When Elizabeth Stepp, a corporate litigator in Dallas, learned she had breast cancer, one of her greatest fears about the impending chemotherapy regimen she’d been prescribed was the possibility of developing a side effect called ” chemo-brain.” Also known as chemo fog and chemotherapy-related cognitive impairment or dysfunction, this condition manifests as mental fogginess, a loss of ability to concentrate and word-finding issues in many patients.
“People say it makes you stupid, and I was worried about that,” Stepp says. With her job, she needs to be super sharp and able to adjust arguments on the fly in court. The prospect of not being able to find the right word when she needed it was understandably concerning.
Chemotherapy isn’t the only treatment that can cause cognitive disturbances in patients. Some endocrine therapies — hormonal treatments that help starve breast cancers that feed on estrogen or progesterone — have also been known to cause cognitive changes. Many breast cancer patients receive both chemotherapy and endocrine therapies, and that can create a distressing one-two punch of mental changes for some patients.
[See: A Tour of Mammographic Screenings During Your Life.]
For Andraya Lombardi of Danvers, Massachusetts, chemo- and endo-brain were very real side effects from her recently completed chemotherapy course. Lombardi, who works as an owner’s project manager in the construction industry, was diagnosed with stage 2, estrogen- and progesterone-positive breast cancer last May, meaning that her cancer was using both hormones to grow. She was prescribed a common 16-round chemotherapy protocol that included four infusions of a particularly robust drug called Adriamycin, nicknamed the Red Devil. This drug was administered every other week over the course of eight weeks, and Lombardi says “those first eight weeks were brutal.”
In addition to nausea and hair loss, Lombardi says she also noticed changes in her cognitive abilities almost immediately. “It’s a very foggy feeling. You can’t focus,” and when she was asked a multi-layered question that required more than two answers, she says she would frequently need to have the question repeated.
At work — she continued on full-time during treatment — some of these issues would surface as difficulty comprehending an email, occasional difficulty finding the right word and difficulty with multi-tasking. She also experienced headaches, and she says taken all together, the experience felt a bit like having a concussion. “I just felt like mush, like I had a concussion: when you hit your head and it hurts to read and see.” She says blurry vision was also a problem.
Dr. Maryam Lustberg, associate professor of medicine and medical director of survivorship at the Stefanie Spielman Comprehensive Breast Center at the Ohio State University James Cancer Hospital, says these symptoms are typical of what many patients experience when undergoing chemotherapy and endocrine therapy for breast cancer. She says that while the symptoms are real and can be very bothersome for patients, “it’s important to emphasize that these symptoms tend to be very subtle and most noticeable to the patient or survivor herself. These individuals tend to be very functional at work, and the family may not notice necessarily that something is different.”
[See: 7 Innovations in Cancer Therapy.]
Nevertheless, it can be distressing, especially to high-functioning multitaskers who lead busy lives. The good news is that once treatment concludes, these symptoms tend to fade away. Lombardi says that’s been the case for her — she’s only two weeks out from her final chemo session, but says she already feels a little less foggy. Lustberg says most patients report progressive resolution of symptoms that result in being back to normal within two years. Some continue to notice subtle changes indefinitely, though these symptoms are usually much better than when the patient was in active treatment.
But what causes these problems? Doctors aren’t 100 percent sure of the mechanism, and it’s difficult to predict who is likely to experience these problems, but Lustberg says “it’s something we’re studying in the lab right now.” She says there are likely several factors at work in whether a patient experiences fogginess during treatment for breast cancer, including hormonal changes that induce early menopause. Chemotherapy and endocrine treatments induce early menopause in many patients by reducing the circulating levels of estrogen in the body. These hormonal changes may impact cognition. “Some of these changes occur naturally as a consequence of aging,” Lustberg says, and women without breast cancer sometimes report cognitive changes when they go through menopause.
Beyond that, brain imaging has shown neuronal changes indicating changes in the way parts of the brain communicate with each other. “It takes more networks to accomplish the same task” in these patients than it does in a healthy subject who hasn’t had chemo or endocrine drugs, Lustberg says. “What patients report is that it’s taking them longer and it’s harder to do the same thing, and we can see that in the imaging network. So, there’s definitely something real going on.”
She says there’s also evidence that inflammation in the brain plays a role, too. “In our lab models, we actually see increased inflammation in the brain that is essentially being caused by some of the cytokines released by the chemo itself.” (Cytokines are proteins cells use to signal one other.) The discovery of this cytokine involvement has led to an ongoing debate about whether the observed inflammation is caused directly by the drug or if it’s an immune system response. Either way, Lustberg says her team is “studying ways to dampen that inflammation in order to prevent some of these changes.”
[See: What Not to Say to a Breast Cancer Patient.]
If you’re undergoing treatment for breast cancer and have noted changes in your ability to concentrate or other alterations to aspects of how your brain is working, talk to your doctor about what you’re experiencing. Particularly if it’s impacting your ability to perform your job, Lustberg says neuro-cognitive testing may help pinpoint the issue and offer some solutions. “What you may have thought was chemo-brain could actually be adult onset attention deficit disorder,” she says as an example. It may also be the result of undiagnosed depression, a sleep disorder, thyroid issues, anemia or a side effect of another medication you’re taking not related to your cancer treatment. “I can’t emphasize enough the importance of looking at other contributors. I think it’s really important to have that global, holistic view of what might be contributing,” Lustberg says, so have your doctor analyze your medications and test for other common causes of cognitive change.
All of this will help you gain a better understanding of the issue, which may help you develop ways to get around it. That may include working with an occupational therapist or a psychologist to develop compensatory strategies, or if you’re like Lombardi, you’ll figure out ways to get around the brain fog on your own. One strategy she employed when she had difficulty deciphering email was to set it aside and come back later when she felt a little clearer. She also learned to take copious notes during work meetings and to make to-do lists every day. “If I put it on a piece of paper, I won’t forget to do it,” she says. “I didn’t want people to think I couldn’t handle the stress of the job or tasks that were given to me, so I had to take a lot of notes. It was hard, but I hid it well,” she says.
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What Causes Chemo- or Endo-Brain in Breast Cancer Patients? originally appeared on usnews.com
