Treating a debilitating medical condition characterised by loss of word retrieval, memory and executive function, and an inability to concentrate – often called “chemo brain and which affects about 75% of cancer patients, 35% of them still reporting symptoms after treatment ends – requires a multi-pronged approach, say physicians.
Cognitive behavioural therapy may provide some relief to the cancer-related cognitive impairment (CRCI), they said, but why some people get the condition and others don’t, and why some have symptoms that persist for years while others’ symptoms are resolved in a few months, remains baffling.
What causes 'chemo brain’?
Jeanne Mandelblatt, inaugural director of the Georgetown Lombardi Institute for Cancer and Ageing Research, believes inflammation plays a part.
“Cancer treatment kills cancer cells, but it also causes damage to cells that can accelerate ageing and increase inflammation, including inflammation in the brain. That can affect cognition,” said Mandelblatt, who leads Thinking and Living with Cancer, a 15-year longitudinal study focusing on ageing breast cancer patients and cognitive impairment.
But “chemo brain” is a misnomer, she added, because patients experience cognitive impairment from immunotherapy and hormone therapy as well as chemotherapy. “It is not all one thing, but it is a real phenomenon and people have cognitive problems that interfere with their lives.”
Chemo brain probably also kicks in simply because of the cancer itself, reports The Washington Post.
“When people are going through cancer and recovering, they’re experiencing other problems that can affect their functioning but which don’t necessarily affect their brain. There’s a high rate of insomnia in this population, but there can also be high rates of anxiety and depression, and major lifestyle changes. And those can make you less effective than you were before,” said Nicolette Gabel, division director of rehabilitation psychology and neuropsychology at the University of Michigan Rogel Cancer Centre.
Treatments that work
Neuropsychologists such as Gabel and Eric Zhou, an assistant professor at Harvard Medical School who specialises in disease recovery, said treating chemo brain required a multi-pronged approach.
“It’s a combination of cognitive retraining, and mindfulness practices to help reduce stress (and) improve things like sleep and relaxation …reduce that high-level cortisol stress when people are undergoing these changes,” Gabel said.
Zhou urged patients to speak to their doctors as soon as possible about cognitive symptoms. A recent study showed symptoms improved with the following interventions:
Exercise: In a study of more than 500 breast cancer patients, those who exercised for 150 minutes a week maintained cognitive function similar to a control group of those without cancer, said Michelle Janelsins-Benton, study author and associate professor at the University of Rochester Medical Centre.
“People who were physically active at diagnosis, even if they didn’t maintain that during treatment, had better cognitive maintenance than those who were not physically active before treatment.”
She speculated that exercise combats inflammation in the body, which could be a contributing factor.
In another study, moderate exercise also helped patients maintain attention span. “This needs further study, but I think it’s a very promising benefit of exercise,” she said.
Cognitive behavioural therapy (CBT): Resetting thought patterns and behaviour can improve symptoms and make life easier, Zhou said.
“If you are very forgetful, creating a very structured home environment so you have a specific place for things will be very helpful,” he added. “Using calendars, especially those on our phones or smartwatches that can ring alarms, can prompt behaviour.”
A type of CBT called memory and attention adaptation training is especially effective, Gabel said, and can easily be practised at home.
Sleep: A lack of sleep “amplifies the physiological changes occurring for somebody with chemo brain”. If you’re battling sleepless nights, consult your physician about trying CBT, which is considered the best method for addressing insomnia. Techniques might include adjusting bed times, making the bedroom more restful and “sleep restriction,” which involves limiting time in bed only to those hours spent sleeping – not watching TV or reading or playing on your phone.
Mindfulness: Meditation, deep breathing and yoga can also improve cognitive complaints, according to a small study of breast cancer patients.
Psychostimulants: Although there is not yet clinical evidence for their effectiveness, drugs like Adderall may help.
Fear of cognitive impairment may lead cancer patients to opt out of treatments, but they shouldn’t, Gabel pointed out.
“All of this can sound scary, and I worry that people will turn down treatments that could be curative,” she said. “There are survival rates for cancer now that 20 years ago would have been off the table. It’s not guaranteed chemo brain is going to happen, and if it does, there are ways to address it.”
No approved medications are available for the condition, although Mandelblatt predicted it would not be long before physicians were able to offer pharmaceutical solutions to patients.
“We are making some progress, and I expect that already approved drugs will be repurposed for chemo brain,” she said, noting that studies in mice showed promise.
One showed that Cisplatin, a widely used chemotherapy drug, alters the sphingolipid metabolism in a mouse brain’s hippocampus (where memory is stored), which plays a key role in chemo brain, according to the study’s author, Daniela Salvemini, director of the Institute for Translational Neuroscience at St Louis University School of Medicine.
Salvemini’s team then administered Fingolimod and Zeposia – already approved by the FDA to treat multiple sclerosis – and found they could block the development of chemo brain in mice.
Although human trials are needed, Salvemini said: “This could be a revolutionary approach to the treatment of cancer patients and cancer survivors. We are very excited … Chemo brain is real. For those whom it affects, it has a real impact on their lives.”
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