December 15, 2000

When you are diagnosed with cancer, your first thought is one of survival. You need to beat the cancer. You want to live.

To that end, you submit to tests, scans, surgery, and chemotherapy, and possibly radiation and hormone therapy. You use every arsenal available to you to wage a war against your cancer. In some cases this assault takes a few months, sometimes the rest of your life. But you do what you need to do to fight the fight of, and for, your life.

Of course, before you begin any of the components of this journey you are given the obligatory pamphlet outlining all the common, and even rare, side effects for each type of treatment. Even a person who has never had cancer can probably tell you the major side effects to chemotherapy; the ones we all dread. Losing your hair and nausea are temporary side effects, which though debilitating you will eventually return to normal.

Years ago, the primary focus cancer treatment was survival. Even then, survival was, in many cases, an unrealistic goal. Long-term side effects were, therefore, not of major consideration. These days, with more successful therapy regimens, long-term survival is a reality for a great many of us.

One side effect never mentioned and mostly unacknowledged is a cognitive one. Patients will often refer to this as “chemobrain.”

Chemobrain may be first noted while undergoing chemotherapy treatment. Patients have complained of a general loss of focus, some mental confusion, loss of memory, cognitive impairment, and decreased thinking clarity. Physicians are willing to accept that chemotherapy might impinge on the neurological functions of the patients. It is well-documented that chemotherapy is nondiscriminatory in its attack on cells, killing the healthy cells as well as the cancer cells which accounts for the most visible side effect, hair loss.

However, little attention has been given to neuropsychological and cognitive problems. Many physicians do not understand how to deal with what they consider a “non-problem”. You also need to gauge how much chemotherapy may add to memory loss in relation to factors such as aging, depression, and menopause. Low Blood counts, medication, other than chemo and/or emotional upheaval of cancer may also contribute to the problem.

As a result of this lack of understanding among physicians, many patients receive a diagnosis of depression, anxiety, or stress and are treated with Paxil or similar medications. All this does is merely take away the anxiety associated with a patient’s frustration without dealing with the problem.

It is understandable that a physician would recognize their patients as depressed. Depressed people have memory and cognitive problems as well. 20% of cancer patients are clinically depressed. Fatigue, another side effect of chemotherapy, can cause cognitive problems. Menopause is a known culprit as well.

A Danish study conducted by van Dam, et al was published in the Journal of the National Cancer Institute in 1998. The study involved one-point testing. They tested psychomotor function, memory, concentration, and language. The study tested patients two years post-treatment. The results showed that there was cognitive problems even after control of depression, anxiety, and fatigue in 32% of patients who receive high dose chemotherapy and 17% of those who received traditional chemotherapy. The study, however, failed to conduct testing prior to treatment, so there was no baseline for comparison.

A similar study at Dartmouth looked at patients 10 years out, but again did not pre-study.

Raine Riggs, a doctoral student in the Department of Psychology at the University of Vermont is part of an investigative team looking into the neuropsychological relationship between brain and behavior, the problem known as chemobrain. The study involved an assessment of cognitive function in women under treatment for breast cancer. Baseline testing was done prior to treatment, after 3 months, and with a 6 month follow-up. Evaluation showed a mild impairment of motor speed and psychomotor speech both in women who had chemotherapy and women on tamoxifen, a hormonal therapy.

It is assumed that once treatment is finished, with perhaps a few months leeway following treatment to resume normal functioning, patients will return to normal. However, many patients continue to note problems such as attention and concentration, impaired memory, compromised math skills, brief periods of confusion, an overall slow processing of information. Many continue to have impairment with a marked deceased in switching cognitive sets.

Respondents to an Internet survey reported:

“I think I might be in the beginning stages of Alzheimer’s.”

Another wrote, “I can’t seem to say what I mean. The word is always just on the tip of my tongue.”

“It’s real scary for me these days, because I notice problems while driving. I find myself wondering how I got where I am. I constantly bump into the curb. I can’t parallel park to save my life and I hit the doorjam of the garage have the time”, from yet another.

Riggs says “The problem is not severe, it just seems that way”, though she does admit, “Our tools may not be adequate to assess the problem accurately. They were designed for the brain injured.”

Many breast cancer patients find chemobrain to be a significant problem: 43% of those receiving chemotherapy and 50% of those receiving hormone therapy. There are reasons for this. Breast cancer patients might be the hardest hit population.

1. Treatment for breast cancer is one of the most grueling: surgery, chemotherapy, radiation, and/or hormonal therapy.

2. Most breast cancer patients are postmenopausal. Those who are not are often thrown into “chemopause”. Estrogen replacement often solves the problem, by HRT is contra-indicated for women with breast cancer.

3. Tamoxifen, one of the variables in the Riggs’ study, is typically used for 5 years. Therefore, the effect of chemobrain for these women, might even last for years. Ms Riggs recommends some strategies to help cope with loss of cognitive function, whether it be temporary or permanent.

· Avoid distraction · Ask people to repeat information · Practice tasks · Check in with yourself to train your brain · Write it down, your daily organizer may be a lifeline · Keep a journal · Post reminders · Get organized · Exercise your memory like a muscle . Manage stress. Higher levels of stress hormones adversely effect mental acuity . Get enough sleep , Physical activity. Physical activity changes brain chemistry · Use mnemonic devices · Do crossword puzzles · Ask for help

While the UVM study is narrow in its scope, the hope is that it will serve as an impetus to other, better funded studies which can address the issue of chemobrain. The look into the neuropsychological effects of cancer treatment is just one part of a trend toward more comprehensive treatment of the whole person, rather than just the disease.

Lingering Memory Problems After Chemotherapy

Daniel Q. Haney, The Associated Press for the American Cancer Society 


Ordinary doses of chemotherapy sometimes appear to leave patients with poor memories, muddy thinking and inability to do math in their heads, new research suggests.

 Cancer patients often complain of “chemobrain” during treatment. While they are typically reassured this will go away, little attempt has been made until now to see if these subtle problems linger years later.

 The new study, conducted at Dartmouth Medical School, found that people who get standard chemotherapy appear to be about twice as likely as other cancer patients to score poorly on various intelligence tests an average of 10 years after their treatment.

 Doctors say the findings suggest that aggressive treatment with chemotherapy may be unwise in some people with early-stage cancer unless the drugs can substantially improve chances of survival.

 Tim Ahles, a psychologist, presented the results Tuesday at a meeting in Tampa of the American Cancer Society. He said that while his is one of the first formal studies of the problem, the results are unlikely to surprise many cancer patients.

 Ahles said that when he spoke recently about the findings at a meeting of cancer survivors, he worried his discouraging news would upset the audience. Instead, they seemed relieved that scientists were finally taking seriously a complaint they had made for years.

 He said that many years after treatment, some cancer survivors say they still have trouble remembering and concentrating. Some say they need a calculator for math problems they once could have solved in their heads. Others have to read a page twice to absorb what’s being said.

 “In talking to someone, you’d never notice this,” Ahles said. “But it is very relevant to them.”

 Ahles noted that lots of things during chemotherapy can make people feel unfocused. Often they are anemic, sick from the chemotherapy and sleepy from anti-nausea medicines. But intellectual ability gradually comes back as they recover.

 “The question is whether it returns to pretreatment levels,” he said. “The inference from our data is that for a subgroup of patients, it does not.”

 In his study, Ahles tested 71 patients who were cancer-free after getting chemotherapy an average of 10 years earlier for breast cancer or lymphoma. They were compared with 58 who had been treated with radiation or surgery alone.

 Overall, the chemotherapy patients scored significantly worse, though most were still thinking clearly.

 However, between one-quarter and one-third of those who got chemotherapy scored near the bottom in at least four of the nine areas of intellectual ability that the researchers measured. Only half as many of the patients who got surgery or radiation alone did this badly.

 Dr. William Wood of Emory University in Atlanta noted that patients with early-stage cancer often opt for aggressive chemotherapy, even though statistically it offers only a percentage point or two improvement in survival.

 “This is may give second thoughts to people who really would not get much benefit” from chemotherapy, Wood said.

 Earlier studies have found a chance of lingering intellectual problems in people who receive high-dose chemotherapy, such as those undergoing bone marrow transplants. Doctors treating children with leukemia have also successfully turned to less toxic doses after finding the drugs cause learning problems.