Early intervention key to mitigate neurocognitive effects of pediatric cancer treatment

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Cancer in children

September 21, 2021

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Healio interviews

disclosures:
Krull and Walsh report no relevant financial disclosures.

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As cancer treatment options continue to improve, the growing number of childhood cancer survivors will require individualized strategies and risk assessment to help prevent and control neurocognitive late effects.

Estimates have shown that about a third of all cancer survivors and about 40% or more of brain tumor survivors experience neurocognitive impairment caused by both the disease and its treatments.

Healio spoke to experts in pediatric neuropsychology about best practices to prevent, monitor and address neurocognitive late effects in people undergoing treatment for cancer, following up on our article on the prevalence and assessment of such effects in survivors of cancer. childhood cancer.

Consequence

Neurocognitive impairment, especially when it develops during childhood, can limit educational attainment, including failing to attend college or graduate; may reduce employability to unemployment or lower income occupations; and may limit access to insurance due to complications, according to Kevin R. Krull, PhD, faculty member and endowed chair in cancer survival in the departments of epidemiology and cancer control and psychology at St. Jude Children’s Research Hospital.

“Neurocognitive disorders can also increase the risk of health complications,” Krull told Healio in an interview. “Many individuals with disabilities have difficulties with memory, planning, organization and time management, all of which can affect dietary choices and exercise schedules, and interfere with the ability to adhere to medical screening recommendations or medication schedules.”

Krull went on to say that this impact on health behaviors and health care utilization may, in turn, further exacerbate neurocognitive impairment.

“Neurocognitive impairment has also been shown to disrupt social interactions, including finding a life partner, and make it more difficult to keep up with the rapid information-processing pace of group interactions,” he said. “One of the biggest concerns I have about neurocognitive disorders is the interference with the ability to develop an independent lifestyle. If an adult survivor of childhood cancer cannot live independently and remains dependent on the support of their parents, what happens if they outlive their parents or their parents’ ability to live independently?”

Detect early signs

To prevent or reduce neurocognitive decline in childhood cancer survivors, assessment of an individual patient’s risk and ongoing monitoring are critical.

Early predictions include considering the characteristics of the disease — especially if the cancer is affecting the brain or treatments have targeted the central nervous system — along with age at diagnosis.

Karin S. Walsh, PsyD, pediatric neuropsychologist in the pediatric neuropsychology department at the Children’s National Hospital, said it is helpful to think about these cases with a “biopsychosocial model,” combining the biology of the tumor itself, the interventions used for treatment, and the environmental factors. affect the development of survivors, such as a family’s access to resources and socioeconomic status.

“We take each case with the knowledge that there is a certain level of risk associated with these factors,” Walsh told Healio. “Younger children, especially those diagnosed under 5 years of age, are a higher risk group. It doesn’t mean every case will look the same, but it does mean we’re paying more attention to it.”

Walsh added that some factors cannot be fully predicted, such as genetics and cognitive reserve.

“It’s very important to assess each child individually, despite the fact that we have some general guidelines for what might put one child at higher risk than others,” she said.

Comorbidity is another factor to keep in mind, Krull said, because children who develop serious infections, who require numerous procedures under anesthesia, or who experience side effects such as seizures or strokes during cancer therapy often have worse outcomes.

Patients should also be monitored continuously so that any early signs of neurocognitive effects can be detected earlier, when intervention may be more effective.

“In terms of individual detection, neuropsychological testing can provide the first signs of

neurocognitive impairment prior to the end of cancer therapy,” said Krull. “These include slowed processing speed and variable attention. These initial problems predate academic difficulties and often evolve into problems with memory, learning, and more complex skills such as planning. In general The following applies: the earlier the intervention, the better the result.”

Customized treatment

Many researchers are beginning to explore ways to prevent neurocognitive impairment by adjusting cancer treatment regimens, Krull said.

“This starts with the oncologists now focusing on lowering treatment intensity to improve outcome while maintaining high survival rates,” he said.

A report from Nicholas S Phillips, MD, PhD, and colleagues, published this year in the Journal of Clinical Oncology as part of a special issue on neurocognitive outcomes in childhood cancer survivors, reviewed the growing body of evidence showing that both traditional cancer treatments and emerging therapies reduce the risk of cancer-related neurocognitive disorders, including neurotoxicity observed when using immunotherapy, adoptive cell therapy and immune checkpoint inhibitors.

“There are active efforts to use drugs that reduce oxidative stress during cancer therapy to limit damage to healthy brain cells, although these are still somewhat experimental,” Krull said.

Continuing Care

Because it is difficult to determine if and when a childhood cancer survivor may show signs of neurocognitive decline, prevention is as much about limiting the damage done during treatment as it is about continuing best health practices.

“I cannot emphasize the importance of health behaviors enough,” Krull said.

In cases where a child is at risk or at risk of neurocognitive impairment, Krull said the best advice was to quickly involve them in long-term cognitive stimulation and physical enrichment, including to:

provide age-appropriate learning and enrichment (e.g. reading, art, music); maintaining a healthy diet and a healthy body weight; get regular exercise (both aerobic and resistance training); limit screen time and other sedentary behaviors; ensure good sleep hygiene; and continuing to engage in age-related social interactions with positive peers and role models.

“These actions will help all children, but are essential for children who will become cancer survivors,” he said. “Survivors of childhood cancer and cancer therapy have lower physiological and brain reserves, and they will be affected to a greater extent by these health habits. Therefore, it is essential for survivors to develop and maintain a healthy lifestyle.”

Krull also noted that long-term childhood cancer survivors are at increased risk for chronic health problems, including cardiac, respiratory, neurological and endocrine morbidity. It’s equally important to detect and treat these morbidities early to prevent their progression and limit their negative impact on typical development and aging, he said.

Best practices for these children include monitoring them from treatment through young adulthood, Walsh said.

“Having healthcare teams that include neuropsychology is something that has a very positive impact on the patients and their families,” she said. “That team approach can help with monitoring because different levels of assessment are needed. There are levels of monitoring, some of which are in the clinic with the physician and others that require a comprehensive neuropsychological assessment with a neuropsychologist. In this way we can work together with our physician colleagues to make their work easier and improve the care for these children.”

References:

For more information:

Kevin R. Krull, PhD, can be reached at kevin.krull@stjude.org.

Karin S. Walsh, PsyD, can be reached at kwalsh@childrensnational.org.

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