Cancer Research, Statistics, and Treatment

: 2021  |  Volume : 4  |  Issue : 2  |  Page : 408--409

Cancer-related cognitive impairment in survivors of acute lymphoblastic leukemia

Bhausaheb Bagal1, Dipalee Borade2, George John1,  
1 Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
2 Department of Radiation Oncology, Apollo Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Bhausaheb Bagal
Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra

How to cite this article:
Bagal B, Borade D, John G. Cancer-related cognitive impairment in survivors of acute lymphoblastic leukemia.Cancer Res Stat Treat 2021;4:408-409

How to cite this URL:
Bagal B, Borade D, John G. Cancer-related cognitive impairment in survivors of acute lymphoblastic leukemia. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Sep 17 ];4:408-409
Available from:

Full Text

Cancer-related cognitive impairment (CRCI) is being increasingly recognized as a long-term complication. Various risk factors for CRCI have been described, including age, gender, cognitive reserve, genetic risk factors, and specific treatments (chemotherapy penetrating the blood–brain barrier like high-dose methotrexate [HD-MTX] and 5-fluorouracil, radiation-related variables like total dose, per fraction dose, and areas irradiated for radiation therapy). The pathogenesis appears to be multifactorial and remains to be elucidated in detail. The proposed main mechanism of damage includes impaired hippocampal neuronal generation, white matter damage, oxidative damage, vascular damage with impaired blood flow in the microcirculation, and impaired hypothalamic–pituitary–adrenal axis.[1]

Childhood acute lymphoblastic leukemia (ALL) is an important disease from the perspective of CRCI because of the high cure rates, younger age at presentation, and the use of specific therapies with a high risk of CRCI, like prophylactic cranial irradiation (PCI) and HD-MTX-based central nervous system (CNS) prophylaxis.[2] With intensive systemic therapies such as HD-MTX and cytarabine and the ability to salvage the CNS relapses, PCI is being increasingly avoided for the treatment of childhood ALL, however, it continues to be used where an intensive pediatric inspired protocol and/or salvage of CNS relapse is not feasible.[3],[4],[5]

Abraham et al. have reported on the neuropsychological outcomes in survivors of childhood ALL.[6],[7] We would like to congratulate the authors for taking up this often-neglected work amid the busy clinical practice of a high-volume center like theirs. In a cohort of 51 patients, it was observed that adult survivors had deficits in immediate memory, visuoconstructive ability, verbal learning, immediate recall, and visuomotor speed, whereas adolescent survivors had deficits in immediate memory and verbal working memory. These findings are in line with those reported in the literature. In this cohort of patients receiving PCI, because of the change in the protocol used over time, not all patients received HD-MTX-based systemic treatment. This provides an opportunity to look at the effect of HD-MTX on neuropsychological functioning, and we request the authors to comment on the same.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Hardy SJ, Krull KR, Wefel JS, Janelsins M. Cognitive changes in cancer survivors. Am Soc Clin Oncol Educ Book 2018;38:795-806.
2Hunger SP, Mullighan CG. Acute lymphoblastic leukemia in children. N Engl J Med 2015;373:1541-52.
3Ganesan P, Jain H, Bagal B, Subramanian PG, George B, Korula A, et al. Outcomes in adolescent and young adult acute lymphoblastic leukaemia: A report from the Indian Acute Leukaemia Research Database (INwARD) of the Hematology Cancer Consortium (HCC). Br J Haematol 2021;193:e1-4.
4Radhakrishnan VS, Agrawal N, Bagal B, Patel I. Systematic review of the burden and treatment patterns of adult and adolescent acute lymphoblastic leukemia in India: Comprehending the challenges in an emerging economy. Clin Lymphoma Myeloma Leuk 2021;21:e85-98.
5Pandey A, Ahlawat S, Singh A, Singh S, Murari K, Aryan R. Outcomes and impact of minimal residual disease (MRD) in pediatric, adolescent and young adults (AYA) with acute lymphoblastic leukemia treated with modified MCP 841 protocol. Cancer Res Stat Treat 2020;3:183-91.
6Abraham J, Veeraiah S, Radhakrishnan V. Neuropsychological functioning in long-term survivors of pediatric acute lymphoblastic leukemia: A prospective cross-sectional study. Cancer Res Stat Treat 2021;4:19-28.
7Datta SS, Mukherjee A. “My cancer is cured, but I do not feel normal”: A commentary on neuropsychological outcomes of pediatric acute lymphocytic leukemia in India. Cancer Res Stat Treat 2021;4:119-20.