Prevention of Cognitive Decline After Chemotherapy, With Fluoxetine Treatment
Systematic studies of adverse cognitive and neurobiological changes subsequent to
chemotherapy for lymphoma, breast, and other cancers have attracted substantial interest in
the past decade. Little is known, however, concerning the feasibility and effects of
potentially protective therapies on cerebral function in patients undergoing chemotherapy.
Animal models have recently proved useful in examining some of the toxic effects of
chemotherapy agents on working memory and other abilities, as well as on biological
properties such as proliferation and survival of neuronal precursors involved in hippocampal
neurogenesis. Such models have also proved useful for testing potential neuroprotective
properties of agents given before, during and/or after chemotherapy. For example, impairment
in spatial working memory and decreased hippocampal neurogenesis is induced in rats by the
chemotherapy agent methotrexate, but co-administration of the (FDA-cleared and commercially
available) drug fluoxetine has been shown to counteract the negative long-term effects on
memory and hippocampal neurogenesis otherwise occurring after methotrexate administration.
To determine whether such a strategy could be effective in counteracting effects that
chemotherapy may have on cerebral function in humans, well-controlled experimental data
obtained with cancer patients is needed.
This investigation will employ a prospective, randomized, double-blinded, placebo-controlled
design, to provide a rigorous test of whether fluoxetine, a drug with a long-standing
excellent safety profile in humans most commonly marketed as an antidepressant, can offer
protection to breast cancer or lymphoma patients against changes in cerebral function
occurring after chemotherapy (Specific Aim 1). It will further provide a test of the
durability of any protective effects beyond the period during which fluoxetine is used, by
re-assessing function approximately 6 months after completion of the regimen (Specific Aim
2). Cerebral function will be assessed by determining distributions of regional cerebral
metabolism, previously demonstrated to sensitively detect functional alterations and closely
reflect diminished cognitive abilities with high statistical power, using positron emission
tomography with the glucose analog radiotracer [F-18]fluorodeoxyglucose. Neuropsychologic
testing will be conducted in parallel with neuroimaging studies and, as a step towards
understanding mechanisms underlying neurotoxic effects of chemotherapy and potentially
related to protective effects of fluoxetine, peripheral markers of inflammatory cytokines
will be measured in blood samples drawn at the time of neuroimaging (Specific Aim 3). If
use of fluoxetine in cancer patients can be validated in this manner and lead to its
adoption in the clinical setting, it will constitute the first drug with demonstrated
utility for the prevention of cerebral dysfunction associated with exposure to chemotherapy.
Moreover, as this involves an agent that is already FDA-cleared for other indications,
widely commercially available throughout the U.S. and other parts of the world, and
relatively inexpensive since it is obtainable in generic formulations, it would represent a
pharmacologic approach that is amenable to rapid translation to the clinical setting.
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Primary Purpose: Prevention
Change from baseline in regional cerebral metabolism
Baseline and 6 months
Daniel H. Silverman, M.D., Ph.D.
University of California, Los Angeles
United States: Institutional Review Board
|City of Hope||Duarte, California 91010|
|UCLA Medical Center||Los Angeles, California 90095-7059|