Cancer Answers: Coping with the Effects of "Chemobrain," February 10, 2008

Dr. Evelyn Shatil, Coping with the Effects of
"Chemobrain" February 10, 2008Welcome to Yale Cancer Center Answers with Drs. Ed Chu and
Ken Miller.  I am Bruce Barber.  Dr. Chu is Deputy
Director and Chief of Medical Oncology at Yale Cancer Center and
Dr. Miller is an oncologist specializing in pain and palliative
care.  If you would like to join the discussion, you can
contact the doctors directly.  The address is canceranswers@yale.edu and
the phone number is 1-888-234-4YCC. This evening, Dr. Miller is joined by Dr. Evelyn Shatil. Dr.
Shatil is the Head of Cognitive Science for CogniFit, a company
dedicated to learning techniques to enhance the functions of the
brain.  Dr. Shatil joins us to talk about chemo brain, a term
used to describe memory lapse during and after treatment with
chemotherapy.Miller
 Evelyn, let us start out by having you tell us a little bit about
your background in cognitive research, and about CogniFit.Shatil
 I used to work as a learning disability expert at The University
of Haifa in Israel, and at that time I was interested in the
formation of longterm memories and attention processes in children.
We studied the fact that otherwise healthy and intelligent children
were not capable of successfully forming memories. They could not
acquire very basic skills such as simple arithmetic, facts or word
reading skills. Later I became interested in the retention of
memories and preservation and maintenance, and in attention and
executive processes, in the way we use them and retain them. This
has brought me to our present subject of chemo-fog and this is how
I became interested in this phenomenon.Miller
 Just go back a little bit and think about children who have
problems with learning.  Tell us a little bit more what
executive functioning means.Shatil
 Executive functioning is our ability to manage our cognitive
processes. It is almost our ability to manage our lives.  If
you want to understand it, you have to think about being able to
see what will happen.  There is a lot of prediction. For
example, you think "Okay if I want to invite this couple, are they
going to talk to this couple; whom am I going to invite?"  It
is not just, I am going to have a party on the 17th, it is being
able to look into the future and go into quite a lot of
details.  It is planning and being flexible in your
planning.  It is being able to change your original thought as
you are planning because you have identified a problem.  It is
even being able to monitor what will happen, not only as it is
happening, but in the future.  You anticipate either a problem
or you anticipate a success, and then you continue acting according
to what you anticipate.  Executive functioning is actually
going into the future.3:50into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-10-08.mp3Miller
 This sounds like a problem some young people have as students.
Tell us a little bit about what chemo-brain, or chemo-fog, is.Shatil
 Chemo-brain and chemo-fog are interchangeable terms and actually I
think they were coined by people who had undergone chemotherapy
treatment, or even just cancer treatment. It is the term they used
to describe what they were experiencing, and they came upon the
right term because it is self explanatory.  Think about a fog
in your brain, a brain that is not very clear, and doctors and
researchers have adopted the term and it has become very well known
and referred to.Miller
 Along those lines, what are the symptoms, what would make someone
say to their doctor that they have chemo-fog?Shatil
 There are a few symptoms and most of them are related to people
experiencing problems in memory or in attention.  For example,
a lot of patients report not being able to find the right word in a
conversation, especially in a spontaneous conversation.  What
I mean by spontaneous is one that has not been planned ahead like a
job interview where you may rehearse your answers, but just a
conversation where you grope for the right word.  Everyone
gropes for the right word from time to time, that is a normal
thing, but people who undergo treatment report many instances of
this kind of difficulty.  That is one instance. 
Short-term memory problems are a very common thing that patients
report.  They sit with their doctor and tell them that they
could not remember why they went into the next room.  They are
in the middle of doing something and realize they have forgotten
their pen or whatever it is they have forgotten, and go into the
next room and do not understand or do not know why they went into
the next room. Even this happens to a lot of people, but it happens
many more times.  The instances are fewer when you have not
been sick.Miller
 These are memory and word finding.  We have talked a little
bit about executive function, is that affected?Shatil
 Yes, I think it is very much affected.  It is one of the
common complaints and it is also a little bit frightening for the
person because our lives are very complex and we are always
involved with doing something that looks very simple, but we must
multitask.  We have to divide our attention among several
little tasks. For example, you could be talking on the phone and
you have to remember that you need to leave in another 2 minutes to
pick somebody up and at the same time you need to remember not to
forget to turn off whatever is cooking. Multitasking requires a lot
of divided attention and being aware of what is going on, and every
single little part of your task is important. This is why these
complaints are more frequent when a person either returns to work,
or returns to some kind of fuller functioning, because his or her
tasks become more complex and require more division of
attention.8:51into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-10-08.mp3Miller
 Do you as a scientist, or in general medicine, know what the
mechanism is?  How does chemotherapy work, or is it just the
stress of having had a cancer?Shatil
 This is the $1000 question.  Researchers have been thinking
about whether there is a cause, or a relationship; whether
chemotherapy is the cause and chemo-brain is the result.  They
have been thinking about it since 1974 when the first studies
started to come out. As people started to research the problem,
they realized that like everything else in life, there is no simple
answer.  If we have the time I will tell you what the research
today says, but as you were suggesting, cognitive decline could
occur due to a number of reasons that would have nothing to do with
chemotherapy.  For example, if you are stressed, and people
who have a very serious illness usually are stressed, or if you are
depressed, we know depression is also associated with memory
problems and cognitive problems. If you are fatigued, we know that
multiple sclerosis patients who are very fatigued also report
cognitive decline.  If you have hormone fluctuation, some
women after chemotherapy suddenly go unexpectedly into earlier
menopause and the hormone mechanism changes which may affect your
cognition and you ability to remember and manage your
thinking.  There are many, many possible factors.  It is
very hard for researchers to say today whether chemotherapy is the
cause, although the latest studies do point to chemotherapy as one
of the possible causes.  Also, we must mention that not
everybody is affected by cognitive decline or cognitive
problems.Miller
 We would like to remind you, our listening audience, that if you
have questions or things you would like to share, you can e-mail us
at www.canceranswers@yale.edu
or call 1-888-234-4YCC.Miller
 Welcome back to Yale Cancer Center Answers.  This is Dr. Ken
Miller and I am very happy and privileged to be here with Dr.
Evelyn Shatil who is from Israel and is a researcher doing work on
chemo-brain and what she refers to as cognitive rehab. Evelyn, are
there certain groups of people being treated for cancer who seem to
be more likely to have problems?12:58into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-10-08.mp3Shatil
 There are certain groups that report more problems.  We are
not sure that they are the people who have more problems
though.  For example, most of the problems were reported by
women who had had breast cancer and were reporting problems to
their doctors in large numbers, but if we think about what research
is telling us, I am not aware of groups of people such as more
women than men.  I've been to conferences where men stood up
and told the audience about their problems and women didn't. The
latest research tells us about a connection between the intensity
of chemotherapy and the strength of the cognitive impairment, and
between the duration of chemotherapy and the worsening of cognitive
impairment.  There was an important Dutch study done. 
What we know is that higher doses of medication will cause the fog
to be more severe.  We also know that people who have had
several cycles of chemotherapy do not test as well on cognitive
neuropsychological tests as people who have had fewer cycles. Our
study is to that effect.Miller
 What is the natural history?  Do most people improve?Shatil
 It is quite optimistic because as time passes people report fewer
and fewer problems.  Sometimes, they report problems that are
very subtle. When we use our own batteries they may have
limitations because our batteries were originally designed for
other purposes. Normal people may actually experience a decline,
which the battery is not capable of capturing, but the person is
actually experiencing a subtle deterioration and it is accented
enough that the person knows and realizes that functioning is not
as it used to be. We also know that the drugs, I think they are
called "CMF," that were used for breast cancer in the past were
more conductive to deterioration than the drugs that are used
today.  This is very good news, but still the number of
complaints is not decreasing.  Our studies used to
consistently report that 10% to 30% of patients would report
problems and score low on neuropsychological. Some studies now are
going as high as 45%.Miller
 I want to move on to a very important topic in your field which is
in a sense helping people sort of restore their functioning. 
What can we do for people?Shatil
 I personally believe in an integrated view of life.  As we
were saying before, anything that will help a person feel less
depressed, more relaxed or happier is good. It is not a
recipe-giving thing.  We know that some people love to listen
to music, some people love to read, some people love to go and
visit their grandchildren.  Everyone knows what makes them
happy so perhaps it is a time for introspection and thinking about
oneself what they want to do to make themselves happier and to
recover better.  That is the first thing where the brain is
affected.  You are the doctor so you know more about drugs
than I do, but from what I know drugs are not really doing the job
for restoring memory.  We do not have the18:32into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-10-08.mp3magic drug in cognitive rehabilitation.  I believe in
cognitive training, otherwise I would not be here.Miller
 What does that mean?  What is that?Shatil
 It means that you stimulate your brain knowingly using tools that
were designed for this purpose. I want to explain the difference
between a game and a cognitive training program.  A game may
be excellent for you, it may be fun and it may make you feel very
competent because usually people go back to games they know how to
play and where they feel successful.  You might do this
unconsciously.  On the other hand, a cognitive training
program would start by evaluating your cognitive abilities. 
It would be done in a friendly way.  Knowing what your
cognitive abilities are, we would have a record of what cognitive
abilities are in very good shape and what cognitive abilities need
strengthening or reconstructing.  The program would then start
working but without a baseline, the program cannot build a tailored
regimen of training.Miller
 You are talking in a sense about a computer program that makes an
assessment and then does what with it?Shatil
 Yes, exactly.  I am talking about home-based training, you
can do it in the privacy of your home at a time which suits you.
The computer, as you say, evaluates your abilities and then there
is a very complex mathematical algorithm at work to create a link
between your results on the evaluation and the training you will
get. In our program we take great effort to make sure the person is
always in their comfort zone.  The brain has got to be
challenged, that is for sure.  If the brain is not challenged,
if there is not some effort, then the brain is not working and
those synapses are not being created.  The effort that you
will be experiencing is based on what you can do, as opposed to
other programs that are trying to catch some idyllic average that
we do not know even exists.Miller
 Does it work?Shatil
 We do not have research evidence regarding people who have
undergone chemotherapy.  We have anecdotal testimony, but this
is not research evidence.  We have people who are very happy
to have done it and have felt it has empowered them.  We have
research evidence with other populations, such as multiple
sclerosis, where people who have experienced cognitive decline due
to a traumatic brain injury have beautiful results from the studies
that are been carried out at Tel Aviv Medical Center in Israel. We
have beautiful results being published and that have been
published, but regarding the effect of chemotherapy, it is my
feeling that it is one of the most promising avenues for treatment.
It is fun, it is noninvasive, and as you do the training you say
"Oh My Goodness! I am23:03into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-10-08.mp3
 working on my word finding problem." This is clearly a very
interesting task of divided attention.  You are working on
those problems that you were telling your doctor about.  This
is a very good feeling and it makes you aware that you are becoming
self-sufficient, that you are doing something that is specifically
geared to this problem you are experiencing.Miller
 In some of the other fields where you have tested this, such as
with ageing or multiple sclerosis, are some of the benefits long
lasting?Shatil
 We do not know yet, it is a new product.  It has taken 5
years to do it in such a way that it could be scientifically based
and tested, but lots of studies have been done. We know that
programs that are not as systematic as ours, or as long term and
are not as tailored and do not give feedback, have long term
gains.  There are some programs that only test the verbal
module.  We test all the modules and they have shown long-term
results in affecting the quality of life of the people who have
been using them.  We may generalize that cognitive
rehabilitation is probably a good thing to do.Miller
 It does sound wonderful. I see many women with breast cancer who
talk about their thinking not being as clear or they are not as
quick at word finding. How wonderful it will be to be able to offer
something other than a pill or telling people to go do
crosswords.Shatil
 The program we have is called, "Back on Track" and it is a
cognitive training program that works on the very abilities that
are known to be impaired or affected after you have had cancer and
treatment with chemotherapy.  There is a lot of attention
training there and a lot of word finding.  There is a lot of
planning, predicting, shifting and inhibition which are executive
functioning measures.  The name of this program is "Back on
Track", not "Mind Fit", which is also another program we have.Miller
 The name "Back on Track" makes a lot of sense.  For people
who go through a cancer experience, it is a feeling that you are
off the track.Shatil
 Yes.Miller
 It is bringing things around again.  With all the interest in
science and different scans that can be done on the brain, in
general, when you stimulate people's brains and do work like this,
do we know what happens to the brain itself?Shatil
 What happens to the brain is interesting.  In most studies,
they have had MRI scans, and professor Altmiller at the University
of Illinois at Urbana-Champaign for example, has trained older
adults and the scans show that before training, several parts of
the brain that were usually active in the normal population, he was
training older people, were not active.26:53 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-10-08.mp3
 It was not an economical way of processing information. 
After training, there were some specific areas, which we know are
identified with that kind of processing, that were activated. He is
not the only one, there have been other studies.  That is the
main finding, that if you trick the brain into believing that he
needs that skill by telling the brain, "I need it, I am doing it",
then the brain will say, "Oh! My God, I have got to do it." So,
after you stick with it for awhile, you see those areas in your
brain have become active.  You could have fascinating
interviews here on this subject with people who are much more
expert than I am.Miller
 This has been terrific. I want to thank Dr. Evelyn Shatil, Head of
Cognitive Science for CogniFit, an organization that is looking
into rehab. Evelyn, thanks for being with us.Shatil
 Thank you very much.Miller
 I want to thank our audience for joining us.  This has been a
wonderful program.  Until next week, this is Dr. Ken Miller
from the Yale Cancer Center wishing you a safe and healthy
week.If you have questions, comments, or would like to subscribe
to our Podcast, go to www.yalecancercenter.org
where you also find transcripts of past broadcasts in written
form.  Next week, we will meet Dr. Lynn Wilson who will
discuss radiation therapy.