How to Manage Chemo Brain

A combination of several approaches has been found to be more effective.



Openly accepting the truth of the chemo brain is the first step towards understanding and, ultimately, to alleviating the range of symptoms it brings.

While there is a robust combination of anecdotal and proven evidence from cancer survivors on the effects of cancer treatment on cognition, there is limited high-quality evidence guiding how best to help cancer survivors when it comes to dealing with these effects or even preventing them in the first place. No pharmacological agents have been approved to reduce these side effects and despite encouraging results based on animal models, none of the drugs examined in animal models have proceeded to clinical trials.


The other issue is that despite increased awareness, there are currently no validated or FDA approved tests for the diagnosis of chemo brain. Current assessment tools lack the level of sensitivity to test for the subtle changes that occur with chemo brain. This is compounded by the fact that cancer patients have significant differences when it comes to their treatment protocols, their personal health conditions including neurological and psychiatric baseline. There are multiple research labs in the US working to understand the mechanisms of chemo brain, however, till date there is no clear understanding. We know that the majority of patients treated for cancer, including breast, lung, colon, brain and many other cancer types, experience difficulties with memory, multitasking, cognitive processing speed, attention, and concentration as a consequence of their treatment.


A comprehensive medical evaluation to rule out other conditions that can mimic certain side effects from chemotherapy is a priority when it comes to trying to figure out how best to tackle chemo brain. Anxiety, insomnia, menopause, or simply normal aging can mimic the symptoms of chemo brain. Endocrine disorders (such as thyroid abnormalities), vitamin deficiencies, medication side effects, chronic infections such as urinary tract infections, anemia, sleep deprivation, or depression should also all be ruled out or treated, as these conditions can also cause changes in memory and brain function. The stress of a cancer diagnosis and treatment can also be a factor. Stress can lead to difficulty in sleeping, changes in diet and activity levels, anxiety or depression that may also cause or worsen the symptoms of chemo brain.




Up to a third of people have cognitive symptoms before they get any cancer treatment, so there is emerging understanding that suggests the inflammatory response to cancer may be contributing to the cognitive symptoms. Although most chemotherapy drugs do not readily cross the blood-brain barrier, the inflammatory cytokines that our body produces in response to the chemotherapy such as interleukin-1, interleukin-6, tumor necrosis factor-alpha and others can cross the blood-brain barrier, and can be neurotoxic. Even patients treated with surgery alone may experience a version of chemo brain related to general anesthesia that has been with cognitive effects lasting between 4 and 6 weeks. On average, most patients report their symptoms of chemo brain revolving within 8-12 months after finishing treatment but for others, these symptoms can last for years after completion of treatment.


Also Read : What You Need to Know About ‘Chemo brain.’


The causes of chemo brain are multifactorial and therefore, effective treatment should include a combination of pharmacologic, behavioral and rehabilitative approaches tailored to the individual patient.

Cognitive Rehabilitation:

This can be part of a comprehensive rehabilitation program. Cognitive rehabilitative approaches include programs in cognitive training or brain training and those that use strategy training also known as cognitive behavioral therapy (CBT) and may include psycho-educational approaches. It includes activities such as learning how the brain works and ways to take in new information and performing new tasks; doing some activities over and over that become harder with time; and using tools to help stay organized such as planners or diaries.



Exercise:

Exercise is a powerful lifestyle component that may have an impact on several mechanisms of cancer-related cognitive impairment. Exercise can help improve your thinking, processing speed and ability to focus. Multiple studies show that staying active during chemotherapy can help limit the severity of cognitive issues that arise. The benefits may be even greater for patients who had an active lifestyle before treatment.



Meditation:

Meditation can help improve brain function by increasing focus and awareness. There have been a few studies looking at mindfulness-based stress reduction programs for improving cognitive symptoms. There are several studies of activities such as qigong, yoga, taichi and other mind/body interventions. In particular, with mindfulness, there is reasonable evidence that it helps with attention, which is an important part of the memory pathway.



Pharmacologic Interventions:

No medications have been approved to treat chemo brain. However certain medications approved for other conditions may be considered by your cancer care team personalized to your specific health and treatment. These can include:

  • Methylphenidate (Concerta, Ritalin, others), a drug used to treat attention-deficit/hyperactivity disorder (ADHD)

  • Donepezil (Aricept), a drug used in people with Alzheimer's disease

  • Modafinil (Provigil), a drug used in people with certain sleep disorders

  • Memantine (Namenda), a drug used to improve memory in people with Alzheimer's disease, may help during radiation therapy to the brain


“Remember small steps are still steps. If you cannot manage a brisk 30-minute walk, “making it to the mailbox and back is something. Any movement,” no matter how brief or gentle, “is likely to have benefits.” Elizabeth A. Salerno, Asst. Professor of Surgery & Public Health, Washington University School of Medicine - St. Louis

There are also several coping strategies that you can employ at home and at work to help deal with the cognitive side effects of treatment. These include:



  • Use a detailed daily planner, reminder notes, or your smart phone. Keeping everything in one place makes it easier to find the reminders you may need. To-do lists can help manage your day-to-day activities and decrease mental stress.

  • Track your memory problems. Keep a diary of when you notice brain fog and what is going on at the time. Keeping track of when the problems are most noticeable can also help you be vigilant and avoid important appointments and tasks during those times. This diary will also be useful when you talk with your doctor about these problems.

  • Do the most demanding tasks when you feel your best. In other words, keep the tasks for that time of the day when you feel your energy levels are the highest.

  • Exercise your brain. Take a class, do word puzzles, or learn a new language to keep your brain sharp, improve focus and daily functionality.

  • Sleep well. Maintaining a regular sleep schedule and getting enough rest and sleep can go a long way in helping with brain fog.

  • Be physically active. Regular, manageable aerobic and weight lifting physical activity is not only good for your body, but also improves your mood and decreases fatigue.

  • Eat a balanced, predominantly plant based diet. Studies have shown that eating more vegetables is linked to keeping your brain healthy as you age.

  • Set up and maintain routines. Try to keep the same daily schedule and try not to overschedule activities.

  • Pick a fixed familiar place for commonly lost objects. This includes things like your wallet, watch, phone and keys. Put them in the same place each time so that you always know where to find them..

  • Try not to multi-task. Focus on one thing at a time and take time to relax. Writing in a journal, listening to music or being with friends are ways to relax and reduce stress.

  • Avoid alcohol and other stimulants. These may impair memory, judgment, coordination and disrupt sleep patterns.

  • Ask for help when you need it. It is important to be frank with your family, friends and members of your care team about what you are going through. Take a look at the Chemo Brain Evaluation Checklist to help you start the discussion with your cancer care team. There is no stigma or shame in dealing with the side effects of treatment, and letting people know that you may be dealing with cognitive side effects will go a long way in easing your journey.

  • Try to accept these changes are temporary and maintain a positive outlook. Accepting that cognitive changes happen to a majority of patients will help you deal with it. You may have little control over cancer-treatment-related memory changes, but you can control other causes of memory impairment that are common to everyone, such as being overly tired, and insomnia.

Find these coping strategies in the form of a handy Chemo Brain Management Checklist here.


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Reason to Hope

Chemotherapy-driven estrogen loss is known to drive bone loss, but significant data suggests the
existence of an estrogen-independent mechanism of bone loss.  A new study in mice suggests
that a biological process known as cellular senescence, which can be induced by cancer
treatments, may play a role in bone loss associated with chemotherapy and radiation. These
findings may lead to treatments for therapy-induced bone loss, significantly increasing quality of
life for cancer survivors.
DOI: 10.1158/0008-5472.CAN-19-2348