Cognitive Function

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Cancer-related cognitive impairment (CRCI) refers to the subacute, chronic, and sometimes progressive decline in thinking and memory that people with cancer may experience due to the cancer itself and/or its treatments. Treatments associated with CRCI include chemotherapy, radiation therapy, surgery, hormonal therapy, targeted therapies (such as antibodies and small molecule inhibitors), and immunotherapy can cause this, and can be commonly referred to as “chemo-fog” or “chemo brain."

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Common signs include:

• Difficulty finding words

• Trouble organizing thoughts and clearly expressing oneself

• Increased forgetfulness (for example, misplacing everyday items like a wallet or keys, or entering a room and forgetting why)

• Difficulty retaining new information (such as forgetting the name of someone you were just introduced to or new instructions)

• Problems with concentration or completing tasks (tasks take much longer to finish)

• Challenges with planning or making decisions

• Difficulty multitasking (struggling to keep track of activities when interrupted or switching between tasks)​

 

Cancer-related cognitive changes can make you feel frustrated, insecure, or fearful about your thinking abilities. Everyday tasks may take more effort, which can affect your daily life and productivity. This may lead to reduced confidence and feelings of helplessness as you try to keep up. You might worry about being seen as “less capable,” which can impact self-esteem and relationships. It’s important to remember that these cognitive changes are common during cancer treatment and do not reflect your intelligence or value. You are adjusting to challenging circumstances, and it is okay to seek support.

 

Why does it happen:

The reasons for CRCI are multifactorial as it can occur due to the tumor itself, sleep disorders, damage to the brain region, stress, DNA damage.

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Risk factors include:

• Older age and pre-existing neurodegenerative conditions

• Known cognitive deficits from previous neurologic injury, such as stroke, TBI, or underlying neurodegenerative disorders

• Medications used during cancer treatment

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Treatment Options: 

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Symptom-Oriented Interventions

• Aerobic exercise

• Yoga

• Mindfulness meditation

• Implementation of compensatory strategies

• Strategies to support cognitive function include: taking notes; using smartphones to set alerts, reminders, or record important conversations; using self-talk (e.g., “What am I supposed to do next?”); practicing active listening by summarizing what you heard to confirm understanding; and keeping essential items, such as keys and your phone, in the same place consistently 

 

Pharmacologic Options:

 

Some of the drugs investigated for use in CRCI include: 

1. Lithium and Fluoxetine  

• These are being investigated as they have the potential to mitigate the harmful impacts of chemotherapy on the brain  

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2. Phosphodiesterase inhibitors

• This has the potential to help with the deterioration in the brain after chemotherapy    

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3. Antidementia drugs

• Medications such as cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonists are commonly used to treat Alzheimer’s disease. Researchers are investigating whether these drugs might also help improve cognitive function in cancer survivors experiencing memory problems or mental fog 

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4. Neurostimulants

• Used for attention-deficit/hyperactivity disorder to help with lack of attention and focus 

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5. Anti-inflammatory agents

• New medications are being developed to reduce damage caused by free radicals (harmful molecules that can harm cells), protect the energy-producing parts of cells called mitochondria, and support their repair. These approaches aim to promote brain health and recovery after cancer treatment 

 

Practical Management

• Routine screening for cancer-related cognitive impairment (CRCI) should be conducted during follow-up visits, whether the patient is currently receiving treatment or has completed it 

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Post-traumatic Stress Disorder (PTSD) 

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PTSD can develop after exposure to traumatic events such as a cancer diagnosis or treatment.  PTSD can affect quality of life which includes life satisfaction and psychosocial functioning even after treatment is completed.  The symptoms associated with PTSD may lead to significant distress and impairments in social interactions, work ability, and other areas of functioning.

 

Common signs:

• Re-experiencing repeated disturbing memories, dreams or flashback 

• Persistence avoided such as avoidance distressing memories, thoughts, feelings, or external reminders of the cancer

• Negative alteration in mood or cognition such exaggerate negative beliefs about oneself or the world, feeling detached or estranged from others, lack of positive emotions, feelings of fear, horror, anger, guilt and/or shame

 

You might be at greater risk of developing PTSD if you:

• Have a history of anxiety or depression

• Have a history of trauma, PTS, ASD, or PTSD before cancer

• Are diagnosed at a younger age, especially in childhood

• Have advanced cancer at the time of your diagnosis

• Don’t have a good support system

 

You can lower your risk by: 

• Having a good understanding of your cancer diagnosis

• Talking honestly and openly with your doctor or cancer care team

• Having a strong support system

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Treatment Options: 

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1. Psychotherapy (talk therapy):  There are many different types of psychotherapy. Common types used to treat PTS, ASD and PTSD include:

• Cognitive behavioral therapy (CBT) or trauma-focused CBT

  • There is mixed results when it comes to using CBT to treat PTSD, some studies show improvement where others found it not helpful 

  • Another study found that it was effective in reducing hyperarousal and intrusive thoughts but not avoidance 

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• Eye movement desensitization and reprocessing (EMDR)

  • EMDR was found to be effective in reducing PTSD symptoms for those going under active treatment 

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• Exposure therapy

  • Exposure therapy was recommended to treat PTSD among adults, however 

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2. Medication

• Medications used to treat anxiety or depression can help reduce negative thoughts and feelings in people with PTSD.

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3. Support or peer groups

• There is mixed results with using peer support groups to treat PTSD symptoms as some studies have found it be ineffective, whereas other found that using online forums have shown improvement 

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Social issues

 

Cancer and its treatment can have a broad reach into the lives of cancer survivors, their caregivers and their social network (eg, friends, community, place of worship). Specific issues that have been evaluated are discussed below.

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Caregivers:

Cancer exerts its effects on the spouse or significant other particularly during active treatment. Caring for a cancer patient can take a toll on the caregiver’s health. It can affect caregivers in many ways:

• Physical exhaustion and health problems

• Emotional stress (anxiety, sadness, fear, burnout)

• Disruption of personal life (work, plans, routines)

• Financial and social difficulties​

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If you are a caretaker it is important to take care of yourself. This can be done through:

1. Making time for yourself: Find a time to unwind and relax for at least 15-30 mins. You can take a nap, bike, go for a walk, or do simple exercises such as yoga and stretching. Take some deep breaths. 

• Try not to avoid or neglect your personal time entirely

2. Ask for help: Try to delegate tasks to another person if you can, it's okay to ask for help. 

3. Maintain routine: Sticking to a routine can help alleviate stress. ​

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Children:

​Children with parents who have cancer can be an emotionally tolling experience. It can affect children in many ways:

1. Emotional impact

• Younger children (0-6 years) may show distress through sleep problems and emotional issues, while school-age children (7-12 years) often feel guilty and anxious. Adolescents (12-18 years) are most vulnerable, experiencing heightened anxiety, depression, and awareness of the potential loss of their parent

​2. Impact of disease stage

• The stage of the parent's illness affects the child's emotional response. Early stages may lead to internalizing issues, while the terminal phase is the most distressing, causing significant behavioral and social problems in children.

3. Risk factors

• Parental depression, poor communication, and unclear family roles, while protective factors are good family communication, cohesion, and support from peers.

4. Communication

• Communication between parents and children is crucial. Open, honest discussions help children cope better, while poor communication can worsen emotional difficulties.

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Adjustment to work

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Symptoms that affect work can arise from a survivor’s treatment or disease status, particularly for those living with cancer long-term or coping with the effects of treatment. Some survivors may continue working during treatment, while others may need to start and stop work multiple times. 

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Assessment for employment: 

• Discuss with your healthcare provider on your concerns, needs, goals and desires related to work 

  • What abilities are required for the job (e.g., cognitive tasks, long periods of standing, use of hands)

• Discuss barriers 

• Practical concerns regarding employment (e.g., transportation, caregiving responsibilities, health insurance coverage, financial instability)

• Discuss job flexibility, workplace accommodations, supportive work environment and paid sick leave

• Discuss treatable contributing symptoms

  • Fatigue

  • pain/neuropathy

  • musculoskeletal/neurologic issues

  • Cognitive dysfunction

  • Anxiety, depression, distress 

  • vision/hearing changes 

• Discuss comorbid conditions

  • Organ dysfunction

  • Hematologic dysfunction/infection risk

  • Alcohol/substance use

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Second Cancer

 

Although the risk is low, cancer survivors have a slightly higher chance of developing a second cancer compared to people of the same age who haven't had cancer. Sometimes second cancers happen as a late effect of treatment for cancer during childhood. If secondary leukemias occur, they usually happen within the first 10 years after treatment. Secondary solid tumours most commonly appear 10 or more years after treatment. 

 

​Causes of second cancer:

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Common types of second cancer: ​​ 

1. Leukemia

• most commonly acute myelogenous leukemia (AML), can develop after radiation therapy or treatment with certain chemotherapy drugs or drug combinations. 

• Having had both radiation therapy and chemotherapy to treat cancer increases the risk for leukemia more than having the either treatment alone.

 

2. Breast cancer and lung cancer

• can develop after radiation to the chest

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3. Thyroid cancer

• can develop after radiation to the neck, radioactive iodine or TBI

 

4. Stomach, liver, or colorectal cancer

• can develop after radiation therapy to the abdomen

 

5. Bone, soft tissue sarcoma, non-melanoma skin cancer or melanoma

• can develop in the area where radiation therapy was given

 

6.Oral cavity cancer 

• can develop when cells in the mouth are damaged from chronic graft-versus-host disease (GVHD) following a stem cell transplant

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Symptoms that may suggest a second cancer include:

• easy bruising or bleeding

• paleness

• fatigue

• bone pain

• a change in moles

• sores that don't heal

• a lump or growth

• trouble swallowing

• changes in bowel or bladder habits

• unusual bleeding or discharge

• shortness of breath

• a nagging cough or hoarseness

• constant or recurring headaches

• a change in vision

• early morning vomiting on a regular basis

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How to lower your risk:

• not smoking and avoiding tobacco

• eating a well-balanced diet

• maintaining a healthy body weight

• exercising regularly

• protecting yourself from sun damage

 

Follow-up options:

• Follow-up may include monitoring or screening tests to check for second cancers. You should have a physical exam each year

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