October 2008: Managing Chemo Brain

What is chemo brain?

Question from MC: What is chemo brain?

Answers —Christina Meyers, Ph.D., A.B.P.P.: It's basically inefficiency of certain cognitive functions, related to cancer or cancer treatment. It is characterized by inefficient memory retrieval, so people block on people's names or numbers, but they always come back. There’s a reduction in how much information a person can handle at once, so if I give someone a 12-word list to learn, a person with this syndrome will only get 8 or so. It's almost like an attention deficit; people are slower to do things and it takes more mental effort to do everything. Reasoning, problem solving, talent — those aren't affected.

George Sledge, M.D.: What disturbs me when I hear this is that you're describing me! A challenge to physicians dealing with patients is the lack of something objective to the diagnosis, which is true of many things in psychology and psychiatry. If I'm a patient or physician, can you give me DSM [Diagnostic & Statistical Manual for Mental Disorders] criteria or some specific criteria that determine who has chemo brain and who doesn't?

Christina Meyers, Ph.D., A.B.P.P.: It's a differential diagnosis. Neuropsychological tests are very objective and what we're measuring are subtle declines compared to a person's pre-illness level of function. So I may see a person who complains of these symptoms, but chemo brain is a diagnosis of exclusion, which means a person may subjectively feel their memory isn't as good, but it may be they have cancer-related fatigue so they're too tired to think well or they're preoccupied and can't pay attention to what people are saying. It could certainly be an unrelated condition that has nothing to do with the cancer treatment. We do standardized tests where we know how a person of a given age and education would normally do on these tests, so that's how we test to see if they are having any difficulty. There are no DSM criteria at all, but most insurance carriers do recognize the syndrome and consider it a reason for disability, so it's in there.

How long does chemo brain last?

Question from Linda: I finished chemotherapy in 2007, and I still have problems focusing. How long does chemo brain last?

Answers —Christina Meyers, Ph.D., A.B.P.P.: There is a lot of individual variability. In our studies when we tested women a year after their treatment had stopped, half of them had gotten better and half had not. I do chemo brain workshops at my institution on a monthly basis, and I have 10-year survivors who still have it, so for some it may be permanent while others recover. The main thing to keep in mind is that it's generally very handleable, and the alternative is not good.

George Sledge, M.D.: Anecdotes are always dangerous, but I'd like to share one. I had a patient several years ago who was a flight attendant and part of her job as a flight attendant was to go up and down the rows in the plane taking drink orders. She said prior to receiving her chemotherapy she could take 6, 8, 10 drink orders with perfect memory. After the chemotherapy, she would write down the orders for the drinks because she couldn't remember them any more. To all the world, she appeared to have the same functionality after as before, because she had made an adjustment for the chemo brain that kept her looking functional, but she could tell the difference. That's a pattern I see fairly commonly.

Christina Meyers, Ph.D., A.B.P.P.: That's a perfect example. People can retain their functionality, but there's a cost and effort.

Treatments for chemo brain?

Question from Papyrus: Are there any treatments for chemo brain? I've suffered from it for 9 years, ever since I was treated for breast cancer.

Answers —Christina Meyers, Ph.D., A.B.P.P.: There are a lot of treatments that can be helpful. Let's start with medication. For people who have a lot of fatigue and distractibility issues, stimulants can be helpful. We definitely do that quite frequently if there are no other contraindications. Exercise can help but it has to be done thoughtfully because stamina and fatigue can be worsened with too much exercise, so it has to be the right amount. Energy conservation, learning compensatory strategies, especially for people in school — using a day planner or PDA, cell phones with audible alerts — there are a lot of things that can lessen the impact on daily life.

George Sledge, M.D.: Let me just mention one additional point — one thing that patients who are suffering from what they think is chemo brain should allow their physicians to do is to become good physicians. There are many cognitive problems that are unrelated to chemo brain, such as depression. That would require treatment such as drug therapy or talk treatment, both of which can improve many of the problems related to depression. In addition, there are medical conditions that in my experience can mimic the symptoms reported for chemo brain. The common one is hypothyroidism, i.e. having low circulating thyroid levels, and this is associated with a variety of cognitive problems but is also a common endocrine disorder in women with and without a history of breast cancer. So because testing for this is cheap and simple and safe, and because the treatment is both cheap and highly effective (taking a thyroid replacement pill every day), this is something that ought to be tested for.

Christina Meyers, Ph.D., A.B.P.P.: That's an excellent point, and I could not agree more. Having a medical evaluation to make sure there isn't a treatable underlying cause is absolutely essential. I think sleep disturbance can be a cause, and managing it is essential.

George Sledge, M.D.: That's particularly true with breast cancer survivors. Chemotherapy can turn people into couch potatoes and being a couch potato can contribute to weight gain that goes along with therapy. Weight gain can contribute to sleep apnea. It's very common, and sleep apnea syndrome can make you feel drowsy much of the time and mimic many of the symptoms of chemo brain. So the bottom line is your medical oncologist was trained in general and internal medicine for a reason!

Stimulants researched for chemo brain?

Question from Post: My oncologist is researching Focalin (chemical name: dexmethylphenidate), a cousin to Ritalin (chemical name: methylphenidate), to combat chemo brain. The study is still in process, but my doctor has provided access to this drug for some patients. Speaking only for myself, Focalin has been a miracle. My mental clarity and focus has improved beyond all expectations. Yet I never hear anything about this drug therapy. What is your perspective?

Answers —Christina Meyers, Ph.D., A.B.P.P.: We started a course with Ritalin, the old standby stimulant, but it can have side effects especially for people who tend to be anxious or have high blood pressure. But Focalin sounds very interesting.

George Sledge, M.D.: Our group did publish a paper on Ritalin for patients who had fatigue after adjuvant chemotherapy and it was effective in relieving fatigue. It also had a high level of side effects. Methylphenidate is the chemical name of this drug, more commonly known as Ritalin, and it can cause elevated blood pressure and make the patient feel hyper. This belongs to the class of drugs known as "speed" so this type of agent may have real benefit, but there are some real side effects. They also tend to not be a permanent fix — in our experience, while the patients were on the agents, they saw real benefit but as soon as they stopped, that benefit disappeared.

Help others understand chemo brain?

Question from Sharon: How do you handle it when someone looks at you strange and cannot figure you out when you have chemo brain? What do you say? Should I tell them? Will they believe it?

Answer —Christina Meyers, Ph.D., A.B.P.P.: That's a tough one because people who experience this have more or less tolerance for the symptoms, and it's like blowing it off as opposed to getting upset about it or avoiding social contact because they're afraid they'll block on a word or a name. The fix for that depends on the person and their environment, but a sense of humor goes a long way in my view!

Chemo brain restrictions?

Question from Zenia: You talked about some of the things we should be doing to help with chemo brain. Are there are things we should NOT be doing?

Answers —Christina Meyers, Ph.D., A.B.P.P.: I don't know anything specific not to do. I know things that don't work, but they're not in the category of “don't do it.” Mental exercises, for example, don't help chemo brain although they're not bad on their own. A caveat: herbal supplements have to be thought through very carefully. There may be a lot of information on the web that isn't particularly correct. There may be misinformation or advertising. Consumer beware if someone is promising a miracle cure, as you would be in any other venue.

George Sledge, M.D.: I agree entirely. Another point worth pointing out is that in the clinic when we speak of chemo brain, we are speaking of a moving target. That patient who is receiving chemotherapy is different from the patient who has completed all her therapy a month ago who is different from a patient who completed her treatment a year ago who is different from a patient who is 10 years out. So because things can change (and often for the better), one needs to be careful in terms of assigning benefit to things that are offered to patients. Many of the improvements are just improvements that would happen anyway in the fullness of time.

Christina Meyers, Ph.D., A.B.P.P.: I would be especially wary of the miracle drug or thing, the only information on which is put out by the people who market it.

Computer programs help chemo brain?

Question from CMac: My question is about a computer program developed by CogniFit entitled "MindFit Back-On-Track," specifically for breast cancer survivors who are experiencing "chemo fog." Have you heard of this and would something like this be helpful? Thanks!

Answers —Christina Meyers, Ph.D., A.B.P.P.: I have heard of it, and it isn't helpful, and it is expensive. Mental stimulation is good, because all of us — breast cancer survivors or not — develop cognitive function if stimulated. But these types of programs don't generalize. You could do Nintendo or crossword puzzles, but to think it will generalize or undo an injury that may have been caused, say, by cancer treatment, just isn't true. What happens is that when you practice a thing like that, you get better at it but it doesn't stop you from blocking on words in conversation or eliminate the other symptoms of chemo brain. So you can pay a lot of money for CogniFit, or just do the crossword in your local paper, and you will get better at either, but it won't cross over into other aspects of your life. If you enjoy it, fine. But to think it will undo an injury is not correct.

George Sledge, M.D.: It's important to add that in addition to mental stimulation, physical stimulation is good as well. Literature says that patients who exercise tend to have better mental activity as well. This is especially important for breast cancer survivors, where exercise may cause better outcome for patients.

Christina Meyers, Ph.D., A.B.P.P.: Exercise benefits the cardiovascular system and everything else as well.

Tests to measure brain changes?

Question from Bess: Do you know what areas of the brain are impacted by each drug and for how long? Are there studies that scan the brain before and after to see what changes and maybe tailor special stimulation exercises focused on specific area of the brain for improving/helping regeneration?

Answers —Christina Meyers, Ph.D., A.B.P.P.: There have not been pre-treatment/post-treatment scans done so far because it's a very expensive study to do, but the pattern of neuropsychological studies shows an inefficiency of the frontal subcortical white matter. Just in the last year there are now a number of animal studies working on the effect of a variety of common chemotherapy agents on brain function in animals, so we are starting to understand some of the way these agents affect brain structure. Vascular effects, effects on the white matter are starting to be documented, so they are coming out and hopefully will help us understand the mechanism better and give us better ways to treat proactively.

George Sledge, M.D.: My colleague here at Indiana University, Dr. Andrew Saykin, who is a neuroimager, is actually in the process of neuroimaging studies in patients having chemotherapy. While he hasn't published anything yet, it's my experience that he's already seen some impressive neuroimaging changes in patients receiving chemotherapy.

Christina Meyers, Ph.D., A.B.P.P.: The bottom line is there are real anatomical brain changes in some people, not all, but the relationship to functional problems has to be connected as well.

George Sledge, M.D.: One of the things that fascinates me, from a grant I am working on that looks at treatment of brain metastases in breast cancer, is how little we know about how agents penetrate the brain.

Christina Meyers, Ph.D., A.B.P.P.: And there may be other ways to cross the blood/brain barrier. There are also agents that may induce secondary messengers: that is they induce other biochemicals that might then cross the blood/brain barrier. There may be hormonal and autoimmune reasons as well.

George Sledge, M.D.: This is still largely unexplored territory.

Christina Meyers, Ph.D., A.B.P.P.: And we know not everyone has this. Some people will go through treatment with no problems at all, but a majority has mild problems related to how they functioned before. They could be due to a number of reasons.

Is chemo brain an injury to the brain?

Question from Diane: Are you saying that chemo brain is an injury to the brain?

Answers —Christina Meyers, Ph.D., A.B.P.P.: It's a differential diagnosis, so yes, for some people it is an injury to the brain. For others it is a symptom, related to fatigue or depression, which is not necessarily a brain injury. So there are multiple ways to have the same feelings about things.

George Sledge, M.D.: This may be gilding the lily, but if you look at a woman who comes into an oncology clinic and receives chemotherapy, that woman has recently been given a serious diagnosis which can lead to anxiety or concern or depression that may alter mental function. She has likely undergone surgery and received anesthetics, she may be fatigued from the chemotherapy itself, and fatigue in and of itself may be affecting her. Because she is fatigued, she may be getting less exercise, which may affect her overall feelings about herself. She may be gaining weight and be at a higher risk of developing sleep apnea. She may be going through menopause as a result of the chemotherapy. So there are a large number of things that are going on simultaneously. One of those things may be a direct effect of the drugs on the brain, but it may be difficult to tease that out in many patients.

Christina Meyers, Ph.D., A.B.P.P.: That's why a complaint of these symptoms requires a workup.

George Sledge, M.D.: I agree, and that workup should include things we know are reversible.

Christina Meyers, Ph.D., A.B.P.P.: Go to your oncologist and say, “I have this symptom,” then go through all the appropriate diagnostic tests to see what could be causing these symptoms. There are a lot of things you can deal with in the interim.

George Sledge, M.D.: That workup might include looking for some endocrine disorder or sleep apnea. It may include a test for clinical depression. All these are reversible causes of cognitive dysfunction.

Christina Meyers, Ph.D., A.B.P.P.: It could include anemia or menopause as a potential contributor.

CT treatment destroys brain cells?

Question from Dray: Are brain cells destroyed by Cytoxan (chemical name: cyclophosphamide) and Taxotere (chemical name: docetaxel) treatment?

Answers —Christina Meyers, Ph.D., A.B.P.P.: There have been no studies looking at Cytoxan other than very acute changes. Cytoxan can cause oxidative stress in the brain, but there's nothing to my knowledge that damages the brain from Cytoxan, i.e. long-term cell death. They know there is an effect on the brain for sure, but that doesn't necessarily translate to dead brain cells that don't come back.

George Sledge, M.D.: As with so many things tonight, we don't know. A decade ago when we looked at high-dose chemotherapy for breast cancer patients and compared that to standard-dose chemotherapy, there was higher incidence of brain effects in high-dose. In many cases, we were talking about higher doses of Cytoxan.

Does chemo damage the brain?

Question from Dayse: Does chemotherapy damage the brain? And is it reversible?

Answer —Christina Meyers, Ph.D., A.B.P.P.: There are a couple of answers to this. Animal models show that some chemotherapy agents can damage the brain. They study rodents who are genetically all the same. Humans are not genetically all the same, and so what we know is some people have no problem, some have moderate, and some have severe problems. So there may be a genetic reason for this. Even though there is some evidence that some chemotherapy agents can cause brain injury, again, it's from genetically related animal models and you can't just transfer that to what happens to people.

Lifestyle changes to help chemo brain?

Question from DIDI: If things like crossword puzzles and computer games don't necessarily help a person recover from chemo brain, what can a person really do aside from look for drug treatment? Are there lifestyle changes I can make? Anything specific?

Answer —Christina Meyers, Ph.D., A.B.P.P.: There are lots of lifestyle things that can help diminish the effects on everyday function, but I wouldn't rule out crosswords if you enjoy them. They don't help chemo brain, but people should do things they enjoy. You can have a memory station in your house where your keys, etc., are in one place so you never have to worry where they are. Use a day planner. Break things into smaller chunks so you plan ahead and do it a bit at a time. You end up in the same place, you just go about it a little differently. For instance, students going back to school who may have been able to cram for an exam the night before may not be able to do that. I would say that for the huge majority of people, the symptoms of chemo brain will not prevent them from doing anything they want, but they may have to do it in a slightly different way.

Memory loss from chemo or aging?

Question from RebeccaH: I went through dose-dense chemotherapy (Adriamycin [chemical name: doxorubicin] and Cytoxan [chemical name: cyclophosphamide] plus Taxotere [chemical name: docetaxel] or Taxol [chemical name: paclitaxel]) at the age of 43. Now, 3 years out, I am still blaming chemotherapy for my memory loss. Is it time for me to start blaming my age or is chemotherapy still the culprit?

Answers —Christina Meyers, Ph.D., A.B.P.P.: It's very clear that these symptoms can last for a long time, maybe forever. It probably is related to your treatment, because you don't age that dramatically to have that big an effect. Blowing it off at all is not really helpful. The truth is, going through cancer and cancer treatment is a process that takes a bite out of you. It's taken something out of you — it's handleable, but it's there.

George Sledge, M.D.: As a physician, I hate blaming things on age! Not just because I’m aging, but when doctors blame things on age, they tend to miss things that are treatable and reversible.

Christina Meyers, Ph.D., A.B.P.P.: That's why it's important to get a diagnostic workup and not assume you're older or depressed or fatigued. That's not a diagnostic workup, and that's not helpful.

When does chemo leave the system?

Question from Pardue: How long does chemotherapy remain in your system after you stop treatment? Is it possible to experience side effects from treatment that ended 3 years ago?

Answers —Christina Meyers, Ph.D., A.B.P.P.: I know the effects on brain function outlast the half-life of the actual drug itself.

George Sledge, M.D.: Here we need to distinguish between how long the drug remains around and how long the side effect remains around. Most chemotherapy agents have had the vast majority of the chemotherapy metabolized or excreted by the body within 2-3 days of treatment. However, complications of therapy, such as if one damages an organ, can last for prolonged periods of time.

Christina Meyers, Ph.D., A.B.P.P.: That's why survivorship issues are so important. You could have Adriamycin (chemical name: doxorubicin) treatment and have heart issues long after the therapy is finished, so those issues are very important at this time.

Best doctor to see for chemo brain?

Question from LSuarez: What kind of doctor is the best specialist to see about chemo brain?

Answers —Christina Meyers, Ph.D., A.B.P.P.: I think a person needs to go to their oncologist first for a diagnostic workup of potential medical problems that might be contributing. Depending on those workups, a neuropsychologist would determine a person's strengths and weaknesses and what the treatment would be after that.

George Sledge, M.D.: I would add that for many patients, if they have a good general internist, the internist may be able to look into things like endocrine disorders, sleep apnea, or depression, which are treatable. Depending on the internist and oncologist, the internist may be able to do a better job there than the oncologist. But once one has excluded the common reversible causes, it's well worth the trip to a neuropsychologist, and that's something I do frequently with my patients.

Trauma of experience affects brain?

Question from LynnD: How much of chemo brain can be attributed to post-traumatic stress disorder after going through the ordeal of diagnosis, surgery, chemotherapy, radiation, and immunotherapy? I have recently been diagnosed with generalized anxiety disorder and was not having any problems until after my cancer diagnosis, treatment, and now recovery.

Answer —Christina Meyers, Ph.D., A.B.P.P.: That is a huge complicating factor. I would consider that an overlay that makes everything worse. It doesn't mean that chemo brain doesn't exist, but the reaction may be huge which makes it more difficult to function.

Does insurance cover diagnostic workup?

Question from Ettevyva: Do insurances generally cover diagnostic workup? If not, is it expensive?

Answers —Christina Meyers, Ph.D., A.B.P.P.: Where I work, insurance does cover it. It is a diagnostic procedure for brain function, so it is covered. And it's not that expensive compared to surgery, MRI scans, etc.

George Sledge, M.D.: Some of the ancillary tests like thyroid or sleep apnea tests are relatively inexpensive diagnostic tests and are reimbursable.

Chemo brain without chemo?

Question from Camber: What you describe is what I experience, but I have never had chemotherapy. For three cancers, I've had four major and about a dozen minor surgeries with anesthesia and medications. So, is the chemo brain effect only from chemotherapy, or the other chemicals that are put into our bodies as well?

Answers —Christina Meyers, Ph.D., A.B.P.P.: That is a very interesting question. All our studies in all types of cancer show about a third of people have cognitive deficit which is likely related to the body's reaction to the cancer itself. So the cancer itself can do it. Surgery and anesthesia can both contribute too.

George Sledge, M.D.: There was a recent publication that looked at baseline cognitive dysfunction before a woman ever receives chemotherapy. Women who had ductal carcinoma in situ had less dysfunction than women who had stage I or II, and that raises the question of whether the cancer itself causes the symptoms.

Christina Meyers, Ph.D., A.B.P.P.: There are a lot of unanswered questions, but about a third of people experience these symptoms without chemotherapy.

Which medications cause chemo brain?

Question from Terp: Which chemotherapy drugs are most likely to cause chemo brain?

Answers —Christina Meyers, Ph.D., A.B.P.P.: I would have to say we don't know enough. There are a number of agents that have been tested in animal models, and they all show something but there is really no basis for comparison.

George Sledge, M.D.: The other issue is it's rare for us to treat a woman in the adjuvant setting with just one chemotherapy agent. It's common for a woman to receive several drugs at once.

Christina Meyers, Ph.D., A.B.P.P.: I'm not sure it even matters, because cancers come across various drugs so I look at patients with leukemia, prostate cancers, etc. — all different cancers with different drugs, and they all may have chemo brain symptoms.

George Sledge, M.D.: High doses of drugs may give you more effects than a lower dose of the drugs, but again that doesn't tell us which drug. And a question we haven't looked at is whether regimens that are being administered for shorter periods of time are different from regimens for a longer time.

Antidepressants to treat chemo brain?

Question from Tyka: I believe that in my case, my chemo brain was the result of clinical depression. A 3-4 month course of an SSRI fixed my brain chemistry and I could once again think straight and form a complete and coherent sentence, a valuable asset to have back again in my line of work as a paralegal. Have there been studies involving the use of antidepressants to treat chemo brain?

Answers —Christina Meyers, Ph.D., A.B.P.P.: Again, that's the differential diagnosis that Dr. Sledge referred to. If treating the depression is the best thing to do, then it's probably going to work.

George Sledge, M.D.: I still think it's a great question, and I don't know the answer. If we have a population of patients who are not clinically depressed, and we treat them with an SSRI, does it have an effect?

Christina Meyers, Ph.D., A.B.P.P.: I don't think that study has been done, but if I thought depression was not a contributing factor I would treat the symptom with a stimulant as opposed to an antidepressant. But that's just me; that's not data.

Genetic tests for cognitive difficulties?

Question from Shadie: How can I find out if I am genetically at risk for developing neurocognitive symptoms?

Answers —Christina Meyers, Ph.D., A.B.P.P.: There is no way right now. We're just starting those studies, and we're looking at DNA, metabolizing genes, genes that might make someone more prone to dementia in later life. We're looking at all sorts of things, but we're just starting so there is zero information right now. If we can identify who will or will not have problems, the search for personalized medicine will go to the next level.

George Sledge, M.D.: This raises an important point — the best way to avoid any toxicity is to not receive the drug that causes toxicity. One of the major changes that has occurred in breast cancer in recent years is the attempt as a result of genomic technology to determine which women do and do not benefit from chemotherapy. So my hope is that the burden of chemo brain will be decreased in the future by decreasing the number of women who are being attacked with certain chemotherapy agents.

Christina Meyers, Ph.D., A.B.P.P.: That's closer to the chemo brain point — who will benefit from chemotherapy?

George Sledge, M.D.: We've made huge changes in the last few years in lymph-node-negative tumors, estrogen-receptor-positive tumors. I probably administer half as much chemotherapy as I did 4 years ago.

Christina Meyers, Ph.D., A.B.P.P.: And that is a huge advantage.

Tests to diagnose chemo brain?

Question from CarlaG: What kinds of tests can a person take to find out for sure if she has chemo brain?

Answers —Christina Meyers, Ph.D., A.B.P.P.: I have to protect my trade here, but you have to go to a neuropsychologist who knows how to test for brain function.

George Sledge, M.D.: That's an important point. Your medical oncologist or internist may be able to tell you what it's NOT, but you need a neuropsychologist to tell you what it is.

Head trauma affects chemo brain risk?

Question from JW: Is the risk of chemo brain higher if one has had earlier head trauma?

Answer —Christina Meyers, Ph.D., A.B.P.P.: Unknown. Really unknown. If you've had an earlier head trauma and you have a problem related to that already, it doesn't increase your chance of having a reaction to chemotherapy. Women who have had chemo brain are no more likely to decline than anyone else, but that's a pretty big leap right there so I can't say other than for women who have problems before chemotherapy, they are unlikely to have more problems than anyone else. So we don't know.

Chemo brain vs. Alzheimer's disease?

Question from TWave: How can you identify the difference between chemo brain and Alzheimer's disease?

Answers —Christina Meyers, Ph.D., A.B.P.P.: That's easy! It's totally different. If a person has Alzheimer's disease, they have rapid forgetting of information. Earlier I referred to learning a list of 12 words. People with chemo brain and Alzheimer's may remember the same number of words, but later the person with Alzheimer's will remember 0 and the person with chemo brain will remember all of them. So a person with chemo brain has problems with memory retrieval. If someone is worried about having Alzheimer's disease, they don't have it! People with Alzheimer's aren't aware.

George Sledge, M.D.: Personally, I find that very reassuring!

Christina Meyers, Ph.D., A.B.P.P.: With chemo brain, nothing is lost from memory, it's just not retrieved efficiently. We all have that tip-of-the-tongue thing — trying to remember something like the name of an actor in a movie. For people with chemo brain, the information will come back to them later — they don't forget it. That's the difference.

Symptoms of chemo brain?

Question from Julie: What are some clues that you have chemo brain? Is it losing your train of thought or is it not being able to concentrate? Please give me some info. Thanks.

Answers —Christina Meyers, Ph.D., A.B.P.P.: All of the above. It is sometimes losing your train of thought, it's sometimes blocking on words. It is sometimes being distractible, having trouble multitasking. Those are all potential symptoms.

George Sledge, M.D.: Are numeracy issues something you see?

Christina Meyers, Ph.D., A.B.P.P.: Yes, holding things in your head, like doing mental calculations, might be difficult. I have clients who are nurses who might have to calculate a dose of medication per kilogram of body weight, who used to be able to do it in their heads and now can't. You can't take in the load of information you previously did, so you miss stuff and get it slower. People tell me it takes more time and effort to do than for normal people. But given enough time, they still do it — they can be quite functional and do everything in appearance just as they used to, but the person knows there is an increased effort and increased cost.

George Sledge, M.D.: One thing that I observe in the clinic not uncommonly is that the patient's perception of how she's doing and the perception of other people is not the same.

Christina Meyers, Ph.D., A.B.P.P.: They are maintaining their level of function, but they know the cost internally. Which is one of the reasons it may have been blown off as a syndrome — they may not be losing their jobs over it, but they know.

Does chemo brain affect intellect?

Question from Bev: I'm assuming that just because you have chemo brain, it doesn't necessarily affect your intellect. Is this correct?

Answers —Christina Meyers, Ph.D., A.B.P.P.: Yes, it is correct. It does not affect your intellect, problem solving, talent, skill, etc. It affects your efficiency and, depending on what kind of job you have, how efficiency matters makes it more or less a problem. So let's say you're a person who can do their job without a lot of time pressure — it may not have much impact. If you're in a job with a lot of time pressure or pressures that might tap into your inefficiency, like an attorney in a courtroom and you have to think quickly on your feet, that could be a real problem. So it depends on what the demands are on you in your life.

George Sledge, M.D.: I had a lawyer as a patient who expressed exactly the issues just stated after her chemotherapy. For her it was disabling and she lost her job because she couldn't do what she used to do.

Christina Meyers, Ph.D., A.B.P.P.: A lot of these clients are covered by the Americans with Disabilities Act, so employers have to offer reasonable accommodation. But if you are a trial lawyer, you may be disabled. But that person is still very smart and skillful, so there may be another venue where that person can work that can overcome the difficulties they are having. So I work with employers to see how we can deal with issues like this.

Is chemo brain reversible?

Question from Bron: Is chemo brain reversible?

Answers —Christina Meyers, Ph.D., A.B.P.P.: Sometimes it reverses by itself and sometimes it doesn't.

George Sledge, M.D.: I do not have Dr. Meyers' expertise, although reading this literature I have seen data all over the map on this issue.

Christina Meyers, Ph.D., A.B.P.P.: Some people never have it, some people get over it, some people never get over it. It's very individual. But I still want to mention it's very handleable and it's better than the alternative, so keep that cost/benefit of treatment in mind. You can't be seen by someone like me unless you are alive!

George Sledge, M.D.: The analogy might be when someone has bad vision, we don't tell people, "Don't look" — we tell them, "Get some glasses."

Christina Meyers, Ph.D., A.B.P.P.: That's absolutely correct!

Estrogen deprivation vs. chemo brain?

Question from BerniceT: How can we differentiate between the effects of chemotherapy on memory problems and the effects of estrogen deprivation? In my case I had an oophorectomy following chemotherapy, which induced a sudden menopause. I was 40 at the time but 3 years on I still struggle to think clearly.

Answers —Christina Meyers, Ph.D., A.B.P.P.: I don't know that you can separate it exactly, but a sudden menopause does cause cognitive problems unlike normal menopause where it happens gradually and you have some hormones hanging around.

George Sledge, M.D.: This is a literature I find confusing. There has been, as a subset of one of the large adjuvant hormonal therapy trials, a randomized look at women who received an aromatase inhibitor as opposed to women who received a placebo. If I read the results of this trial correctly, there was no difference in neurocognitive function between these two groups of women.

Christina Meyers, Ph.D., A.B.P.P.: We have a trial that will be published soon looking at tamoxifen and we find the same pattern we do with chemotherapy — some women have no problems, most women have moderate problems, some have such severe problems they must be moved to another agent. Abrupt hormone ablation (and it's the same for men with prostate cancer) can cause problems.

George Sledge, M.D.: And the age at which this happens can make a difference. The effects on a 35-year-old are quite different from the effects on a 60-year-old.

Explain chemo brain to boss?

Question from IIC: In addition to not being able to "pin down the right word," I am slower at mental tasks than I used to be. How do I convince my boss that just because the chemotherapy is over doesn't mean I'm back to normal (and I'm not faking it to get out of doing work)?

Answers —Christina Meyers, Ph.D., A.B.P.P.: I don't know how you convince your boss. It is the real deal, and there is a lot of literature out there, so marshal the scientific literature that shows it's a real thing with real symptoms and show it to him. Also mention you might be covered by the Americans with Disabilities Act.

George Sledge, M.D.: My answer was that you should see a neuropsychologist and have formal testing to document it.

Christina Meyers, Ph.D., A.B.P.P.: Thank you for that, and I agree completely!

Chemo brain awareness among doctors?

Question from Carson: Why do doctors not address this with patients when they ask questions? I was treated like the village idiot by my oncologist and am changing doctors now because of it.

Answers —George Sledge, M.D.: This is an area where medical oncologists have difficulty, partly because the sophisticated neuropsychology testing is not available to the medical oncologist in the clinic. Partly it's because this is an area where physicians are good at taking care of acute toxicities of therapy but not nearly as good at taking care of chronic toxicity. And finally, unfortunately but realistically, having these discussions actually takes a fair amount of time in the clinic, and medical oncologists are frequently running in and out of rooms quickly to get through the day. That's not an excuse, but it's a reality.

Christina Meyers, Ph.D., A.B.P.P.: I agree. Unfortunately, it means that patients need to be their own advocates. Patients need to be informed and they need to ask what they need — a sleep study or a physical therapist or a neuropsychologist. They need to promote it as patient advocacy. Dr. Sledge is right — physicians have limited time. They just do. And you need to know what kind of treatment you need and ask for a referral.

George Sledge, M.D.: Like many things in medicine, this is a rapidly evolving field, and how we addressed it 10 years ago is different from how we address it now. The reality is that for many medical oncologists, because their training is in cancer treatment instead of the brain, they have trouble dealing with this. The informed consent forms even today have minor mention of potential cognitive problems, partially because we don't have enough data to give patients enough information.

Christina Meyers, Ph.D., A.B.P.P.: And a lot of the things in informed consent are about what can kill you, and chemo brain is not fatal. We're not talking for most people about a horrible thing; we're talking about an aggravating problem that keeps them from doing their normal activities in their normal fashion. It has to be in perspective.

George Sledge, M.D.: I think this is part of a larger trend we're seeing in oncology. In the recent past, oncologists considered themselves heroic if their patients survived 5 years out. Now that patients survive 5, 10, 15 years out, we are seeing more long-term effects.

Christina Meyers, Ph.D., A.B.P.P.: In fact, it is a chronic problem now instead of an acute problem. It's a chronic disease you keep treating as it flares up.

Chemo brain treatments being developed?

Question from Izzard: What therapies or treatments are being developed to treat the long-term effects of chemo brain? I am 3 years out of treatment and still suffering cognitive difficulties which impact my job. Thanks.

Answers —Christina Meyers, Ph.D., A.B.P.P.: I just have to say that there are no specific treatments for cancer patients. We borrow from the brain injury field and other neurologic illnesses. There is nothing really specific to cancer, but we go with what is evidence-based in other neurological conditions and we apply it to cancer patients.

George Sledge, M.D.: If indeed we get better at diagnosing this on a routine basis and doing functional neuroimaging, that points to specific defects. Let’s imagine 5 years from now we know on a reliable basis that chemotherapy drug X causes a particular effect in this part of the frontal lobe. Once we have those diagnostic techniques in place, then we can think about developing interventions that might interfere with those things we see in imaging. There's a lot of work to tie imaging to the other functional tests we do, but I think we'll get there soon and be able to come up with interventions that may reverse that.

Christina Meyers, Ph.D., A.B.P.P.: I agree, and that's the direction that it's going in.