Neuropsychological Practice in the Oncology Setting

Abstract

Oncology has experienced positive shifts in survival curves for many cancers largely due to the development of earlier diagnostics and better therapeutics. This has increased the visibility and need for survivorship services, including clinical neuropsychology. Patients with cancer frequently experience cognitive dysfunction related to the presence of cancer itself and treatment neurotoxicity. These cognitive difficulties can profoundly impact patient functioning and autonomy with accompanying declines in quality of life. Clinical neuropsychologists are uniquely positioned to evaluate the cognitive and affective sequelae of cancer and treatment and provide interventions and recommendations that can benefit well-being and potentially alter the disease course. Despite increasing recognition of the importance of neuropsychological issues to cancer survivorship, many neuropsychologists have limited training and guidance regarding navigating and implementing services within the oncology setting. This article provides the basic rationale for neuropsychological practice and research activities in oncology, as well as the experience of the Section of Neuropsychology at The University of Texas MD Anderson Cancer Center.

Rationale

Cancer is one of the most common life limiting illnesses with a worldwide incidence estimated beyond 14 million. It is now well-recognized that cognitive dysfunction is associated with cancer and treatment, with rates ranging from up to 75% in patients with non-central nervous system disease to even greater in patients with primary central nervous system (CNS) involvement (Rosano, Ikram, & Ganguli, 2016). Many patients also experience decreased functional independence, reductions in competitive employment, and role limitations due to their cognitive changes. Cognitive impairment may be attributable to cancer itself, the effects of anti-cancer treatment, as well as the sequelae of the often numerous symptomatic interventions accompanying primary therapies. Accordingly, cognition is increasingly acknowledged as an important outcome in oncology, both in practice (Kayl, Collins, & Wefel, 2008) and in clinical trials (Blakeley et al., 2016; Brown et al., 2013, 2016; Chang et al., 2009).

The following provides the general basis for neuropsychological evaluation in adult cancer patients, though the rationale for CNS and non-CNS populations is treated separately given important differences in typical presentation, course, and assessment considerations between populations. It should also be emphasized that cancer patients contend with a host of physical symptoms and psychosocial concerns in addition to cognitive changes. While a complete review of these important issues is beyond the scope of this article, concerns frequently encountered across most patient populations are briefly addressed, including fatigue, pain, and affective distress.

CNS Cancer

While CNS cancer, especially primary brain tumors, represents a relatively small niche population, cognitive impairment is ubiquitous in these patients and represents one of the most frequent patient-reported concerns. Specifically, cognitive impairment has been observed in over 90% of patients with supratentorial brain tumors, even prior to treatment (Tucha, Smely, Preier, & Lange, 2000). However, the nature and severity of difficulties vary by a variety of factors, such as lesion location and growth characteristics (Kesler, Noll, Cahill, Rao, & Wefel, 2016; Noll, Sullaway, Ziu, Weinberg, & Wefel, 2015; Wefel, Noll, Rao, & Cahill, 2016). First line antitumor treatment can also significantly impact cognition in these patients. Surgical resection of brain tumors may damage healthy tissue surrounding the tumor, which can result in focal dysfunction and/or more diffuse problems secondary to disruption of distributed networks. Importantly, preoperative neuropsychological test results are useful in predicting postoperative outcomes (Gehring, Sawyer, Etzel, Lang, & Wefel, 2011). Neuropsychological evaluation is also useful for informing other preoperative neuromedical procedures, such as functional MRI, transcranial magnetic stimulation, and intraoperative brain mapping, all of which are frequently employed to minimize surgical morbidity.

Unfortunately, cognitive decline following neurosurgical resection of brain tumors is not uncommon, even when preventive surgical planning and intraoperative mapping techniques are utilized (Noll, Weinberg, et al., 2015; Satoer et al., 2012). Nonetheless, measuring these postoperative changes in cognitive functioning via formal neuropsychological evaluation can provide useful prognostic information (Armstrong et al., 2013; Johnson, Sawyer, Meyers, O’Neill, & Wefel, 2012). Evidence also shows that depressive symptoms identified early in the disease course are independently associated with reduced survival in patients with glioma (Litofsky et al., 2004; Noll, Garbarino, Turner, Verhaark, & Wefel, 2014). Accordingly, neuropsychological evaluation in the neuro-oncological setting can identify complex cognitive and psychosocial issues which may be amenable to interventions that bolster quality of life and potentially impact morbidity and survival.

Aside from neurosurgery, adjuvant therapies also pose risk of cognitive decline in patients with CNS tumors. While the cognitive impact of chemotherapy is often difficult to disentangle from other treatment effects, data suggest that even relatively well-tolerated agents, such as temozolomide, pose some risk of decline in patients with primary brain tumors (Armstrong et al., 2013; Gilbert et al., 2014). Radiation therapy for CNS neoplasms also comprises a unique set of risks, though much interindividual variability exists. Some patients may experience acute but transient cognitive decline following radiotherapy, while others can develop subacute or late neurotoxicity in the months to years after completion of radiation (Crossen, Garwood, Glatstein, & Neuwelt, 1994; Keime-Guibert, Napolitano, & Delattre, 1998). Due to the potential for these later emerging effects, long-term neuropsychological follow-up is often necessary.

Notably, the work of neuropsychologists involved in large multi-center clinical trials has changed standard of care for many CNS cancer patients. It is now well established that patients with brain metastases receiving stereotactic radiosurgery plus whole brain radiation therapy (WBRT) exhibit increased risk of memory decline compared to those who are treated with stereotactic radiosurgery alone (Brown et al., 2016; Chang et al., 2009). Additionally, for patients requiring WBRT, neuropsychological outcomes demonstrate that memantine offers some neuroprotection (Brown et al., 2013). Other work has shown that radiation delivery techniques that minimize exposure to the hippocampus lead to greater preservation of memory function (Gondi et al., 2014). As such, neuropsychological assessment has proven valuable both at bench and bedside in the neuro-oncology setting.

Non-CNS Cancer

Even when cancer does not invade the brain, cognitive impairment often occurs at some point in the disease course and may even be present prior to initiation of therapy. For instance, up to 35% of women with breast cancer exhibit cognitive impairment before beginning systemic treatment (Hurria et al., 2006; Wefel, Lenzi, Theriault, Davis, & Meyers, 2004). Treatment-related cognitive decline, often generically termed “chemobrain,” is also common, though prevalence estimates vary widely across studies (e.g., 17–78% in patients with breast cancer) (Schagen & Wefel, 2013). Some of this variability relates to differences inherent to primary cancer type, site, and chemotherapy agents utilized. Regarding chemotherapeutic regimens, recent neuropsychological research has begun to elucidate the neurofunctional consequences of specific therapies, informing the neurotoxicity profiles of particular agents (Correa et al., 2010; Kesler & Blayney, 2016; Wefel et al., 2014). Recent research has also investigated the cognitive impact of non-chemotherapeutic agents. In addition to (or in lieu of) chemotherapy, some non-CNS cancers (e.g., breast and prostate cancers) are treated using hormonal therapies. Studies investigating the neuropsychological impact of these therapies have been mixed, but some research raises concern regarding potential untoward cognitive and neuropsychiatric effects (Dinh et al., 2016; McGinty et al., 2014; Schilder et al., 2010).

In contrast to the progressive course typical of patients with most primary CNS tumors, some patients with non-CNS cancers may experience recovery of cognitive function following cessation of active therapy. However, in others, cognitive decline can be persistent (Koppelmans et al., 2012) and may even worsen over time (Wefel, Saleeba, Buzdar, & Meyers, 2010). Accelerated aging has been proposed as a potential mechanism of progressive cognitive decline in these non-CNS patients (Wefel, Kesler, Noll, & Schagen, 2015). As such, elderly cancer patients may be particularly vulnerable to cancer-related cognitive decline in addition to being at risk for potentially co-occurring neurodegenerative processes. Level of premorbid functioning and genetic factors (e.g., APOE status) have also been associated with degree of cognitive vulnerability to cancer treatment (Wefel et al., 2015). Despite the varied constellation of factors contributing to cognitive impairment in these patients, cancer-related cognitive impairment tends to present with a particular pattern on testing. Specifically, patients with non-CNS cancer-related cognitive decline often show a “subcortical” profile on testing, involving reduced learning efficiency, processing speed, and executive functioning (Root, Andreotti, Tsu, Ellmore, & Ahles, 2016; Wefel et al., 2015). Accordingly, a solid understanding of the impact of particular cancers and treatments upon cognition, in conjunction with close inspection of a patient’s known risk factors and neuropsychological profile, can help distinguish between cancer-related and other etiologies of cognitive impairment.

As with all types of cancer, patients with non-CNS disease are often medically complex. Cancer-related cognitive impairment is typically observed alongside numerous other symptoms and issues, including fatigue, pain, sleep disruption, and affective distress to name but a few. While cancer-related cognitive decline is independent of these symptoms (Ahles et al., 2008), such comorbidities should be assessed during a thorough neuropsychological evaluation given potential impact on test engagement, and most importantly, patient quality of life. That is, neuropsychologists are uniquely positioned to not only examine cognitive issues, but also other important contributors to general well-being. Through comprehensive assessment involving cognitive testing alongside mood and quality of life measurement, targets for intervention may be identified to ultimately improve patient well-being.

Essential Skills and Competencies

All neuropsychologists at the University of Texas MD Anderson Cancer Center (MDACC) have training consistent with Houston Conference guidelines. All are ABPP certified or eligible with expectation of completing certification within 3 years of faculty appointment. With regard to routine clinical activities, knowledge of factors unique to the neuropsychology of cancer is essential. First and foremost is an advanced understanding of the neuropsychology of brain tumors. A solid grasp of the various types of brain tumors and their associated growth kinetics is essential for appropriately evaluating their cognitive sequelae. Brain tumor histology (low grade vs. high grade), including associated genetic and molecular factors, affects prognosis, response to treatment, and cognition (Wefel, Noll, & Scheurer, 2016). Knowledge of the anticipated course of cognitive changes based on tumor and treatment factors is also an important determinant of the optimal follow-up schedule for repeated cognitive evaluation. Chronicling cognitive changes in the dynamic setting of tumor growth is particularly important given that cognitive changes often anticipate tumor progression and predict prognosis (Meyers & Hess, 2003; Meyers, Hess, Yung, & Levin, 2000).

A thorough understanding of non-CNS cancers and associated treatments is also paramount. Given that treatments vary greatly depending upon specific pathology, a solid grasp of the neurotoxicology of various treatments, such as chemotherapy, hormonal therapy, and stem cell transplantation, is needed. It is also essential to have a strong working knowledge of the neuropsychological issues associated with aging, including the differential diagnosis of dementias and neuromedical comorbidities common in medically complex elderly patients. Neuropsychologists should also be aware of other factors common in cancer settings, such as fatigue, which tends to be ubiquitous. Many cancer patients are also in pain, and/or being treated with pain medications. An appreciation of the types of psychological distress experienced by cancer patients, such as fear of recurrence, distress related to a shortened life span, and end of life issues is also beneficial. In addition to the standard assessment competencies, there are also several clinical activities at MDACC that require specialized training, such as brain mapping with functional magnetic resonance imaging (fMRI) and intraoperative direct cortical stimulation.

Roadmap to Integration

In 1983, a group of physicians specializing in neurology, neurosurgery, and pain management were loosely organized into the MDACC Department of Neuro-oncology. They recruited the first neuropsychologist, Dr. Christina Meyers, to MDACC in 1984. The next neuropsychologist was not hired until 1999. In 2001, the Section of Neuropsychology was officially recognized within the Department of Neuro-Oncology. Today, the Section of Neuropsychology is the largest clinical neuropsychology service in a cancer setting in the United States, comprised by five faculty neuropsychologists, four clinical psychometrists, two research psychometrists, an imaging scientist, and clinical predoctoral practicum and postdoctoral fellowship training programs. The section is academically situated within the Department of Neuro-Oncology and the outpatient Neuropsychology Clinic is located within the multi-disciplinary Brain and Spine Clinic that also includes Neurosurgery, Neuro-Oncology (including Cancer Neurology and Neurophysiology), and representatives from Radiation Oncology and Neuroradiology.

Approximately half of referrals consist of patients with CNS tumors. Neurosurgical patients are routinely evaluated pre- and post-surgery as part of standard of care. Neuropsychologists at MDACC are also responsible for preoperative fMRI task selection, administration, and evaluation of compliance during fMRI scans, in addition to being involved in intraoperative brain mapping. Patients are followed serially postoperatively to monitor cognitive change and update recommendations, with re-testing intervals determined by tumor pathology and treatment plan. The remaining half of referrals involves patients with non-CNS cancer. Referrals are made by physicians and other providers throughout a broad range of departments to answer specific questions pertaining to cognitive and emotional functioning. Serial evaluations are conducted for specific populations (e.g., pre- and post-stem cell transplantation, question of progressive neurodegenerative disease) or as requested by the referral source.

One of the key factors driving clinical referrals and integration within an academic oncology institute has been active programs of collaborative research. This work has helped define the field of cancer-related cognitive impairment and increased the visibility of neuropsychological services both within the institution and throughout the broader oncology community. The utility of neuropsychological evaluation in differentiating between neurotoxicity and comorbid neurologic illness is now well-recognized by our colleagues across departments and is a hallmark of the clinical service. Research into and provision of compensatory and restorative interventions have likewise increased utilization of our clinical service. Importantly, neuropsychologists at MDACC have a deep understanding of oncology allowing effective communication with referral sources and a strong partnership with providers and patients with the aim of maximizing cognitive function and quality of life across the cancer survivorship continuum.

Reimbursement

Neuropsychologists at MDACC are salaried faculty within The University of Texas system. Standard CPT codes for neuropsychological services are used, including 96116, 96118, and 96119 for neuropsychological evaluations, as well as 96020 for fMRI task selection and administration. Diagnostic codes vary based on the patient population and results of evaluation. Although we routinely provide feedback including compensatory strategy training, we do not routinely bill for these services.

Setting

The bulk of clinical activity takes place in the outpatient Neuropsychology Clinic, which consists of four exam rooms and one staff workroom. Functional magnetic resonance imaging studies are performed in outpatient diagnostic radiology MRI suites located in an adjacent building. Less commonly, we perform consultations at bedside for hospitalized inpatients (e.g., question of delirium). An emerging role for certain members of our team includes participating in intraoperative brain mapping, which is performed in the operating suite.

Cases Per Week

The outpatient clinic is staffed by three clinical neuropsychologists who each see one to three outpatients per day. Evaluations range from 2 to 5 h of face-to-face time, with a 3 h evaluation being typical. Approximately 1–3 preoperative fMRI studies are performed per week and a minority of these cases is followed into the operating room where awake craniotomies with intraoperative direct cortical stimulation brain mapping are performed. Services are provided on the inpatient units as needed and research patients are seen as indicated per protocol.

Focus of the Evaluation

The focus of the neuropsychological evaluation varies depending on the clinical context, patient population, and referral question. In patients with CNS disease, imaging studies have generally already identified the structural lesion(s). Thus, the neuropsychological evaluation is not used to diagnose or localize the lesion but rather to clarify the nature and severity of the cognitive impact of the known lesion. In non-CNS cancers, assessment may help determine whether cognitive complaints are consistent with the untoward impact of cancer and cancer therapy, suggestive of an unrelated neurodegenerative process, or perhaps reflective of other factors such as distress, pain, and fatigue. In both CNS and non-CNS disease, the neuropsychological evaluation may answer questions regarding the impact of cancer and associated treatment on the ability to independently execute critical life roles, relative need for supervision and assistance, and capacity for decision-making and other important functions. Need for more aggressive monitoring and management of mood or personality changes may also be identified.

Factors important for consideration in test selection include a patient’s disease status, expected prognosis, and physical stamina. Given that many oncology patients exhibit significant fatigability, the evaluations are brief and focus on key cognitive domains. Patients are often seen for numerous serial evaluations given the dynamic nature of cancer and treatment, particularly patients with primary brain tumors. Accordingly, careful selection of reliable and valid measures sensitive to subtle changes but robust to practice effects is crucial. Whenever possible, alternate forms are used. A thorough neuropsychological examination in the oncology setting should also include an assessment of affective functioning and quality of life, which are commonly compromised in cancer patients and can negatively impact subjective self-reported cognitive functioning (Castellon et al., 2004).

There is no single assessment battery appropriate for every oncology patient, but we have identified several tests and measures that provide a repeatable core battery with robust psychometric properties. Table 1 describes a sample battery particularly suited for patients with brain tumors. Flexibility around these core tests and measures is often necessary, with supplementation and adjustment varying according to diagnosis, lesion location, and referral question. Somewhat greater variability in tests and measures is common for non-CNS referrals given a broader array of referral questions. Additionally, tests with greater sensitivity (e.g., Paced Auditory Serial Addition Test, continuous performance tests) are often supplemented in cases involving questions of non-CNS cancer-related cognitive impairment, as deficits can be relatively subtle in some cases.

Table 1.

Core battery for assessment of cognition in neuro-oncology

Domain	Test/Measure
Premorbid Functioning	Wechsler Test of Adult Reading
Memory	Hopkins Verbal Learning Test-Revised Brief Visuospatial Memory Test-Revised
Language	Boston Naming Test MAE: Controlled Oral Word Association MAE: Token Test
Attention/Processing Speed	WAIS-IV Digit Span WAIS-IV Arithmetic WAIS-IV Coding WAIS-IV Symbol Search Trail Making Test Part A
Executive Functioning	WAIS-IV Similarities Trail Making Test Part B
Visuospatial	WAIS-IV Block Design
Motor	Grooved Pegboard
Mood/Symptom/Quality of Life	Beck Depression Inventory-II Beck Anxiety Inventory MD Anderson Symptom Inventory-Brain Tumor EORTC QLQ C30/BN20

Note: Test references provided in the Appendix of this issue.

Recommendations

Recommendations vary greatly based upon the differing referral questions asked, patient population assessed, and specific patient and caretaker goals. Nonetheless, the primary objective is to provide information and resources that will ultimately preserve or improve patient functioning and quality of life.

Perhaps the most common recommendations across patient populations at MDACC involve compensatory strategies. Patients who exhibit significant cognitive impairment can benefit from education and instruction regarding implementation of environmental modifications, external aids, and internal strategies for optimization of cognitive functioning (Ferguson et al., 2007; Gehring et al., 2009). For patients exhibiting more severe cognitive impairment, perhaps with accompanying daily functional limitations, neurorehabilitation is often recommended. Home health services may also be recommended for patients with cognitive impairment limiting autonomous self-care.

Depression and anxiety disorders comprise the most frequent psychiatric comorbidities in patients with cancer (Mehnert et al., 2014). In addition to recommending individual psychotherapy, such as CBT and other evidence-based psychological interventions, we often refer patients for psychiatric consultation. As an adjunct, we make every effort to engage our patients in various peer and professionally-led support networks, both within and outside the institution.

Complaints regarding fatigue and sleep disturbance are often elicited via interview or completion of inventories. When identified, we frequently recommend and provide education regarding sleep hygiene and energy conservation techniques. At MDACC, we are also fortunate to have specialty Fatigue and Sleep clinics to whom we refer as appropriate. Formal evaluation and treatment of sleep issues can also yield cognitive and quality of life benefits (Ferini-Strambi et al., 2003). Safety permitting, patients with fatigue and/or cognitive impairment are often instructed to participate in regular cardiovascular exercise, given evidence of benefit to energy level and cognition in patients with cancer (Mustian, Sprod, Janelsins, Peppone, & Mohile, 2012).

Many patients are referred for evaluation of suspected dementia with various neuromedical rule-outs, including cancer treatment-related cognitive impairment. While our evaluations are useful in differential diagnosis, we also often refer patients to our Cancer Neurology clinic to further clarify etiology. Recommendations for specific neuroimaging studies (e.g., PET and MRI) as well as consideration of pharmacologic interventions (e.g., nootropics) are often specified in our recommendations and referrals to Neurology. It is also common to refer patients with probable dementia and their family/caregivers to their local Alzheimer’s Association for additional supportive services. For those with “chemobrain” and other cancer-related cognitive issues, cognitive training may be beneficial (Kesler et al., 2013; Morean, O’Dwyer, & Cherney, 2015).

Given the impact of cancer and cancer therapy upon cognition, it is unsurprising that many patients experience disability (Mehnert, de Boer, & Feuerstein, 2013). When demonstrably valid testing reveals cognitive impairment of a severity expected to interfere with work functioning, various workplace accommodations can be recommended. If consideration of disability is warranted, it is clearly documented in the evaluation report. Although the Neuropsychology Clinic only serves adult patients, some patients are higher education students or are considering various academic activities. As such, neuropsychological evaluation can be useful in identifying cognitive strengths and weaknesses, with recommendations including academic accommodations where appropriate. Questions of medical decision-making and driving capacity also arise for many patients, and recommendations in support of or against these capacities are made with explicit documentation in the report.

Communication

Impressions and recommendations are clearly conveyed in every neuropsychological evaluation report (see Box 1 for an example report summary). Reports are relatively brief, conveying only background information pertinent to interpretation of the results, as referral sources are medical providers familiar with the patient’s medical history. Results are also communicated succinctly as referral sources tend to be most concerned with the clinical impression and recommendations. Nonetheless, guidelines for interpretation of results are also included in the report and raw data are always available to qualified providers upon request. In addition to timely completion of reports (usually within 1 week), results and recommendations are often conveyed to referral sources within 24 h via personal communication, such as direct conversation or email. Referrals to other providers are often made on the same day as evaluation through the electronic medical record system. All patients (and caregivers with whom we have permission to speak) are encouraged to contact their neuropsychologist for feedback, after which the physical report can be provided. Since many of our patients are not local to Houston, feedback sessions are frequently conducted via telephone.

Box 1. Example Report Summary.

Background and test results redacted for brevity.

IMPRESSION Mr. XXXX is a 50-year-old, right handed, Caucasian male with history of left frontal glioblastoma status post partial resection on 05/14/20XX, concurrent chemoradiation with temozolomide completed on 08/07/20XX, and 12 cycles of adjuvant single-agent temozolomide completed in 08/20XX. Following radiographic evidence of progression in 08/20XX, he was re-initiated on adjuvant temozolomide and is status post eight cycles. Most recent MRI of the brain on 05/12/20XX was concerning for progressive disease in the left frontal periventricular centrum semiovale. He is scheduled to undergo awake craniotomy for surgical resection on 05/28/20XX.

Results of preoperative neuropsychological testing revealed aphasia, expressive worse than receptive, significant impairment with attention and executive functioning, as well as variable visual scanning and processing speed. Regarding memory, verbal learning was severely impaired while retention and recognition were intact, indicating primary difficulty with encoding. Mild visuospatial learning difficulty was additionally noted, though delayed reproduction and recognition of the designs were intact. Right hand dexterity was mildly reduced relative to intact left hand performance. Visuoperception and visuoconstruction were within expectation. Mild depression and anxiety were noted, in addition to fatigue and sleep difficulty impacting general well-being.

Overall, the findings indicate prominent aphasia, learning inefficiency, executive impairment, and reduced right hand dexterity, consistent with his history of glioblastoma and treatment lateralized to the left frontal region.

RECOMMENDATIONS Despite noted aphasia, performance on a semantic fluency task appeared adequate for attempting fMRI language mapping with the analogous paradigm.

Intraoperative awake language mapping may be complicated by expressive aphasia given paraphasic errors noted on a naming task. Accordingly, establishing baseline performance with the intraoperative stimuli set is of particular importance.

Given current difficulties with language, speech therapy intervention may be helpful within the postoperative period. In light of some comprehension difficulties, information should be presented to him in brief and simplified terms. He may also require repetition of information to ensure understanding.

Motor functioning was relatively well-preserved, with the exception of mild dexterity and speed reduction for the right upper extremity. Given the proximity of the lesion to long motor pathways and current mild difficulties, he may be at risk for postoperative hemiparesis. Rehabilitation Medicine consult with physical therapy may be useful if deemed necessary postoperatively by his physicians.

Mood should be closely monitored given indication of mild depression and anxiety. In the event of postoperative worsening, Psychiatry consultation and supportive counseling may be warranted.

We will arrange for postsurgical follow-up neuropsychological evaluation in 3–6 weeks to monitor cognitive functioning and symptoms, and to provide further recommendations. Thank you for including us in the care of this very pleasant gentleman.

Impact

Neuropsychological services at MDACC have a large impact upon patient care, safety, and quality of life. Perhaps most directly, presentation of our clinical impressions and recommendations to the patient and caregivers can result in functional improvements through implementation of compensatory strategies and environmental modifications. Additionally, feedback can be therapeutic in itself, patient questions regarding cognitive functioning can be answered, and often times, anxieties allayed. Patients may also gain a sense of control over their situation through development and implementation of a targeted treatment plan. These plans may include changes to medication regimens, initiation of rehabilitative services, and participation in psychotherapy, all of which can impact a broad array of cancer-related comorbidities.

Importantly, our evaluations can result in direct modifications of patient evaluation and treatment plans. For instance, modification or cancellation of fMRI language mapping can either improve the interpretability of the exam or prevent an unusable scan from taking place. Either way, both yield benefit from a health economics standpoint. Similarly, when significant neurotoxicities are detected via serial neuropsychological testing, primary anti-cancer treatment may be modified to help preserve patient quality of life. Our test results can also help patients gain disability benefits where appropriate, as well as workplace and academic accommodations. Our recommendations can further help ensure patient safety through determination of various capacities, such as driving and medical decision-making.

Role Satisfaction

Neuropsychology in the oncology setting has grown rapidly over recent years but continues to represent an exciting growth area for both research and practice. The critical involvement of neuropsychologists in this large-scale multi-disciplinary field has been increasingly recognized by patients, colleagues, and administrators as essential to patient care and survivorship. Additionally, ever-increasing opportunities to mentor neuropsychology trainees and medical colleagues further reinforce the value of our specialty area. The research opportunities are as diverse as the clinical work and cut across the basic, translational, and clinical spectrum. On a more personal note, it is a humbling privilege to care for patients at one of the more vulnerable times of their lives. Throughout our work we continue to learn, not only from the scientific literature but also through the experiential encounters with our patients, providing the inspiration to advance our mission of improving the lives of cancer survivors.

Advice

Like many other areas of neuropsychological practice, oncology represents a medically complex space. However, few settings involve a similar degree of mortality, and an understanding and sensitivity to end of life issues is crucial. Fortunately, advances in cancer therapeutics are improving prognosis for many. However, the survival benefit of these treatments often comes at a cost, including changes in neuropsychological functioning. Accordingly, given the rapid changes in the therapeutic landscape, it is essential to stay abreast of these developments through continuous education. For those planning to work primarily in the oncology setting, consideration of specialization through structured training in the neuropsychology of oncology (i.e., postdoctoral training) is recommended. Additional education and training may be attained through attending meetings of specialty organizations outside INS and NAN, including the meetings of the Society for Neuro-Oncology and the International Cognition and Cancer Task Force.

Perhaps most importantly, it cannot be overemphasized that cancer patients are fighting not only against the devastating morbidity and mortality associated with their disease but also against losing their cognitive and physical capacities and general sense of well-being. It is essential to never lose sight of the purpose of our work, namely, to help patients maintain dignity, independence, and hope in the face of their illness. Partner with your patients, their support network, and the other healthcare providers to help maximize cognitive function and quality of life.

Funding

This work was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number R01NR014195 (JSW). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of Interest

None declared.