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{{SK}} Chemotherapy-induced cognitive dysfunction; Chemo brain; Chemo fog; Chemobrain; PCCI
==Overview==
'''Post-chemotherapy cognitive impairment''' (also known as '''chemotherapy-induced cognitive dysfunction''') is defined as the [[cognitive]] impairment that can result from [[chemotherapy]] treatment. Post-chemotherapy cognitive impairment was first discovered and described in 1980. Post-chemotherapy cognitive impairment is characterized by changes in [[memory]], [[fluency]], and other [[Cognitive|cognitive abilities]] that impeded their ability to function as they had pre-[[chemotherapy]]. Approximately 20-30% of patients that undergo [[chemotherapy]] experience some level of post-chemotherapy cognitive impairment. The exact [[pathogenesis]] of post-chemotherapy cognitive impairment is not fully understood. However, the underlying mechanisms of the [[disease]] are believed to be caused by direct [[neurotoxicity]]. [[Genes]] involved the development of post-chemotherapy cognitive impairment, include [[COMT]] [[Polymorphism|nucleotide polymorphism]], [[Apolipoprotein E]] [[gene]], and [[BDNF]] [[Gene mutation|gene mutations]]. Post-chemotherapy cognitive impairment is more commonly observed among middle aged and [[elderly]] [[Patient|patients]]. The [[median]] age at [[diagnosis]] ranges between 40-70 years old. There are no specific [[imaging]] findings associated with post-chemotherapy cognitive impairment. However, in some cases [[Magnetic resonance imaging|MRI]] may detect accurate measurement of therapy-induced changes in [[Grey matter|grey]] and [[white matter]] volumes. Recent studies suggest further investigation on the underlying mechanisms of [[cognitive impairment]].
 
==Historical Perspective==
Post-chemotherapy cognitive impairment was first discovered and described in 1980 following the increasing number of [[breast cancer]] survivors.<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref>
 
==Classification==
There is no classification system for post-chemotherapy cognitive impairment.<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref>
 
==Pathophysiology==
*The [[pathogenesis]] of post-chemotherapy cognitive impairment is not fully understood.<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref>
*However, the underlying [[pathophysiology]] is believed to be caused by direct [[neurotoxicity]].
*[[Genes]] involved the development of post-chemotherapy cognitive impairment, include:<ref name="NgLee2017">{{cite journal|last1=Ng|first1=Terence|last2=Lee|first2=Ying Yun|last3=Chae|first3=Jung-woo|last4=Yeo|first4=Angie Hui Ling|last5=Shwe|first5=Maung|last6=Gan|first6=Yan Xiang|last7=Ng|first7=Raymond C. H.|last8=Chu|first8=Pat Pak Yan|last9=Khor|first9=Chiea Chuen|last10=Ho|first10=Han Kiat|last11=Chan|first11=Alexandre|title=Evaluation of plasma brain-derived neurotrophic factor levels and self-perceived cognitive impairment post-chemotherapy: a longitudinal study|journal=BMC Cancer|volume=17|issue=1|year=2017|issn=1471-2407|doi=10.1186/s12885-017-3861-9}}</ref><ref name="AhlesLi2014">{{cite journal|last1=Ahles|first1=Tim A.|last2=Li|first2=Yuelin|last3=McDonald|first3=Brenna C.|last4=Schwartz|first4=Gary N.|last5=Kaufman|first5=Peter A.|last6=Tsongalis|first6=Gregory J.|last7=Moore|first7=Jason H.|last8=Saykin|first8=Andrew J.|title=Longitudinal assessment of cognitive changes associated with adjuvant treatment for breast cancer: the impact ofAPOEand smoking|journal=Psycho-Oncology|volume=23|issue=12|year=2014|pages=1382–1390|issn=10579249|doi=10.1002/pon.3545}}</ref>
 
:*[[COMT]] nucleotide polymorphism
:*[[Apolipoprotein E]]
:*[[Brain-derived neurotrophic factor|Brain-derived neurotropic factor]] ([[Brain-derived neurotrophic factor|BDNF) gene]]
 
==Causes==
* Common [[Chemotherapeutic agent|chemotherapeutic]] agents causing post-chemotherapy cognitive impairment, include:<ref name="polink">Aleah J. McHenry, MSN, RN. Management of Chemotherapy Induced Cognitive Impairment. http://www.oncolink.org/resources/article.cfm?id=1057 Accesed on May 18, 2016</ref>
:*[[Cyclophosphamide]]
:*[[5-fluorouracil]]
:*[[Methotrexate]]
 
==Differentiating Post-Chemotherapy Cognitive Impairment from Other Diseases==
*Post-chemotherapy cognitive impairment must be differentiated from other diseases that cause cognitive impairment (such as, [[Inattentiveness|lack of attention]], orientation to time and space), such as:<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref>
:*[[Dehydration]]
:*[[Infection]]
:*[[Sepsis]]
 
==Epidemiology and Demographics==
 
=== Prevalnce ===
 
* The [[prevalence]] of post-chemotherapy cognitive impairment remains unknown but approximately 20-30% of patients that undergo [[chemotherapy]] experience some level of post-chemotherapy cognitive impairment.<ref name="JanelsinsKesler2014">{{cite journal|last1=Janelsins|first1=Michelle C.|last2=Kesler|first2=Shelli R.|last3=Ahles|first3=Tim A.|last4=Morrow|first4=Gary R.|title=Prevalence, mechanisms, and management of cancer-related cognitive impairment|journal=International Review of Psychiatry|volume=26|issue=1|year=2014|pages=102–113|issn=0954-0261|doi=10.3109/09540261.2013.864260}}</ref>
 
===Age===
*Post-chemotherapy cognitive impairment is more commonly observed among patients aged 40-70 years old.
 
===Gender===
*Females are slightly more commonly affected with post-chemotherapy cognitive impairment than males.
 
===Race===
*There is no racial predilection for post-chemotherapy cognitive impairment.
 
==Risk Factors==
The most common [[risk factor]] in the development of post-chemotherapy cognitive impairment include:
 
* High number of cycles of [[chemotherapy]].<ref name="polink">Aleah J. McHenry, MSN, RN. Management of Chemotherapy Induced Cognitive Impairment. http://www.oncolink.org/resources/article.cfm?id=1057 Accesed on May 18, 2016</ref>
*[[Smoking]]<ref name="AhlesLi2014" />
 
== Screening ==
There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for Post-chemotherapy cognitive impairment.
 
== Natural History, Complications and Prognosis==
*The majority of patients with post-chemotherapy cognitive impairment are initially [[asymptomatic]].<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref>
*Early clinical features, include:
 
:*[[Inattentiveness|Lack of attention]]
:*[[Memory loss]]
:*Problems to recall
:*Lack of orientation
*If left untreated, [[Patients With Cervical Artery Dissection|patients]] with post-chemotherapy cognitive impairment may progress to develop severe [[cognitive impairment]].
*Common [[complications]] of post-chemotherapy cognitive impairment, include:<ref name="polink">Aleah J. McHenry, MSN, RN. Management of Chemotherapy Induced Cognitive Impairment. http://www.oncolink.org/resources/article.cfm?id=1057 Accesed on May 18, 2016</ref>
 
:*Decreased executive function
:*[[Cerebrovascular disease|Cerebrovascular disorders]]
:*[[Focal neurologic signs|Focal neurological deficits]]
 
*[[Prognosis]] is generally good, and [[symptoms]] of post-chemotherapy cognitive impairment typically disappear in about four years.
 
== Diagnosis ==
 
=== Diagnostic Study of Choice ===
There are no established criteria for the diagnosis of post-chemotherapy cognitive impairment. The diagnosis of post-chemotherapy cognitive impairment is based on the history and symptoms.
 
=== History and Symptoms ===
 
*Patients with post-chemotherapy cognitive impairment may have aggravating factors such as:


==Overview==
::*[[Anxiety]]
In [[medicine]], '''post-chemotherapy cognitive impairment''' (also known as '''chemotherapy-induced cognitive dysfunction''' or, colloquially, as '''chemo brain''' or '''chemo fog''') describes the [[cognitive]] impairment that can result from [[chemotherapy]] treatment. Approximately 20-30% of people who undergo chemotherapy experience some level of post-chemotherapy cognitive impairment. The phenomenon first came to light because of the large number of breast cancer survivors who complained of changes in memory, fluency, and other cognitive abilities that impeded their ability to function as they had [[pre-chemotherapy]].
::*[[Depression]]


Although the causes (and indeed, existence) of post-chemotherapy cognitive impairment have been a subject of debate, recent studies have confirmed that post-chemotherapy cognitive impairment is a real, measurable side-effect of chemotherapy treatment, at least in some patients. A UCLA study published in October 2006 showed that the brains of [[breast cancer]] survivors who were treated with chemotherapy have to work harder to perform tasks than survivors whose treatment was surgical.   Even more recently, Japanese researchers have demonstrated that a year after treatment, the brains of cancer survivors treated with chemotherapy had physically shrunk; those of people not treated with chemotherapy had not.
*Post-chemotherapy cognitive impairment is usually [[asymptomatic]] at [[diagnosis]].
*[[Symptoms and Signs|Symptoms]] of post-chemotherapy cognitive impairment may include the following:<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref>


Post-chemotherapy cognitive impairment comes as a surprise to many cancer survivors. Often, survivors think their lives will return to normal when the cancer is gone, only to find that the lingering effects of post-chemotherapy cognitive impairment impede their efforts. Working, connecting with loved ones, carrying out day-to-day tasks—all can be very challenging for an impaired brain. Although post-chemotherapy cognitive impairment appears to be temporary, it can be quite long-lived, with some cases lasting 10 years or more.
:*[[Memory loss]]
:*[[Inattention|Lack of attention]]
:*Difficult language [[fluency]]
:*Poor calculation and recall
:*[[Loss of appetite]]
:*[[Irritability]] or constant [[mood swings]]
:*Hopelessness


== Treatment ==
=== Physical Examination ===
To date, most people who experience post-chemotherapy cognitive impairment have had to live with it until it (hopefully) dissipates over time. The [[Mayo Clinic]] lists several suggestions for coping with post-chemotherapy cognitive impairment, from exercising your body to taking notes that can help guide you through the day.  
*Patients with post-chemotherapy cognitive impairment usually appear [[malnourished]] and pale.
*[[Physical examination]] shows no remarkable findings for patients with post-chemotherapy cognitive impairment.<ref name="polink">Aleah J. McHenry, MSN, RN. Management of Chemotherapy Induced Cognitive Impairment. http://www.oncolink.org/resources/article.cfm?id=1057 Accesed on May 18, 2016</ref>


There may be good news on the treatment front, however. Very recently, anecdotal evidence has begun to suggest that certain plasticity-based brain training programs may reduce the effects of post-chemotherapy cognitive impairment. At least one clinical study is underway at [http://www.positscience.com/ Posit Science], other companies are also exploring the field.
=== Laboratory Findings ===
*There are no specific laboratory findings associated with post-chemotherapy cognitive impairment.<ref name="pmid21600374">{{cite journal |vauthors=Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR |title=An update on cancer- and chemotherapy-related cognitive dysfunction: current status |journal=Semin. Oncol. |volume=38 |issue=3 |pages=431–8 |year=2011 |pmid=21600374 |pmc=3120018 |doi=10.1053/j.seminoncol.2011.03.014 |url=}}</ref><ref name="AhlesLi20142">{{cite journal|last1=Ahles|first1=Tim A.|last2=Li|first2=Yuelin|last3=McDonald|first3=Brenna C.|last4=Schwartz|first4=Gary N.|last5=Kaufman|first5=Peter A.|last6=Tsongalis|first6=Gregory J.|last7=Moore|first7=Jason H.|last8=Saykin|first8=Andrew J.|title=Longitudinal assessment of cognitive changes associated with adjuvant treatment for breast cancer: the impact ofAPOEand smoking|journal=Psycho-Oncology|volume=23|issue=12|year=2014|pages=1382–1390|issn=10579249|doi=10.1002/pon.3545}}</ref>
*In some cases, elevated levels of [[apolipoprotein]] (APOE) allele may be seen in patients with post-chemotherapy cognitive impairment


One study was done of patients 10 years after chemotherapy, which found post-chemotherapy cognitive impairment persists for the affected subgroup.{{fact|date=May 2007}} No study has found that long-term post-chemotherapy cognitive impairment disappears after 10 years, but that is simply the longest post-chemo period studied to date. Organic nerve damage, one suspected root cause of the condition{{fact|date=May 2007}}, is not generally believed to repair itself. Research into treatments is ongoing but is at an early stage.
===Electrocardiogram===
There are no ECG findings associated with post-chemotherapy cognitive impairment.
===X-ray===
There are no x-ray findings associated with post-chemotherapy cognitive impairment.
===Echocardiography or Ultrasound ===
There are no echocardiography/ultrasound findings associated with post-chemotherapy cognitive impairment.
===CT scan===
There are no CT scan findings associated with post-chemotherapy cognitive impairment.
=== MRI===
There are no MRI findings associated with post-chemotherapy cognitive impairment.
===Other Imaging Findings===
There are no other imaging findings associated with post-chemotherapy cognitive impairment.
===Other Diagnostic Studies===
There are no other diagnostic studies associated with post-chemotherapy cognitive impairment.


The drug Provigil, [[modafinil]], approved for [[narcolepsy]] has been used off-label in trials with people with symptoms of chemobrain. Modafinil is a wakefullness promoting agent  that can improve alertness and concentration.<ref>[http://content.hamptonroads.com/story.cfm?story=133730&ran=181335 Doctors are finding it harder to deny "Chemobrain"]The Virginian-Pilot © October 2, 2007</ref> A University of Rochester study of 68 subjects had significant results. "We knew from previous studies that modafinil does alleviate problems with memory and attention, and were hoping it would do the same for breast-cancer patients experiencing chemo-brain, which it did," related the study's lead author Sadhna Kohli, Ph.D, a research assistant professor at the University of Rochester's James P. Wilmot Cancer Center.<ref>[http://pn.psychiatryonline.org/cgi/content/full/42/15/31  Modafinil Relieves Cognitive Chemotherapy Side Effects]  Psychiatric News, Stephanie Whyche, August 3, 2007 Volume 42 Number 15, page 31</ref>
*


== References ==
== Treatment ==
{{reflist|2}}
=== Medical Therapy ===
* Tannock IF, Ahles TA, Ganz PA, Van Dam FS. Cognitive impairment associated with chemotherapy for cancer: report of a workshop. ''J Clin Oncol'' 2004;22:2233-9. PMID 15169812.
*The majority of cases of post-chemotherapy cognitive impairment are self-limited and require only supportive care including:
* Schagen SB, Muller MJ, Boogerd W, Mellenbergh GJ, van Dam FS. Change in cognitive function after chemotherapy: a prospective longitudinal study in breast cancer patients. ''J Natl Cancer Inst.'' 2006 Dec 6;98(23):1742-5. PMID 17148777
**Behavioral interventions
* Inagaki M et al. Smaller Regional Volumes of Brain Gray and White Matter Demonstrated in Breast Cancer Survivors Exposed to Adjuvant Chemotherapy. ''Cancer.'' DOI 10.1002/cncr.22368. PMID 17131349
***[[Relaxation]]
* Silverman DH, Dy CJ, Castellon SA, Lai J, Pio BS, Abraham L, Waddell K, Petersen L, Phelps ME, Ganz PA. Altered frontocortical, cerebellar, and basal ganglia activity in adjuvant-treated breast cancer survivors 5-10 years after chemotherapy. Breast Cancer Res Treat. 2006 Sep 29; [Epub ahead of print]
***[[Exercise]]
* Inagaki M, Yoshikawa E, Matsuoka Y, Sugawara Y, Nakano T, Akechi T, Wada N, Imoto S, Murakami K, Uchitomi Y. Smaller regional volumes of brain gray and white matter demonstrated in breast cancer survivors exposed to adjuvant chemotherapy. Cancer. 2007 Jan 1;109(1):146-56.
***Group therapy
* Posit Science Press Release. “Study on Non-Invasive Therapy for “’Chemobrain.’” [http://www.positscience.com/newsroom/press_releases/pr/110606.php 2006 Nov 6].
***Brain-training programs
** Pharmacologic interventions
*** [[Modafinil]]
*** [[Methylphenidate]]
*** [[Donepezil]]


== External links ==
=== Surgery ===
* [http://bfc.positscience.com/concerns/chemobrain.php What Is Chemobrain?]
[[Surgery]] is not recommended for patients with post-chemotherapy cognitive impairment.
* [http://www.medpagetoday.com/Neurology/GeneralNeurology/tb/4590 Temporary Brain Shrinkage May Explain 'Chemobrain']


* [http://www.cancer.org/docroot/MBC/content/MBC_2_3x_Chemobrain.asp?sitearea=MBC]
=== Primary Prevention ===
There are no [[Primary prevention|primary preventive]] measures available for post-chemotherapy cognitive impairment.


=== Secondary Prevention ===
There are no secondary prevention measures available for post-chemotherapy cognitive impairment.
<br />
==References==
{{Reflist|2}}
[[Category: Oncology]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Oncology]]
[[Category:Oncology stub]]
[[Category:Medicine]]
[[Category:Neurology]]
[[Category:Neurology]]
{{WH}}
{{WS}}

Latest revision as of 17:17, 22 October 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D., Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Chemotherapy-induced cognitive dysfunction; Chemo brain; Chemo fog; Chemobrain; PCCI

Overview

Post-chemotherapy cognitive impairment (also known as chemotherapy-induced cognitive dysfunction) is defined as the cognitive impairment that can result from chemotherapy treatment. Post-chemotherapy cognitive impairment was first discovered and described in 1980. Post-chemotherapy cognitive impairment is characterized by changes in memory, fluency, and other cognitive abilities that impeded their ability to function as they had pre-chemotherapy. Approximately 20-30% of patients that undergo chemotherapy experience some level of post-chemotherapy cognitive impairment. The exact pathogenesis of post-chemotherapy cognitive impairment is not fully understood. However, the underlying mechanisms of the disease are believed to be caused by direct neurotoxicity. Genes involved the development of post-chemotherapy cognitive impairment, include COMT nucleotide polymorphism, Apolipoprotein E gene, and BDNF gene mutations. Post-chemotherapy cognitive impairment is more commonly observed among middle aged and elderly patients. The median age at diagnosis ranges between 40-70 years old. There are no specific imaging findings associated with post-chemotherapy cognitive impairment. However, in some cases MRI may detect accurate measurement of therapy-induced changes in grey and white matter volumes. Recent studies suggest further investigation on the underlying mechanisms of cognitive impairment.

Historical Perspective

Post-chemotherapy cognitive impairment was first discovered and described in 1980 following the increasing number of breast cancer survivors.[1]

Classification

There is no classification system for post-chemotherapy cognitive impairment.[1]

Pathophysiology

Causes

Differentiating Post-Chemotherapy Cognitive Impairment from Other Diseases

  • Post-chemotherapy cognitive impairment must be differentiated from other diseases that cause cognitive impairment (such as, lack of attention, orientation to time and space), such as:[1]

Epidemiology and Demographics

Prevalnce

  • The prevalence of post-chemotherapy cognitive impairment remains unknown but approximately 20-30% of patients that undergo chemotherapy experience some level of post-chemotherapy cognitive impairment.[5]

Age

  • Post-chemotherapy cognitive impairment is more commonly observed among patients aged 40-70 years old.

Gender

  • Females are slightly more commonly affected with post-chemotherapy cognitive impairment than males.

Race

  • There is no racial predilection for post-chemotherapy cognitive impairment.

Risk Factors

The most common risk factor in the development of post-chemotherapy cognitive impairment include:

Screening

There is insufficient evidence to recommend routine screening for Post-chemotherapy cognitive impairment.

Natural History, Complications and Prognosis

  • The majority of patients with post-chemotherapy cognitive impairment are initially asymptomatic.[1]
  • Early clinical features, include:
  • Prognosis is generally good, and symptoms of post-chemotherapy cognitive impairment typically disappear in about four years.

Diagnosis

Diagnostic Study of Choice

There are no established criteria for the diagnosis of post-chemotherapy cognitive impairment. The diagnosis of post-chemotherapy cognitive impairment is based on the history and symptoms.

History and Symptoms

  • Patients with post-chemotherapy cognitive impairment may have aggravating factors such as:

Physical Examination

  • Patients with post-chemotherapy cognitive impairment usually appear malnourished and pale.
  • Physical examination shows no remarkable findings for patients with post-chemotherapy cognitive impairment.[4]

Laboratory Findings

  • There are no specific laboratory findings associated with post-chemotherapy cognitive impairment.[1][6]
  • In some cases, elevated levels of apolipoprotein (APOE) allele may be seen in patients with post-chemotherapy cognitive impairment

Electrocardiogram

There are no ECG findings associated with post-chemotherapy cognitive impairment.

X-ray

There are no x-ray findings associated with post-chemotherapy cognitive impairment.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with post-chemotherapy cognitive impairment.

CT scan

There are no CT scan findings associated with post-chemotherapy cognitive impairment.

MRI

There are no MRI findings associated with post-chemotherapy cognitive impairment.

Other Imaging Findings

There are no other imaging findings associated with post-chemotherapy cognitive impairment.

Other Diagnostic Studies

There are no other diagnostic studies associated with post-chemotherapy cognitive impairment.

Treatment

Medical Therapy

  • The majority of cases of post-chemotherapy cognitive impairment are self-limited and require only supportive care including:

Surgery

Surgery is not recommended for patients with post-chemotherapy cognitive impairment.

Primary Prevention

There are no primary preventive measures available for post-chemotherapy cognitive impairment.

Secondary Prevention

There are no secondary prevention measures available for post-chemotherapy cognitive impairment.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR (2011). "An update on cancer- and chemotherapy-related cognitive dysfunction: current status". Semin. Oncol. 38 (3): 431–8. doi:10.1053/j.seminoncol.2011.03.014. PMC 3120018. PMID 21600374.
  2. ↑ Ng, Terence; Lee, Ying Yun; Chae, Jung-woo; Yeo, Angie Hui Ling; Shwe, Maung; Gan, Yan Xiang; Ng, Raymond C. H.; Chu, Pat Pak Yan; Khor, Chiea Chuen; Ho, Han Kiat; Chan, Alexandre (2017). "Evaluation of plasma brain-derived neurotrophic factor levels and self-perceived cognitive impairment post-chemotherapy: a longitudinal study". BMC Cancer. 17 (1). doi:10.1186/s12885-017-3861-9. ISSN 1471-2407.
  3. ↑ 3.0 3.1 Ahles, Tim A.; Li, Yuelin; McDonald, Brenna C.; Schwartz, Gary N.; Kaufman, Peter A.; Tsongalis, Gregory J.; Moore, Jason H.; Saykin, Andrew J. (2014). "Longitudinal assessment of cognitive changes associated with adjuvant treatment for breast cancer: the impact ofAPOEand smoking". Psycho-Oncology. 23 (12): 1382–1390. doi:10.1002/pon.3545. ISSN 1057-9249.
  4. ↑ Janelsins, Michelle C.; Kesler, Shelli R.; Ahles, Tim A.; Morrow, Gary R. (2014). "Prevalence, mechanisms, and management of cancer-related cognitive impairment". International Review of Psychiatry. 26 (1): 102–113. doi:10.3109/09540261.2013.864260. ISSN 0954-0261.
  5. ↑ Ahles, Tim A.; Li, Yuelin; McDonald, Brenna C.; Schwartz, Gary N.; Kaufman, Peter A.; Tsongalis, Gregory J.; Moore, Jason H.; Saykin, Andrew J. (2014). "Longitudinal assessment of cognitive changes associated with adjuvant treatment for breast cancer: the impact ofAPOEand smoking". Psycho-Oncology. 23 (12): 1382–1390. doi:10.1002/pon.3545. ISSN 1057-9249.
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