October 7, 2009

At the beginning of his senior year in high school, Amir Steinberg attended Yom Kippur services with his family in Houston and listened to what has since become known in their family as “the bitachon sermon,” referring to the Hebrew word for trust or faith.

The rabbi shared inspiring stories of people who had beaten the odds to achieve their goals, including his son, who had been shot and severely wounded during a robbery, yet lived to become a psychologist.

The message couldn’t have been timelier for Steinberg. Just weeks later, he was diagnosed with Hodgkin’s lymphoma, a type of cancer that primarily affects people between the ages of 16 and 35.

Today, Dr. Amir Steinberg, who beat his cancer, is an oncologist, treating others who have received a similar diagnosis.

Steinberg, 34, joined the Blood and Marrow Transplant Program at Cedars-Sinai’s Samuel Oschin Comprehensive Cancer Institute last year, where he treats patients with myelomas, leukemias and lymphomas and conducts research on stem cell transplants.

As a cancer survivor, Steinberg began his medical career with an innate sense about a healthy bedside manner, something that can take other doctors years to learn.

“I try to be as reassuring and encouraging as possible, as my doctor was with me. I have a sense of how to develop a rapport and connection with my patients, and to get inside their heads fairly quickly,” he said.

Yet Steinberg doesn’t automatically tell patients about his own medical history. “It can’t seem contrived,” he said. “I only say something if the moment seems right.” 

One such moment was when a college-aged patient with Hodgkin’s lymphoma appeared understandably depressed.

“I spoke to him as a confidant more than as doctor, and told him about my experience with cancer. It gave us an extra bond, and I told him the same thing that my doctor and parents told me: don’t give up, keep on fighting.” Fortunately, the patient did well.

During his treatment, Steinberg only missed a few days of his senior year, but exhaustion sidelined him from many basketball games.

“No one says it’s easy, but I’m also glad I got the cancer,” said Steinberg, who earned his medical degree from Texas Tech University School of Medicine. “I may not have become a doctor had I not gotten cancer, and I appreciate life more. Everything is beautiful to me: the flowers, my co-workers, family and friends. Even this desk is beautiful,” he said, smiling as he lightly slaps the smooth dark wood in his office.

While clinical studies haven’t provided proof, Steinberg is convinced that thinking positively has an unquantifiable benefit in the face of a serious medical diagnosis. One of his main priorities is to give that hope to all patients, regardless of age.

“Younger patients worry about being able to marry and have children, since cancer treatments can damage fertility, and also worry about not achieving their career goals. I try to instill hope in them that they can still get married and possibly have children, as I was able to do,” said Steinberg, who has a 1-year-old daughter. “I tell them, ‘All your dreams are still ahead of you.’ With older patients, I convey my belief that there is hope for everybody, even patients with late-stage cancers.”

With more than 12 million cancer survivors in the United States, long-term care and targeted health screenings are critically important for this population. Steinberg is helping to organize a new survivorship program at Cedars-Sinai to help patients deal with the risks of medical complications arising from previous treatments, including risks for other cancers and heart disease. The program’s initial focus is on patients with hematologic malignancies, such as lymphoma, leukemia and stem cell transplant survivors. Steinberg is currently developing long-term care guidelines for health care monitoring that the patients can take to their family physicians. 

He becomes visibly animated when discussing developments in cancer treatment, particularly the use of stem cell transplantation, which can treat and possibly cure patients with far fewer side effects than previous regimens. He refers to Gleevec, chemotherapy in pill form, as a “wonder drug” for chronic myeloid leukemia, and points to promising treatments for breast cancer, lymphoma, multiple myeloma and even lung cancer, in the form of new medications and innovative combinations of treatments.

Despite such advances, some cancers resist treatment.

“It’s very difficult for me to give up on a patient,” Steinberg said of such situations. “It’s frustrating that we can’t cure everybody, but there is always hope for new therapies. The most important thing to remember is that life is precious; we need to live every day to its fullest.”

Judy Gruen (judygruen.com) is the author of “The Women’s Daily Irony Supplement” (Creative Minds Press, 2007).

When Idelle Davidson was diagnosed with breast cancer in 2005, the furthest thing from her mind was safeguarding her memory. Radiation and chemotherapy took her energy, and most of her time. But months later, she began to forget things and become more and more disoriented — losing her car at the mall, forgetting friends’ phone numbers. She became concerned something was wrong.

“I didn’t understand what was happening to me,” said Davidson, a health and science journalist.

It wasn’t until she began attending support groups for cancer patients that she discovered something called “chemo brain.”

“People started describing their symptoms, and I said, ‘That’s happening to me, too,’” she said.

After doing some research, Davidson discovered that as many as 80 percent of chemotherapy patients experienced similar symptoms. And yet, little has been written about the phenomenon. Wanting to normalize the condition and provide a source of comfort and information for people like herself, Davidson reached out to Dr. Dan Silverman, head of neuronuclear imaging in the Ahmanson Biological Imaging Division at Ronald Reagan UCLA Medical Center. Together, they wrote the recently released book, “Your Brain After Chemo: A Practical Guide to Lifting the Fog and Getting Back Your Focus” (Da Capo Lifelong Books, $25).

While lacking a clear-cut medical definition, chemo brain can be described as the cognitive impairment that some people experience during and after chemotherapy. Research into the condition is relatively new, but it’s beginning to offer hope. And a study that recently began at UCLA will seek to help patients manage their symptoms, by focusing on rehabilitation and coping strategies. 

In addition to memory loss — a leading symptom of chemo brain — patients also describe a mental fog and trouble with daily activities. Many, including Davidson, report that the condition heavily impairs the quality of their work.

“I write for a living,” Davidson said. “Everything took a little bit longer, because you’re much slower cognitively. I think my writing suffered quite a bit.”

Clinical evidence supports patients’ claims. Based on his research, Silverman says that “the most common problems are with what they call executive function.” Controlled by an area in the front of the brain called the prefrontal cortex, executive functioning refers to the ability to maintain focus, multitask and concentrate, among other things.

A 2004 study by Jeffrey S. Wefel published in the journal Cancer provides further confirmation. In it, researchers tracked 18 women who underwent chemotherapy for breast cancer. Participants took neuropsychological tests before treatment, after treatment and then again one year later. The tests showed that cognitive ability had declined in 61 percent of the women.

While the data uphold a link between cognitive impairment and cancer treatment, experts remain perplexed as to how, exactly, chemotherapy could affect the brain. One of the most puzzling aspects has to do with the blood-brain barrier, a separation between the brain’s blood vessel branches and its cells, which is responsible for preventing anything harmful from entering the brain — including, in theory, chemotherapy agents.

Some researchers wonder if chemotherapy alone is to blame for patients’ symptoms. A leading theory that suggests otherwise, according to Silverman, is that chemotherapy causes the immune system to release molecules called cytokines. Produced during times of illness, cytokines often result in feeling tired or nauseous.

“Cytokines can more readily get into the brain than the chemo can,” Silverman said, “but they can also damage the brain.”

Another potential culprit is endocrine therapy, including the commonly used drug Tamoxifen. Endocrine therapy’s effect on cognitive functioning has yet to be studied thoroughly.

“Part of what we suspect,” said Dr. Steven Castellon, a neuropsychologist who has done extensive research on chemo brain, “is that there’s something about chemo and endocrine therapy, that [people who get both] seem to have more cognitive difficulties.”

As the search for a cause continues, medical professionals still must find appropriate treatments for patients who are suffering. Castellon suggests starting with lifestyle changes, such as using a PDA and consciously building structure into every day. Mental exercises can also be beneficial, including “crossword puzzles, sudokus, anything that’s cognitively stimulating,” he said. Some patients also see improvement from practicing yoga or meditating.

Following the implementation of these techniques, if a patient is still exhibiting symptoms, medication may be the next step. “Stimulants work very well for those executive problems,” Silverman said. Ritalin, which is commonly used to treat attention-deficit disorder, is one such option to fight fatigue and promote concentration.

Cognitive impairment can be devastating, but the good news is that recovery is likely. In the results of the Wefel study, 50 percent of sufferers were found to have recovered within one year of finishing chemotherapy treatment. And in her book, Davidson reports that 75 percent of patients recovered after two years.

In the future, experts may be able to use positron emission tomography (PET) and magnetic resonance imaging (MRI) scans to flag patients who are at a greater risk for developing chemo brain prior to treatment, and monitor them throughout.

Davidson, who is now four years out from her initial diagnosis and fully recovered, hopes that her book will help define chemo brain for those seeking answers, and forward research in the field.

“By understanding the cause,” she said, “scientists can find out how to fight chemo brain, or find ways so that people don’t experience it at all.”