Up to 75% of people with cancer experience cognitive problems during treatment, and up to 35%

have issues that continue for months after treatment has finished. These difficulties usually vary in
severity and often make it hard to complete daily activities. People who experience serious cognitive
problems are encouraged to talk with their doctor, nurse, social worker, or another member of the
health care team about ways to manage these issues.

Signs and Symptoms

Relieving side effects, also called symptom management, palliative care, or supportive care,
is an important part of cancer care and treatment. Talk with your health care team about any
symptoms you or the person you are caring for experiences, including any new symptoms or
a change in symptoms.
Cognitive problems include difficulties in many areas, such as:

Trouble concentrating, focusing, or paying attention (short attention span)

Mental fog or disorientation
Difficulty with spatial orientation
Memory loss or difficulty remembering things (especially details like names, dates, or
phone numbers)
Problems with comprehension or understanding
Difficulties with judgment and reasoning
Impaired arithmetic, organizational, and language skills (such as not being able to
organize thoughts, find the right word, or balance a checkbook)
Problems performing multiple tasks (multitasking)
Processing information slower
Behavioral and emotional changes, such as irrational behavior, mood swings,
inappropriate anger or crying, and socially inappropriate behavior
Severe confusion (delirium)

The severity of these symptoms often depends on the persons age, stress level, history of
depression or anxiety, coping abilities, and access to emotional and psychological resources.
Causes
Although cancer survivors commonly use the term chemo brain to describe difficulty
thinking clearly after cancer treatment, people who do not receive chemotherapy report
similar symptoms. Continuing research into the wide range of cognitive problems
experienced by people with cancer has shown they can be caused by a number of factors in
addition to chemotherapy, including:

Radiation treatment to the head and neck, or total body irradiation

Brain surgery, in which areas of the brain may be damaged or disrupted during a
biopsy or the removal of a cancerous tumor
Hormone therapy, immunotherapy, and other medications (such as anti-nausea
medications, antibiotics, pain medications, immunosuppressants, antidepressants,
anti-anxiety medications, heart medications, and medications to treat sleep disorders)
Infections, especially those of the central nervous system (brain and spinal cord), and
infections that cause a high fever

Brain cancer
Other cancers that have metastasized (spread) to the brain
Other conditions or symptoms related to cancer or cancer treatments, including
anemia, sleep problems, fatigue, hypercalcemia (high blood calcium), and electrolyte
(a mineral in your body, such as potassium and sodium) imbalances that can lead to
dehydration or organ failure
Emotional responses, such as stress, anxiety, or depression
Not having enough of specific vitamins and minerals, such as iron, vitamin B, or folic
acid
Other brain or nervous system disorders unrelated to cancer

Management
Cognitive problems caused by a reversible condition, such as anemia or an electrolyte
imbalance, usually resolve after the condition is treated. Likewise, problems caused by a
medication should go away after the medication is stopped. Problems related to cancer in the
brain usually improve with treatment, but some symptoms may continue. Unfortunately,
cognitive problems related to chemotherapy (chemo brain), radiation therapy, or other
cancer treatments may continue indefinitely. Management of these long-term cognitive
problems may include:

Medications, including stimulants, cognition-enhancing drugs commonly used to treat

Alzheimer's disease, antidepressants, and opiate antagonists (drugs that block the
actions of narcotics, such as morphine)
Occupational therapy and vocational rehabilitation, to help people with the activities
of daily living and job-related skills
Cognitive rehabilitation (also known as neuropsychological rehabilitation) and
cognitive training, to help patients improve their cognitive skills and find ways to
cope with cognitive problems

Strategies for coping with cognitive problems

The following strategies may help you better cope with attention, thinking, and memory
difficulties and help keep you mentally sharp:

Keep a log or checklist of daily reminders. Put it in a convenient location, where you
can look at it frequently throughout your day. If necessary, keep a duplicate copy at
work.
Take on one task at a time and avoid distractions.
Carry around a small pad and a pen or pencil to easily write down notes and
reminders. There are also a number of note-making apps available for most
smartphones and tablets.
Use a calendar or daily organizer to keep track of upcoming appointments, activities,
and important dates.
Place post-it notes around the house and workplace to remind you of important tasks.
You may also want to set reminders using your phone or email calendar.
Use word play, such as rhyming, to help you remember things.
Get plenty of rest.

Make time for physical activity, as it can increase mental alertness. Try walking,
swimming, or gardening. Yoga or meditation can also help you relax and regain some
mental clarity.
Exercise your brain by doing brain-strengthening mental activities, such as solving
crosswords or puzzles, painting, playing a musical instrument, or learning a new
hobby.
Dont be afraid to ask questions at your doctors appointments, even if you feel like
you are repeating yourself. Then keep track of the important facts you discuss with
your doctor using a special notebook, a voice recorder, or a resource from Cancer.Net,
such as the Cancer.Net mobile app or an ASCO Answers guide. If it is too
overwhelming, ask a friend or family member to go to the appointment with you so he
or she can take notes and review them with you after the visit.
Talk with your employer if you are having problems at work. Discuss potential ways
your employer could support you, such as modifying your workload and deadlines.
Read more about going back to work after cancer.
Prepare for the next day by setting out the things you will need the night before.
Color code or label certain cabinets or drawers where you store things around your
home.
Put things, such as car keys, back in their designated place after you use them so they
will be easy to find the next time you need them.
Eliminate clutter.
Make sure important phone numbers are stored in your cell phone or are visibly
displayed next to your home phone. You may also want to carry a small address book
in case you forget to bring your cell phone when you go out.

For years cancer survivors have worried

about, joked about, and been frustrated by
the mental cloudiness they sometimes notice
before, during, and after cancer treatment.
Even though its exact cause isnt always
known, this mental fog is commonly called
chemo brain. Patients have been aware of
chemo brain for some time, but only
recently have studies been done that could
help to explain it. Research shows that some
cancer drugs can cause certain kinds of
changes in the brain. But it also shows that

chemo and radiation arent the only things

that can cause thinking and memory
problems in people with cancer. What is chemo
brain?
Here are just a few examples of what patients call chemo brain:

Forgetting things that they usually have no trouble recalling (memory lapses)
Trouble concentrating (they cant focus on what theyre doing, have a short attention span,
may space out)
Trouble remembering details like names, dates, and sometimes larger events
Trouble multi-tasking, like answering the phone while cooking, without losing track of one
task (they are less able to do more than one thing at a time)
Taking longer to finish things (disorganized, slower thinking and processing)
Trouble remembering common words (unable to find the right words to finish a sentence)

Doctors and researchers call chemo brain mild cognitive impairment. Most define it as being unable
to remember certain things and having trouble finishing tasks or learning new skills. But some doctors
call it chemo brain only if it doesnt go away or get better over time. How long it lasts is a major
factor in how much it affects a persons life.
For most people, brain effects happen quickly and only last a short time. Others have long-term
mental changes. Usually the changes that patients notice are very subtle, and others around them may
not even notice any changes at all. Still, the people who are having problems are well aware of the
differences in their thinking. Many people dont tell their cancer care team about this problem until it
affects their everyday life.
One study even noted that changes like this are reported by people with cancer who didnt get
chemo. This may mean the tests used in the study werent sensitive enough to pick up smaller
changes. It also suggests that something other than chemo might have caused the problems. Still,
chemo is one of the causes of brain problems in some people with cancer. Many of these people
have brain function problems that are directly related to cancer or its treatment, and most of these
problems do show up on testing.
Beyond the chemo brain symptoms that start during and just after treatment, it is clear that there
are some cases where brain symptoms start and even get worse after treatment is over. Many
cancer treatments, including certain kinds of chemo and radiation, can cause short-term, long-term,
and delayed problems.
Differences in how chemo brain is defined can also make it hard to get a handle on how often it
happens. There is a wide range of estimates of how many people get chemo brain. One expert noted
that, among people who get chemo, between 15% and 70% have brain problems. Another expert
put the upper limit of the range at 50%. So based on these numbers, the risk of chemo brain (for
people who get chemo) can be higher than 1 out of 2 or as low as 1 in 6. This may not take into
account people with brain or thinking problems that may be caused by their cancer, radiation, or
other causes.
Studies suggest that there may be more than one cause of chemo brain, especially for the short-term
symptoms. Some people with cancer have very real brain problems even though they have not had

chemo. Still others notice problems when getting hormone treatments, such as estrogen blockers or
androgen deprivation therapy (treatments to lower testosterone levels). For some, problems start after
surgery. Along with chemo, many different problems can worsen brain function.
For instance, brain problems could be caused or worsened by any one or any combination of these
factors:

The cancer itself

Other drugs used as part of treatment (such as steroids, anti-nausea, drugs used for surgery, or
pain medicines)
Low blood counts
Sleep problems
Infection
Tiredness (fatigue)
Hormone changes or hormone treatments
Other illnesses, such as diabetes or high blood pressure
Nutritional deficiencies
Patient age
Depression
Stress, anxiety, or other emotional pressure

Most of these cause short-term problems, and get better as the underlying problem is treated or goes
away. A few, such as depression, can cause long-lasting brain problems unless the cause is treated.
So far, there is no known way to prevent chemo brain. For some people, treating their cancer will
mean trouble with thinking, memory, planning, and word finding.
In some studies, these problems were more common in those who got high-dose chemo (such as
chemo used for stem cell or bone marrow transplant). But a 2009 study of people who were tested
before stem cell transplant noted that some problems had started before the transplant was done,
and that memory greatly improved over the next 18 months. At that time some still had trouble with
slower reaction times and fine muscle coordination, but other functions were better. In another
series of studies, brain problems that were present 2 years after treatment were much better 4
years after treatment.
A 2011 study looked at patients who had a stem cell transplant from another person, which involves
both high-dose chemo and immune-suppressing drugs. The researchers tested these patients early then
observed them for 5 years after the transplant. Although their thinking problems had improved after a
year, more than 40% still had mild brain problems after 5 years. The patients had improved in all
other areas tested, but they were still somewhat low on hand speed and dexterity as well as word
recall.
Pictures of the brain have shown lower resting brain activity in breast cancer survivors treated with
chemo when compared with those who were not treated with chemo. These changes were still seen on
scans of some women 5 to 10 years after treatment stopped. And during memory testing, these women
had to call on and use larger areas of their brains than women who had not gotten chemo.
Its not all related to chemo and radiation, though. A small 2012 study looked at women after breast
cancer surgery, before any other treatment was given. When tested, about 1 in 4 showed problems
with word skills and about 1 in 7 had memory issues. Although surgery, surgical drugs, or other
factors may have had some effect, the women who reported worse brain problems also reported
higher stress levels.

In people with brain problems, tests of memory usually show the person is slow to learn new things,
and they take longer to recall what they know. Response or reaction times slow down; attention and
concentration often suffer. Most often, tests find that the person with chemo brain has more trouble in
using recalled information (executive function), and in using language.
More studies are being done to try to better understand chemo brain. What is known for sure is that
brain slowdown is a real problem that affects both men and women. Most of these people will notice
that the problems get better over time. But others will have to learn ways to deal with brain problems
that dont go away.