Cutting Through Chemo Fog: Understanding and Managing Cancer-Related Cognitive Impairment

Dr. Linda Ercoli (00:03.374)
Hello, my name is Dr. Linda Erkeley and welcome to The Memory Moment. Today we’re going to talk about cancer-related cognitive impairment. You may have heard that before, but maybe it’s called in your world chemo brain or chemo fog. But these are the kinds of cognitive problems that people have after they’ve had cancer or cancer treatment.

So today we’re going to talk about how to cut through the chemo fog. We’re going to talk about what causes it, who gets it, and what you can do about it. Well, let’s talk about who gets it. About 75% of people during treatment may complain of cognitive problems. And these problems could be problems with memory, with concentration, feeling distractable, difficulties doing things in the right order, problems with planning.

Or seeing a plan through to the end. Right? Folks may complain about difficulties at work, forgetting how to use a software program, for example, problems with navigating or wayfinding or with mental calculations. But generally, people don’t feel like themselves. In addition, they may also feel fatigued and not be sleeping and depressed as well. So during treatment, about 75%.

of folks may complain about that. After treatment, about 15 to up to 75%, depending on the study, may also continue to complain. But generally cancer related cognitive impairment resolves in one to two years. But for a subset of people, and these are these 15%, they may either not have problems until after treatment ended and the problems may come on

Come on late, like a a year later, or they may have problems persist for more than two years, so sometimes five years or ten or even more years. Interestingly, 20 to 30 percent of people before they start chemotherapy but who have cancer, they may also complain of these cognitive difficulties. And this could be due to cancer itself, or in some people they have pre-existing problems.

Dr. Linda Ercoli (02:26.72)
And in some of this 20 to 30 percent, the problems don’t necessarily worsen with treatment. So the exact number of people and how common cancer related cognitive impairment is, it isn’t a hundred percent figured out, still kind of an unknown because we have so many different types of treatments, different types of cancer and ways to evaluate who has quote chemobrain.

That we don’t necessarily have really solid, consistent numbers. Now, who’s likely to get chemobrain include the very young and older adults, people who have underlying health problems, people who may already have some cognitive problems, so when they get chemotherapy, they get worse.

goes directly to the brain. So for example, people with lymphoma and those treatments or brain radiation, those individuals are more likely to have chemobrain, right, than other folks that have different types of treatment that don’t go directly to the brain. What are the causes of chemobrain? Well it’s actually multi-determined. And a number of categories, first of all

The types of meds that people take, and not only the types, but how many do they take at one time and what’s the dosing? So the more you take, the higher the dose, the more likely somebody is going to get these side effects. Now, also they have other types of treatment like monoclonal antibody treatments, there might be immune therapy side effects.

Certainly, people that are on hormone blockers, for example, anti-estrogen and anti-uh androgen drugs, so things like tamoxifen, for example, aromatase inhibitors, these too can result in changes in cognition. What’s actually going on in the brain could be a number of things. So, one is that people get

Dr. Linda Ercoli (04:48.236)
more inflammation in their body either because of the cancer, because of the treatments, including even surgery, and because of the type of drugs that they take. People also get oxidative stress, which is affects the health of cells and can result in cell death in the brain. There also be changes in people’s vasculature in the brain. Again, changes from blocking hormones

Impaired ability for neurons to repair or to create new neurons in the brain, changes in brain white matter, which affects how quickly our brain regions communicate with each other, and alterations in the chemical messengers in the brain that are called neurotransmitters, and also alterations in people then ability to, for example,

Form long-term memories, etc. Now, what what can you do if this is you? And for some for some people you definitely can engage in some cognitive rehabilitation that can help, but also there are other symptoms that go along with people who are undergoing cancer treatment.

And some of those may be side effects of chemotherapy, or they may also be contributors to chemobrain. So, what are those? For example, sleep problems. So, people who sometimes are undergoing chemotherapy sometimes can’t sleep, or they have poor sleep, disrupted sleep, they may sweat, can’t get to sleep, for example. Also, pain and people who have had surgery.

For example, and in addition, fatigue, so feeling really tired, and some folks get depressed or get very anxious. And again, those types of symptoms can be side effects of chemotherapy, or they can be effects of all these changes, right, that are going on in the brain. But what they do, those kinds of symptoms feed back and make chemobrain worse.

Dr. Linda Ercoli (07:11.468)
Now there are some folks that have a genetic susceptibility to chemobrain. It’s nothing that they’re doing, but the way their their genetics are you know combined may mean that they don’t handle inflammation well, for example. So we know that there are discoveries right now that are being made about how to identify those folks by their genetics. So, what do you do if this is you? Well, first treat the things that are treatable.

Certainly, insomnia is treatable, mood disturbances are treatable, and people can get help to fall asleep and stay asleep. They can take antidepressants or anti-anxiety medications, or they can even use more holistic approaches to reduce anxiety anxiety like meditation or doing yoga, for example. So there are

Treatments for some of these peripheral types of symptoms that really affect one’s quality of life but also can affect your thinking. So treat what you can treat and then also think about going into a support group. There are lots of people who have chemo brain or chemo fog that feel like you know it’s difficult to cope with, perhaps their families aren’t understanding what they’re going through.

And they need support. I would advise that the whole family learn about chemo brain and what it is and what somebody is going through so that they can all have a similar set of expectations about what how long it might take to get better, what kinds of things may be difficult, and what someone may need help with. And then going into a support group where you’re

In a group with people who are undergoing the same thing, right? Experiencing similar symptoms can be tremendously helpful and supportive. Many people, when I’ve worked with breast cancer survivors, for example, they talk about the new normal and what their brain is like after having chemotherapy, and people talk about that with each other and they find it very helpful in in really coping with these changes.

Dr. Linda Ercoli (09:34.198)
Now there are cognitive rehabilitation types of exercise that people can do, and I’m going to talk about three different types. One is to improve concentration, the second is to improve memory, and the third is to improve your tracking or being able to do things in the proper sequence. So starting with concentration, this is a big problem, big complaint.

That people can’t focus at work or they can’t even read for enjoyment. Or if they can, it’s much diminished from what they used to be able to do. And one thing that people do quite a bit is they hit the wall, like you can see in the slide. Avoid hitting the wall. The wall is when you work to the point of frustration or exhaustion or negative feelings about yourself. Stop.

When you get there, you’re beyond the point of really return. So if you find that you’re starting to hit that wall, let’s say you’re reading in 10 minutes, then set a timer for nine minutes and start reading. And if you can read for nine minutes without feeling distracted, stop and take a break. Don’t surpass that nine minutes. Come back.

Read for nine minutes again, take another break. After you’ve been able to read for nine minutes, then you can start expanding it to nine and a half minutes, to ten minutes, and get past that baseline 10-minute wall. If for some reason you feel like you’re struggling again, then just go back to a shorter time and keep going. So, what you’re doing is you’re avoiding that hard stop.

at the wall, you’re stopping sooner, taking a break, and continuing, and you are avoiding that frustration and you’re pushing the envelope, right, of the brain. You’re saying a little more, a little more. It’s like stretching a muscle, right? You have to gradually work on stretching that muscle. So you gradually work on increasing your

Dr. Linda Ercoli (11:58.816)
attention span and you can do this at work you can do it you know with a computer program software etc the reading is a great place to start now what about memory well probably a very sensible way to approach memory is to use more memory aids so your smartphone a calendar even a notebook

But check it a few times a day and so that you can remind yourself of what is on the agenda for the day. Set timers for for when you need to do something or stop to do something. So if you’re cooking something in the oven, don’t rely on your memory to know when it’s ready. Set the timer so that you don’t burn it. there are

Other ways that you can sort of avoid taxing your memory, like using automatic bill pay and essentially tech to help with reminders and doing things that you don’t have to keep track of, but you can have a record of. Also, people can use what we call mnemonic techniques, these are techniques using verbal associations, rhymes, and

Making up stories to help you remember a grocery list and forming images of what you want to remember. And these have been around for a long time and they work, they’ve been studied in older adults, and they can be helpful also to people with memory inefficiencies, such as those related to chemobrain. Now, what about problems with

Planning, so these executive functions. There are a number of things that one can do. I recommend using checklists to keep track of what you’re doing. You can actually find templates for tech checklists on the internet or you can write your own and you write down the steps of what you have to do in order. And then as you go along, say the steps out loud and check them off so you know that you completed them and go down.

Dr. Linda Ercoli (14:22.2)
The checklist until you’re finished and then go over it one more time and make sure that you hit every step. Also preparing ahead of time. So if you’re going to cook something, get all your spices out, get all your ingredients out ahead of time. Same thing if you’re building something right, get all your tools out and get the right size nails out, but don’t be

Hunting and pecking for all of these things as you go along, but you have to be more organized. So you can again use these checklists for putting something together and for building something, making sure that you’ve included every step along the way. Now, what about programs for cognitive rehabilitation, such as those on the computer?

There is some evidence to suggest that they can definitely improve your thinking, they can help you. The question that is not answered is do these computer based trainings really pertain to or generalize to daily life? So if you’re working on a computer program that helps you remember where something was on your

computer monitor. Is that going to translate into remembering to call somebody on the phone during the week? Not clear. But we know that the more you practice those computer games, the better you will get on those computer games. And there’s a few that have actual studies and support for them, such as Brain HQ or Insight by Posit Science, and one called Happy Neuron.

These have been studied in individuals that have had chemotherapy. Again, though, there are not a lot of studies on this, not a huge body of literature on this. The dosage about this should be maybe studying these or doing these exercises at least 15 minutes a day, a few times a week, or maybe even two hours a week in total, but you should be doing them.

Dr. Linda Ercoli (16:44.436)
On and off, right, every day, not just once a week for two hours. And you need to do this for about 10 weeks or more. There’s also another type of program called MAPPT MAPT training, and this is a combination of cognitive skill training and some behavioral training as well. It can be done in person and it can be done virtually.

And this has a good track record of helping people with cognition and other types of problems that are associated with cancer-related cognitive impairment. So I am going to put up some research resources associated with this podcast so you can look into these potential therapies more. But in the meantime

one of the messages that I want to really make clear to you is don’t get on yourself for this. Get your family involved. Have them help help them understand rather than new normal. Because a lot of families think that once somebody is treated and they’re in remission or they’re cured that the that they’re not gonna have any more problems. But we know that because certain things persist, like fatigue, sleep problems,

pain and also chemobrain that they need to understand that you’re not gonna necessarily snap back to your old self again once chemotherapy ends. Now some people eventually do, actually, most people do, but there’s a sizable number of people who don’t. And you can you can learn to deal with this and make accommodations in your life, some of those which we talked about here to help you.

So thank you so much for listening and have a good day.