“Thinking and Memory Changes”

Guest speaker for this conference was Patricia A. Ganz, M.D. and our moderator was Marisa Weiss, M.D.

August 2006

Patricia A. Ganz, M.D. is a medical oncologist and serves as Director of the Division of Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center at UCLA Medical School. During the past 20 years, Dr. Ganz has focused on understanding how people adjust to the diagnosis of breast cancer, including its effects on their physical, emotional, social, and sexual well-being. She developed a way to predict which people are likely to develop significant psychological distress in the year following their diagnosis, and has completed several studies examining the quality of life in breast cancer survivors. In July 1999, Dr. Ganz was awarded an American Cancer Society Clinical Research Professorship and honored with the Komen Foundation Professor of Survivorship Award. Dr. Ganz is also a member of the Professional Advisory Board.

Marisa Weiss, M.D. is Founder and President of Dr. Weiss is a radiation oncologist specializing in breast cancer, and serves as Director of Breast Radiation Oncology at Lankenau Hospital in Wynnewood, Pa. She is the author of Living Beyond Breast Cancer, and the founder of a national nonprofit organization of the same name. Dr. Weiss received the 2003 Professor of Survivorship Award from the Susan G. Komen Breast Cancer Foundation and was selected as Doctor of the Year 2005 by Philadelphia Magazine. From 1998 to 2004, Dr. Weiss co-produced and appeared on the NBC Today Show’s Special Breast Cancer Series. Dr. Weiss is also a member of the Professional Advisory Board. Welcome! Thanks for joining our special Ask-the-Expert Online Conference: Thinking and Memory Challenges. As much as possible, we’ll answer those questions that cover the topics most of you are interested in. We’ll be answering only questions that relate to this month’s topic from participants in this live, online conference, as well as questions from members of the community who couldn’t join us tonight. And now, let’s go to our first question.

Nancy: I was recently diagnosed with breast cancer (multi-focal DCIS) and have had a bilateral mastectomy. No chemo or radiation is needed. Lack of cognitive speed and efficiency has been an issue for the last year or so. Can it be related to the cancer itself and not the effects of chemo, radiation or any medication? I am 47 and perimenopausal. What can you suggest I do to address this issue?

Dr. Ganz: This question is a very good one because people in midlife who are perimenopausal have disruption in their sleep and as a result have difficulty concentrating. It is unlikely that your complaints are related to the cancer itself even though we know that the cancer was developing before you were diagnosed.

Dr. Weiss: Women are very finely tuned animals and we are very sensitive to small as well as big changes in our lives. When things get us rattled or upset or a little disoriented, our ability to think clearly tends to be affected. We are often in charge of coordinating so many things in our lives. When you are juggling six balls at the same time and someone throws you a seventh ball to juggle, it can be unnerving. It throws off a lot of sensitive functions that you expect yourself to do well, including thinking clearly and remembering well.

For people with breast cancer, memory can be affected by many factors:

·    Chemotherapy treatment

·    Medicines that treat side effects

·    Low blood counts

·    Hormonal changes

·    Menopause

·    Stress, anxiety, helplessness, uncertainty, depression

·    Abrupt changes in your life: altered routines, expectations, responsibilities

·    Fatigue

·    Growing older

PS: How long can a patient expect to experience memory issues? I am seven months out from eight rounds of chemo and then radiation, and I still have terrible short-term memory, which seems worse than if it were long-term.

Dr. Ganz: The experience of memory loss associated with cancer treatments usually occurs at the time of treatment and in a small number of women persists beyond that time. Some things that may contribute to short term memory difficulties are loss of energy, difficulty sleeping, and anxiety related to fear of the cancer coming back. In addition, some of the research we are doing suggests that there may be a relationship between the cancer treatment and changes in hormones. The changes in hormones could be [due to] going through menopause as a result of the treatment or from the endocrine treatments we give as part of therapy. In terms of recovery, most women will have slow but steady improvement in memory especially if they pace themselves and try to decrease activities that may make it more difficult to concentrate.

Dr. Weiss: I remember taking care of someone who was exactly in your situation. She could barely string a sentence together without faltering. During treatment she had stopped work, lost her confidence, and began to doubt herself particularly when doing everyday normal things including talking. I just saw her two years later this past week and she was chatting up a storm. Things had gotten back to normal for her. She had put in place a number of regular rituals and routines back into her life, and she found new ways to reduce her anxiety about how she was “performing” at home, at work, and in her community. It was great to see her bounce back like that, though it did take a lot of time and effort as Dr. Ganz has suggested.

Short-term and long-term memory

·    Short-term memory is the ability to remember information over minutes to weeks:

o Reading a phone number and then reciting or dialing the number

·    Long-term memory is the ability to remember information over months to years:

o Remembering a neighbor, friend, or pet from early childhood

Leanna: What if you took hormone replacement therapy before your diagnosis? Would that affect whether or not you had memory problems during breast cancer treatment?

Dr. Ganz: As far as I am aware there is no impact of prior hormonal replacement therapy on the post-treatment complaints. However, it is now known from the Women’s Health Initiative hormone therapy trials that women who were randomly assigned to estrogen and progesterone or estrogen alone had a significant decline in memory functions compared to women who were given a placebo. It used to be thought that hormone replacement was good in terms of preventing Alzheimer’s or memory loss, but that is not the case. So getting off hormones as a result of breast cancer may be beneficial.

Dr. Weiss: Whenever you make a change in your life, like going between medicines or stopping medicines, you’re likely to feel a few bumps in the road. It gets back to my point that we as women do so many things at the same time and not only do people around us expect but we also expect from ourselves that all of our responsibilities will be balanced and done properly and on time, just like we used to. All these expectations can feel burdensome when you are dealing with a breast cancer diagnosis and all the treatments that may be involved. It is important to adjust your expectations when you are facing this big challenge in your life. Give yourself some wiggle room.

Toni2: I am one year post-chemo, radiation and a hysterectomy. I have noticed some improvement with memory. Is there anything I can do to help improve it further? I am 40 years old and this is very frustrating. Thanks for your help.

Dr. Ganz: There are issues related to memory loss as we all age and there are actually some interesting books that are written describing how to keep your memory in shape. They’re focused primarily on older people, but keeping mentally active, reading, doing puzzles, and being intellectually engaged in some activity will exercise your brain just like you would exercise your body.

Use a diary

·    Keep a detailed diary of memory problems that arise throughout your day.

·    When memory problems occur, jot down the time of day and the situation.

·    If you notice that remembering is more of a challenge at a certain time of day, avoid scheduling appointments or deadlines at that time.

Ruta: How long do chemo brain and memory lapse last? I’m still struggling, especially when tired, and it’s been two years since my chemo sessions.

Dr. Ganz: You’re asking a very good question about two interrelated problems that many women will experience after breast cancer. The first is problems with memory and concentration. The second is fatigue. Fatigue actually occurs in about a third of all women after breast cancer treatment and does not seem to be related to a specific cancer treatment. That is to say, some women who just have surgery and no chemotherapy may feel fatigued. In addition, a smaller number of women complain of memory concentration problems. We have a difficult time knowing for sure what the number is but it’s probably in the range of 15 percent, which is much lower than initially thought. It’s also becoming evident that women who complain of difficulties with their memories and concentration are not necessarily women who perform poorly on standardized memory tests that a neuropsychologist would administer. What I’m trying to say is the perception or sense that one is having trouble with one’s memory may not always lead to poor performance on a test, and sometimes it’s anxiety, depression, difficulty with sleep, and fatigue that are making one have difficulty concentrating. Therefore, it’s important for us to treat anxiety, depression and difficulty sleeping before assuming that someone has serious difficulty with concentrating.

Dr. Weiss: This point that Dr. Ganz is making is critically important. Basically, all of the anxiety, depression and the other conditions that she described actively interfere with your memory and your thinking ability as well as your capacity to learn new things. And that’s why it is so important to address those concerns, to free your mind up to do the work of thinking and remembering. Your ability to perform “executive functioning” requires coordination of many different functions of the brain and anxiety in particular can completely undermine your ability to coordinate all the different things you ask your mind to do throughout each day.

How long do memory and thinking problems last after chemo?

·    According to recent research, chemotherapy can impact the thinking ability of the brain for up to 10 years after treatment.

·    This occurs in a small number of patients and seems to be more pronounced with larger doses of chemotherapy.

·    Most people’s thinking and remembering ability will recover to normal a year or two after chemotherapy.

LisaM: I call my memory lapses chemo brain, but I’ve been told this can also be a symptom of menopause. Is this something that may get better as the symptoms of menopause abate?

Dr. Ganz: You’re raising a very interesting question and many women with breast cancer have two colliding situations. One is the onset of menopause, which may be premature and at a time in life when you’re not expecting it. The second is breast cancer, which is very distressing in terms of the seriousness of the diagnosis as well as the complexity and toxicity of its treatment. Many women going through menopause normally (which would actually gradually occur over a 10-year period of time from the mid-to-late 40s into the mid-to-late 50s) notice changes in their memory, and this may be related to difficulties sleeping. They may awaken at night with sweats and hot flashes.

In addition, there is well-documented evidence that estrogen plays an important role in verbal word fluency, which is the medical phrase to indicate remembering words, remembering names. The only single deficit that lowered levels of estrogen is related to is the ability to remember words and names. Many women, such as myself, who have transitioned to menopause will have difficulty remembering the specific names of people or places and it may take a painfully long time to retrieve a word or name. When a woman has chemotherapy and all of a sudden she’s 45 and menstruating, and within two months has stopped, she has condensed what might have been a 10-year experience to a few months. Suddenly, the body has to adjust to a much lower level of estrogen. This may lead to very serious night sweats, hot flashes, changes in mood, and memory problems from not sleeping and the sudden changes in her hormone levels. So in addition to the chemotherapy that she’s receiving, which may possibly contribute to the syndrome that’s called chemo brain, she also has the sudden onset of a chemical menopause which is very severe in its symptoms and side effects. So many women who ultimately complained to their doctor a year after the treatment that they couldn’t think clearly, that they were having difficulty remembering names and doing tasks, may have this experience because of the onset of menopause, but it could also be contributed to by the treatment. This is the real challenge we have: to try and figure out what’s going on and whether this is just menopause or being contributed to by the cancer treatment.

How can chemotherapy affect the brain?

·    Some people treated with chemotherapy develop problems with short-term memory.

·    Long-term memory is usually okay.

·    Most memory and concentration problems improve after chemotherapy is finished.

Taton: Should any patient consider not taking Arimidex any more even though the five-year period is not complete just to avoid or try to diminish the medication side effects? Are there any new studies that may refer to shortening the time period of five years and have good results?

Dr. Ganz: This is an interesting question, but it’s really not on target for our discussion tonight, which is about changes in memory with cancer treatment.

Dr. Weiss: We will provide links and content within to help you answer this question.

Editor’s note: There are no data yet that can tell us whether taking Arimidex for less than five years has the same protective benefit as taking it for five years, although this is currently being studied. If you find that it’s difficult to manage the side effects of hormonal therapy, ask your doctor about management strategies, or possibly switching to another type of hormonal therapy.

Dr. Ganz: One of the questions is whether Arimidex has any association with memory. In my clinical experience I have not seen women report memory change with Arimidex, but that does not mean it is not an issue. I do think it is an important question and I will be starting a study in the near future that will hopefully begin to answer this question.

Does hormonal treatment cause thinking and memory problems?

·    Few studies have been done on whether hormonal treatment affects thinking and remembering.

·    In one small 2003 study, researchers concluded that anti-estrogen (hormonal) therapy for breast cancer may have an effect on a person’s ability to think and remember.

·    Much larger studies are needed before we have solid answers.

Ireece: Is there a medication for this memory problem?

Dr. Ganz: At this point in time, there is not a specific medication that I would recommend, although some studies are being conducted with the drug Provigil (chemical name: modafinil). This is a drug that is approved for the treatment of narcolepsy, a condition where people have trouble staying awake. It makes them more alert. Clinically, this is being tested for individuals who have difficulty thinking clearly after treatment. I’ve seen some patients who have used it for treatment of fatigue and memory and concentration problems. At this point in time, this is not an FDA-approved usage for this drug.

Dr. Weiss: If you are having persistent difficulty with your memory and being able to think clearly, you may need to be evaluated by a neurologist (an expert on the nervous system including function of the brain). These doctors have a lot of experience helping people improve their memory with lifestyle changes, mind exercises, and even medication. An experienced neurologist may have additional ideas.

Editor’s note: If you have persistent problems with memory loss and clear thinking, consult a neurologist. Special tests can be done to better understand the nature of your situation, called neuropsychological testing. A medication used for memory issues for patients with Alzheimer’s disease, Aricept (chemical name: donepezil HCI), may also be considered for patients with other illnesses—but only with careful expert evaluation and management.

Dr. Ganz: A neuropsychological exam may help in making recommendations because [neurologists] are used to being with people with brain injuries.

Jennie: Twelve months after chemo finished, and I still can’t concentrate for more than four hours at a time. I do puzzles, sudoku, and crosswords to aid functioning. What else can I do?

Dr. Ganz: It sounds like you’re already doing a lot of exercise for your brain, which is helpful but you may need to look at your overall situation and make sure that you’re not tired or having difficulty sleeping. If you need to take a nap or a break from work, that’s very important. Even people who have not had cancer treatment may have difficulty concentrating for more than four hours at a time. So be kind to yourself and make sure that you’re taking care of your whole body, not just your brain.

Dr. Weiss: Be careful about drinking too much coffee to help overcome fatigue during the day because in many individuals caffeine can stick around for a long time into the night, and interfere with your ability to get a good night’s sleep.

Lily: How can I better concentrate my full attention on what someone is saying? Since chemotherapy, I’ve really had a difficult time focusing.

Dr. Ganz: It sounds like you may be having some stress related to your treatment and your cancer experience. Many patients tell us that one of the most stressful times is actually when they finish their treatment, more than when they’re on it. All of the sudden they feel out of control, nothing’s protecting them from the cancer, and they may not be seeing their physician as frequently as they were. Having this extra stress may be a distraction and prevent you from concentrating when someone is talking to you. You may also feel that you have different priorities after cancer treatment and that inconsequential things that someone may be saying to you may not be as important. It’s also clear that if you’re tired, if you haven’t slept well, or if you’re not eating and exercising properly, that these may affect your ability to concentrate.

Dr. Weiss: One important communication tip to help you talk to the people you want to talk to and avoid or minimize the amount of time listening to people who might bring you down is through communication like email, letters, voicemail. With this type of communication, you can respond at your own convenience instead of immediately. Avoid the telephone or get call waiting. Many people are calling you to talk and offer you help. If you can avoid disruptions of work you might be doing and deal with the phone calls and emails during a break, you can save some energy. One place people go to connect with each other for support and to build energy and a sense of community with others who share their concerns is the discussion boards and chat rooms.

Canuck: Is it better to confess to a boss that you are experiencing chemo brain (cognitive loss) or just try to cope and cover it up (make detailed lists, etc.)? Will an employer see this as a sign of weakness?

Dr. Ganz: This is a very good question because discrimination in employment is still a problem for patients with cancer, unfortunately. I’m not sure where you are living. If it’s the US you have the Americans With Disabilities Act which is supposedly available to protect patients with a cancer history and diagnosis against discrimination at work and accommodations are supposed to be made for disabilities or limitations that a person may have as a result of their illness. The particular kinds of cases either where someone is fatigued or has trouble concentrating are very difficult sometimes for the employee to get accommodation for. I’m helping some lawyers who are defending women in the situation, and not all employers are sympathetic to the situation. I think it really depends on what kind of an organization you’re working in and how comfortable you feel. If your employer knows you had cancer and may have some needs for modification to your schedule or activities, then you should be direct and speak to the Human Resources supervisor in the organization. If you’re in a small office or employed by a small business, this may be more difficult. One of the challenges is that women who have survived breast cancer treatment often look well and people think that they should be doing everything that they did before diagnosis. But we know that there may be many subtle physical and emotional scars that may limit the ability to do work at the same level that it was performed before the cancer diagnosis.

Dr. Weiss: Let your doctor be your advocate. A carefully written note from your doctor to your employer, with your permission, can be very effective. A letter could help you cut back your hours for a finite period of time with a plan for reevaluation. Shifting some of the communications from your own shoulders over to your doctor can be a relief to you, and your boss might be more responsive to a more “authoritative” correspondence. An offer to your boss to talk to your doctor if he/she has any additional questions also works well. In my professional experience, many of my patients make this offer to their boss and nearly no boss ever picks up the phone to question the recommendations I’ve made. Ultimately, it eases your worries about your work performance, so this is a good approach.

Managing memory challenges at work

·    Make a point of arriving at meetings on time:

o  To avoid anxiety

o  To get settled and organized

o  To project your respect and professionalism to others attending the meeting

·    Put key items in the same place each time: eye glasses, keys, phone, address book, purse, stapler, scissors, tape

Barbie: What are your feelings on sleep medication?

Dr. Ganz: Sleep medication may be very helpful to some women, particularly if you’re having difficulty sleeping on an occasional basis because of pain after surgery or if you’re having difficulty with anxiety or stress. Long term sleep medication may not be the best solution and it may be best to obtain a better understanding of why you’re not sleeping well. One of my colleagues here at UCLA will be starting a study to test whether tai chi may be helpful in sleep management for women after breast cancer. Part of the thought here is that this kind of exercise has both a physical and a relaxation component to it. There are many aspects to sleep disturbance, which may be related to lack of physical exercise during the day, as well as the inability to relax. So we need to understand what’s really causing the sleep disturbance. Is the individual anxious and can’t fall asleep, or are they being awakened by hot flashes, which is a physiological problem? Or if the problem is sleeping and napping during the day due to fatigue, then they don’t feel tired at the time they should be sleeping at night. All of these issues have to be reviewed very carefully and if one can identify the cause of the sleeplessness it’s far better to treat that condition rather than use medication. Again, medications are fine for short term problems that disrupt sleep such as pain and anxiety. But if there is a chronic ongoing sleep problem, then it’s important to try and find out what’s causing it.

Protect your sleep

·    During the day, grab a cat nap to feel refreshed

·    Make sure your bedroom is quiet and dark

·    Avoid caffeine products after noon

·    No scary movies or disturbing news shows before bed

·    Don’t make pre-bedtime phone calls that could be potentially upsetting

·    Turn off the phone after a certain time, such as 9 p.m.

·    BB@B: Boring Books at Bedtime!

PGEvans: Is there any research demonstrating that physical exercise improves short-term memory?

Dr. Ganz: At this point in time, I’m not aware of physical exercise improving short-term memory. If someone is exercising regularly, one is more likely to sleep better, and that may help someone’s memory due to better sleep.

Dr. Weiss: For people who are having difficulty sleeping, avoid alcohol. While it may help you go to sleep initially, you’re more likely to wake up during the evening. Also, alcohol can interfere with your ability to think and remember well.

HollyD: My mother-in-law took tamoxifen for five years after breast cancer and then developed Alzheimer’s disease, which progressed rapidly. Is it possible there is a link between tamoxifen and dementia? She did not receive chemotherapy, just radiation.

Dr. Ganz: This is an excellent question, Holly, and one that I’m very interested in. In a limited study that we did of women who’d been treated for breast cancer five to six years earlier, we did neuropsychological testing and PET scans of the brain to see how the brain functioned in these women. We saw worse brain function in those who had chemotherapy and tamoxifen in comparison to those who had no chemotherapy or chemotherapy only. We did not have a group of women who had tamoxifen alone, which would be comparable to your mother’s situation. However, as I mentioned earlier, the Women’s Health Initiative study comparing estrogen and progesterone or estrogen alone to placebo demonstrated a decline in cognitive function. Tamoxifen is a mixed estrogen and anti-estrogen drug and therefore could possibly have estrogen-like effects on the brain that could be similar to what was seen in the Women’s Health Initiative study. I’m hoping that the study that I’ll be conducting over the next five years will allow us to examine if tamoxifen has such an effect.

Dr. Weiss: Dr. Ganz has been a leader in research on quality of life for women who’ve had breast cancer. Her championship has made remarkable advances in our understanding of all of these issues that you are sharing with us this evening. It’s terrific that you are conducting this important study. Thank you!

NireenT: Which kinds of chemotherapy are more likely to cause cognitive difficulty?

Dr. Ganz: At this point in time, we really have no certainty about whether it is chemotherapy or chemotherapy in addition to menopause or other factors that lead to this cognitive difficulty that women complain of. We have no specific association with a particular chemotherapy regimen or type of drug.

Dr. Weiss: The studies that have been done so far have been too small to determine if a particular treatment is associated with these things.

Karen: Have there been any controlled studies on long-term follow-up of cognitive ability of women who have received chemotherapy for breast cancer?

Dr. Ganz: Some of the studies that we and others have done have been in long-term breast cancer survivors. As I indicated the changes in cognitive functioning that we see on tests are very subtle and don’t necessarily correlate with women’s complaints. Another challenge that we have is that the women who have been studied are highly selective and we really need to see a representative sample of women that have been treated for cancer to determine how frequent this is as a long-term problem.

Dr. Weiss: In addition, most studies do not have a pre-treatment baseline on memory and thinking function that could be compared to those after exposure to the various treatment agents.

Dr. Ganz: The other problem that I think is working here is that many women with breast cancer are very high-functioning professional women with high IQs, and even the most subtle changes in their memory or ability to do multiple tasks is noticeable. As Dr. Weiss mentioned earlier, they are used to doing multiple tasks, which require high levels of attention and focus and if this is disrupted in even a small way they may become distressed by their inability to function at the same level. So it may not necessarily mean they have a tremendous change in their performance, but it may be that it is in the presence of such a high level of function that a minor change is noticeable. I’ll give an example from my practice. I routinely ask everyone I have given chemotherapy to whether they have noticed any change in their memory or their ability to concentrate. I find that older women or women who are retired will rarely voice concerns about this. These are generally women who can set the pace of the day, do not have work obligations, are not taking care of children and are able to adjust disruption that this may have caused in terms of receiving cancer treatment. In contrast, younger women may be trying to work, take care of their children and house, and deal with the emotional distress of cancer coming at a time of their life when it is not expected. These women would more often complain about difficulties with concentrating, memory, and doing the multiple tasks that they were used to doing.

During and after treatment with chemotherapy, you may have trouble:

·    Learning new tasks

·    Remembering names

·    Paying attention, concentrating

·    Finding words

·    Multitasking

·    Organizing

·    Remembering where you left something (those darn keys!)

Noreen: Since having chemo I developed neurological problems including restless legs, nerve pain and numbness in the hands, plus cognitive problems. I am taking Requip (chemical name: ropinirole Hcl) and Neurontin (chemical name: gabapentin), and I am tired all the time. Any suggestions?

Dr. Weiss: Keep in mind that you live with yourself 24 hours a day and the expectations that you place on yourself are usually greater than what others place on you. Therefore, these changes tend to be more noticeable to you than they are to other people. If you are wondering if other people are noticing that you may be slipping here or there, ask a close friend or relative for their honest feedback.

Dr. Ganz: Your question really reflects a series of common complaints and problems women may have after chemotherapy. You may have had a taxane drug as part of your chemotherapy treatment and this could certainly be the cause of the pain in your hands and feet. It may certainly be helped by the Neurontin. The other issue of fatigue again is that a third of women will report post-treatment fatigue. This may get better over time, although for some women this may persist. But as we have discussed earlier, women who are fatigued may also have complaints of difficulty concentrating, so it is important to try and address your fatigue by pacing yourself, taking good care of yourself physically, and addressing any pain or anxiety or depression that you may be having. Some of our research has actually found immune changes in women who have persistent fatigue which may possibly explain their difficulty responding to physical and mental challenges and it is an active area in laboratories. I can’t say that this is what you have, but it is a definite syndrome that we and others have found in about a third of women after breast cancer treatment.

Dr. Weiss: When Dr. Ganz says take care of yourself, she is very serious about this. We’re not just talking about handling a crisis in your life and treating yourself here and there. We’re talking about taking good care of yourself on an everyday basis, like you would a baby who needs nurturing: plenty of sleep, lots of liquids, good food, and comfort. You may be doing too much. You may have to cut back some of the responsibilities and demands you have in your life. In my practice, I have seen a number of high-powered women, trying to do it all and do it all well, reach their breaking point. Under these circumstances I’ve had to step in and insist that they cut back immediately. This might mean cutting back from full-time to part-time work, or it might mean taking short-term disability. There is a reason why those benefits exist. The breast cancer experience can create crisis for many people, and time off from work can be very therapeutic. Many patients have also gotten benefit from learning meditation techniques, doing visualization, regular prayer, quilting, knitting. Any kind of regular, relaxing, peaceful activity that gets your mind off of what is stressful onto something that is relaxing, comforting, and fun are good things. Support groups are another way to learn helpful tips from other people as well as to get encouragement and support.

Dr. Ganz: When you are not feeling your best, you must be careful about your safety. Do not start cooking and leave the kitchen. Make sure you remember to put your safety belt on. Schedule various tasks and things that you have to do or remember and write them down. Rather than depend on your memory for a lot of mundane, everyday tasks, use list-making and other prompts to help you remember.

Staying safe when alertness isn’t at its peak

·    Don’t use your cell phone when crossing the street or driving.

·    Don’t start cooking or ironing and leave the room.

·    Put your safety belt on first before starting your car engine.

·    Take a friend along when running errands.

Jean: I am taking Herceptin and radiation. Could that interfere with sound sleep?

Dr. Weiss: The demands of daily radiation (delivered five days a week over about five to seven weeks) can disrupt your regular routine. It adds one more big task onto each day. If your radiation follows chemotherapy, then radiation can add to fatigue that you still have left over from your chemo. Most people who use Herceptin (chemical name: trastuzumab) are taking it with or beyond their chemotherapy, so the fatigue they may experience while on Herceptin and radiation may in part be left over from all prior forms of treatment. Radiation to a large area can lead to a drop in blood count, but this is usually a relatively small drop and unlikely to cause significant fatigue. Radiation can be associated with various types of discomfort including shooting pain, soreness, and skin irritation. Towards the end of radiation and for the first few weeks afterward, these symptoms might wake you up at night. The good news is that the discomfort can usually be treated with over-the-counter medication and with a good skin care protocol.

Kathy: Are younger women experiencing this cognitive difficulty at the same rate as older women?

Dr. Ganz: That’s an excellent question. We really haven’t had large enough studies of women of all ages to answer this question. My clinical impression is, though, that this is more common in women less than 55 years of age.

Jashery: In the 2002 conference, it was mentioned that there was a study that was going to look at stimulant-type drugs in helping with attention and fatigue. What were the results of this study?

Dr. Ganz: There has been a study underway being conducted by investigators in Toronto. As far as I’m aware, it has not become available either in a scientific presentation or published paper.

Dr. Weiss: Until we know more about the role of stimulants, be careful with their use. Stimulants, which include coffee and other medications, affect people in very different ways. I would only consider their use with careful medical management.

Bonnie: I couldn’t get here in time for the conference (I didn’t forget it though!). Will there be a way to read it later?

Dr. Weiss: Yes. We will post it approximately one week after the conference. It will be available through in the Support & Community area. Click on Ask-The-Expert Online Conferences. Please sign up for our free email updates, which will include a link to the transcript. There are a lot of holidays coming up this fall. As you receive invitations to join family and friends make sure you write down the names of people from whom you’ve accepted invitations. Many patients who are in the midst of treatment may accept more than one of these invitations, not remembering that they had made a previous commitment. This is just one example of using a simple system, a calendar, to organize some of the important events in your life.

Strategies for memory challenges

·    Decrease your workload.

·    Try to avoid multiple tasks at the same time.

·    Avoid distraction when learning new information and tasks.

·    Write detailed notes to yourself.

·    Use a hand-held organizer.

·    Discuss the role of medications with a neurologist.

TimKim: I had invasive ductal carcinoma and ovarian cancer, with six treatments of Cytoxan/Adriamycin/5FU for the breast cancer, and four treatments of Taxotere [chemical name: docetaxel] and carboplatin [brand name: Paraplatin] for the ovarian cancer. How long will chemo brain affect me? I am 42 and it aggravates me when I know what I want to say but can’t get the words to come out right. Is this a forever thing?

Dr. Ganz: It sounds like you have had a lot of treatment for two cancers and that’s a lot to go through. I also assume because of your ovarian cancer that you are post-menopausal surgically for treatment of this cancer. Surgical menopause (removal of the ovaries) leads to very extreme symptoms that are more severe than the normal onset of menopause or even the chemotherapy-induced menopause that I described earlier. Some of the problems you are having in finding words may be related to estrogen loss. Like I said earlier, difficulty in finding words is commonly experienced as a result of menopause and hopefully your brain will adjust to the new hormone environment your brain is functioning in.

Acorrid: I was told that my cognitive problems with Arimidex are side effects of loss of estrogen. My symptoms are verbal function, flow of thinking, and memory loss. I was also told by my psychiatrist that if I take Wellbutrin (chemical name: bupropion HCI), it will help my serotonin levels and help with this problem. I would like you to address taking anti-depressants to alleviate the cognitive issue.

Dr. Ganz: Thank you for your interesting question. At this point in time we don’t have enough studies to address your concern about cognitive problems and their association with Arimidex. I think this is a real possibility; that is, when women take a drug like Arimidex their estrogen levels fall to extremely low levels, almost zero. And for some women this may possibly affect how they’re able to do verbally and recall words due to the low estrogen state. However, this is not universally true. Most women on Arimidex do not complain about these problems and we need to do more research to know who’s at risk. I’m not personally aware of any studies that have shown Wellbutrin to help in these situations, but perhaps your doctor has had some clinical experience with this treatment strategy.

Dr. Weiss: Over time, women tend to be very adaptive and learn how to compensate for changes in their lives, including changes in their ability to function relative to memory and thinking. It is a good time to be resourceful and creative about various ways that you can compensate for these changes in your life. Also keep in mind that each one of you is unique and different. You may have had preexisting challenges with thinking, attention, memory, learning, concentration, etc. It’s unlikely that those problems will go away with treatment. More likely they can become more pronounced through treatment and beyond. It’s true that a breast cancer diagnosis may make you confront some of the issues that may have been present in your life prior to your diagnosis. Some of these issues can include problems with depression and anxiety, which should be addressed at this time. There are a lot of very capable health professionals who can make a big difference in your life by listening to your concerns, figuring out what’s happening in your life overall, and helping you manage the situation. It will require a lot of introspection as well as patience and persistence. 

More ways to keep your mind alert

·    Do crossword puzzles

·    Play card and board games with your friends or children

·    Play computer games

·    Learn a new language

·    Get regular physical exercise

·    Try relaxation techniques such as meditation or guided imagery. Stress makes thinking more difficult.

Dr. Ganz: Also to complement what Dr. Weiss has said, women who have experienced somehow many women—not all, but many—find the strength and resilience to move forward in their lives and see the positive aspects of this experience. You are all very courageous and we hope to find better ways to support you through the difficulties such as the things we’ve talked about tonight. Thanks for being with us this evening. We hope the support and information you’ve gotten here tonight will help you discuss some of these issues with your doctor and make the best choices for YOU. We also look forward to hearing from you at future Ask-the-Expert Online Conferences right here at

The materials presented in these conferences do not necessarily reflect the views of A qualified healthcare professional should be consulted before using any therapeutic product or regimen discussed. All readers should verify all information and data before employing any therapies described here.