A virtual online rehabilitation option may show promise in the detection and treatment of cognitive impairments among patients with cancer, caused by the disease or its treatments, according to Aileen Moreno, LCSW.
At Miami Cancer Institute’s Brain Fitness Lab, patients who are suspected of having cancer-related cognitive impairment (CRCI) undergo a 30-minute computerized assessment of key cognitive domains, and then receive a personalized rehabilitation training program. Patients can choose the therapeutic path that best aligns with their budget and lifestyle.
To help clinicians understand more about CRCI and what can be done about it, Moreno, neuropsychological technician, Miami Cancer Institute, Baptist Health South Florida, presented an overview of the process her organization uses to assess these impairments, the therapeutic programs they offer, and the pros and cons of those programs.
Not Just Chemobrain
Research has shown in recent years that cognitive impairments experienced by patients with cancer are not necessarily just effects from chemotherapy. “CRCI can also happen for other reasons related to a cancer diagnosis,” Moreno said during a presentation at the Association of Community Cancer Centers 35th National Oncology Conference in Phoenix. “It can relate to the cancer diagnosis itself, radiation, surgery, hormonal therapy ... or some of the newer drug therapies can also have a component of affecting someone’s cognitive function.”
Because patients may have cognitive effects from other sources, the term CRCI is replacing “chemobrain” in cancer lingo, Moreno added. CRCI can include deficits in working, episodic, remote, and verbal memory; executive function; processing speed; motor speed; visual memory; visual-spatial ability; reaction time; and attention/concentration.
Estimates vary widely, but up to 75% of patients develop CRCI during treatment, and effects vary from patient to patient, ranging from subtle to dramatic. “Approximately 35% of patients have CRCI lasting months or years after treatment ends,” she said.
Recognizing the Signs
Moreno explained how nurses and others can identify the signs and symptoms of CRCI, which are described differently by each patient. For example, she said, patients may say they can’t focus, they have a short attention span, or they “space out.” They may have trouble remembering details like people’s names, common words, or events like birthdays and anniversaries.
Patients may say they have trouble multitasking. When they are cooking and talking on the phone, for example, they can’t do both without losing track of one of the tasks. They may also say it takes longer for them to finish things. When oncology nurses are assessing or treating a patient, they should listen for such mentions that could be indicative of CRCI.
When a patient is referred to the Brain Fitness Lab, a neuropsychological technician administers a 30-minute, computer-based test called CNS Vital Signs–which is available in 60 different languages. The test assesses the key cognitive domains of memory (verbal/visual), processing (psychomotor) speed, attention (simple/complex), concentration, and executive function (mental flexibility).
The technician assists patients with instructions and reduces test performance anxiety. Results are generated immediately and interpreted by a clinical neuropsychologist. If it is determined that patients have cognitive deficits, they are scheduled for a comprehensive neuropsychological battery to confirm CRCI in accordance with International Cognition and Cancer Task Force recommendations.
A Choice of Therapies
A diagnosis of CRCI is not necessarily cause for despair in that brains can be trained, and most recently, researchers have been exploring the idea of cognitive reserve.
“Cognitive reserve refers to your brain’s ability to improvise and find alternate ways of doing things when you are faced with a challenge,” Moreno said. “Cognitive reserve is developed by your education, work, and any experiences that have challenged your brain over your lifetime. The great thing about it is that we can always do something to improve our cognitive reserve.”
The Brain Fitness Lab offers patients a choice between a traditional speech and/or occupational therapy program or a virtual cognitive training program, BrainHQ, during which the patient’s progress is monitored by a neuropsychological technician. Patients log into the BrainHQ website and undergo cognitive training and exercises helping them to regain their cognitive skills.
Whether the program is traditional or virtual, patients dedicate the same amount of time to their therapy. With the virtual program, patients must log on for 20-25 minutes a day, 4 days a week for several weeks to train the skills for which they are deficient. In a traditional setting, patients would visit with an occupational therapist or speech therapist twice a week for a longer period of time, usually for anywhere from 6-12 weeks.
Pros and Cons
Each mode of therapy has its own advantages and potential barriers, Moreno said. The virtual program is more self-directed, and therefore, patients have to be diligent about committing to the process. “With BrainHQ you really have to be disciplined to comply with doing it for enough time for several times a week for several weeks—that’s a challenge—keeping up with the protocol,” she said.
However, if a patient can’t afford the copay, or has issues with insurance, transportation, scheduling, or lifestyle constraints, then virtual cognitive therapy may be a more viable choice.
With traditional therapy, the advantage is that the patient can be motivated by the therapeutic relationship. In particular, they are held accountable for going to appointments by the presence of their therapist, Moreno said.
How do the treatments compare? Since the program is so new, no data is yet available to determine which therapeutic form is more effective. Therefore, Moreno concluded that more time is needed before assessments can be completed.
Moreno A. Detecting and treating cancer-related cognitive impairment. Presented at: Association of Community Cancer Centers 35th National Oncology Conference; October 17-19; Phoenix, AZ.