The impact on recovery

It is not possible to predict who will experience cognitive impairment after chemotherapy. Also, it would be rare indeed to find a person in addiction or cancer recovery who has not experienced symptoms of depression and anxiety to some degree. Once entering into chemotherapy treatment, however, these individuals see that their symptoms are usually exacerbated and are joined by other mental difficulties, often as a result of the medications used in the chemotherapy—of which there are currently nine groupings of more than 360 drugs.

For example, men who undergo prostate cancer treatment with hormonal medications to reduce the testosterone that cancer cells thrive on often receive Lupron, a medication with several side effects associated with long-term use (including anxiety, delusions, depression, and extreme changes in mood). In general, the Physician's Desk Reference (PDR) information on the various chemicals given in chemotherapy generally concentrates on physical side effects as opposed to possible neurological effects.

Juan Hernandez, a licensed professional counselor in Texas with 16 years of experience in the hospice counseling arena, has met with hundreds of patients having undergone chemotherapy. Having seen the symptomology previous listed, he also relates that many people act out of character, as if undergoing a personality change. He finds that patients often become suspicious about their spouses and others in their lives as part of a delusional thought process. Not only is the abuse of prescription medication more frequent with these individuals, there is also a higher risk of consuming alcohol and/or illicit drugs, he says.

Of course, the survival benefits of chemotherapy far outweigh the potential risks to cognitive functioning and other mental difficulties for most patients. But unfortunately, many of these memory and cognitive problems also can persist for years after treatment has been concluded.4

Christina Meyers, PhD, chief of neuropsychology services at the M.D. Anderson Cancer Center in Houston, relates that “in these cases, individuals may be embarrassed and even ashamed—feeling they should be thankful that their battle with cancer is over, instead of being distressed by a ‘memory problem’ in the context of an otherwise successful outcome.” She adds, “Unfortunately, cognitive symptoms can lead to emotional distress and impede a patient's ability to successfully meet scholastic, vocational, and social goals.” These cognitive deficits can affect a patient's ability to make informed treatment decisions.

Research also concludes that the constellation of deficits as a phenomenon is assuming greater significance as cancer survival rates improve.5 Ordinary doses of chemotherapy sometimes appear to dull survivors' intellectual abilities over the long term, leaving them with poor memories and muddy thinking. While these individuals typically have been reassured that these problems will go away, little attempt has been made until recently to see if these issues linger years later.

The effects of this can be very traumatic to the individual. Acting “out of character,” for example, can affect family members, friends, and colleagues, who not only do not understand what is going on but also do not know what they can or should do. Individuals in addiction recovery are particularly at risk, as symptoms might appear as “blackouts.” Some individuals reacting to the symptoms of a person experiencing adverse effects of chemotherapy might believe that the individual has relapsed, because similar behaviors occurred when the person was actively engaged in drinking or drug use.

When the symptoms are severe, the person usually relies on family, friends, and colleagues for empathetic understanding and support. Unfortunately, this might often be seen erroneously as attention-seeking behavior, and that can lead to grave misunderstandings and even abandoning the person. This not only exacerbates the individual's symptoms but can create further psychological trauma.

Treatment professionals' role

Addiction professionals often do not understand “chemo brain.” The closest co-existing diagnostic findings they can make, if they are aware of the person's cancer treatment history, are “a mental disorder due to a general medical condition” as given in the Diagnostic and Statistical Manual of Mental Disorders, or a “substance-induced disorder.” They might end up arranging for the prescription of psychotropic medications that might not be beneficial and safe for the person in addiction recovery. Clinicians, regardless of specialization, are encouraged to consider the possibility of chemo brain in order to prioritize the delivery of rehabilitative strategies in an effort to mitigate or reverse its features.

Addiction professionals can and should be involved along with neuropsychologists in assessment of problems relative to brain function, and develop with the patient strategies toward memory recovery and improvement, such as memory aids and the strengthening of cognitive skills. Counselors also can assist the patient in working through emotional distress.

Interventions to help alleviate the symptoms of chemo brain could include nonpharmacologic treatment such as antioxidants and cognitive-behavioral therapy. As individuals in cancer treatment are being infused with various chemical substances, and might temporarily require medications for pain, appetite enhancement, etc., addiction professionals must be cautious in recommending total abstinence from prescribed chemical substances. At the same time, a detailed understanding of the mechanisms that cause chemo brain as well as a comprehension of what specific cognitive domains are affected is crucial in developing more specific treatments to improve patients' cognitive functioning and overall quality of life.

Counselors and others performing substance abuse evaluations and assessments should include questions such as: Have you ever had cancer? Have you received chemotherapy as a treatment? If so, how long ago and how many treatments? What symptoms did you have during your chemotherapy? Have there been any persistent symptoms since your treatment? When a patient presents with cognitive complaints, the problems can be evaluated for intervention when an overall understanding exists of chemotherapy-related cognitive changes based on a conceptual model that continues to be informed through well-conceptualized and well-designed research.

For the individual undergoing chemotherapy at the time of treatment for addiction, it is imperative that the addiction professional know which drugs the client is being given in order to understand and treat symptoms that might overlap during addiction recovery.

Addiction professionals are trained to help individuals cope with the emotional impact of alcohol and other chemicals of abuse. Much of the training and experience associated with the addiction field might also be applied to the many types of problems associated with chemo brain, allowing professionals to work with the individual in developing a plan to address the various difficulties. Treatment methods that have been used adjunctively in addiction recovery for many years also may be effective in the treatment of chemo brain. These include hypnosis; progressive muscle relaxation training and imagery; systematic desensitization, attention diversion or redirection; and biofeedback.

Case example

“John” is a married 67-year-old white male with nearly 40 years of sobriety. He developed prostate cancer at age 56 and began treatment with radiation and hormone injections. After 33 radiation treatments, he was declared cancer-free, but within one month the cancer returned. He was referred to a major cancer hospital and continued on hormone therapy and other infused and oral cancer medications. The extreme nausea, fatigue, and other symptoms from his treatment caused him to retire from his employment.

His cancer began to metastasize and he underwent surgery in 2006, with partial removal of the prostate. Although often experiencing pain, John refused to take prescribed pain medications because of susceptibility to relapse of his alcoholism. In 2007 his cancer had metastasized to his bladder, and he had major surgery that included bladder removal. From the onset of his treatment he began experiencing the physical symptoms of radiation and chemotherapy. After the second year in treatment he began developing mental symptoms, beginning with depression, anxiety, and memory problems. He also felt loneliness and abandonment from family members, friends, and colleagues, and was beginning to have thoughts about returning to drinking. He sought counseling at that time.

While in counseling, John was provided a treatment plan comprising various strategies to improve memory, attention, and general cognitive functioning, such as organizing and structuring daily activities, using mnemonics to help remember lists, and using repetition. He also was provided stress management training in the forms of meditation, imagery, and relaxation therapies. He maintained appointments with his psychiatrist for treatment of his anxiety and depression, a nutritionist for dietary concerns, his physician for pain management, and oncologists for continued cancer treatment. In addition to his addiction recovery groups, he joined a cancer survivor's support group and participated in online chat rooms with other cancer survivors.

John was very responsive to counseling, and followed through with his treatment strategies. Although still having problems with his cognitive abilities, he has managed to compensate extremely well. Much of his memory has returned, and he relates to feeling comfortable about his drastic body changes and the management of his anxiety and depression. His family also has developed its understanding of the problems brought about by his cancer treatment, and has become more empathetic toward him.

Conclusion

It is crucial for cancer survivors, providers, and families to know that steps can be taken to manage adverse cognitive and emotional symptoms. The first step involves understanding how and why the symptoms have developed so that appropriate management strategies can be implemented.

Above all, family members, friends, colleagues, and others need to be empathetic toward the person exhibiting symptomology of the chemo brain syndrome—being patient, tolerant, and nonjudgmental is most crucial in the re-establishment of the person's characteristic behavior. For individuals in addiction recovery, wherein it is imperative that they continue their individual regimens of recovery, the effort to work through chemo brain issues is much more difficult, requiring added effort on the part of others as well.