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Identifying and managing cognitive

and behavioral effects of CNS

cancers

Michael Feuerstein, PhD, MPHMiami Neuro Nursing Symposium

Baptist Health Neuroscience Center

December 1-3, 2016

The Biltmore Hotel

Coral Gables, Florida

Speaker Disclosure

There are no relevant commercial

relationships to disclose

M. Feuerstein, PhD., MPH

Learning Goals

• Major cognitive problems, clinical correlates and bio-behavioral mechanisms in prevalent CNS cancers

• Approaches used to assess cognitive problems and distress in CNS cancer survivors

• Interventions to manage cognitive problems in CNS cancer survivors

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Long term and late effects Brain Tumors

• Sensory – Hearing

– Sight

– Taste

• Fatigue

• Depression/Anxiety/Fear

• Health Behavior changes (activity, diet, weight gain, smoking)

• Work

• Financial strain

• Health seeking skills (health care literacy)

• Co-morbidity

Caregiver Concerns Brain Tumors

Cognitive Problems BT Survivors

Cognitive processing speed

Attention

Cognitive control and flexibility

Organization

Verbal learning

Working memory

Planning and foresight

Gerke, et al. J. Neurooncology, 2013

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Cog Impairment Healthy Older AdultsCNS Meds

N=2737

Biobehavioral Plausability

• Brain slower

• Brain works

harder

Clinical Assessment

• Cognitive Function – Neuropsych testing

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356068/pdf/fonc-05-00056.pdf

– Patient-Reported Outcomes (PROMISE)• https://commonfund.nih.gov/promis/index

– Cognitive challenges at work (CSC Work)• https://www.ncbi.nlm.nih.gov/pubmed/24270293

• Distress – Distress Thermometer (DT)

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585197/pdf/fonc-05-00203.pdf

• Unmet needs- Post Treatment

– Cancer Survivor Profile (CSPro)

• https://www.ncbi.nlm.nih.gov/pubmed/25820913

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Case: MF• Male, age 52

• Diagnosis: Anaplastic astrocytoma, Grade 3, rt cerebellum

• Resection, 59 gy fractioned targeted radiation, 12 months of

Temozolomide- 5 days on 25 off 12 months

• Premature aging- post neurosurgery and radiation

• -short term memory, executive functioning, info processing

• Brain MRI with contrast revealed absence of tumor activity

• Reported cognitive complains at each visit

• Referred to a speech pathologist-Boston Naming Test

• Report to neuro-oncologist-” WNL”

• Referral to PT NCI-perplexed reaction from Rehab Why?

• Problems Persisted

Neuropsychology ConsultMD Anderson 2005

1.5 yrs post tx

Results • Cognitive processing speed (sig problem)

• Mental flexibility (sig problem)

• Working memory (sig problem)

• Fine motor coordination on right (sig problem)

• Visual constructional skills/right hemispace neglect (difficulty)

• Tests that were timed or required mental manipulation (difficulty)

• Mild depression (secondary to suboptimal function)

Impression

– Results consistent with dysfunction of the ascending white matter tracts from the cerebellum to the frontal-sub cortical region

Management

– Methylphenidate, Buproprion, B6 and B12, Folic Acid, Manage Stress, Acupuncture, PDA with alarm, periodic neuropsychevaluations

Follow Up

Cognitive Neurologist: 2013

• Memory problems

• “Cerebellar cognitive-Affective Syndrome”

• Recommend • neuropsychological testing

• cog rehab

• keep mind active

• aerobic exercise

• Mediterranean diet lots of fish, no red meat

• hobbies ball room dancing, book club

• Tai chi practice

• online cog exercises/games

• For neuroplasticity to settle in human takes several- 2 years

Neuropsychologist: 2005/2015

• 2005 FU• Cognitive processing speed • Mental flexibility • Working memory • Fine motor coordination on right• Visual constructional skills/right

hemi space neglect (difficulty)• Tests that were timed or required

mental manipulation• Mild depression (secondary to

suboptimal function)

• 2015 Comprehensive• Verbal and visual memory (encoding

and retrieval)• Information processing speed• Visual-spatial processing• Verbal fluency (phonemic and

semantic • Mild depression

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“

Female Marine’s Story “Golf-ball-sized brain tumor called an astrocytoma”

Brain surgery Sept. 25, 2006. Left leg was paralyzed from the surgery. Given a walker

released from hospital after five days. Highly motivated to recover, used walker right

away upon arriving home. Walking on her own by Thanksgiving. April 2007, started

taking Temodar. Temporary Disability Retired List for five years. Was angry and

devastated . Never thought this would happen.

Eventually began seeing a counselor who helped her deal with her emotions. June 1,

2007, medically retired. Later in June, family moved back to Virginia her husband had

been transferred there. Over the next few years, received an MRI every three months.

The tumor had shrunk even more due to the radiation and chemotherapy, and while it

was still there, it was at least stable.

Pregnant with second child, husband walked out. Moved in with parents then into

her own house. Started working part-time at a bridal shop supplement her retirement

pay. Toward end of her five-year retirement, decided she wanted to come back on

active duty. Her tumor was stable, feeling healthy. March 2013, re-enlisted. Assigned

to Basic School so she could stay in the area where her family and support system

were located. Promoted to sergeant in January 2014.

Cognitive Problems

BT Survivors

Cognitive processing speed

Attention

Cognitive control and flexibility

Organization

Verbal learning

Working memory

Planning and foresight

Gerke, et al. J. Neurooncology, 2013

Typical Neuropsychological Evaluation

Brain Tumor

• Abstract Reasoning

• Memory

• Attention

• Language

• Verbal Perception

• Executive Functioning

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Cognitive Problems at Work

Ottati and Feuerstein

2013

Distress and Unmet Needs

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Intervention Options

• Symptom Management

– Pharma

– Non Pharma

• Cognitive Management

– Cog Rehab

– Pharma- assess continuously

– Compensatory strategies

– Lifestyle change

Cognitive Rehab

Back et al 2013

“Trial” of Cognitive Rehab

Back et al 2013

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Cognitive Rehab for Gliomas

Interventions

• Neuropsych training software

• Virtual reality and computer assisted cog rehab

• Computer exercises guided by neuropsychologist

• Holistic mnemonic training program

• Cognitive training, compensatory techniques, computerized homework

• Cognitive rehab, problem solving therapy, use of a memory notebook

Outcomes

• Memory, attention, visual

spatial function, language,

reasoning

• Sequential recall, verbal

recall

• Verbal and non verbal

memory

• Creativity

Bergo et al 2016

Exercise and Cognitive Function

Neuro-

Plasticity

K

o

n

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Transient PlasticityDraganski et al 2004

Work and Cancer Survivors

AccommodationsStergiou-Kita et al 2016

• 40 semi-structured interviews• cancer survivors=16

• Health/voc providers=16

• Employer=8

• Four types accommodations recommended

– Gradual return to work plans/flexible schedule

– Modification of work duties and expectations

– Retraining and supports at the workplace

– Modification of the physical work environment and/or adaptive aids/technologies

We need a new approach

• Conventional health care model

– Improve the cognitive abilities of the impaired

worker-

–“change to worker to fit the job”

• Public Health model

– Engineer the problem out of the workplace-

– “change the work to fit the person”

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Discrimination of Cognitive Demands in Breast Cancer and BT Survivors

Mathan et al., 2010, Conf Proc IEEE Eng Med Biol Soc

Detect and mitigate: Memory, Information Processing Speed, Executive Function,

Attention

Bottom Line: What does the research tell us ?

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Thank you