Living with Cancer: Coping with Chemo Brain

One of the side effects cancer patients may experience following chemotherapy and other types of cancer treatments is a clinically recognized syndrome called Cancer-Related Cognitive Dysfunction (CRCD). What are the risks and symptoms of “Chemo Brain,” as it is commonly called, and can it be treated?

M. Beatriz Currier, M.D., medical director of the Cancer Patient Support Center at Baptist Health Miami Cancer Institute and the cancer center’s chief of psychosocial oncology, shares helpful insights on CRCD, which for some people can be frustrating and even debilitating.

Dr. Currier says that CRCD is highly prevalent, experienced by 25 percent of patients before treatment, as a result of the effects of the cancer itself, and by 75 percent of patients during treatment. Up to 35 percent of patients continue to experience CRCD after completing cancer treatment. “The presentation and course of these cognitive deficits vary and they may be very stable or dramatic, temporary or permanent, or remain unchanged or progressively worsen,‘’ she says. “We can’t really predict how any one patient will be affected.”

Cancer related cognitive dysfunction (CRCD) is defined as a pattern of cognitive deficits due to the impact of cancer and its treatment on the brain. Dr Currier states, “These cognitive deficits typically manifest as disturbances in the patient’s verbal memory, sustained attention, executive function and processing speed.”

CRCD symptoms can be subtle

Usually, CRCD starts to subside within a few months after treatment but sometimes it can be more prolonged and some patients may need up to two years to fully recover, Dr. Currier says. “These cognitive deficits can be subtle and many people don’t even realize they’re affected until they return to work or school and realize they’re having difficulty keeping up.”

An individual’s tendency to exhibit word finding difficulty (especially with proper nouns) is not a symptom of CRCD, Dr. Currier says. “That is something that happens to many people as a normal part of the aging process and it doesn’t mean they’re experiencing CRCD, which has a specific set of symptoms that we can test for.”

Subjective reports from patients and a typical memory test administered during an office visit are often unreliable to detect CRCD. Dr. Currier notes, “Some patients say they’re just not feeling as ‘sharp’ as they were before or they’re having more trouble remembering things,” she says. “However, that alone does not provide a basis for a CRCD diagnosis.” 

The International Cognition and Cancer Task Force has developed CRCD guidelines and standardized psychometric tests that can confirm if a patient does indeed have the syndrome, Dr. Currier says. The tests take just a few hours and provide objective confirmation of CRCD, she adds.

Who’s at risk for CRCD?

There are a number of risk factors that may predispose cancer patients to developing CRCD, including age, race, ethnicity and other demographic characteristics as well as medical factors such as stage of disease, menopausal status, body mass index and genetics. “Advancing age is certainly a risk factor. However, pediatric cancer patients also can develop CRCD,” notes Dr. Currier. 

Additionally, certain types of cancer treatment are more toxic to the brain than others, according to Dr. Currier. Studies have shown that patients taking Tamoxifen – a hormone deprivation therapy to prevent recurrence of breast cancer and certain other types of cancer – tend to experience a significant decline in verbal memory and executive function after one year of treatment, as compared to women on Exemestane, an aromatase inhibitor, who did not experience any significant deficits one year later.

Other factors that can increase one’s risk for developing CRCD include advancing age, menopausal status, and existing medical issues such as chronic hypertension or diabetes, both of which can impact cognitive function over time, Dr. Currier says. “Also, some people are genetically predisposed to developing CRCD, particularly those who have the APOE4 allele carriers and COMT Val+ genes.”

Diagnosing and treating CRCD

Always innovating on behalf of both today’s and tomorrow’s cancer patients, Miami Cancer Institute last year launched the Brain Fitness Lab, which Dr. Currier says was specifically designed to diagnose and treat CRCD. 

“Patients receive comprehensive evaluation, including brain scans, if needed, and bloodwork, to identify if any vitamin deficiencies or electrolyte disturbances are exacerbating the cognitive deficits,” says Dr. Currier. “They receive a computerized neurocognitive assessment, which reveals which if any of the brain’s domains are affected and if so, they move on to a series of neuropsychological tests which may take up to two hours of testing to confirm the diagnosis.”

To date, the Brain Fitness Lab has already assessed more than 450 patients, 24 percent of whom were clinically diagnosed with CRCD, Dr. Currier says. Of children who were treated at Miami Cancer Institute and underwent assessment at the Brain Fitness Lab, 25 percent were diagnosed with CRCD. It’s a reminder, she says, that “Chemo Brain” can affect young and older cancer patients alike. 

It’s important to get this type of testing done, Dr. Currier says – for younger patients who have been treated for cancer and whose brains are still developing. “The implications could be huge,” she says. “That’s why early detection and treatment is critical.”

Exercise your brain and care for your body

The good news, says Dr. Currier, is that CRCD is “potentially reversible” and most patients do return to baseline cognitive function, usually within six months to two years at most. “There are very few cases where CRCD is progressive and permanent,” she says.

Also, Dr. Currier says, there are treatment and management strategies that can help mitigate the effects of CRCD and shorten the duration of the syndrome so that patients can get back to their baseline work or academic performance more quickly.

“There are pharmacological therapies such as Modafinil, a stimulant that has been shown to improve attention span,” Dr. Currier says, “but behavioral therapies have proven to be highly effective in treating CRCD.” While Miami Cancer Institute offers outpatient cognitive rehabilitation services which are covered by most insurance plans, Dr. Currier says there are also web-based brain-training courses that patients can take at home, four days a week for 12 weeks. Brain HQ by Posit Science is a highly recommended web-based program.

Just 30 minutes a day of computerized cognitive remediation training can help improve verbal memory, sustained attention, executive function and processing speed, according to Dr. Currier, who recommends breaking the brain exercises into two 15-minute sessions. “These increasingly difficult exercises require intense focus and concentration and can be mentally exhausting if you try to do too much at once,” she says, adding that they can be equally effective for patients experiencing normal age-related cognitive decline.

Anti-inflammatory lifestyle can help

Healthy eating and sleeping habits are also important, says Dr. Currier. “Cancer and its treatment can ramp up inflammation in the body, and when that inflammation crosses into the brain it can cause some of these cognitive problems,” she explains. “An anti-inflammatory lifestyle – getting plenty of sleep, exercising regularly and eating a Mediterranean-type diet – will dampen inflammation and can restore and enhance cognitive function.”

While much is already known about CRCD, Dr. Currier says further research is needed. “We’re learning more about it every year, but we need to develop effective cognitive remediation interventions and prevention models.” 

In the meantime, Dr. Currier recommends that CRCD patients – as well as anyone experiencing or hoping to forestall age-related cognitive decline – adopt brain-training management strategies they can do at home to stay focused and sharp.

“Maintaining organized routines at home; keeping to-do lists; placing your keys or glasses in the same place every time you come home; doing crossword puzzles or Sudoku 15 minutes a day, these are all little things you can do to exercise your brain,” advises Dr. Currier.