Cognitive effects of cancer systemic therapy: implications for the care of older patients and survivors

Abstract

The number of patients with cancer who are age 65 years or older (hereinafter "older") is increasing dramatically. One obvious aspect of cancer care for this group is that they are experiencing age-related changes in multiple organ systems, including the brain, which complicates decisions about systemic therapy and assessments of survivorship outcomes. There is a consistent body of evidence from studies that use neuropsychological testing and neuroimaging that supports the existence of impairment following systemic therapy in selected cognitive domains among some older patients with cancer. Impairment in one or more cognitive domains could have important effects in the daily lives of older patients. However, an imperfect understanding of the precise biologic mechanisms underlying cognitive impairment after systemic treatment precludes development of validated methods for predicting which older patients are at risk. From what is known, risks may include lifestyle factors such as smoking, genetic predisposition, and specific comorbidities such as diabetes and cardiovascular disease. Risk also interacts with physiologic and cognitive reserve, because even at the same chronological age and with the same number of illnesses, older patients vary from having high reserve (ie, biologically younger than their age) to being frail (biologically older than their age). Surveillance for the presence of cognitive impairment is also an important component of long-term survivorship care with older patients. Increasing the workforce of cancer care providers who have geriatrics training or who are working within multidisciplinary teams that have this type of expertise would be one avenue toward integrating assessment of the cognitive effects of cancer systemic therapy into routine clinical practice.

Fig 1.

Trajectories of cognitive decline based on theories of aging and frailty phenotype. Adapted from Ahles et al.

Fig 2.

Pre- to post-treatment change in processing speed by treatment, age group, and level of cognitive reserve among patients with breast cancer (assessed by the Wide Range Achievement Test-Reading. (A) Patients with low cognitive reserve, (B) patients with high cognitive reserve. The bar heights represent post-treatment averages pooled over assessments; the error bars represent the standard error of the averages accounting for repeated measurements from the same individuals. Reprinted with permission.^,