Sleep, diet and exercise key to preserving cognitive function during cancer survivorship
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Up to 25% of cancer survivors are affected by persistent symptoms of cognitive dysfunction.
Although this phenomenon often is referred to as “chemo brain” — due to memory or thinking problems that may arise after chemotherapy — cancer-associated cognitive dysfunction can occur after other treatments, such as radiation or hormonal deprivation. It also may be a consequence of the disease itself.
“If we look at cognition in general over our lifetimes, a number of factors make us either more resilient or more vulnerable to cognitive impairment as we get older,” Rhonna S. Shatz, DO, Bob and Sandy Heimann chair in research and education of Alzheimer’s disease, medical director of the Memory Disorders Center, and associate professor at the University of Cincinnati department of neurology, told Healio. “When someone has cancer, this is almost like an accelerant to any fire that is going on inside someone’s body.”
Shatz — who led a session on cognitive function during Cancer Center Survivorship Research Forum — helped develop University of Cincinnati Cancer Cognitive Clinic.
The clinic provides assessment, treatment and monitoring of cognitive issues for people with cancer and cancer survivors. Individuals are assessed for sleep, exercise, nutrition and social support to optimize brain function.
“We try to think of all the ways in which the individual in front of us has preexisting risk factors, and the ways in which cancer and its treatments are impacting that,” Shatz said. “Then we figure out a very comprehensive plan for how we can help this person.”
Importance of sleep
Ensuring adequate, quality sleep is particularly important for maintaining cognitive health and brain function, Shatz said.
“Sleep, it turns out, is important not just for the processing of information during the day,” she said. “There’s a stage of deep sleep in which there is an elimination of toxic materials that build up during the day.”
Inflammatory processes that occur in cancer may worsen preexisting issues and lead to a serious inflammatory response that can cause cognitive impairment, Shatz said.
“If these individuals also have issues with sleep and they can’t eliminate these excess inflammatory factors, it can cause a dip in thinking,” Shatz said. “We actually do see some cognitive changes before cancer treatment. So there’s something about the cancer itself.”
Shatz and colleagues created a registry to track information about patients seen in their clinic. The registry data showed approximately 97% of patients who visit the Cancer Cognitive Clinic have a sleep disorder.
Identifying people with undiagnosed sleep apnea is one of the clinic’s priorities, Shatz said.
Additionally, it is valuable to teach patients and survivors how to craft a healthy sleep environment, she said.
“The idea of sleep is to allow our brains to be offline — to turn to internal organization and processing,” Shatz said. “However, if we have a sleep environment where other things are happening or there are distractions, the brain feels a need to keep us awake.”
Consistency in a sleep regimen is important, Shatz said. The body works on clocks, and the sleep clock is the “master clock,” she added.
“If sleep is off, all other clocks that have to do with metabolism and immune function are off, too, and those are very important in cancer,” Shatz said. “What we really need to do is have a consistent sleep schedule. If sleep works on a clock, then all other circadian rhythms are entrained to that, and we get optimal immune function and optimal metabolism to prevent cancer recurrence.”
Diet and exercise
Cancer survivors may seek guidance on the most appropriate diet for preventing recurrence and optimizing all aspects of their health.
For cognitive function, the Cancer Cognitive Clinic recommends the Mediterranean-DASH Diet Intervention for Neurodegenerative Delay, or MIND diet.
The MIND diet contains foods rich in vitamins, carotenoids and flavonoids that are thought to decrease oxidative stress and inflammation to the brain. Berries, dark leafy greens and olive oil are the most important items, Shatz said.
“What we’ve tried to convey is the fact that in the MIND guidelines, the foods are chosen specifically for anti-inflammatory activity,” Shatz said. “We walk people through the ways in which they can meet the requirements of the MIND guidelines.”
Exercise is another important aspect of survivorship that patients and survivors may embrace as part of an overall healthy lifestyle — and as part of efforts to prevent recurrence.
As with healthy diet, regular exercise can have specific, positive impacts on cognitive function, Shatz said.
“They’ve just discovered that this muscle metabolite, a muscle breakdown that occurs during aerobic activity, crosses the blood-brain barrier and promotes memory formation,” she said. “We’ve always known that people who exercise, particularly in the morning, have improved memory all day long.”
How oncologists can help
It is important for oncologists to understand the other potential causes of cognitive impairment.
When a patient or cancer survivor presents with cognitive concerns, Shatz said she makes sure to rule out undetected or undiagnosed neurodegenerative disease.
“[We] look at age and family history, and we rely heavily on that to make predictions about neurodegenerative disease in the background,” she said. “If someone is over age 50 years with strong family history and cognitive complaints, we look for the biomarkers of degenerative disease. We’ve had a number of patients who were certain it was their letrozole, or their particular adjuvant therapy, but we found out they actually had Alzheimer’s disease.”
Although clinicians may address cognitive concerns for patients who raise the subject, it would be much more beneficial if these issues were included as part of routine cancer assessment, Shatz said.
“Although the main goal is to get rid of cancer, we also want to prepare patients for post-cancer and preserve their brain,” she said. “From a brain health perspective, we recommend baseline testing when people walk in. Look at family history for risk, and look at sleep issues, because I think that is key information for all of us.”
Shatz also emphasized new paradigms in neurodegenerative disease that she believes should be applied to cancer treatment and survivorship.
“Testing for these biomarkers should be routine — we actually could know more about how different treatments affect the brain,” she said. “It would be valuable to start using these biomarkers and measuring them, just like we measure blood counts and enzymes for other things. The advances we have made in this other arena really can inform what is going on in cancer.”
References:
- Ahles TA, et al. Annu Rev Clin Psychol. 2018;doi:10.1146/annurev-clinpsy-050817-084903.
- Shatz R. Cognitive dysfunction. Presented at: Cancer Center Survivorship Research Forum; Sept. 11-12, 2023, Stanford, California.
For more information:
Rhonna S. Shatz, DO, can be reached at University of Cincinnati, 3113 Bellevue Ave., Cincinnati, OH 45219; email: shatzra@ucmail.uc.edu.
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Shatz R. Cognitive dysfunction. Presented at: Cancer Center Survivorship Research Forum; Sept. 11-12, 2023, Stanford, California.
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