A Neuropsychologic Perspective: Cognitive Impairments in Cancer Patients

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A Neuropsychologic Perspective Cognitive
Impairments in Cancer Patients

• J. Aubrey Burhart
• State University of New York at Buffalo

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What is a neuropsychologist?

• A neuropsychologist is an expert in the applied
  science of clinical neuropsychology concerned
  with the behavioral expression of brain
  dysfunction

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Dimensions of Behavior
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What does a Neuropsychologist do?

• Diagnose Differentiate btw. Psychiatric and
  neurological symptoms distinguishing btw. 2
  neurological disorders predict outcome of a
  condition
• Patient care and planning Identify how the
  disease might affect patients behavior for
  family members Assess patients capability for
  managing daily activities and following treatment
  regimen Repeated assessments at intervals allows
  for tracking disease progression
• Rehabilitation and Treatment evaluation provide
  information to various healthcare providers
  regarding patients capacities, defective
  behaviors, etc.
• Research study brain activity and its effect on
  behavior

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Lateralization in the Brain

• Left Side
• Speech
• Writing
• Main Language Center
• Calculation

• Right Side
• Spatial Construction
• Simple Language
• Copying/Drawing Geometric Designs
• Some Musical Ability
• Odors

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Major Neuropsychology Domains

• Memory
• Visual/Spatial
• Attention/Concentration
• Intellectual

• Executive
• Motor
• Speech/Language

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The Domains Defined (Lezak, 1995)

• Attention and Concentration
• Refers to several processes that are related
  aspects of how the organism becomes receptive to
  stimuli and how it may begin processing incoming
  or attended to-information

• Memory
• The complex of systems by which an organism
  registers, stores, retains, and retrieves some
  previous exposure to an event or experience
• Visual/Spatial
• The memory for familiar routes or for the
  location of objects and places in space

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Definition of Domains..contd.

• Executive
• Those capacities that enable a person to engage
  successfully in independent, purposive,
  self-serving behavior
• Motor
• Primarily concerned with use of the hands,
  although gait is qualitatively assessed. Gross
  and fine motor skills are assessed to varying
  degrees of precision.

• Intelligence
• Tendency for cerebral regions subserving
  different intellectual functions to be
  proportionately developed in any one individual
• Speech Language
• Refers to the understanding and expression of
  language in all realms (spoken, written,
  auditory). Incl.s quality/quantity of
  spontaneous speech, aud. Comp., reading
  recognition and comp., writing, repetition, and
  confrontation and generative naming.

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Cancer is Devastating

• The incidence of cancers of the breast and lung
  in women, as well as non-Hodgkin lymphoma,
  melanoma of the skin, and liver in men and women,
  is rising
• Lung cancer deaths in women continue to rise,
  though not as effectively as before
• More people are overweight and obese, and
  physical activity is increasing only slightly
• Cancer treatment spending continues to rise along
  with total health care spending

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Cognitive Functioning is Essential For

• Comprehending disease treatment and progression
• Making informed healthcare decisions
• Adhering to a treatment regimen
• Medication compliance
• Occupational success
• Maintaining social networks

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Risk Factors for Cognitive Deficits

• Disease Induced
• Infections
• Pain
• Metastases to CNS
• Disturbances of endocrinologic system

• Treatment Induced
• Chemotherapy
• Radiation
• Bone marrow transplantation
• Medications
• Biologic Response Modifiers

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All of these things can cause..

• Combination treatments are often implemented
  which may be more effective in combating the
  cancer, but poses even greater risks of
  neurotoxicity for the patient

Encephalopathy
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Effects of Chemotherapy on Cognitive Functioning

• Cognitive dysfunction can appear soon after
  treatment initiation or as late as 10 years later
• Altered cognitive functioning can be transient or
  permanent
• Even when cognitive function appears to be in the
  normal range, low-normal functioning is
  associated with previous chemotherapy treatment
• There is new evidence that supports the theory
  that carriers of the e4 allele of apoliprotein
  are at greater risk for reduced
  neuropsychological performance when coupled with
  chemo treatment, their risk substantially
  increases for cognitive dysfunction

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Neurological complications of chemotherapy

• Acute encephalopathy (begins with insomnia,
  rapidly followed by a state of confusion
  associated with agitation
• Stroke-like episodes (characterized by acute
  onset of encephalopathy with fluctuating motor
  deficit)
• Chronic encephalopathy develops progressively
  for months to years after treatment

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Neurological Complications of radiation

• Acute encephalopathy (headache, nausea,
  drowsiness, fever)
• Early-delayed Complications (2 weeks-3 or 4
  months) hypersomnia, irritability, headache,
  attention deficits, memory problems
• Late-delayed complications (4 months-years)
  radiation necrosis, dementia syndrome, vision
  and/or hearing loss, lower cranial nerve
  paralysis, radiation-induced tumors

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Potential Mediators ?

• There have been some agents identified that might
  reduce cognitive impairment
• Erythropoietin
• Aspirin
• Methylphenidate (has demonstrated improvement in
  children undergoing chemo)

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What is Bone Marrow Transplantation (BMT)?

• Used to treat cancers that have not responded
  well to more standard medical interventions
• Bone marrow transplants involve the destruction
  of a patients own bone marrow via chemotherapy
  and/or radiation therapy, followed by infusion of
  new cells to generate healthy bone marrow
  function
• BMT can be classified as allogeneic or
  autologous
• Allo bone marrow is transferred from a donor
• Auto replacement marrow is harvested from the
  patient, cleaned from disease, and reinfused into
  patient

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BMT patients are at high risk for cognitive
deficits

• Most patients undergoing BMT receive chemotherapy
  or combination chemotherapy/radiation as a
  preparatory regimen prior to BMT
• Toxicity from high-dose chemotherapy combine with
  whole-body radiation puts patient at risk for
  extended hospitalization, posthospitalization
  recovery, and risk of death from the procedure
• Neurological acute complications are frequent,
  including transient drowsiness, occasional
  seizures, or severe encephalopathy delayed
  complications typically include mild/moderate
  cognitive dysfunction with cerebral atrophy.

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BMT

• Studies investigating cognitive impairment in BMT
  patients have used various methods of assessment
  including a review of medical records,
  interviews, self-reported questionnaires, and
  standardized neuropsychological testing
• Cognitive impairment has been found to persist
  for months to years following BMT

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BMT

• Several domains of cognitive functioning have
  been found to be affected, ranging in severity
  from mild to severe impairment, including memory,
  attention/concentration, language, motor, and
  executive functioning
• Most studies investigating cognitive impairment
  as a result of BMT do not include a baseline
  assessment, lack long-term follow-up assessment,
  do not include standardized neuropsychological
  protocols, and lack a measure of Quality of Life.

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• Research Shows
• More than 20 of people who receive cranial
  irradiation suffer significant CNS damage and
  neurocognitive impairment (Levin, 1999).
• Andrykowski et al., (1992) 56 of their sample
  of adult BMT candidates scored 1.5 S.Ds below
  the norm on neuropsych battery
• van Dam et al., (1998) High-dose chemotherapy
  impairs cognitive functioning more than
  standard-dose chemotherapy on breast cancer
  patients
• Significant dose escalations of opioids (gt or
  30) cause impaired psychomotor and cognitive
  functions in cancer patients (Sjogren, 1997).

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Research shows..(contd.)

• Chemotherapy and radiation therapy have a
  negative impact on cognitive functioning (Ahles,
  1998).
• In a study by Pereira et al. (1997), 44 of
  terminal cancer patients had prevalent cognitive
  impairment upon admission to a palliative care
  unit. Just prior to death, 62.1 of patients had
  prevalent cognitive impairment.
• Both non-small-cell lung cancer and glioma
  patients suffer from a number of
  condition-specific neurologic and
  neuropsychologic problems that have a significant
  impact on their daily lives.

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In Conclusion

• As cancer treatments become more efficacious, the
  greater consideration needs to be given to choose
  a treatment modality that might minimize risk for
  cognitive dysfunction
• Family members are a critical component of
  follow-up treatment for cancer patients/survivors
  cognitive deficits are often more apparent to
  others rather than the patient themselves.
  Family members should track the nature and
  frequency of notable deficits

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Critical Issues

• Where is the literature concerning cognitive
  impairments in other cancer populations?
• Since normal cognitive functioning is critical
  for intellectual and academic development,
  occupational achievement, development and
  maintenance of social relationships, and
  appropriate self-care, why werent QoL measures
  included in all of the studies conducted?
• If certain meds and treatments are correlated
  with cognitive impairments even prior to surgical
  procedures, how well informed are patients
  regarding their consent?
• If tamoxifen is used in the treatment of breast
  cancer and has been shown to adversely effect
  cognition, are there other cancer populations for
  which this is prescribed?

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Thanks for your attention!
Any Questions?