment.7-9 As patients begin to recommence their goals and quality of life, processing thoughts and memory loss make daily functions an issue for many. Approximately 25% of breast cancer patients who are treated with chemotherapy will experience chemo brain after treatment is completed.3 Recovery from cancer management can take 1 or 2 years, but as long as 5: cognitive dysfunction can be a part of this long process.2 Per Dr S. David Nathanson, surgical oncologist at Henry Ford Health System, this raises another inquiry; that not everyone is at risk for cognitive effects and science has not yet determined indications of that possibility. Among the 25% who will have a loss in cognitive function: he asks, how can we determine who should get chemotherapy?3
Physiological Evidence of Brain Changes After Chemotherapy Brain scans after chemotherapy show less mental metabolism (brain energy) in specific areas of the brain. Scientists have found using positron emission tomography (PET) and computed tomography (CT) that after chemotherapy, the areas of the brain related to planning and decision-making use less energy.1 Rachel A. Lasgos, MD, of the West Virginia University School of
Clinical Breast Cancer April 2015
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Yes, Virginia, Chemo Brain is Real Medicine and West Virginia University Hospitals, advocates that ‘chemo brain’ phenomenon is not depression: a change in brain function is evident on PET/CT brain imaging after treatment. Her team studied PET/CT scans of 128 patients before and after chemotherapy. Using technical software, they identified differences in brain metabolism before and after chemotherapy, and then distinguished patient history, information from neurological examinations, and chemotherapy treatments. They determined that there was an association between reductions in regional brain metabolism and symptoms of chemo brain. These are the energy areas known to be responsible for planning and prioritizing. PET/ CT imaging can reveal a diagnosis of chemo brain, enabling oncologists to manage symptoms and care plans earlier and perhaps more effectively.1 The Journal of Clinical Oncology in 2012 published a study of 34 young premenopausal women with breast cancer conducted by S. Deprez and team. They determined using magnetic resonance diffusion tensor imaging before and after chemotherapy, the organization of cerebral white matter (WM) could be measured. After treatment, significant declines in attention tests, psychomotor speed, and memory were noted in the frontal, parietal, and occipital WM tracks, providing evidence of changes in cognitive functioning and cerebral WM integrity after chemotherapy.6
Educating the Patient and Family Realistic expectations and cognitive training are important coping tools. Oncologists and nurses need to make changes in educating patients and families, including that chemotherapy can cause a condition of mental fog that might last several months to several years after completion.2 Dr Christina Meyers, professor, Neuropsychology Department at M.D. Anderson Cancer Center, Texas, has concluded that chemo brain toxicity might continue for 45% of patients after treatment is completed or withdrawn.3 The abilities of word-finding, concentration, planning daily activities, and multitasking might be temporarily compromised for an indefinite period of time, also compromising the quality of life patients and their family would expect after treatment completion.2 Dr Meyers allows that repetitive mental exercises such as honing a new skill might take longer to learn. And you can still forget your zip code. The cure rate for stage I breast cancer is 90%, and of those patients treated aggressively, 25% could be affected by chemo brain.5 With the possibility of cognitive impairment altering daily abilities and the dynamics of home life and employment, this again raises quality of life issues.2,5 An informed patient voiced concerns about current publicity of the condition and that public awareness of chemo brain “gives employers another reason to think cancer patients and survivors are going to be less productive workers.”
Suggested Adaptive Behaviors to Discuss and Send Home With the Patient According to Morgan5 and Burmeier3: Compensate with external memory aids (daily planner, notes,
maps, and reminder calls).
88
-
Clinical Breast Cancer April 2015
Do not criticize yourself for not being able to remember.
Accepting the problem will help you to cope with it. Give yourself permission to focus on one thing at a time. Get enough rest. Try relaxation training to help focus your attention. For example,
Yoga meditation and/or simple poses are mentally and physically calming and focus concentration. Learn what your cognitive strengths are and work on those (what is your best time of day to accomplish a task?). The Web site “Luminosity” has been shown to help with memory, processing speed, and executive function after chemotherapy. Set a routine or schedule that you follow consistently every day. Alter your work environment or expectations; simplify. Discuss frustrations with friends and family about slower moments. Exercise that increases respirations and heart rate elevates mood and alertness (for example, walking, lifting 1-3 lb hand weights, or going up a staircase). Write in a journal to see what influences your memory problems. Take a break with distraction by watching television or a funny movie.
Are There Pharmaceutical Aids Available? As yet there are no successful drugs to contest brain tissue damage.3 Research has shown that modafinil (Provigil), a drug that stimulates the brain’s memory, concentration, and learning, does so only as required and lasts approximately 12 hours. Ritalin has been tried, but is addictive. Modafinil is nonaddictive.
Listen to the Patient Everyone’s cancer experience is not alike. It is important that a patient is reassured that the oncology team wants to know about and address any concerns or changes they believe are different from their normal. In response to the validation of chemo brain, a survival patient commented that she knows when things are her normal, but also knows when things are not as they should be, and that her oncology team needed to understand that “it is real, and it hurts.”
Disclosure The authors have stated that they have no conflicts of interest.
References 1. Paddock C. Scientists find evidence for “chemo brain” in scans. Available at: http://www.medicalnewstoday.com/articles/253277.php. Accessed: June 5, 2014. 2. Parker-Pope T. Estimated cognitive recovery time post chemotherapy. Casematched control; thought processing, memory and motor skills. Chemo brain may last 5 years or more. The New York Times May 4, 2011. Available at: http:// well.blogs.nytimes.com/2011/05/04/chemo-brain-may-last-. 3. Burmeier, B. Recognizing the symptoms of central nervous system toxicity post chemotherapy; research; pharmacy. “Chemo Brain”. 2013 copyright. University of New Mexico Cancer Center/UNM Health Sciences Center. http://cancer.unm.edu/ cancer. Accessed: January 13, 2014. 4. Mason S. Relevant neuropsychological function abnormalities found post chemotherapy. Study led by Dr. Patricia Gantz, director of UCLA’s cancer prevention and control research Jonsson Comprehensive Cancer Center. “UCLA study finds scientific basis for cognitive complaints of breast cancer patients.” Published: Journal of the National Cancer Institute. April 18, 2013.
Joyce O. Hislop Available at: http:/newsroom.ucla.edu/releases/ucla-researchers-find-scientific-basis. Accessed: January 6, 2014. 5. Morgan MA. Cancer survivorship: history, quality-of-life issues, and the evolving multidisciplinary approach to implementation of cancer survivorship care plans. Oncol Nurs Forum 2009; 36:429-36. 6. Deprez S, Amant F, Smeets A, et al. Longitudinal assessment of chemotherapyinduced structural changes in cerebral white matter and its correlation with impaired cognitive functioning. J Clin Oncol 2012; 30:274-81. 7. Ahles, Tim A, Schapira L. “Your Patient’s Brain on Drugs—Cancer Drugs”; Cognitive side effects post chemotherapy. Medscape Oncology; October 31,
2013. hptt://www.medscape.com/viewarticle/813507. Accessed: November 24, 2013. 8. Ahles T, Rodin G. “Accumulating Evidence for the Effect of Chemotherapy on Cognition”. Controlled studies with breast cancer patients re: cognitive decline in verbal ability and thought processing post chemotherapy. http//dx.doi.org/1299/ JCO.2012.43.5776 JCO 102012, vol 30, no 29, pp3568-69. http://hwmaint.jco. ascopubs.org Accessed: January 13, 2014. 9. Clinical Breast Cancer. “Cognitive Training for Improving Executive Function in Chemotherapy- Treated Breast Cancer survivors”. http//dx.doi.org/10.1016/j.cbc. 2013.02.004.
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Yes, Virginia, Chemo Brain is Real Joyce O. Hislop Clinical Breast Cancer, Vol. 15, No. 2, 87-9 ª 2015 Elsevier Inc. All rights reserved.
Introduction Twenty years ago, while interviewing a newly assigned patient on our hospital’s oncology unit, she apologized to me for “being stupid.” Startled at this self-deprecating response to a medical history question I had just asked, I put down my pen and met her eyes. “What makes you think you’re stupid?” Embarrassed, she blushed with her answer. “Ever since getting chemo, I feel like I’m forgetting everything. I never used to be like that. Now I can’t remember names of people or things. At work I can’t find the right words or write the drafts I’ve been doing for years . or spell or type. I’m sure I (appear) as though I’m not educated.” This was my first introduction to “chemo brain,” also described as “brain fog.” What we know currently is that this phenomenon is a toxicity of the nervous system causing cognitive impairment in verbal ability, visuospatial ability, problem solving, and affecting concentration and memory. Until around 1995, medical practitioners referred a patients’ concern with these symptoms to the commonly known chemotherapy side effects such as anemia, fatigue, depression, and hormonal changes. Primarily it was breast cancer patients who voiced concerns: studies during early acknowledgment of this phenomenon were noted only as a supplement to pharmaceutical clinical study and not specifically addressed. However, research now indicates that men with prostate cancer and subsequent treatment with hormonal therapy, such as leuprolide and goserelin, can be at risk for cognitive side effects, particularly memory maintenance. Tamoxifen, an oral drug long used to inhibit estrogen in hormone receptorpositive breast cancer, might cause neurological function changes such as concentration and planning ability.1-3 Besides chemotherapy and radiation, immunotherapy (interleukin-1 and interleukin-6) can generate increased inflammation and fatigue, both thought to contribute to cognitive dysfunction.3
Copycat Side Effects: Is It Really Chemo Brain? The complaints of a patient who believe they are experiencing chemo brain mimic some common noncancer syndromes such as Hematology-Oncology Association, Lehigh Valley Physicians Group, Allentown, PA Submitted: Jul 12, 2014; Accepted: Sep 17, 2014; Epub: Oct 7, 2014 Address for correspondence: Joyce O. Hislop, RN, AD, Hematology-Oncology Association, Lehigh Valley Physicians Group, Allentown, PA E-mail contact: [email protected]
1526-8209/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clbc.2014.09.004
cognitive dysfunction, anemia, hormonal changes, psychosocial distress, vasomotor symptoms, nutritional deficit, insomnia, and fatigue.4,5 Patients report memory lapse, poor concentration, problems with finding the right word, multitasking, and slower ability to think and process; for example, learning something new takes longer than before chemotherapy. Prolonged survival and increased life span has indicated that a breast cancer survivor’s physical condition might diminish faster than their peers: it has been suggested that managing them in a multidisciplinary approach,5 as with a geriatric population, might clarify a nonpharmacological cause of cognitive change, versus, for example, a diagnosis of chemo brain. Science needed a definitive assessment. Research scientists have found, using imaging, that after chemotherapy, there were a diminished number of the cells producing myelin, the insulation surrounding and protecting the nervous system. The reduced cells increased vulnerability to nervous system toxicity and cognitive dysfunction symptoms.6 Dr Tim A. Ahles, lead researcher at the Neurocognitive Laboratory at Memorial Sloan-Kettering Cancer Center, has addressed the prevalence of longer survivor length after diagnosis and treatment.7-9 As patients begin to recommence their goals and quality of life, processing thoughts and memory loss make daily functions an issue for many. Approximately 25% of breast cancer patients who are treated with chemotherapy will experience chemo brain after treatment is completed.3 Recovery from cancer management can take 1 or 2 years, but as long as 5: cognitive dysfunction can be a part of this long process.2 Per Dr S. David Nathanson, surgical oncologist at Henry Ford Health System, this raises another inquiry; that not everyone is at risk for cognitive effects and science has not yet determined indications of that possibility. Among the 25% who will have a loss in cognitive function: he asks, how can we determine who should get chemotherapy?3
Physiological Evidence of Brain Changes After Chemotherapy Brain scans after chemotherapy show less mental metabolism (brain energy) in specific areas of the brain. Scientists have found using positron emission tomography (PET) and computed tomography (CT) that after chemotherapy, the areas of the brain related to planning and decision-making use less energy.1 Rachel A. Lasgos, MD, of the West Virginia University School of
Clinical Breast Cancer April 2015
- 87
Yes, Virginia, Chemo Brain is Real Medicine and West Virginia University Hospitals, advocates that ‘chemo brain’ phenomenon is not depression: a change in brain function is evident on PET/CT brain imaging after treatment. Her team studied PET/CT scans of 128 patients before and after chemotherapy. Using technical software, they identified differences in brain metabolism before and after chemotherapy, and then distinguished patient history, information from neurological examinations, and chemotherapy treatments. They determined that there was an association between reductions in regional brain metabolism and symptoms of chemo brain. These are the energy areas known to be responsible for planning and prioritizing. PET/ CT imaging can reveal a diagnosis of chemo brain, enabling oncologists to manage symptoms and care plans earlier and perhaps more effectively.1 The Journal of Clinical Oncology in 2012 published a study of 34 young premenopausal women with breast cancer conducted by S. Deprez and team. They determined using magnetic resonance diffusion tensor imaging before and after chemotherapy, the organization of cerebral white matter (WM) could be measured. After treatment, significant declines in attention tests, psychomotor speed, and memory were noted in the frontal, parietal, and occipital WM tracks, providing evidence of changes in cognitive functioning and cerebral WM integrity after chemotherapy.6
Educating the Patient and Family Realistic expectations and cognitive training are important coping tools. Oncologists and nurses need to make changes in educating patients and families, including that chemotherapy can cause a condition of mental fog that might last several months to several years after completion.2 Dr Christina Meyers, professor, Neuropsychology Department at M.D. Anderson Cancer Center, Texas, has concluded that chemo brain toxicity might continue for 45% of patients after treatment is completed or withdrawn.3 The abilities of word-finding, concentration, planning daily activities, and multitasking might be temporarily compromised for an indefinite period of time, also compromising the quality of life patients and their family would expect after treatment completion.2 Dr Meyers allows that repetitive mental exercises such as honing a new skill might take longer to learn. And you can still forget your zip code. The cure rate for stage I breast cancer is 90%, and of those patients treated aggressively, 25% could be affected by chemo brain.5 With the possibility of cognitive impairment altering daily abilities and the dynamics of home life and employment, this again raises quality of life issues.2,5 An informed patient voiced concerns about current publicity of the condition and that public awareness of chemo brain “gives employers another reason to think cancer patients and survivors are going to be less productive workers.”
Suggested Adaptive Behaviors to Discuss and Send Home With the Patient According to Morgan5 and Burmeier3: Compensate with external memory aids (daily planner, notes,
maps, and reminder calls).
88
-
Clinical Breast Cancer April 2015
Do not criticize yourself for not being able to remember.
Accepting the problem will help you to cope with it. Give yourself permission to focus on one thing at a time. Get enough rest. Try relaxation training to help focus your attention. For example,
Yoga meditation and/or simple poses are mentally and physically calming and focus concentration. Learn what your cognitive strengths are and work on those (what is your best time of day to accomplish a task?). The Web site “Luminosity” has been shown to help with memory, processing speed, and executive function after chemotherapy. Set a routine or schedule that you follow consistently every day. Alter your work environment or expectations; simplify. Discuss frustrations with friends and family about slower moments. Exercise that increases respirations and heart rate elevates mood and alertness (for example, walking, lifting 1-3 lb hand weights, or going up a staircase). Write in a journal to see what influences your memory problems. Take a break with distraction by watching television or a funny movie.
Are There Pharmaceutical Aids Available? As yet there are no successful drugs to contest brain tissue damage.3 Research has shown that modafinil (Provigil), a drug that stimulates the brain’s memory, concentration, and learning, does so only as required and lasts approximately 12 hours. Ritalin has been tried, but is addictive. Modafinil is nonaddictive.
Listen to the Patient Everyone’s cancer experience is not alike. It is important that a patient is reassured that the oncology team wants to know about and address any concerns or changes they believe are different from their normal. In response to the validation of chemo brain, a survival patient commented that she knows when things are her normal, but also knows when things are not as they should be, and that her oncology team needed to understand that “it is real, and it hurts.”
Disclosure The authors have stated that they have no conflicts of interest.
References 1. Paddock C. Scientists find evidence for “chemo brain” in scans. Available at: http://www.medicalnewstoday.com/articles/253277.php. Accessed: June 5, 2014. 2. Parker-Pope T. Estimated cognitive recovery time post chemotherapy. Casematched control; thought processing, memory and motor skills. Chemo brain may last 5 years or more. The New York Times May 4, 2011. Available at: http:// well.blogs.nytimes.com/2011/05/04/chemo-brain-may-last-. 3. Burmeier, B. Recognizing the symptoms of central nervous system toxicity post chemotherapy; research; pharmacy. “Chemo Brain”. 2013 copyright. University of New Mexico Cancer Center/UNM Health Sciences Center. http://cancer.unm.edu/ cancer. Accessed: January 13, 2014. 4. Mason S. Relevant neuropsychological function abnormalities found post chemotherapy. Study led by Dr. Patricia Gantz, director of UCLA’s cancer prevention and control research Jonsson Comprehensive Cancer Center. “UCLA study finds scientific basis for cognitive complaints of breast cancer patients.” Published: Journal of the National Cancer Institute. April 18, 2013.
Joyce O. Hislop Available at: http:/newsroom.ucla.edu/releases/ucla-researchers-find-scientific-basis. Accessed: January 6, 2014. 5. Morgan MA. Cancer survivorship: history, quality-of-life issues, and the evolving multidisciplinary approach to implementation of cancer survivorship care plans. Oncol Nurs Forum 2009; 36:429-36. 6. Deprez S, Amant F, Smeets A, et al. Longitudinal assessment of chemotherapyinduced structural changes in cerebral white matter and its correlation with impaired cognitive functioning. J Clin Oncol 2012; 30:274-81. 7. Ahles, Tim A, Schapira L. “Your Patient’s Brain on Drugs—Cancer Drugs”; Cognitive side effects post chemotherapy. Medscape Oncology; October 31,
2013. hptt://www.medscape.com/viewarticle/813507. Accessed: November 24, 2013. 8. Ahles T, Rodin G. “Accumulating Evidence for the Effect of Chemotherapy on Cognition”. Controlled studies with breast cancer patients re: cognitive decline in verbal ability and thought processing post chemotherapy. http//dx.doi.org/1299/ JCO.2012.43.5776 JCO 102012, vol 30, no 29, pp3568-69. http://hwmaint.jco. ascopubs.org Accessed: January 13, 2014. 9. Clinical Breast Cancer. “Cognitive Training for Improving Executive Function in Chemotherapy- Treated Breast Cancer survivors”. http//dx.doi.org/10.1016/j.cbc. 2013.02.004.
Clinical Breast Cancer April 2015
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