Chemo Brain: 15 Tips to Come Out of the Fog

Chemo Brain TipsOften when we think about side effects of cancer treatment, we think about the body. But, what about the frustrating experience of not being able to organize your grocery list or forgetting your doctor’s name or feeling unable to find the right word in a sentence? “Chemo brain” is the term commonly used by people who have experienced this firsthand. The medical community has come to recognize these thinking and memory problems as side effects of chemotherapy and use the term, chemotherapy-associated cognitive impairment. Some of these symptoms may sound familiar:

  • Memory lapse—especially details like names, places, common words
  • Poor concentration, short attention span
  • Difficulty multi-tasking
  • Taking longer to accomplish tasks—less organized, slower thinking

Research is underway to learn more about the exact causes of chemo brain. Current theories suggest that some chemotherapy drugs are not only directly toxic to brain cells, but also cause damage by reducing blood flow to brain cells and by increasing the inflammatory response of the immune system. Additionally, some cancer treatment drugs can change hormone levels and alter neurotransmitter function (neurotransmitters are messengers between brain cells), which affects thinking and mood.

Although there is no established medication or treatment for chemo brain, there are many ways to cope with brain fog and minimize its impact on your life.

  1. Keep perspective: you are not crazy or alone. Frequently, these symptoms improve or resolve just like other side effects of treatment.
  2. Track your symptoms: keep a diary to find what makes symptoms worse. Where were you, were you hungry, stressed, tired, etc.?
  3. Exercise your brain: Sudoku, crosswords or a new hobby all keep your brain in shape.
  4. Exercise your body: a short brisk walk will increase blood flow to your brain, improve fatigue, stress and your mood—all will help you think more clearly.
  5. Get adequate sleep: brains don’t work well when they are tired. Chemotherapy or not.
  6. Eat nutritious foods: adequate protein, essential fatty acids and lots of vegetables provide basics your brain needs to function well. Help reduce your body’s inflammatory response by limiting inflammatory foods like alcohol and sugar.
  7. Manage your stress: like tired brains, stressed brains don’t work well. Chemotherapy or not.
  8. Improve normal elimination of chemotherapeutic drugs: good hydration and digestive function help your body clear out drugs once they’ve done their job.
  9. Put important information in one place: use a day planner or smartphone to keep track of appointments, medications, contact info and reminders.
  10. Follow a routine: keep things in the same place and try to maintain consistent times for appointments or regular activities.
  11. Create a peaceful environment: avoid a workspace full of distractions.
  12. Focus on one task at a time: avoid multi-tasking and take frequent breaks.
  13. Talk to yourself: auditory clues help you remember. Repeat information out loud as you write it.
  14. Ask for help: friends and family can help you remember appointments, keep organized or take a walk with you.
  15. Talk to your doctor about your general health and well-being: address issues that may impact your response to treatment.
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Caring for our aging parents – Mobility

MobilityIt’s hard watching our parents get older and less able to navigate the physical and mental challenges of a world where the necessities of life such as healthcare, travel and activities of daily living are becoming increasingly difficult to access. These changes affect not only our loved one but also place an increased burden on caregivers and family. The good news is that there are effective albeit underutilized steps you can take to improve or, at least, maintain their function.

Mobility, the ability to walk and function independently, is a critical marker for long term survival and quality of life and a great place to start. Reduced mobility can contribute to greater risk for falls, infection, loss of cardiovascular function, mood problems and declining mental acuity to name just a few. I have outlined strategies for optimizing mobility for elderly patients.

Mind over Matter

The first objective is to get your loved one motivated to improve his/her status. Set achievable goals in small steps. If the process seems too long and difficult it will result in discouragement at a time when sadness, depression or anxiety may already be factors. Celebrate every achievement even if that achievement is holding steady. Don’t allow the phrase “You’re just getting old” to be spoken anywhere in their presence. I’ve found it useful to spend time as their doctor with the patient outlining goals and expectations when family encouragement isn’t doing the trick.

This is very much a mind game and motivation is a key element to succeed.

Muscle strength

Muscle strength is a requirement for mobility. It doesn’t take a lot of strength; just enough to get around.

Don’t be fooled into concentrating on just leg strength. A balanced approach using all muscle groups is important. Core muscles and upper extremities are necessary for maintaining balance, recovering from a trip or misstep and using support structures such as handrails. A balanced program can be developed by a physical therapist or physiatrist and carried out with that provider, at a club or at home with a minimum of equipment. Set up a regular routine with variety from day to day. Make the exercise pleasant with your parent’s favorite tunes, good lighting and understandable instructions. Measure progress in long enough intervals so that it will be obvious and avoid measuring if there has been a setback such as a cold.

Muscle strength requires absorption of nutrients especially protein. A doctor or registered dietitian (RD) can create a diet plan that is enjoyable and meets the requirements for muscle strength. If there are digestive issues such as gas, reflux or nausea, or the patient doesn’t seem to progress at a rate consistent with the level of effort being expended, this is a sign that nutrients may not be absorbing and should be addressed. This is a common problem that is resolved in a straightforward manner.

Balance

Balance is accomplished by a remarkable combination of body systems working together including the inner ear vestibular apparatus, vision, motor and sensory nerves, muscles and joints, all orchestrated by the brain. If any one of these is lacking or there are obstacles such as pain or reduced confidence, balance will suffer.

Balance can be tested. The results can sometimes provide information about what is causing the problem but not always. If there is not a clear culprit it may be worthwhile to assess each of the body systems associated with balance to see which one is underperforming. It is not adequate to just say balance is lacking without identifying, to the extent possible, why it is lacking so that you have the opportunity to fix it.

Pain

Pain from joint diseases such as arthritis, injuries or even unrelated organ systems such as dyspepsia (digestive discomfort) can limit mobility. Joint pain may be temporarily relieved by non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen but they are not a permanent solution. Natural medicine adjuncts such as glucosamine and chondroitin are controversial but there are many positive reports. They are worth a try but done best with a doctor familiar with their use since many treatment failures are a result of inadequate dosage and timing. They are generally safe but some have side effects. Glucosamine, for example, can increase the risk for bleeding in some patients. Give them at least 6 weeks to work. In some cases, it may take a few intravenous doses to speed things along but that can be done quickly and inexpensively.

There are many other naturopathic strategies for controlling pain that address the cause and are worth considering.

Vision

Elderly patients frequently do not get adequate eye care. A comprehensive eye exam and, perhaps, corrective lenses can have a dramatic effect. Visual acuity, cataracts, poor adaptation and other eye problems can affect mobility as well, especially when lighting is poor.

Eye exercises may also be helpful. They are controversial but I have seen them provide benefit.

Range of Motion/Flexibility

Flexibility and range of motion can be a game changer, especially when recovering from an unstable moment. Specific, gentle exercises are effective even when there is pain or injury in the affected body area. Range of motion exercises are easily incorporated into an overall exercise program.

Fatigue

There are reasons for fatigue including insomnia, hormones, metabolic issues and drug side-effects.

Poor sleep quality is the most common reason for fatigue in our practice, usually a result of pain, malabsorption, metabolism issues, use of stimulants (a vicious cycle to be avoided), digestive problems, respiratory complaints such as sleep apnea or anxiety. The resulting fatigue can be difficult to diagnose but the effect on mobility can be substantial when the patient is simply too exhausted to move effectively.

Sleep studies are helpful but I start with a comprehensive Review of Systems, a medical diagnostic tool where the patient is asked questions about the function of literally every body system. This information is combined with the principal complaint, history and other diagnostic information to create a plan that addresses all of the possible culprits. Everything is connected (anatomy 101) and the big picture from the Review of Systems is important.

Stimulants are not the answer. The initial jolt is paid for by the resulting slump when the stimulant wears off and further when the residual effects adversely affect future sleep.

Confidence and security

Self-confidence and personal security are increasing concerns with age and affect the patient’s willingness to try to improve mobility. Our society, sadly, presents endless negative images of aging and they have their effect. The antidote is success, positive reinforcement, achieving goals and receiving respect. This means removing negative influences where possible.

When you are older you may not be able to fight or run as well as when you were younger and this is a common concern for elders. Keeping the environment as safe and secure as possible helps a lot. For example, if your loved one ends up in a hospital room with a disruptive or aggressive roommate, get a new roommate immediately. It can take years to get over the trauma of a night with a screaming, delusional person in the next bed and no one answering the call button

Our relationships with our parents can be complex, confusing and burdensome as they age. This is the stuff that has underwritten many a new Mercedes in psychiatrists’ driveways. It is my hope that these suggestions will provide a roadmap for making objective decisions that are not affected by your own anxiety, guilt or the other emotions that frequently come with the territory.

Be as consistent and vigilant an advocate as possible without abandoning your own life and don’t let the healthcare system bully you. Medicare, insurances, providers and institutions may need a push or an appeal to provide what is needed. Don’t be afraid to challenge the system, respectfully and with purpose.

Finally, do not allow anyone to treat your parents as children; the inability to perform or understand some tasks does not take away from their entitlement to respect.

Managing mobility can yield great rewards for the patient and the family. This is an investment well worth making.

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Diagnosis Cancer… Survivorship

By Dan Labriola ND

survivors

Because there is more to dealing with cancer than just killing cancer cells.

In today’s world there are many important services available beyond conventional oncology that address a broad range of issues facing cancer survivors.

Supportive care is showing up increasingly in cancer centers as a result of positive patient response, new evidence that these services deliver real deliver benefit and requirements for cancer centers to offer them as part of their accreditation. At the treatment level there are licensed naturopathic physicians, MDs, DOs, nurses, physician assistants, social workers, acupuncturists, massage therapists, chiropractors, dietitians and others providing herbal medicine, nutrition, diet, lifestyle, rehabilitation, weight loss, psycho-oncology, and counseling to name just a few. In addition, there are non-treatment supportive services ranging from financial counseling to art and music therapy.

The potential benefits for these services frequently outweigh the risks by supporting improved quality of life, better outcomes and reduced adverse effects from treatment. Consider services that your cancer center offers or refers to. Done correctly, supportive treatments are very safe but applied incorrectly they can interfere with treatment, worsen side effects or create new problems so choosing a provider who is well known by your oncology doctor or institution helps ensure you use someone who is knowledgeable. In conventional medicine board certifications guarantee that the doctor received training and was evaluated in a particular specialty. In complementary and alternative medicine, however, there are some good certifications while others are nothing more than meaningless letters after their name. The best strategy is to depend on a referral from your cancer doctor.

There are also support organizations that provide a broad range of terrific services including educational classes, support groups, financial counseling and support, 24 hour telephone support line and more and they are mostly free. The patient navigator or social worker at your doctor’s office can help you find the right service or you can check out their websites. They include Cancer Lifeline (cancerlifeline.org), Gilda’s Club (gildasclubseattle.org), Komen for the Cure (komenpugetsound.org), Team Survivor Northwest (teamsurvivornw.org), American Cancer Society (cancer.org), NW Hope and Healing (nwhopeandhealing.org) and more. By way of full disclosure I serve on the board of directors of Cancer Lifeline, medical advisory committees for Gilda’s and Komen, and have been on the speaker’s bureau and leadership council for American Cancer Society.

Cancer prevention is an important element of survivorship. The American Cancer Society estimates that one-third of cancer deaths are a result of diet, overweight, obesity and lack of physical activity and therefore preventable. Controlling cancer risks with a healthy and satisfying diet, exercise and other strategies will certainly improve your quality of life and may help avoid a recurrence.

Cancer care and survival have improved greatly and you will have the best experience and outcome by choosing the providers, institutions and treatments that are uniquely suited to you.

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Diagnosis Cancer…Deciding on Treatment Options

By Dan Labriola ND

Now that you’ve chosen your cancer doctor(s) you need to decide on treatment. Options come with differing effectiveness, side effects, duration of treatment and, frequently, a recommendation. You can simply accept the first recommendation from your doctor, which may well be the best, but, since you are unique and know yourself best, I suggest you participate in the decision process. There can be points about one treatment versus another that are more important to you than the doctor realizes. At this point you are probably ready to just move on but you don’t want to look back later with regret for a decision made in haste.

The treatment decision process comes down to evaluating the benefits versus risks for each option. Your cancer doctor can walk you through the details keeping in mind that you will not experience every possible side effect. The most effective treatment with the least side effects wins although there may be some tradeoffs. For example, with breast cancer, under some circumstances a woman can choose between lumpectomy, removal of just the tumor and some surrounding tissue with radiation or mastectomy without radiation. Both procedures have very similar effectiveness.

Fortunately there is a lot of credible evidence for evaluating benefits based on well done research. In most cases you will be presented with relapse and overall survival statistics for a time period after treatment such as 5 or 10 years depending on the particulars of your diagnosis. These numbers help you choose the treatment that is statistically best but keep in mind that these are still just statistics and you are not a statistic. Don’t let the numbers bring you down.

In addition to FDA approved therapies there are clinical trials that are worth considering. Enrolling in a clinical trial not only moves us closer to finding an answer to cancer but may also offer an opportunity to benefit from a new therapy. Some clinical trials also present risks so it’s important to weigh the benefits and risks for you before signing up. Cancer clinical trials are separated into 5 phases.

Phase 0 trials represent the first step in using a new treatment on humans. Small numbers of patients are given minimal doses of the treatment to see how it acts chemically in the body. These trials do not usually collect information about effectiveness or side effects and are generally only for patients for whom there is no known, effective treatment.

Phase 1 trials determine the safety of a new, experimental treatment by evaluating the maximum tolerated dose. Side effects are evaluated carefully but effectiveness data may or may not be evaluated.

Phase 2 trials are the first step to evaluate how effective a new treatment is once safety considerations are understood.

Phase 3 trials also evaluate treatment effectiveness but in much greater detail with larger cohorts of patients than phase 2. These investigations are frequently randomized where some patients receive placebo. They also frequently evaluate how the new treatment compares to existing treatments.

Phase 4 trials are usually conducted after the new treatment has received FDA approval to collect more data. They are called Post Marketing Surveillance Trials and may be funded by pharmaceutical companies.

If you are invited to participate in a clinical trial you will be given information including an FDA approved Informed Consent Form. Every trial is different and your oncologist will help you understand the benefits and risks. You can find a list of all the current FDA approved clinical trials in the U.S at www.clinicaltrials.gov.

Once you have chosen a treatment you have the option of getting a second opinion, a valuable service that is underutilized because patients feel that seeking one would offend their doctor. The fact is that no one will be offended. Second opinions are a normal part of cancer care and they provide you with an opportunity to have another pair of eyes look at your diagnosis and treatment to see if there is something better or different that should be considered. The process is simple, can happen quickly and is usually covered by insurance.

You start the second opinion process by getting referrals as you did when looking for your cancer care team. There may be a doctor you already know about. It is best to choose a provider from an unaffiliated institution. Different cancer programs sometimes have different, possibly interesting protocols for the same diagnosis and it also minimizes the possibility for a rubber stamp if the reviewing doctor works too close to your doctor. The reviewing doctor’s office will help you get a copy of your records sent.

The second opinion can have 3 possible results. First and easiest is agreement with the planned treatment. If you’re satisfied you can move forward with the plan. The second, not uncommon, response is a recommended plan that is different but equivalent effectiveness. Unless the differences are significant you will likely go forward with the original plan.

If, however, the reviewing doctor recommends much more, much less or something very different you now need resolution. This doesn’t happen often and is most frequently settled by the 2 doctors speaking with each other. If that doesn’t work or isn’t possible then you need a tie breaker, a rare occurrence but when it happens you need to get to the bottom of it before starting treatment. You can find your 3rd opinion using the same strategy you used finding the second opinion. You may want to consider a larger cancer center even if it means traveling. If travel is not an option, some record reviews can be done without the patient present.

One final note on choosing therapies. The FDA does not allow claims to be made about a treatment without first substantiating them with human trials. Unfortunately, there are individuals and clinics in the US and elsewhere claiming cancer cures without the human evidence to back them up. Be aware that while test tube and animal studies are useful in science they only rarely translate into treatments that work on people. We were curing cancer in laboratory animals using just vitamin E 50 years ago but when the same protocol was tried in humans it didn’t work.

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Diagnosis Cancer…What do I do now?

Dan Labriola ND

 Introduction

No one is prepared for a cancer diagnosis. The words “you have cancer” are a life changing moment you never forget. You must now make decisions for which no one is prepared; choosing doctors, selecting treatments and managing life issues that are suddenly front and center such as financial survival, personal responsibilities, relationships, quality of life, your dreams and plans for the future and, in some cases, survival. And if that wasn’t enough, you must do this while navigating medical and insurance systems that are less than user-friendly.

When you receive the diagnosis you will likely be referred to a conventional oncology physician who will outline a course of treatments or treatment options but it is not uncommon for daunting questions to remain: Is this the best treatment? Is this the right doctor? Where do I look to learn more about the diagnosis and treatments? How do I pay the rent, get transportation to doctor appointments or deal with side effects? If you consult the internet, chances are you will be even more confused.

What you need is a plan that enables you to answer these questions and guide you through the cancer experience with the confidence that you’ve made the best decisions. Such a plan will also restore control of your life.

You don’t want to go this alone. Taking advantage of the training and experience of knowledgeable cancer treatment and support providers will result in the best plan so we begin with a strategy for choosing your cancer team including doctors, other providers and institutions. These are the experts you will rely on to provide the information necessary to make treatment decisions and, in most cases, deliver the treatment. We will start with choosing your team.

Depending on your particular circumstances, the treatment selection process can involve multiple choices that may also include clinical trials, complementary and alternative medicine, other supportive therapies or doing nothing. In the second part of this series we will look at ways to evaluate these choices and tailor your treatment to meet your unique needs.

The third and final installment will address the services and resources that can be critically important in addition to killing cancer cells such as reducing side effects, maintaining quality of life, finances, psychological issues, diet, prevention and much more. These services have a name, cancer survivorship, and can remarkably improve your life and outcome.

 Choosing your care team

Cancer is not a single disease but actually many diseases with a few characteristics in common. Each kind of cancer acts differently, has different treatments and in many cases different kinds of treating doctors.

At this moment in science conventional medical oncology programs have the best diagnostic tools and treatment effectiveness and are the place to start. Even if you are considering using alternative medicine, you can take advantage of the very credible evidence and experience available from the conventional cancer world and then apply the same criteria for evaluating benefits and risks that I have listed below for all of the treatments you are considering. Knowledge brings clarity.

The first step I recommend is to identify the specific kinds of medical specialists that treat your cancer. Referrals are especially valuable from someone you trust such as your family doctor or the provider who delivered the diagnosis. Top Doctor surveys are useful as well but there are many excellent docs that don’t make it into Top Docs. Be cautious of blogs and sites that may be influenced by just a few opinions. If it’s colon, lung or breast cancer, for example, you will likely start with a surgeon or medical oncologist but may need a radiation oncologist (not to be confused with radiologists who read diagnostic studies such as x-rays). For prostate cancer you will probably start with a urologist or radiation oncologist. Medical oncologists, the doctors who administer chemotherapy, also frequently act as quarterback even if you’re not receiving chemo.

Once you have narrowed your choices down to a few, the easiest next step is to schedule an appointment and evaluate your experience with the help of the guidelines below. You can also request a meet and greet to see if a prospective doctor is a good fit but the experience will not be as complete as a formal visit. If the first doctor is a home run you’re set. If not, then seek out more referrals and try again. There are many excellent cancer docs and institutions who would be honored to be your provider. You will be working with this person for some time so it’s worth the effort now to get the doctor that meets your needs.

 Here is a checklist you can use to evaluate prospective doctors:

1. Familiarity and experience treating your diagnosis.
Board certification is a must. Doctors increasingly sub-specialize in specific cancers and specific patient cohorts such as pediatric, adolescent and young adult and others.

2. Covered by your insurance.
Insurance can be tricky. There are different levels of coverage depending on whether the doctor is in network, out of network, preferred etc. The right doctor may be worth a difference in cost but ask the question at the beginning to avoid a nasty surprise later.

3. Has an acceptable disciplinary record.
Log on to your state department of health website to see the doctor’s history, www.doh.wa.gov for Washington State.

4. Practices at a hospital that is highly rated for safety and has all of the other services you may need.
Check reputable hospital ratings such as Leapfrog Group, www.leapfroggroup.org. If you have heart disease, for example, you will want an organization that can also care for your heart issues especially in an emergency.

5. Communicates effectively.
You want a doctor whose communication style and demeanor are consistent with yours, who is approachable, provides clear information and works well with your decision-making process. Be clear about your preferences to give the doctor a chance to meet them.

6. Office staff that is friendly and cooperative.
Front desk, nursing and other support staff are there to meet your needs. They should be approachable, responsive and make you feel like a priority, not an interruption. Today’s healthcare world is pretty lean so keep your expectations reasonable.

7. Is in the same healthcare delivery system as your other medical specialists and hopefully your primary care doctor.
Modern communication has made care coordination much easier but having doctors who are all in the same electronic medical record or otherwise connected will make your care coordination more seamless.

8. The doctor’s gender is not as important as the other items.
We all tend to be modest but doctors have seen thousands of whatever it is you are modest about. The other criteria above will have a greater effect on your satisfaction.

If you belong to an HMO or other restricted plan your choices are different but you can still interview doctors in the oncology group and, in some cases, be treated at affiliated cancer centers.

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