There is an increasing interest in cognitive impairment in survivors, first of all because the time of survival is prolonging a lot and also in elderly patients. In fact, my topic was particularly in elderly patients. Unfortunately, this type of symptom related to cognitive impairment are not regularly assessed in clinical practice as it’s likely to assess pain, for example, fatigue, anxiety, depression. This is one of the problems because these kinds of symptoms are underestimated in general in cancer patients and particularly in elderly cancer patients.
Most patients may have cognitive impairment during anti-cancer treatment – chemotherapy, hormone therapy – but also patients at the moment of diagnosis, without previous anti-cancer treatments, may have cognitive impairment. So this is a particularly important topic now and for the next future because we are expecting that increased survival will be very high in the next future.
Cognitive impairment is detected by clinical evaluation, first of all, and listening to the patients and speaking with the patients about the possibility to develop these kinds of symptoms during treatment. Then we have some instrument like the mini-mental status examination that are not conclusive to do a diagnosis because some patients have to be admitted to neuropsychological testing, a battery of neuropsychological tests, to have a good assessment of the cognitive impairment and also to monitor this quantity and this type of cognitive impairment during the trajectory of cancer treatment.
We hope that in the next future that there is a change in the attitude of oncologists and also of the primary care physicians regarding the assessment of these symptoms, the evaluation of these symptoms and also the consideration of aging as a possible risk factor and the frailty of the patients as another possible risk factor for worsening of the cognitive impairments.
How should oncologists treat situations involving cognitive decline?
They have to recognise and ask the patients and also to the relatives, to the caregivers, what is happening regarding the memory, for example, regarding the concentration. In the same way we assess pain, fatigue, we assess sleeping disorder, we have also to assess these kinds of problem cognitive symptoms. Then we have to tailor the pharmacological treatment, the oncological treatment, according to this kind of problem. So we can’t be very aggressive with many therapies while the patients have this kind of problem, cognitive impairment. Also in survival we have to recognise that some kinds of cognitive impairments can be recognised 10-20 years after the end of treatment. So survivorship is very important and there is a new model of follow-up of the patients in the oncological setting. I believe that the future is onco-geriatrics because we need absolutely in the oncological setting the presence of a geriatrician with training in oncology to better assess the patients before treatment but also before surgery. Also at the moment of diagnosis, the distress that this kind of communication can provoke in patients, then to continue monitoring the patients during treatment and during survivorship.
How would you advise clinicians to take this into practice?
First of all they have to speak to the patients and speak regarding the possibility of a toxic effect on cognition of the anti-cancer treatment. In general we speak of the possibility to have nausea and vomiting, to have fatigue, to have constipation or diarrhoea related symptoms but we don’t speak to the patients about the possibility to have cognitive impairment. So first of all speak to the patients and family and the caregivers about this possible toxic effect of treatment. Then evaluate it over time because it’s not easy to treat it. Really we don’t have sure treatments; in particular we have no evidence at all regarding the pharmacological treatments of this cognitive impairment. We have exercise, even if there is no great evidence, but we know that exercise works very well with all kinds of patients. We have rehabilitation programmes to increase memory, to increase cognitive exercises and there are now some new programmes like insight programmes, recent programmes, that have shown to be better, much better, in respect to standard of care. It’s possible to treat also these patients by a website and not only in the hospital but also at home.