The New Great Mimics: Cancer Treatment-Related Neuropsychiatric Syndromes

Abstract: One of the hallmarks of consultation-liaison (CL) psychiatry is the determination of whether a patient’s symptoms are psychiatric or more accurately attributable to other disease processes. Few patients pose as great a challenge as those with cancer in this regard. Impacting various organ systems, managed by large multidisciplinary teams, and involving potentially devastating complications, cancer-related treatments present with a variety of neuropsychiatric syndromes. If CL psychiatrists are unaware of relevant hematological and oncological interventions and their associated symptom patterns, then these sequelae may be falsely ascribed to underlying psychopathology, progression of the patient’s cancer, CNS metastases or other etiologies of delirium.

Neurotoxicity and the associated cognitive sequalae are some of the most challenging for patients undergoing active treatment and can persist into survivorship. The mechanism, associated symptoms, and clinical manifestations of a patient’ neurotoxicity is dependent on the specific agent or intervention: Chemotherapy results in alterations in DNA repair and microtubule functioning, radiation engenders both direct and indirect cellular injury, while new biologic and immunotherapies cause an autoimmune response via cross-reactivity with noncancerous cells (Stone, 2016).

Each speaker will describe a representative case that exemplifies a broader array of pathology, neurotoxicities, and etiologies.

Dr. Lahijani will discuss a case of immune effector cell associated neurotoxicity syndrome (ICANS) associated with chimeric antigen receptor T-cell therapy.

Dr. Fishman will discuss a case of cancer-related cognitive impairment or “chemobrain” following exposure to immune checkpoint inhibitors.

Dr. McFarland will discuss a case of neurotoxicity following standard of care chemotherapy.

Dr. Baer will discuss a case of SMART Syndrome while detailing the broader neuropsychiatric effects of radiation therapy.

Extensive communication and nuanced education with patients’ oncologists are critical to guide the diagnosis of these neuropsychiatric syndromes and ensure cancer therapeutics can be adjusted appropriately. This symposium will be of interest to not only psycho-oncologists but also general CL psychiatrists who are hoping to better understand and evaluate oncology patients or patients undergoing cancer treatments in their hospitals and clinics.

References

Stone, J. B., & DeAngelis, L. M. (2016). Cancer-treatment-induced neurotoxicity—focus on newer treatments. Nature reviews Clinical oncology, 13(2), 92-105.