After improving pediatric cancer survival from nearly nil in the 1950s to more than 85% today, health care providers face new challenges, especially long-term cognitive deficits associated with chemotherapy.

In addition to attacking cancer cells, chemotherapy also can affect healthy cells, including those in the central nervous system. This can lead to a range of cognitive impairments, often referred to as “chemobrain” or “chemofog.”

“As the population of childhood cancer survivors continues to grow, identifying and managing long-term effects, particularly cognitive deficits, grows in importance,” said Kerry K. McGowan, M.D., pediatric hematologist/oncologist with Norton Children’s Cancer Institute, affiliated with the UofL School of Medicine.

“By adopting a multidisciplinary approach in partnership with primary care pediatricians, we can empower survivors to lead fulfilling lives beyond their cancer journey.”

Potential cognitive deficits

• Memory impairment: Difficulty with short-term memory, recalling recent events or learning new information
• Attention deficits: Challenges with focusing, maintaining attention and multitasking
• Processing speed: Slowed information processing, making it difficult to keep up with conversations or tasks
• Executive function: Impairments in planning, organizing and problem-solving

More than 60% of pediatric cancer survivors experience at least one late effect, with a third having clinically significant events, including cognitive deficits that can significantly affect quality of life, academic performance and career prospects.

“A survey of childhood cancer survivors showed that they face problems,” Dr. McGowan said. “They are at risk to have learning disabilities or require support programs in school. A lot of these survivors, just by virtue of being in the hospital for extended periods, don’t get to form the regular social and parent interactions that they would normally have, and face problems reintegrating into school,” she said.

Early identification and intervention are crucial for mitigating the impact of cognitive deficits. This requires a multidisciplinary approach, involving:

• Neuropsychological assessments: To evaluate cognitive function and identify specific areas of impairment
• Cognitive rehabilitation: To improve cognitive skills through targeted exercises and strategies
• Educational support: To provide accommodations and support in academic settings
• Psychological counseling: To address the emotional and social impact of cognitive deficits

To better address the challenges faced by pediatric cancer survivors, pediatric oncologists and others who treat these patients can pursue routine cognitive screenings for childhood cancer survivors, increased awareness among health care providers and additional research toward effective interventions for cognitive rehabilitation.

Clinical pearls: cognitive deficits in childhood cancer survivors

• Early identification is key: Integrate routine cognitive screenings into follow-up care for all childhood cancer survivors, even those who appear to be doing well. Early detection allows for timely intervention and support.
• Chemotherapy is a major culprit: While various treatments can contribute to cognitive deficits, chemotherapy, especially with high-dose methotrexate or cranial radiation, is a significant risk factor. Be particularly vigilant with survivors who received these treatments.
• “Chemobrain” is real: Don’t dismiss patient or family reports of cognitive difficulties. Acknowledge their concerns and conduct thorough assessments to identify specific impairments.
• Cognitive deficits are diverse: The presentation varies widely. Some survivors may struggle with memory, while others have difficulty with attention, processing speed or executive function. Tailor interventions to individual needs.
• Multidisciplinary care: Effective management requires a team approach. Involve neuropsychologists, educators, occupational therapists and counselors to provide comprehensive support.
• Cognitive rehabilitation: Targeted interventions, such as memory training, attention exercises and organizational strategies, can improve cognitive function and quality of life.
• School support: Work closely with schools to implement accommodations, such as extra time on tests, reduced workload and assistive technology to help survivors succeed academically.
• Psychosocial support: Cognitive deficits can impact self-esteem, social relationships and mental health. Provide counseling and support groups to address these challenges.
• Lifelong monitoring: Cognitive deficits can persist or even emerge years after treatment. Continue to monitor cognitive function throughout survivorship and adjust interventions as needed.
• Research is ongoing: Stay informed about the latest research on cognitive deficits in childhood cancer survivors. New findings may lead to improved screening, prevention, and treatment strategies.