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Cognitive challenges

Dr. Lori Bernstein, PhD, CPsych

Dr. Lori Bernstein is a licensed clinical neuropsychologist and works as a clinician investigator in the Department of Supportive Care at Princess Margaret Cancer Centre. She is an Assistant Professor in the Department of Psychiatry, University of Toronto, and holds a faculty position in the Graduate Psychology program at York University. Dr. Bernstein’s clinical practice includes neuropsychological assessment and psycho-educational interventions to teach patients self-management skills to better cope with cognitive impairment during and after cancer treatment. Her research focuses on understanding and characterizing cognitive changes that cancer and/or its treatment has on people and ways to help cancer survivors improve functioning so they can return to pre-cancer activities.

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Dr. Christine Maheu, RN, PhD

Dr. Christine Maheu is an Associate Professor in the Ingram School of Nursing, Faculty of Medicine, McGill University. Dr. Maheu is also an Affiliate Scientist at the University Health Network and the University of Toronto. At McGill University, she teaches research methods, supervises graduate students (masters, doctoral, post-doctoral), mentors practicing nurses and students in research, and conducts research in English and French. She has held research awards with the Canadian Institutes of Health Research, the Canadian Cancer Society, and the Canadian Partnership Against Cancer. These awards funded her research in psychosocial oncology, which focuses on developing and testing psychosocial interventions or measurements tools for various cancer populations. Additionally, in partnership with Ipsos Canada and funded by the Canadian Partnership Against Cancer, she is co-leading a nationwide survey of the needs of cancer patients for transition care from the end of their treatment to three years after their diagnosis. Dr. Maheu received awards for excellence in nursing research (2013, 2015, 2016) from Ovarian Cancer Canada, the Canadian Association of Nurses in Oncology, and the Quebec Association of Nurses in Oncology.

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Ms. Rosemary Cashman

Ms. Rosemary Cashman is a nurse practitioner at the BC Cancer Agency and an Adjunct Professor in the Faculty of Nursing at the University of British Columbia. Her professional experience includes the care of lymphoma, lung cancer and brain cancer patients. She co-chairs the Patient and Family Advisory Council, which guides the brain tumour care program at the BC Cancer Agency. She has authored book chapters and articles related to the care of brain tumour patients and their families. Ms. Cashman was involved in developing and implementing a rapid-access radiotherapy clinic for the palliative treatment of lung cancer and she continues to work in this clinic.

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Kyla Johnson, Occupational Therapist, Segal Cancer Centre, Jewish General Hospital

Ms. Kyla Johnson, M.Sc.A., originally from Edmonton, Alberta, Kyla Johnson works as an Occupational Therapist at the Segal Cancer Center of the Jewish General Hospital. She holds a Master of Science in Occupational Therapy from McGill University. Her goal as a rehabilitation professional in Oncology is to enable people with cancer to be able to do what they want and need to do, in all stages of their cancer experience. Kyla helps develop strategies and accommodations to facilitate a return to meaningful life roles, including work. She is specialized in cancer-related cognitive dysfunction and runs a weekly group teaching strategies to improve daily cognitive functioning. Kyla also leads a volunteer yoga class for young adults with cancer. She lives in Montreal, Quebec.

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Ms. Maureen Parkinson, Vocational Rehabilitation Counsellor, M.Ed. C.C.R.C, BC Cancer

Ms. Maureen Parkinson is the province-wide vocational rehabilitation counsellor at the BC Cancer Agency. She has also been vocational rehabilitation counsellor at a public rehabilitation hospital and vocational rehabilitation consultant to insurance companies and the court system. She has instructed and facilitated Service-Canada-funded programs on job searching and career exploration. Ms. Parkinson has a Masters in Counselling Psychology, is a Canadian Certified Rehabilitation Counsellor, and completed the Certified Return to Work Coordinator Program through the National Institute for Disability Management and Research. She has developed return-to-work and job-search seminars for cancer patients and created the guidebook “Cancer and Returning to Work: A Practical Guide for Cancer Patients” as well as on-line articles about returning to work and school. She also co-authored a paper commissioned by the Canadian Association of Psychosocial Oncology, “Cancer and Work: A Canadian Perspective”.

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First author, Dr. Lori Bernstein, is part of the Cancer and Work core team member and is a neuropsychologist.

Many people report experiencing cognitive challenges during and after cancer treatment. Cognitive challenges may be influenced by the type and location of cancer, the type and duration of treatment, the presence of other disease and medical conditions, and mental health challenges such as depression, anxiety and stress.

People treated for cancer may notice changes in their cognitive abilities, especially with their concentration, and ability to focus and multi-task. They may also find it harder to learn new information or recall previously learned information, and find words speaking or writing. Gradual recovery usually happens after treatment is over, but it varies greatly from one person to another. Some symptoms are minor, and others may be more bothersome. Persisting symptoms are more common in people who have had chemotherapy (often called “chemo brain” or “chemofog”) even though these symptoms can occur in people who haven’t received chemotherapy. The reasons why these changes occur are still unclear, but it is believed that there are many factors, and the problems are made worse in stressful environments.

Cognitive challenges may persist when a tumour is located in the brain. Because the brain’s different parts are highly specialized for particular functions, the location and the size of the tumour will cause specific types of deficits. Also, brain tumour treatments, the unique physiology of the individual and various medications can alter cognitive functioning.

Vocational implications

Patients will need to consider how long they can concentrate on an activity, and whether they require additional assistance to support (re)training. There may be periods during the day when patients feel more or less mentally alert. Being aware of these patterns will help patients identify work tasks and times when strategies for maximizing cognitive performance are needed.

For additional information patients might find helpful (even they you are not youths) see Pathways to Success for Youth Facing Neurocognitive Challenges (PDF; pages 9–12, Pediatric Oncology Group of Ontario).

Some problems that patients may experience at work include:1

  • answering questions quickly
  • shifting from one task to another
  • following step-by-step instructions when more than one is given
  • following written instructions
  • remembering the details of conversations and/or meetings
  • organizing or assembling materials needed for a task
  • remembering one’s train of thought while speaking
  • remembering specific words or names (“tip of the tongue”)
  • following the flow of events

What patients can do

There are strategies that both patients and employers can use to help manage cognitive deficiencies and reduce their impact in the workplace.

For instance, to cope with mental fatigue at work, the patient can take more frequent breaks. They can also be aware of stress levels and try to reduce distress. Distress can worsen weaknesses in cognitive function, affecting performance. Some aspects of the work environment can add unnecessarily to stress levels, for example, too much talking or other noise. If the stress trigger cannot be removed, slow deep breathing and relaxation exercises may help.

When patients are feeling overwhelmed, writing a short “to do” list and ordering the items in a way that makes sense given priorities or constraints can help. Patients can then focus only on the first item and not think about anything else. Thinking about all the items on the list may be distracting or stressful, and concentration will suffer. While patients may have been able to multi-task before, it is mentally taxing and adds to feelings of being overwhelmed.

Consider referring the patient for a formal cognitive assessment before returning to work. A cognitive assessment can help identify challenges and tailor strategies to help the patient deal with cognitive difficulties.

For more on cancer-related brain fog, view the following video presentation by Dr. Lori Bernstein: Brain Fog: What Is It & What Can You Do About It? (Princess Margaret Hospital, UHN)

Here are some other resources on brain fog and challenges with brain tumours, as well as cognitive problems:

Job accommodations

Modify work tasks:

  • Ask the patient to identify tasks that are most challenging for them.
  • Suggest that the patient review with their manager whether these tasks can be simplified, shared with a co-worker, or whether the employee can be given more time to complete them.
  • Ask that instructions be given in writing rather than verbally.
  • Rehearse before making a presentation.
  • Develop or enhance time management and organizing skills.
  • Reduce multi-tasking.
  • Make to-do lists and prioritize items. Check the list throughout the day.
  • Use electronic calendar alerts.
  • Put keys, files, coat and other items in the same place every day.
  • Conserve energy. Anticipate and work with individual energy patterns.

Personal strategies:

  • Practice stress management techniques.
  • Take more frequent breaks throughout the workday.
  • Practice self-acceptance: being kind to oneself when something cannot be remembered without a reminder.

Modify the work environment:

  • If the patient is comfortable disclosing their cognitive challenges, tell the supervisor and colleagues about the challenges.
  • Ask trusted co-workers for prompts and reminders.
  • Request a period each day when the patient is not to be interrupted which they can use to accomplish their most challenging tasks.
  • Create a quiet work environment when possible or provide noise-cancelling headphones or earplugs.
  • Declutter the workspace.
  • Move the workstation to face a wall instead of a busy hallway to decrease visual distractions.
  • Optimize the lighting in the workplace (neither too dark nor too bright).

View the BC Cancer Agency’s video Returning to Work for Brain Tumour Patients.

Back to the list of common cancer treatment side effects