Intended for healthcare professionals

Clinical Review State of the Art Review

Cognitive impairment after cancer treatment: mechanisms, clinical characterization, and management

BMJ 2023; 380 doi: (Published 15 March 2023) Cite this as: BMJ 2023;380:e071726
  1. Ben Fleming, research assistant1,
  2. Paul Edison, clinical reader in neuroscience and professor, honorary consultant1 2,
  3. Laura Kenny, clinical senior lecturer, consultant medical oncologist3
  1. 1Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
  2. 2College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
  3. 3Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
  1. Correspondence to: L Kenny l.kenny{at}


Cognitive impairment is a debilitating side effect experienced by patients with cancer treated with systemically administered anticancer therapies. With around 19.3 million new cases of cancer worldwide in 2020 and the five year survival rate growing from 50% in 1970 to 67% in 2013, an urgent need exists to understand enduring side effects with severe implications for quality of life. Whereas cognitive impairment associated with chemotherapy is recognized in patients with breast cancer, researchers have started to identify cognitive impairment associated with other treatments such as immune, endocrine, and targeted therapies only recently. The underlying mechanisms are diverse and therapy specific, so further evaluation is needed to develop effective therapeutic interventions. Drug and non-drug management strategies are emerging that target mechanistic pathways or the cognitive deficits themselves, but they need to be rigorously evaluated. Clinically, consistent use of objective diagnostic tools is necessary for accurate diagnosis and clinical characterization of cognitive impairment in patients treated with anticancer therapies. This should be supplemented with clinical guidelines that could be implemented in daily practice. This review summarizes the recent advances in the mechanisms, clinical characterization, and novel management strategies of cognitive impairment associated with treatment of non-central nervous system cancers.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: BF did the initial literature search. BF was the first author of the manuscript and created the first draft and revised it. PE and LK conceptualized and designed the work. LK and PE reviewed and revised the manuscript. PE and LK are the guarantors.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: PE was funded by the Medical Research Council and is now funded by Higher Education Funding Council for England (HEFCE); he has also received grants from Alzheimer’s Research UK, Alzheimer’s Drug Discovery Foundation, Alzheimer’s Society UK, Medical Research Council, Alzheimer’s Association US, Van-Geest foundation, and the European Union; he is a consultant to Roche, Pfizer, and Novo Nordisk and has received educational and research grants from GE Healthcare, Novo Nordisk, Piramal Life Science/Life Molecular Imaging, Avid Radiopharmaceuticals, and Eli Lilly; he was a member of the Scientific Advisory Board at Novo Nordisk and is on the scientific advisory board of CytoDyn; LK was a member of the scientific advisory board of General Electric Healthcare and is a consultant to General Electric Healthcare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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