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Q&A: Neuropsychology and its role in cancer care

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Jeffrey Wefel, Ph.D.,By Jeffrey Wefel, Ph.D.

A clinical neuropsychologist is an expert in identifying, diagnosing and treating changes in a person's cognitive function (ability to think), personality, behavior and mood. 

While brain tumor identification and localization are done primarily with MRI, the picture of the brain that's generated does not tell us about the functional impact of the lesion (such as a brain tumor) on a person's cognition, behavior and mood. (All cancer types can affect cognition and behavior.) That's where a neuropsychologist comes in.

Below, I answer some common questions about neuropsychology and its role in cancer care.

What role does a neuropsychologist play in brain cancer diagnosis and treatment

A neuropsychological evaluation enables us to better understand how a patient has been affected cognitively and behaviorally by his or her
brain tumor. 

In addition, many treatments used to combat cancer also place normal healthy brain tissue at risk, which may result in changes in cognition, behavior and mood that adversely affects quality of life and patients' abilities to maintain their occupational, academic or family and social roles.

These changes are not generally visible on standard imaging studies. So, we frequently follow patients as part of a multidisciplinary treatment team to monitor recovery, disease progression, effects on the brain and treatment effectiveness, as well as provide neuropsychological interventions. 

What is a neuropsychological assessment?

A neuropsychological evaluation consists of three components:

1. Clinical history and interview - The neuropsychologist obtains information from the patient (and sometimes family and friends) about their symptoms, medical history and other important factors. 

2. Cognitive testing - During this portion of the evaluation, patients are administered paper-and-pencil or computerized tests. There are no needles or painful machines. 

Many patients find the process interesting and even fun. Patients also complete self-report questionnaires to help us understand their mood and symptoms and the impact their illness has had on their daily lives. These first two portions of the evaluation generally require 2-4 hours at MD Anderson based on the patient's specific situation and the referral question. 

3. Recommendations - After the evaluation, the neuropsychologist puts together a report in which the pattern of cognitive strengths and weaknesses are described, diagnoses are rendered, specific referral questions are addressed and treatment plans are issued.  These results are provided to the patient, family and their health care providers. 

What type of interventions do you offer adult cancer patients?

Patients are provided personalized rehabilitation plans such as training on memory aids, adaptation and problem solving strategies and recommendations on ways that they can modify their behavior, like structuring their environment to reduce distractors and developing an energy conservation plan. These help reduce the impact that memory or thinking problems can have on people's daily activities.

We know that changes in behavior can change connections or structures in the brain. This ability for the brain to reorganize itself is called neuroplasticity. For example, in animal models, we've seen that exercise can increase the creation of new nerve cells and improve learning and memory function.

Recently, cognitive exercises based on the brain's ability to modify itself have been shown to preserve and enhance cognitive function in both healthy older individuals at risk for age-related cognitive decline and in cancer survivors.  

What research is being done at MD Anderson in regards to cognitive dysfunction?

It was previously thought that once brain cells were injured, they would never recover and other areas were unable to pick up those lost functions. 

We now know that the brain, like our skin, continuously replaces damaged mature cells well into adulthood. 

Unfortunately, these cells are particularly sensitive to certain cancer treatments. Using this knowledge, we're changing the way we deliver cancer fighting treatments so that they are effective without damaging the nervous system. We are also devising ways to take advantage of the brain's ability to repair itself and then within the larger scientific field increase this ability with stem cell replacement therapies. 

In addition, our research includes identifying biological characteristics that could put a patient at  risk for cognitive decline. We use  neuropsychological measures, advanced neuroimaging tools and genetic data to find these biomarkers and determine the risks.

We also recently completed a trial that demonstrated medicine used to treat patients with vascular and Alzheimer's dementia is effective in preventing cognitive decline associated with whole-brain radiation in patients with brain metastases. 

 What clinical trials are currently available for cognitive dysfunction?

We're currently studying a computerized neuroplasticity-based cognitive intervention in patients with brain tumors. We're hopeful this will provide a much needed treatment option for patients.

Jeffrey Wefel, Ph.D., is associate professor in Neuro-Oncology and chief ad-interim in Neuropsychology.

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