Fatigue, Chemo Brain and Other Cancer Symptoms

Cancer and its treatments can bring with it a number of side effects — from depression and fatigue to the infamous “chemo brain.” As more patients are continuing to live longer after their treatment, it is becoming apparent that these effects can last well into survivorship.

Matthew Carlson, M.D., an assistant professor at UT Southwestern Medical Center, recently sat down with OncLive, a sister publication of CURE, to discuss the long-term effects that chemotherapy and other cancer treatments can have on individuals.

Let's talk about depression. What can health care providers do better manage this?

Carlson: I think it's important having a high index of suspicion. The NCCN guidelines recommend screening patients who are in surveillance for depression. So, you should ask them, "In more days than not, have you had low mood or trouble sleeping or basic depressive symptoms?" And those simple screening questions can then prompt us to dig a little deeper and hopefully help the patient with the depression, because that can have long-term effects as well.

Do you feel that this is being done often enough?

The answer to that is unfortunately probably not. We probably don't screen just because we see the surveillance patient, we ask them how they're doing, and unless they bring it up, at least for me personally, I don't do it as often as I should, I'll admit. But it's something that I've paid more attention to, and we've considered adding some screening questionnaires to our practice.

Another common long-term effect is fatigue. Can you discuss some strategies to handle this?

Fatigue is common in post-menopausal women, it is common in patients who have cancer and in patients who had chemotherapy. It's also common in patients with heart and thyroid disease and anemia, and all sorts of other things.

When a patient complains of fatigue, we have to dig a little bit and get to the root of what's causing that because it may not just be from the chemotherapy. It may be from thyroid disease or depression or poor sleep and diet. It may be from any number of things that we can actually fix. That's why this is an important side effect to pay attention to.

Now, if we rule out all those other things, there are some medications we could use to help with giving them a little bit more pep. That's actually something like methylphenidate, which they use for kids with ADD, but it really does give patients a lot more energy. There are some other less-proven things, like American ginseng, that actually has some good data behind it, but it's not approved [by the Food and Drug Administration (FDA)] or regulated by the FDA.

In terms of neuro-cognitive dysfunction, is there any research about the benefit of cognitive behavioral therapy?

Neuro-cognitive dysfunction, or chemo brain, is a little bit difficult to figure out. The assessment tools don't always correlate well with what the patients complain of. Cognitive behavioral therapy can help patients with their quality of life, but the studies don't really pan out as well as far as the objective measurements. But in my estimation, if the patient is happier and feels that her quality of life has improved, then I'm happy.

You also mentioned peripheral neuropathy. What is currently being done in this space?

That's a big one. We use a lot of taxanes in our treatments, and one of the things that we very commonly see during treatment is peripheral neuropathy. In a good proportion of patients, it doesn't go away. Unfortunately, there are a lot of small studies or retrospective studies on a whole host of different treatments or preventative measures to try to either reduce those symptoms after the fact or to prevent them altogether. Unfortunately, we haven't found anything that really pans out.

In our practice, we are very fortunate to have a physical medicine and rehabilitation physician. That's her focus. So, we're able to send a lot of patients to her, and in talking to her, she oftentimes will recommend some specific physical therapy exercise and refer them to a physical therapist. There is some data to show that it improves the outcomes — it decreases the falls and increases patients' quality of life on survey scores. Anecdotally, I've seen patients leave pretty happy, but for some patients it doesn't work quite as well.

What are the glaring challenges here in terms of symptom management?

It's a chronic thing. It's very bothersome to have constant pins and needles in your hands and feet. There's even numbness, where patients can have trouble doing activities of daily living, such as fastening buttons or putting in earrings and things of that nature. That really becomes somewhat bothersome, and it can even become dangerous if they have a lot of numbness in their feet and don't feel the ground under their feet and then are subject to fall.

It is a big issue and, unfortunately, not a lot is being done. I think they are actively looking at different agents to decrease the risk — things that we can give during chemotherapy to reduce the incidence of that during chemo, and therefore would very likely decrease it after as a long-term side effect. But progress has been slow.