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{{CMG}} {{AE}} {{MV}}
{{CMG}} {{AE}} {{MV}}
   
   
{{SK}} Chemotherapy-induced cognitive dysfunction; Chemo brain; Chemo fog; Chemobrain
{{SK}} Chemotherapy-induced cognitive dysfunction; Chemo brain; Chemo fog; Chemobrain; PCCI
   
   
==Overview==
==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 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. Recent studies suggest further investigation on the underlying mechanisms of cognitive impairment.
'''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.<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 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.<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 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 gray and white matter volumes. Recent studies suggest further investigation on the underlying mechanisms of cognitive impairment.<ref name="wiki">Post-chemotherapy cognitive impairment. Wikipedia. https://en.wikipedia.org/wiki/Post-chemotherapy_cognitive_impairment Accessed on May 18, 2016 </ref>


==Historical Perspective==
==Historical Perspective==
*Post-chemotherapy cognitive impairment was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
*Post-chemotherapy cognitive impairment was first discovered and described in 1980.<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==
==Classification==
*There is no classification system for post-chemotherapy cognitive impairment.
*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==
==Pathophysiology==
*The pathogenesis of post-chemotherapy cognitive impairment is not fully understood.  
*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.  
*However, the underlying pathophysiology is believed to be caused by direct neurotoxicity.  
*Genes involved the development of post-chemotherapy cognitive impairment, include:
*Genes involved the development of post-chemotherapy cognitive impairment, include:<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>
:*COMT nucleotide polymorphism
:*COMT nucleotide polymorphism
:*Apolipoprotein E
:*Apolipoprotein E
:*BDNF gene  
:*BDNF gene  
*On gross pathology, characteristic findings of post-chemotherapy cognitive impairment, include:  
*On gross pathology, characteristic findings of post-chemotherapy cognitive impairment, include:<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>
:*No remarkable findings
:*No remarkable findings
*On microscopic histopathological analysis, characteristic findings of post-chemotherapy cognitive impairment, may include:
*On microscopic histopathological analysis, characteristic findings of post-chemotherapy cognitive impairment, may include:
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==Causes==
==Causes==
* Common causes 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>
* Common causes 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>
:*Cyclophosphamide
:*[[Cyclophosphamide]]
:*5-fluorouracil
:*[[5-fluorouracil]]
:*Methotrexate
:*[[Methotrexate]]


==Differentiating Post-Chemotherapy Cognitive Impairment from Other Diseases==
==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:
*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:<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
:*[[Dehydration]]
:*Infection
:*[[Infection]]
:*Sepsis
:*[[Sepsis]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
* Post-chemotherapy cognitive impairment is rare  
* Post-chemotherapy cognitive impairment is rare.
* The prevalence of post-chemotherapy cognitive impairment remains unknown.  
* Approximately 20-30% of patients that undergo chemotherapy experience some level of post-chemotherapy cognitive impairment.
* The prevalence of post-chemotherapy cognitive impairment remains unknown.<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>
===Age===
===Age===
*Post-chemotherapy cognitive impairment is more commonly observed among patients aged 40-70 years old.
*Post-chemotherapy cognitive impairment is more commonly observed among patients aged 40-70 years old.
*Post-chemotherapy cognitive impairment is more commonly observed among middle aged adults and elderly patients.  
*Post-chemotherapy cognitive impairment is more commonly observed among middle aged adults and elderly patients.  
===Gender===  
===Gender===  
*Females are slightly more commonly affected with post-chemotherapy cognitive impairment than males.  
*Females are slightly more commonly affected with post-chemotherapy cognitive impairment than males.<ref name="wiki">Post-chemotherapy cognitive impairment. Wikipedia. https://en.wikipedia.org/wiki/Post-chemotherapy_cognitive_impairment Accessed on May 18, 2016 </ref>
===Race===
===Race===
*There is no racial predilection for post-chemotherapy cognitive impairment.
*There is no racial predilection for post-chemotherapy cognitive impairment.<ref name="wiki">Post-chemotherapy cognitive impairment. Wikipedia. https://en.wikipedia.org/wiki/Post-chemotherapy_cognitive_impairment Accessed on May 18, 2016 </ref>


==Risk Factors==
==Risk Factors==
*The most common risk factor in the development of post-chemotherapy cognitive impairment are number of cycles of chemotherapy.
*The most common risk factor in the development of post-chemotherapy cognitive impairment are 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>
   
   
== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
*The majority of patients with post-chemotherapy cognitive impairment are initially symptomatic.  
*The majority of patients with post-chemotherapy cognitive impairment are initially symptomatic.<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:
*Early clinical features, include:
:*Lack of attention   
:*Lack of attention   
:*Memory loss
:*Problems to recall
:*Problems to recall
:*Lack of orientation
:*Lack of orientation
*If left untreated, patients with post-chemotherapy cognitive impairment may progress to develop  
*If left untreated, patients with post-chemotherapy cognitive impairment may progress to develop severe cognitive impairment.
*Common complications of post-chemotherapy cognitive impairment, include:
*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
:*Decreased executive function
:*Cerebrovascular disorders
:*[[Cerebrovascular disease|Cerebrovascular disorders]]
:*Focal neurological deficits
:*Focal neurological deficits
*Prognosis will generally depend on the underlying cause of cancer.
*Prognosis will generally good, and symptoms of post-chemotherapy cognitive impairment typically disappear in about four years.


== Diagnosis ==
== Diagnosis ==
===Diagnostic Criteria===
*The diagnosis of post-chemotherapy cognitive impairment is made with the following diagnostic criteria:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]
=== Symptoms ===
=== Symptoms ===
*Post-chemotherapy cognitive impairment is usually symptomatic at diagnosis  
*Post-chemotherapy cognitive impairment is usually symptomatic at diagnosis  
*Symptoms of post-chemotherapy cognitive impairment may include the following:
*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>
:*[symptom 2]
:*[[Memory loss]]
:*[symptom 3]
:*Lack of attention
:*[symptom 4]
:*Difficult language fluency
:*[symptom 5]
:*Poor calculation and recall
:*[symptom 6]
:*[[Loss of appetite]]
:*Irritability or constant mood swings
:*Hopelessness
*A directed history should be obtained to ascertain:
*A directed history should be obtained to ascertain:
:*Aggravating factors, such as:  
:*Aggravating factors, such as:  
::*Anxiety  
::*[[Anxiety]]
::*Depression
::*[[Depression]]


=== Physical Examination ===
=== Physical Examination ===
*Patients with post-chemotherapy cognitive impairment usually appear [general appearance].
*Patients with post-chemotherapy cognitive impairment usually appear malnourished and pale.  
*Physical examination may be remarkable for:
*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>
* Temperature
:*High grade fever
:*Low grade fever
:*Rapid pulse


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


===Imaging Findings===
===Imaging Findings===
*There are no imaging findings associated with post-chemotherapy cognitive impairment.
*There are no imaging findings associated with post-chemotherapy cognitive impairment.
*In some cases, MRI may detect accurate measurement of therapy-induced changes in gray and white matter volumes.


== Treatment ==
== Treatment ==
=== Medical Therapy ===
=== Medical Therapy ===
*There is no treatment for post-chemotherapy cognitive impairment; the mainstay of therapy is supportive care.
*There is no treatment for post-chemotherapy cognitive impairment; the mainstay of therapy is supportive care.
*Common medical therapies for the treatment of post-chemotherapy cognitive impairment, include:
*Common medical therapies for the treatment 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>
:*Hormonal Therapy
:*[[Hormonal therapy]]


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


=== Prevention ===
=== Prevention ===
*There are no primary preventive measures available for post-chemotherapy cognitive impairment.
*There are no primary preventive measures available 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>
*Once diagnosed and successfully treated, patients with post-chemotherapy cognitive impairment are followed-up every visit.
*Once diagnosed and successfully treated, patients with post-chemotherapy cognitive impairment are followed-up every visit.
*Follow-up testing includes cognitive function assessments (such as, mini–mental state examination)
*Follow-up testing includes cognitive function assessments (such as, mini–mental state examination)

Latest revision as of 20:42, 18 May 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: 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.[1] 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.[1] 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 gray and white matter volumes. Recent studies suggest further investigation on the underlying mechanisms of cognitive impairment.[2]

Historical Perspective

  • Post-chemotherapy cognitive impairment was first discovered and described in 1980.[1]

Classification

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

Pathophysiology

  • The pathogenesis of post-chemotherapy cognitive impairment is not fully understood.[1]
  • However, the underlying pathophysiology is believed to be caused by direct neurotoxicity.
  • Genes involved the development of post-chemotherapy cognitive impairment, include:[1]
  • COMT nucleotide polymorphism
  • Apolipoprotein E
  • BDNF gene
  • On gross pathology, characteristic findings of post-chemotherapy cognitive impairment, include:[1]
  • No remarkable findings
  • On microscopic histopathological analysis, characteristic findings of post-chemotherapy cognitive impairment, may include:
  • Smaller tumor size
  • Reduced cellularity
  • Extensive cytoplasmic vacuolization causing tumor cells to resemble histiocytes
  • Tumor necrosis
  • Atrophy and marked nuclear atypia

Causes

  • Common causes of post-chemotherapy cognitive impairment, include:[3]

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

  • Post-chemotherapy cognitive impairment is rare.
  • Approximately 20-30% of patients that undergo chemotherapy experience some level of post-chemotherapy cognitive impairment.
  • The prevalence of post-chemotherapy cognitive impairment remains unknown.[1]

Age

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

Gender

  • Females are slightly more commonly affected with post-chemotherapy cognitive impairment than males.[2]

Race

  • There is no racial predilection for post-chemotherapy cognitive impairment.[2]

Risk Factors

  • The most common risk factor in the development of post-chemotherapy cognitive impairment are number of cycles of chemotherapy.[3]

Natural History, Complications and Prognosis

  • The majority of patients with post-chemotherapy cognitive impairment are initially symptomatic.[1]
  • Early clinical features, include:
  • Lack of attention
  • Memory loss
  • Problems to recall
  • Lack of orientation
  • If left untreated, patients with post-chemotherapy cognitive impairment may progress to develop severe cognitive impairment.
  • Common complications of post-chemotherapy cognitive impairment, include:[3]
  • Prognosis will generally good, and symptoms of post-chemotherapy cognitive impairment typically disappear in about four years.

Diagnosis

Symptoms

  • Post-chemotherapy cognitive impairment is usually symptomatic at diagnosis
  • Symptoms of post-chemotherapy cognitive impairment may include the following:[1]
  • Memory loss
  • Lack of attention
  • Difficult language fluency
  • Poor calculation and recall
  • Loss of appetite
  • Irritability or constant mood swings
  • Hopelessness
  • A directed history should be obtained to ascertain:
  • 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.[3]

Laboratory Findings

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

Imaging Findings

  • There are no imaging findings associated with post-chemotherapy cognitive impairment.
  • In some cases, MRI may detect accurate measurement of therapy-induced changes in gray and white matter volumes.

Treatment

Medical Therapy

  • There is no treatment for post-chemotherapy cognitive impairment; the mainstay of therapy is supportive care.
  • Common medical therapies for the treatment of post-chemotherapy cognitive impairment, include:[3]

Surgery

  • Surgery is not recommended for patients with post-chemotherapy cognitive impairment.[1]

Prevention

  • There are no primary preventive measures available for post-chemotherapy cognitive impairment.[1]
  • Once diagnosed and successfully treated, patients with post-chemotherapy cognitive impairment are followed-up every visit.
  • Follow-up testing includes cognitive function assessments (such as, mini–mental state examination)

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 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. ↑ 2.0 2.1 2.2 Post-chemotherapy cognitive impairment. Wikipedia. https://en.wikipedia.org/wiki/Post-chemotherapy_cognitive_impairment Accessed on May 18, 2016
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