Cognitive rehabilitation for cancer-related cognitive dysfunction: a systematic review

The Role of Rehabilitation for Women with Cancer

As the prevalence of female cancer survivors increases, their quality of life (QOL) and function have become key areas of focus in the context of survivorship and rehabilitation needs. Although behavioral modifications may help to decrease the development of malignancy, women are still at increased risk of developing a cancer diagnosis in their lifetime. Cancer and its treatment can lead to significant functional impairments and symptomatic challenges. However, rehabilitation interventions and medical management provide options to address these issues throughout the oncological continuum of care. With appropriate treatment, women are enabled to experience improved QOL and performance status.

Effect of Fangxia-Dihuang Decoction on doxorubicin-induced cognitive impairment in breast cancer animal model

Objective

Based on the murine model, this study explored the efficacy of Fangxia-Dihuang Decoction (FXDH) in interfering with cognitive impairment induced by doxorubicin (DOX) after chemotherapy for breast cancer.

Methods

Build 4T1 breast cancer xenograft tumor model in Balb/c mice, intraperitoneal injection of DOX (5mg/kg) once a week, build the model of DOX induced chemotherapy related cognitive impairment (CRCI), and the administration lasted for three weeks. From the first week, while DOX was given, FXDH was given high, medium and low doses by gavage every day. Conduct Y-maze and Novel object recognition (NOR) tests, detect inflammatory factors and oxidative stress-related indicators in serum and hippocampus, observe neuroinflammation and neurodegenerative changes through immunofluorescence and Nissl staining. Observation of heart and liver injury through blood routine and cardiac Hematoxylin-Eosin(HE)Staining.

Results

Administration of FXDH significantly improved cognitive impairment in mice. FXDH reduced the levels of pro-inflammatory cytokines IL-6, IL-12p70, and TNF-α (P<0.05), and increased the levels of anti-inflammatory cytokines IL-10 and IL-4 (P<0.05). FXDH increased the levels of GSH, GSH-PX, SOD, and CAT in serum and hippocampus (P<0.05), and decreased the level of MDA (P<0.05). The results of Nissl staining and immunofluorescence staining showed that FXDH improved the neurodegenerative lesions caused by DOX and the neuroinflammatory response in the hippocampus (P<0.05). The intermediate dose group of FXDH showed better efficacy. The results of blood routine and cardiac HE staining showed that compared with the 4T1 group, the serum ALT, AST, CK, LDH, and CKMB in DOX group mice were significantly increased (P<0.05). After FXDH administration, all indicators in mice were decreased, but there was no statistical difference. FXDH improved the disordered arrangement of myocardial cells, uneven cytoplasmic staining, and loose and disordered arrangement of myocardial fibers caused by DOX.

Conclusion

In the animal model, FXDH has the effect of anti-cognitive impairment after chemotherapy for breast cancer, and can improve the DOX induced learning, memory and cognitive impairment in mice. FXDH can reverse DOX induced neuroinflammation by improving the neurodegenerative changes caused by DOX, reducing pro-inflammatory cytokine levels in mouse serum and hippocampus, increasing anti-inflammatory cytokine levels, and reducing oxidative stress response.

Utilization outcomes of a cancer rehabilitation (CRNav) program: getting to the quadruple aim in cancer care

BACKGROUND

A cancer rehabilitation navigation (CRNav) program is an evidence-based care delivery model that uses a rehabilitation professional in the navigation role to support oncology care delivery, provide functional screening for early identification of impairment, and coordinate care delivery services to optimize early rehabilitation. There is limited research showing how a CRNav impacts healthcare utilization. The objective of this study was to assess utilization data for a CRNav Program and demonstrate how the program influences the effectiveness of cancer care delivery and patient and provider satisfaction.

METHODS

Data was collected from the electronic health record of the Brooks Rehabilitation/Halifax systems at a community cancer center to assess program and service utilization over 3.2 years using a retrospective design.

RESULTS

Over 3.2 years, the CRNav program received 1585 referrals and screened 1447 (91.3%) patients. Of the 1447 screenings performed, 73.6% were recommended to receive outpatient rehabilitation (n = 1065). Among patients screened, breast cancer was the most common cancer diagnosis (47%) followed by head and neck cancers (14%). There were 638 total rehabilitation visits identified for patients who were seen for services within the health system, with physical therapy encounters accounting for the greatest number (n = 462). The most common reasons for receiving physical therapy services included lymphedema (27%), pain (25%), and limited range of motion (12%). Patients reported high satisfaction (≥ 95.4%) in the areas of how well rehabilitation met expectations and overall satisfaction with the rehabilitation experience.

CONCLUSIONS

Using a CRNav in a community cancer center resulted in efficient care of patients with cancer, improved patient satisfaction and patient outcomes, and an enhanced clinician experience. This program provides a value-based approach to care supporting the quadruple aim and improving the identification and management of cancer-related functional morbidity.

Unveiling Cognitive Impairment in Older Adults with Cancer on Systemic Anticancer Therapy: A Comprehensive Review

Cancer-related cognitive impairment significantly affects cancer management and decision-making. While the exact mechanisms underlying cancer-related cognitive dysfunction remain complex and multifaceted, different factors have been identified that may help predict which patients are at increased risk for cognitive decline. In this article, we provide a comprehensive overview of systemic cancer therapy-induced cognitive impairment in older adults, including signs and symptoms, diagnosis, and management. In addition, we discuss the evidence available on the impact of endocrine therapy, cytotoxic chemotherapy, immunotherapy and targeted agents on cognition in this population.

Internet-Based Cognitive Rehabilitation for Working Cancer Survivors: A Process Evaluation

OBJECTIVE

The aim of the study was to evaluate the process of an online cognitive rehabilitation program aimed at supporting cancer survivors experiencing cognitive problems at work.

METHODS

Cancer survivors ( N = 279) were randomized to one of the intervention groups (ie, basic and extensive online cognitive rehabilitation) or waitlist control group. Recruitment, reach, dosage, implementation, perceived usefulness, and experiences with the program were evaluated using questionnaires and logbooks.

RESULTS

Implementation (ie, reach multiplied by dosage) was acceptable for both versions of the program (range 63%-76%). Cancer survivors and cognitive therapists perceived the overall program as moderately to highly useful and generally reported positive experiences.

CONCLUSIONS

Both a basic and extensive versions of the online cognitive rehabilitation program were successfully implemented in the context of a randomized controlled trial, suggesting their feasibility as intervention to support cancer survivors with cognitive problems at work.

Psychological Intervention for Patients with Biopsychosocial Late Effects Following Surgery for Colorectal Cancer with Peritoneal Metastases-A Feasibility Study

Background: Up to 80% of patients experience late effects (LE) one year after surgery for peritoneal metastases (PM) from colorectal cancer (CRC). We tested the feasibility and outcome of a treatment strategy to address LEs. Methods: During January 2021-May 2023, patients who had undergone surgery for CRC-PM in Denmark were screened for biopsychosocial LEs (anxiety, depression, fear of cancer recurrence, insomnia, cognitive impairment, pain, fatigue). Patients scoring according to clinical cut-offs were referred to a Multi-Disciplinary Team conference (MDT). The patients, surgeon(s), nurse(s), and psychologists participated in the MDT, identified key concerns and proposed a personalized intervention. Pre- and post-intervention, patients completed a "Measure Yourself Concerns and Wellbeing" (MYCaW) questionnaire, rating the two most distressing LEs and general wellbeing on a 7-point Likert scale. Results: Of 28 eligible patients, 13 (59 years (mean), 85% women) accepted referral, participated in the MDT, and were offered a personalized intervention. The intervention was completed by 11 patients. Improvement in MYCaW score was observed 1 month postintervention for all three items: (1) the primary LE (p = 0.003, Hedges's g 1.54), (2) the secondary LE (p < 0.001, Hedges's g 1.65), and (3) general wellbeing (p = 0.005, Hedges's g 1.09). This improvement was sustained 6 months postintervention. The 15 non-participants were, in general, older (66 years (mean), men 73%). Conclusions: Screening for LEs and conducting an MDT can provide a personalized intervention plan, which patients are able to complete and may benefit from.

The effect of non-pharmacological interventions on cognitive function in cancer: an overview of systematic reviews

PURPOSE

A significant number of cancer survivors experience cancer-related cognitive impairment (CRCI), which can impact their ability to think, reason, make decisions, and perform daily actions. In recent years, non-pharmacological interventions for CRCI have gained significant attention. These interventions include exercise, cognitive behavioural therapy, cognitive training/remediation, dietary, mind-body, and multi-modal/complex interventions. This umbrella review provides a critical overview to inform guidelines and current practice, identify the most promising interventions, and uncover gaps in the research literature.

METHODS

This umbrella review of systematic reviews was pre-registered on Open Science Framework and PROSPERO. Six databases were searched. Systematic reviews (SR) assessing any non-pharmacological interventions to improve cognition in cancer (any type) were included. The overview followed gold-standard guidelines and recommendations. The results were narratively synthesised, and descriptive statistics and effect size ranges were calculated.

RESULTS

Sixty-four (n = 64) SRs were included. Results were synthesised into four non-pharmacological domains. Cognitive training/rehabilitation had the strongest evidence for efficacy. Physical activity/exercise showed promising efficacy; however, the variability of findings was considerable. Mind-body and psychological/behavioural therapy interventions were limited, but there was evidence for short-term effectiveness. Multi-modal/complex interventions showed potential for improving cognition in cancer but were poorly defined.

CONCLUSIONS

Overall, non-pharmacological interventions demonstrated efficacy for improving cognition in cancer. There were limited intervention characteristics within domains which were consistently related to efficacy. Three key recommendations are provided for future research: (1) adopt harmonisation and reporting guidelines; (2) develop definitional guidelines of cognitive domains for CRCI research; and (3) assess intervention and participant characteristics associated with positive versus null/negative findings.

Perceived cognitive impairment and occupational functioning in prostate cancer survivors: an exploratory cross-sectional analysis

PURPOSE

Perceived cancer-related cognitive impairment (CRCI) has been reported in prostate cancer survivors. Little is known about how CRCI impacts occupational functioning in working-aged prostate cancer survivors (PCS). This study aimed to investigate the association between CRCI and occupational functioning in PCS.

METHODS

Data from 51 PCS, who were employed at the time of diagnosis, undergoing hormonal treatments (e.g., androgen deprivation therapy) or 'watchful waiting'/ 'active surveillance', were analysed. An online survey assessed CRCI using the FACT-Cog Perceived Cognitive Impairments (PCI20) subscale, the EORTC-QLQ-30 two-item cognitive functioning scale, and a single 'Yes/No' CRCI item (i.e., were 'changes in thinking (e.g., memory, attention)' experienced as a treatment side effect). PCS also indicated 'Yes/No' to changes to their ability to work, performance of work duties, and decreased work hours. Logistic regression analyses examined the relationship between CRCI measures and occupational outcomes.

RESULTS

Of the 51 PCS, 19 (37%) endorsed experiencing cognitive side effects from treatment. The single 'Yes/No' CRCI question was significantly associated with perceived changes in work ability and ability to perform work duties at the same level. PCI20 and the EORTC-QLQ-30 cognitive functioning scale were not significantly associated with any occupational outcomes.

CONCLUSION

Perceived CRCI is associated with adverse changes to occupational functioning and is important to consider when PCS are making plans to return-to-work following treatment.

IMPLICATIONS FOR CANCER SURVIVORS

Prostate cancer survivors may experience cognitive changes, which may impact their work ability.

Cognitive Rehabilitation of Brain Tumor Survivors: A Systematic Review

BACKGROUND

Cognitive decline is commonly seen in brain tumor (BT) patients and is associated with a worsened prognosis. Cognitive rehabilitation (CR) for cancer-related cognitive dysfunction has been widely studied for non-central nervous system cancers; however, recent emerging research has commenced documenting CR strategies for BT patients and survivors. Our objective was to review the current literature on various CR modalities in patients and BT survivors.

METHODS

The review was conducted in accordance with the PRISMA guidelines. The studies on CR were searched across 3 databases using a predefined search strategy. After removing duplicates, performing initial and full-text screenings, and applying inclusion criteria, relevant articles were selected. The demographic details, CR technique, cognitive tasks/tests administered, cognitive functions assessed, follow-up time, and outcomes of the intervention were assessed.

RESULTS

A total of 15 studies were included in the review. Neuropsychologist-guided training sessions to improve memory, attention, and executive functioning are effective in improving the mentioned domains. Younger and more educated patients benefited the most. Holistic mnemonic training and neurofeedback were not shown to affect overall cognitive functioning. Computer-based training programs showed improvements in executive functions of pediatric BT survivors, however, feasibility studies showed conflicting results. Aerobic exercises improved executive functions and decreased symptoms of the tumor. Both yoga and combined aerobic and strength training improved overall cognitive functioning. Active video gaming may improve motor and process skills; however, no effect was seen on cognitive functioning.

CONCLUSION

Neuropsychologic training, computer-based programs, and physical exercise have been found effective in improving or preventing decline in cognitive functions of BT patients. Given the limited trials and methodological variations, a standardized CR program cannot be established at present. Ongoing trials are expected to provide valuable data in the near future.

Impact of Cognitive Rehabilitation on Cognitive and Functional Outcomes in Adult Cancer Survivors: A Systematic Review

OBJECTIVES

This systematic review (PROSPERO CRD42021275421) synthesized evidence on the efficacy of cognitive rehabilitation on cognitive and functional outcomes in adult cancer survivors.

METHODS

Articles were identified though PubMed/MEDLINE, EMBASE, PsycINFO, and Web of Science from inception through June 30, 2023. Studies included participants ≥18 years old, diagnosed with cancer. Primary outcomes were validated measures of subjective and objective cognition. Articles were dual reviewed for eligibility and data extraction. Risk of bias was assessed with the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields.

RESULTS

The search yielded 3,811 articles; 65 full-text articles were reviewed; 53 articles (15 cognitive training, 14 strategy-based, 21 combinations, three inpatient rehabilitation), representing 52 unique studies, were included. Positive effects were observed in at least one objective cognitive measure in 93% of strategy training, 81% of cognitive training, 79% of combination rehabilitation interventions. Positive effects were observed in subjective cognition in 100% of strategy training, 55% of cognitive training, and 92% of combination interventions. Among studies with comparator groups, processing speed improved in 60% of cognitive training studies, while strategy training did not improve processing speed; otherwise, cognitive domain effects were similar between intervention types. Impact on functional outcomes was inconclusive.

CONCLUSIONS

Cognitive rehabilitation appear beneficial for cancer-related cognitive impairment (CRCI). Differential effects on specific cognitive domains (eg, processing speed) and subjective cognition may exist between intervention types.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should increase patient and provider awareness of the benefits of cognitive rehabilitation for CRCI.

Online Group Cognitive Rehabilitation Program for Prostate Cancer Survivors: Development Using Codesign and the Theoretical Domains Framework

OBJECTIVES

This study aimed to describe the adaptation of a group cognitive rehabilitation program for prostate cancer survivors (PCS) via telehealth delivery using a codesign approach with PCS experiencing cancer-related cognitive impairment. The Theoretical Domains Framework (TDF) also informed the intervention development.

METHODS

Intervention development consisted of three steps: 1) Adapting an existing cancer-related cognitive rehabilitation program for PCS; 2) Conducting a codesign focus group workshop to gather feedback that was analyzed using a template approach; and 3) Incorporation of consumer feedback to refine the program for future piloting in PCS. Components of the finalized intervention were mapped onto the TDF domains.

RESULTS

Six PCS were involved in the codesign focus group workshop, providing feedback on program structure, the topics and its order, and rehabilitation activities. A manualized four-week online group cognitive rehabilitation program titled "Promoting Cognitive Wellbeing in Prostate Cancer Survivors (ProCog)" was developed. Four sessions of 2-hours' duration were designed exploring: cognitive/brain functions; the impact of cancer treatments and ageing; the relationship between thoughts, feelings and behaviors; values-based goal-setting; and skills/strategies to manage fatigue and improve attention, memory, aspects of executive functioning, and emotional functioning.

CONCLUSIONS

Consumer input and guidance from the TDF ensures a robust development process for the online ProCog intervention, designed for and with PCS experiencing cognitive difficulties. As an important initial step before piloting, this adaptation and development process ensures that ProCog addresses consumer needs and preferences and targets factors increasing behavior change.

IMPLICATIONS FOR NURSING PRACTICE

This research raises awareness of possible cancer-related cognitive impairments in prostate cancer survivors and strategies for rehabilitation. ProCog is an accessible online intervention that nurses can use to refer patients needing cognitive rehabilitation.

Web-based cognitive interventions on subjective cognitive impairment in cancer survivors: A systemic review

Objective

Cancer survivors have experienced subjective cognitive impairment (SCI) when they received cancer diagnoses or treatments. Their psychosocial and emotional statuses were also impacted. With the advancement of web technologies, web-based cognitive interventions have been implemented in the management and the alleviation of the SCI, the psychosocial distress, and the emotional distress in cancer survivors. This review aimed to summarize the intervention contents of web-based cognitive interventions for SCI, and to explore the effects of the interventions on SCI, psychosocial status, and emotional health.

Methods

Six databases (CINAHL Plus, Cochrane Library, Embase, APA PsycInfo, PubMed and CNKI) were searched from the establishment of databases up to December 2023. Literature references were also manually searched for related articles.

Results

This review contained 21 studies that covered the contents of web-based cognitive interventions, such as computer-assisted cognitive training, online cognitive rehabilitation, cognitive behavior therapy with the Internet, telehealth physical exercise, and web-based mindfulness interventions. The effects of web-based cognitive interventions positively impacted SCI for cancer survivors. Also, these interventions showed varying degrees of effectiveness in alleviating psychosocial and emotional distresses.

Conclusion

By summarizing five types of cognitive intervention contents delivered via web technology, this review demonstrated that web-based cognitive interventions optimized SCI and overall psychosocial and emotional statuses for the cancer survivors. It is recommended that future research focus on the development of customized web-based cognitive interventions for individuals with SCI, along with their psychosocial and emotional statuses.

Comparative effectiveness of interventions for cancer treatment-related cognitive impairment in adult cancer survivors: protocol for a systematic review

BACKGROUND

Cancer treatment-related cognitive impairment (CTRCI) can substantially reduce the quality of life of cancer survivors. Many treatments of CTRCI have been evaluated in randomized controlled trials (RCTs), including psychological interventions, pharmacologic interventions, and other therapies. There is a pressing need to establish the benefits and harms of previously studied CTRCI treatments. The proposed systematic review and network meta-analyses will assess the relative efficacy and safety of competing interventions for the management of CTRCI.

METHODS

In consultation with the review team, an experienced medical information specialist will draft electronic search strategies for MEDLINE®, Embase, CINAHL, PsycINFO, and the Cochrane Trials Registry. We will seek RCTs of interventions for the treatment of CTRCI in adults with any cancer, except cancers/metastases of the central nervous system. Due to the anticipated high search yields, dual independent screening of citations will be expedited by use of an artificial intelligence/machine learning tool. The co-primary outcomes of interest will be subjective and objective cognitive function. Secondary outcomes of interest will include measures of quality of life, mental and physical health symptoms, adherence to treatment, and harms (overall and treatment-related harms and harms associated with study withdrawal), where feasible, random-effects meta-analyses and network meta-analyses will be pursued. We will address the anticipated high clinical and methodological heterogeneity through meta-regressions, subgroup analyses, and/or sensitivity analyses.

DISCUSSION

The proposed systematic review will deliver a robust comparative evaluation of the efficacy and safety of existing therapies for the management of CTRCI. These findings will inform clinical decisions, identify evidence gaps, and identify promising therapies for future evaluation in RCTs.

6th and 7th International consensus guidelines for the management of advanced breast cancer (ABC guidelines 6 and 7)

This manuscript describes the Advanced Breast Cancer (ABC) international consensus guidelines updated at the last two ABC international consensus conferences (ABC 6 in 2021, virtual, and ABC 7 in 2023, in Lisbon, Portugal), organized by the ABC Global Alliance. It provides the main recommendations on how to best manage patients with advanced breast cancer (inoperable locally advanced or metastatic), of all breast cancer subtypes, as well as palliative and supportive care. These guidelines are based on available evidence or on expert opinion when a higher level of evidence is lacking. Each guideline is accompanied by the level of evidence (LoE), grade of recommendation (GoR) and percentage of consensus reached at the consensus conferences. Updated diagnostic and treatment algorithms are also provided. The guidelines represent the best management options for patients living with ABC globally, assuming accessibility to all available therapies. Their adaptation (i.e. resource-stratified guidelines) is often needed in settings where access to care is limited.

Cognitive Symptoms Across Diverse Cancers

Importance

Psychosocial health services for adults with cancer should include support for cognitive symptoms and symptom clusters.

Objective

To characterize the frequency and severity of cognitive symptoms and to identify demographic and clinical risk factors associated with moderate to severe cognitive symptoms among outpatient adults with cancer seeking psychosocial support.

Design, Setting, and Participants

This cross-sectional study analyzed data from routine patient-reported symptom screening during clinic appointments at the Princess Margaret Cancer Centre in Toronto, Canada, between January 1, 2013, and December 31, 2019. Participants were outpatient adults (aged ≥18 years) with diverse cancer diagnoses who endorsed interest in receiving psychosocial support from a health care team member. Data analysis was performed from April 2020 to June 2024.

Main Outcomes and Measures

The presence and severity of cognitive symptoms as self-rated by participants were characterized across 12 cancer types: brain or central nervous system (CNS), breast, gastrointestinal, head and neck, gynecological, thyroid, lung and bronchus, sarcoma, genitourinary, melanoma, hematological, and all other cancers. Multivariable logistic regression was used to explore the associations between demographic, clinical, and symptom factors and moderate to severe cognitive symptoms.

Results

Across the sample of 5078 respondents (2820 females [55.5%]; mean [SD] age at time of survey, 56.0 [14.1] years) requesting psychosocial support, 3480 (68.5%) reported cognitive symptoms of any severity, ranging from 59.5% in sarcoma to 86.5% in brain or CNS cancer. Moderate to severe cognitive symptoms were reported by 1544 patients (30.4%), with the proportions being 51.3% for patients with brain or CNS, 37.0% for breast, 36.2% for thyroid, 30.9% for melanoma, 29.6% for head and neck, 28.3% for gastrointestinal, 28.2% for hematological, 28.1% for gynecological, 24.9% for lung and bronchus, 24.9% for sarcoma, 21.0% for genitourinary, and 26.8% for all other cancers. Across the entire sample, moderate to severe cognitive symptoms were associated with recurrence or progression involving the CNS (odds ratio [OR], 2.62; 95% CI, 1.80-3.81), depression (OR, 1.92; 95% CI, 1.59-2.31), tiredness (OR, 1.82; 95% CI, 1.52-2.19), drowsiness (OR, 1.64; 95% CI, 1.39-1.93), anxiety (OR, 1.57; 95% CI, 1.30-1.89), shortness of breath (OR, 1.38; 95% CI, 1.16-1.61), female sex (OR, 1.33; 95% CI, 1.14-1.56), first-line chemotherapy received (OR, 1.22; 95% CI, 1.05-1.41), and metastatic disease at diagnosis (OR, 0.74; 95% CI, 0.61-0.89). Within individual cancer types, tiredness and depression were consistently associated with moderate to severe cognitive symptoms.

Conclusions and Relevance

This cross-sectional study found that cognitive symptoms were frequently reported by patients across a wide range of cancer types; higher severity of cognitive symptoms was consistently associated with higher symptom burden. The findings could be used to inform decision-making regarding access to cognitive screening, assessment, and supportive care in outpatient oncology clinics.

Neuropsychological assessment, intervention, and best practices for women with non-Central nervous system cancer: A scoping review of current standards

Objective: Existing literature has sought to characterize the broad cognitive impact of non-central nervous system cancer and its treatment, including chemotherapy, radiation, surgery, and hormonal regulation. However, despite the frequency of women that are diagnosed with breast and gynecological cancer, there is limited research on the specific cognitive experiences of women undergoing cancer treatment. Presently, the current literature lacks concise guidance for neuropsychologists to support the cognitive health of women facing cancer, despite the acknowledged impact of cancer interventions and chronic illness on cognitive outcomes. Method: Applying scoping review criteria outlined by Peters et al. (2015) and adhering to Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a comprehensive examination of literature spanning multiple databases (Google Scholar, PubMed, PsychINFO) with a focus on the cognitive impact of cancer treatment on women. Conclusions: Women are subject to unique treatment-related outcomes due to the impact of hormonal alterations, differences in metabolization of certain chemotherapies, and psychosocial risk factors. Despite the known impact of cancer intervention, chronic illness, and cancer-related sequelae on cognitive outcomes, the current literature does not parsimoniously outline best practices for neuropsychologists to promote the health of women experiencing cancer. The current paper (1) provides an overview of the cognitive implications of cancer treatment with an intentional focus on cancers that are more prevalent in women versus men, (2) addresses the characteristics of this impact for women undergoing cancer intervention(s), and (3) provides possible intervention and treatment strategies for mental health providers and neuropsychologists.

What is the nature and impact of cognitive difficulties following hormonal treatments for prostate cancer?: An interpretative phenomenological analysis

OBJECTIVE

Prostate cancer hormonal treatments (e.g. androgen deprivation therapy) yield clinical benefits. However, there is increasing evidence these treatments may adversely impact cognitive functioning. This study aimed to qualitatively characterise the nature and impact of cognitive difficulties following these treatments.

METHODS

Prostate cancer survivors (PCS) self-reporting cognitive difficulties following hormonal treatments (via an online survey) and their partners were invited to participate in semi-structured interviews. Telephone or videoconferencing interviews were conducted, then transcribed, double-coded and analysed using the Framework Method, following the principles of Interpretative Phenomenological Analysis.

RESULTS

Eleven participants (six PCS and five partners) were interviewed. PCS reported a range of cognitive difficulties, verified by their partners, including forgetfulness, "fogginess", fatigue and slowed processing speed. For some PCS, word-finding difficulties, tangential speech and memory problems were apparent during interviews. The aetiology of the reported cognitive difficulties was unclear as it was attributed to a possible combination of cancer treatments, compounding side-effects (e.g. fatigue, sleep problems, hot flashes), exacerbation of pre-existing conditions and/or age-related changes. Cognitive difficulties were reported to have led to shifts in self-perception, interpersonal dynamics and increased emotionality. Engagement in cognitively-stimulating activities and reliance on compensatory strategies were reported to be helpful in managing some cognitive difficulties. All participants endorsed the potential benefits of neuropsychological intervention.

CONCLUSIONS

There are a diverse range of cognitive difficulties following hormonal treatments for prostate cancer experienced by PCS and their partners. Understanding the impact of these difficulties is important for the development of targeted neuropsychological interventions.

A systematic review of rehabilitation programs for cognitive impairment related to breast cancer: Different programs at different times?

BACKGROUND

"Cancer Related Cognitive Impairment" (CRCI) defines cognitive disorders related to cancer and its treatments. Many people with breast cancer experience signs of CRCI (incidence between 20 and 30 %) and, although several intervention options exist, there is no established standard of care. Our main objective was to provide a detailed description of the methods and results of randomized controlled trials of interventions for CRCI in breast cancer survivors, paying particular attention to the timing of the interventions within the care pathway.

METHODS

We conducted a systematic literature review following the PRISMA guidelines from 01 to 01-2019 to 16-07-2023 and included randomized controlled trials of interventions for CRCI after breast cancer with at least one objective cognitive assessment as a primary or secondary outcome.

RESULTS

Among 228 identified studies, 35 (including 2821 participants) were retained for inclusion. The interventions were classified into 4 categories: cognitive rehabilitation, physical activity, complementary therapy and pharmacological treatment. Our analysis revealed that pharmacological interventions have no effect, whereas physical activity interventions proposed in the months following the initial cancer treatment improve Quality of Life and Speed of Information Processing while interventions proposed later improve Memory and Attention (Cognitive Rehabilitation) and Perceived Cognitive Function and Depression/Anxiety/Mood (Complementary Therapies).

CONCLUSION

CRCI is multifactorial and affected individuals frequently experience high levels of fatigue, pain, anxiety and depression and are most likely to benefit from holistic approaches that include cognition, physical activity, relaxation, psychoeducation, group support and/or psychological counselling. Thus, rehabilitation programs should be designed on multi-modal approaches, using innovative, cost-effective delivery methods that increase access to treatment, and intervention outcomes should be evaluated using measures of participation.

DATABASE REGISTRATION

The review was recorded on Prospero (01-03-2020), with the registration number 135,627.

Psychosocial Factors Associated with Cognitive Function in Prostate Cancer Survivors on Hormonal Treatments: A Systematic Review

Hormonal treatments (HT) for prostate cancer (e.g., androgen deprivation therapy) yield clinical and survival benefits, yet adverse cognitive changes may be a side effect. Since psychosocial factors are largely modifiable, interventions targeting these factors may help mitigate these adverse cognitive effects. This systematic review aimed to identify a range of psychosocial factors associated with cognitive function in individuals with prostate cancer undergoing HT and to determine whether these factors mitigate or exacerbate this effect. Applying PRISMA guidelines, a comprehensive search of relevant databases conducted in September 2023 using terms related to prostate cancer, hormone therapy, and cognitive outcomes was undertaken. The search yielded 694 unique abstracts, with 11 studies included for analysis examining the relationship between cognitive function and the following psychosocial factors: psychological distress, fatigue, insomnia, and coping processes. Findings were mixed with only two studies reporting significant associations between cognitive performance with fatigue and depression. Three studies that included measures of perceived cognitive function identified associations with depression, anxiety, fatigue, insomnia, illness threat appraisals, and coping styles. However, no studies found evidence for an association between self-reported and objective measures of cognitive functioning. Evidence regarding the association of interpersonal factors is lacking. Moreover, whether these factors mitigate or exacerbate the effect of HT on cognitive function still needs to be determined. Overall, the research exploring the association between psychosocial factors and cognitive function in prostate cancer survivors undergoing HT is still in its infancy. Further research is required to optimize the implementation of neuropsychological interventions for prostate cancer survivors.

Internet-based cognitive rehabilitation for working cancer survivors: results of a multicenter randomized controlled trial

BACKGROUND

Cognitive problems contribute to decline in work performance. We evaluated (1) the effectiveness of basic self-management and extensive therapist-guided online cognitive rehabilitation on attainment of individually predetermined work-related goals among occupationally active cancer survivors, and (2) whether effectiveness of the programs differed for survivors with and without formal cognitive impairment.

METHODS

In a 3-arm randomized controlled trial (NCT03900806), 279 non-central nervous system cancer survivors with cognitive complaints were assigned to the basic program (n = 93), the extensive program (n = 93), or a waiting-list control group (n = 93). Participants completed measurements pre-randomization (T0), 12 weeks post-randomization upon program completion (T1), and 26 weeks post-randomization (T2). Mixed-effects modeling was used to compare intervention groups with the control group on goal attainment, and on self-perceived cognitive problems, work ability, and health-related quality of life.

RESULTS

Participants in the extensive program achieved their predetermined goals better than those in the control group, at short- and long-term follow-up (effect size [ES] = .49; P < .001; ES = .34; P = .014). They also had fewer recovery needs after work (ES = -.21; P = .011), more vitality (ES = .20; P = .018), and better physical role functioning (ES = .0.43 P = .015) than controls. At long-term follow-up, this finding persisted for physical role functioning (ES = .42; P = .034). The basic program elicited a small positive nonsignificant short-term (not long-term) effect on goal attainment for those with adequate adherence (ES = .28, P = .053). Effectiveness of the programs did not differ for patients with or without cognitive impairment.

CONCLUSIONS

Internet-based therapist-guided extensive cognitive rehabilitation improves work-related goal attainment. Considering the prevalence of cognitive problems in survivors, it is desirable to implement this program.

Cognitive-enhanced eHealth psychosocial stepped intervention for managing breast cancer-related cognitive impairment: Protocol for a randomized controlled trial

Introduction

Breast cancer often leads to cancer-related cognitive impairment (CRCI), which includes both objective and subjective cognitive deficits. While psychosocial interventions benefit quality of life and distress reduction, their impact on cognitive deficits is uncertain. This study evaluates the integration of a cognitive module into a digital psychosocial intervention for breast cancer patients.

Methods

In this randomized controlled trial (RCT), 88 recently diagnosed breast cancer (BC) patients will receive the ICOnnecta't program (control group) - a digital stepped intervention addressing a variety of psychosocial needs. The experimental group (n = 88) will receive ICOnnecta't plus a cognitive module. Assessments at baseline, 3, 6, and 12 months will measure the interventions' impact on cognition, emotional distress, medication adherence, quality of life, post-traumatic stress, work functioning and healthcare experience. Feasibility and cost-utility analyses will also be conducted.

Results

The cognitive module includes three levels. The first level contains a cognitive screening using FACT-Cog Perceived Cognitive Impairment (PCI). Patients with PCI <54 progress to a cognitive psychoeducational campus (Level 2) with content on cognitive education, behavioural strategies and mindfulness. Patients with persistent or worsened PCI (≥6) after 3 months move to Level 3, an online cognitive training through CogniFit software delivered twice a week over 12 weeks.

Conclusions

This study assesses whether integrating a cognitive module into a digital psychosocial intervention improves objective and subjective cognition in breast cancer patients. Secondary outcomes explore cognitive improvement's impact on psychosocial variables. The research will contribute to testing efficacious approaches for detecting and addressing cognitive dysfunction in breast cancer patients.

Trial registration

ClinicalTrials.gov, NCT06103318. Registered 26 October 2023, https://classic.clinicaltrials.gov/ct2/show/NCT06103318?term=serra-blasco&draw=2&rank=4.

Long-term changes of cognitive impairment among older breast cancer survivors

PURPOSE

Cancer-related cognitive impairment is common during cancer treatment; however, it is unclear whether the impairment persists over time. Our study aimed to examine long-term cognitive impairment among older breast cancer survivors.

METHODS

Participants included 2420 community-dwelling women aged 65 years or older at enrollment (1986-1988) (404 breast cancer cases and 1:5 matched cancer-free controls) from the Study of Osteoporotic Fractures. Participants were followed for 20 years with measured cognitive function repeated up to 6 times. Cognitive impairment was defined by the Modified Mini-Mental State Examination and Trail Making Test B. Generalized linear models were used to model risk of cognitive impairment in relation to breast cancer status and time from breast cancer diagnosis.

RESULTS

Compared with controls, cognitive impairment in women with breast cancer significantly accelerated after cancer diagnosis. We also observed a more pronounced cognitive impairment after cancer diagnosis for women diagnosed with breast cancer at age ≥ 80 years or at advanced stage for both measures.

CONCLUSION

Our study with more than 20 years of follow-up data found that breast cancer survivors had accelerated cognitive impairment after cancer diagnosis, especially among women diagnosed at older age or at advanced stage, relative to women without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivors may be encouraged to engage in both physical activity and cognitive training.

A randomised controlled trial evaluating two cognitive rehabilitation approaches for cancer survivors with perceived cognitive impairment

PURPOSE

Up to 70% of survivors report cognitive symptoms after chemotherapy. We compared two cognitive rehabilitation programs to a control group in cancer survivors.

METHODS

Study population were adult cancer survivors with cognitive symptoms 6-60 months after adjuvant chemotherapy. Participants randomised to: Attention Process Training (APT), Compensatory Strategy Training (CST), or control group. Active interventions comprised 6-week, 2-h/week small group sessions.

ASSESSMENTS

pre- and post-intervention, 6- and 12-months later. Primary outcome was change in cognitive symptoms (FACT-COG-PCI subscale) between baseline and post-intervention. Secondary endpoints included objective neuropsychological performance, Functional Impact Assessment (FIA), patient-reported outcome measures, and associations. Analyses were on an intention-to-treat basis. Analysis of covariance mixed models were used for continuous outcomes.

RESULTS

Sixty-five participants were randomised (APT n = 21; CST n = 24; controls n = 20): 94% breast cancer, median age 54. Median time since chemotherapy 20.7 months. FACT-COG-PCI, clinical neuropsychological T-scores, and FIA improved in all groups over time, but no significant differences between arms. On mean neuropsychological T-scores 19/65 (29%) were impaired at baseline; post-intervention impairment controls 31.3%, CST 16.7%, APT 20.0%. On FIA at baseline, nine were impaired; this decreased to three post-intervention (one/group). FACT-COG-PCI was weakly associated with neuropsychological tests (rho = 0.24, p = 0.051) at baseline, and had no association with FIA. Neuropsychological total mean T-score was moderately positively associated with FIA (rho = 0.37, p = 0.003).

CONCLUSION

There were no significant differences between intervention groups and controls using linear mixed models adjusted for baseline scores.

IMPLICATIONS FOR CANCER SURVIVORS

Cognitive symptoms and neuropsychological test scores improve over time.

Using Single-Case Experimental Design and Patient-Reported Outcome Measures to Evaluate the Treatment of Cancer-Related Cognitive Impairment in Clinical Practice

Cancer-related cognitive impairment (CRCI) affects a large proportion of cancer survivors and has significant negative effects on survivor function and quality of life (QOL). Treatments for CRCI are being developed and evaluated. Memory and attention adaptation training (MAAT) is a cognitive-behavioral therapy (CBT) demonstrated to improve CRCI symptoms and QOL in previous research. The aim of this article is to describe a single-case experimental design (SCED) approach to evaluate interventions for CRCI in clinical practice with patient-reported outcome measures (PROs). We illustrate the use of contemporary SCED methods as a means of evaluating MAAT, or any CRCI treatment, once clinically deployed. With the anticipated growth of cancer survivorship and concurrent growth in the number of survivors with CRCI, the treatment implementation and evaluation methods described here can be one way to assess and continually improve CRCI rehabilitative services.

Effectiveness of Nonpharmacologic Interventions for Chemotherapy-Related Cognitive Impairment in Breast Cancer Patients: A Systematic Review and Network Meta-analysis

BACKGROUND

Neurotoxicity is a major adverse effect of chemotherapy in breast cancer (BC) patients. A number of nonpharmacologic interventions are used to alleviate chemotherapy-related cognitive impairment (CRCI), but no studies have compared their effectiveness.

OBJECTIVES

The aim of this study was to identify and compare the effectiveness of different nonpharmacologic interventions for CRCI in BC patients.

METHODS

A systematic review and network meta-analysis was conducted following the Cochrane guidelines. All randomized controlled trials were searched in the Cochrane Library, PubMed, MEDLINE (via OVID), Web of Science, EMBASE, and CINAHL databases from inception to September 2021. Studies using nonpharmacologic interventions to manage CRCI symptoms were included. A network meta-analysis and a comparative effects ranking were completed by STATA v14.0.

RESULTS

Twelve studies with 8 nonpharmacologic interventions were included. For subjective outcomes on CRCI, there was no significant difference between nonpharmacologic interventions. For objective outcomes, qigong and exercise were more effective than the psychotherapy. Qigong and exercise were also more effective than music therapy. The top 3 interventions were psychotherapy (83.4%), music therapy (60.8%), and electroacupuncture (52.5%) for subjective outcomes and qigong (87.7%), exercise (82.1%), and electroacupuncture (70.3%) for objective outcomes.

CONCLUSION

In the subjective evaluation, it was difficult to judge which interventions are best, but psychotherapy had the greatest probability. For objective evaluation, qigong and exercise may be the best nonpharmacologic interventions.

IMPLICATIONS FOR PRACTICE

This study provides evidence for the effectiveness of nonpharmacologic interventions for CRCI in BC patients and facilitates support for future clinical trials and work.

Neuroimaging based biotypes for precision diagnosis and prognosis in cancer-related cognitive impairment

Cancer related cognitive impairment (CRCI) is commonly associated with cancer and its treatments, yet the present binary diagnostic approach fails to capture the full spectrum of this syndrome. Cognitive function is highly complex and exists on a continuum that is poorly characterized by dichotomous categories. Advanced statistical methodologies applied to symptom assessments have demonstrated that there are multiple subclasses of CRCI. However, studies suggest that relying on symptom assessments alone may fail to account for significant differences in the neural mechanisms that underlie a specific cognitive phenotype. Treatment plans that address the specific physiologic mechanisms involved in an individual patient's condition is the heart of precision medicine. In this narrative review, we discuss how biotyping, a precision medicine framework being utilized in other mental disorders, could be applied to CRCI. Specifically, we discuss how neuroimaging can be used to determine biotypes of CRCI, which allow for increased precision in prediction and diagnosis of CRCI via biologic mechanistic data. Biotypes may also provide more precise clinical endpoints for intervention trials. Biotyping could be made more feasible with proxy imaging technologies or liquid biomarkers. Large cross-sectional phenotyping studies are needed in addition to evaluation of longitudinal trajectories, and data sharing/pooling is highly feasible with currently available digital infrastructures.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Effectiveness of a Computerized Home-Based Cognitive Stimulation Program for Treating Cancer-Related Cognitive Impairment

Cancer patients assert that after chemotherapy their cognitive abilities have deteriorated. Cognitive stimulation is the clinical treatment of choice for reversing cognitive decline. The current study describes a computerized home-based cognitive stimulation program in patients who survived breast cancer. It aims to assess safety and effectiveness of cognitive stimulation in the oncology population. A series of 45-min training sessions was completed by the participants. A thorough assessment was performed both before and after the intervention. The mini-Mental Adjustment to Cancer Scale, the Cognitive Assessment for Chemo Fog Research, and the Functionality Assessment Instrument in Cancer Treatment-Cognitive Function served as the main assessment tools. The State-Trait Anxiety Inventory, Beck Depression Inventory, Brief Fatigue Inventory, and Measuring Quality of Life-The World Health Organization data were gathered as secondary outcomes. Home-based cognitive stimulation demonstrated beneficial effects in the oncology population, with no side effects being reported. Cognitive, physical, and emotional improvements were observed, along with decreased interference in daily life activities and a better overall quality of life.

Cognitive Retraining and Functional Treatment (CRAFT) for adults with cancer related cognitive impairment: a preliminary efficacy study

PURPOSE

To examine the preliminary efficacy of Cognitive Retraining and Functional Treatment (CRAFT) combining remote computerized cognitive training (CCT) and occupation-based treatment in adults with cancer-related cognitive impairment (CRCI).

METHODS

Three-armed randomized controlled trial including 74 individuals with CRCI, randomized into 12 weeks of either CRAFT, CCT alone, or treatment-as-usual. Assessments evaluating participation in daily life, perceived cognition, cognitive performance, quality-of-life, and treatment satisfaction were administered at baseline, post-intervention, and 3-month follow-up.

RESULTS

Significant time × group interactions in favor of the CRAFT and CCT groups were found for participation in daily life (F_2,34 = 5.31, p = .01, eta = .238), perceived cognition (F_2,34 = 4.897, p = .014, eta = .224), and cognitive performance on speed of processing test (F = 5.678, p = .009, eta = .289). The CRAFT group demonstrated significantly larger clinically meaningful gains on participation in daily life (chi-square = 6.91, p = .032) and significantly higher treatment satisfaction. All treatment gains were maintained at a 3-month follow-up (n = 32).

CONCLUSIONS

CCT and CRAFT were found to have a positive impact on participation and cognitive outcomes among individuals with CRCI. The CRAFT showed an additional advantage in improving self-chosen occupation-based goals suggesting that a combination of cognitive training with occupation-based intervention has a positive synergistic effect resulting in "real world" health benefits.

IMPLICATIONS FOR CANCER SURVIVORS

A combination of cognitive training with occupation-based intervention has a positive effect resulting in clinically meaningful improvements in participation in daily life, objective cognitive performance, and subjective cognitive impairment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT04210778, December 26, 2019, retrospectively registered.

CanCOG®: Cultural Adaptation of the Evidence-Based UCLA Cognitive Rehabilitation Intervention Program for Cancer Survivors in Portugal

Cognitive difficulties are highly prevalent and negatively impact cancer survivors' quality of life. The UCLA Cognitive Rehabilitation Intervention Program (in short, UCLA program) is an evidence-based intervention developed and tested in the US to address the cognitive complaints of cancer survivors. Since there are no cognitive rehabilitation programs available for Portuguese cancer-related settings, this study aimed to culturally adapt the UCLA program to Portugal. Nine steps were implemented for this cultural adaptation: needs assessment, initial contacts, translation, cultural adaptation, independent review by a panel of experts (n = 6), focus group discussions with cancer survivors (n = 11), systematization of inputs and improvement of the final materials, fidelity check, and preliminary acceptability assessment. The findings suggested that changes to the original materials were needed. A Portuguese name, "CanCOG^®-Reabilitação Cognitiva no Cancro" (in English "CanCOG^®-Cognitive Rehabilitation in Cancer"), and a logo were created to make it more memorable and appealing for the Portuguese population. The language was adjusted to ensure content accessibility and semantic and conceptual equivalence. Finally, references to several cultural aspects, such as habits, customs, and traditions, were adapted to fit the new cultural context. The UCLA program may be a promising tool to help alleviate the cognitive difficulties reported by cancer survivors in different cultural contexts. Future research is needed to confirm the feasibility, acceptability, and preliminary efficacy of its Portuguese version, "CanCOG^®-Reabilitação Cognitiva no Cancro".

Effect of cognitive training on patients with breast cancer reporting cognitive changes: a systematic review and meta-analysis

OBJECTIVES

Cognitive training is a non-drug intervention to improve the cognitive function of participants by training them in different cognitive domains. We investigated the effectiveness of cognitive training for patients with breast cancer reporting cognitive changes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library, WOS, CINAHL, CNKI, VIP, SinoMed, Wanfang, Grey literature and trial registries were searched (from inception to 1 October 1, 2022).

ELIGIBILITY CRITERIA

Inclusion of randomized controlled trials (RCTs) assessing the effects of cognitive training on breast cancer patients reporting cognitive changes The primary outcome was subjective cognitive function. Secondary outcomes were objective cognitive functioning (eg, executive functioning and attention) and psychological outcomes(eg, anxiety, depression, and fatigue).

DATA EXTRACTION AND SYNTHESIS

Two reviewers worked independently to screen the literature, extract data, and assess the methodological quality and risk bias of the included studies. Results are reported as standardizedstandardised mean differences (SMDs) with 95% confidence intervals(CI). Grades of Recommendation, Assessment, Development, and Evaluation(GRADE) were used to assess the quality of evidence.

MAIN OUTCOMES AND MEASURES

The primary outcome was subjective cognitive function. Secondary outcomes were objective cognitive functioning (eg, executive functioning and attention) and psychological outcomes(eg, anxiety, depression and fatigue).

RESULTS

A total of 9 RCTs involving 666 patients with breast cancer were included. The frequency of cognitive training varied and the duration was mostly focused on 5-12 weeks. It can be delivered to patients in an individual or group mode, both online and face to face. Meta-analysis revealed that cognitive training aimed at adaptive training in cognitive field has statistically significant effects on improving subjective cognitive function (SMD=0.30, 95% CI (0.08 to 0.51), moderate certainty). Some objective cognitive functions such as processing speed (SMD=0.28, 95% CI (0.02 to 0.54), low certainty), verbal memory (SMD=0.32, 95% CI (0.05 to 0.58), moderate certainty), working memory (SMD=0.39, 95% CI (0.17 to 0.61), moderate certainty) and episodic memory (SMD=0.40, 95% CI (0.11 to 0.69), moderate certainty) were significantly improved after the intervention. In addition, we did not find statistically significant changes in attention, short-term memory, execution function, depression, anxiety and fatigue in patients with breast cancer after the intervention. Subgroup analyses revealed that based on the delivery of individual sessions, the use of web-based cognitive training software may be more beneficial in improving the outcome of the intervention.

CONCLUSION

Evidence of low to moderate certainty suggests that cognitive training may improve subjective cognition, processing speed, verbal memory, working memory and episodic memory in patients with breast cancer reporting cognitive changes. But it did not improve patients' attention, short-term memory, executive function, depression, anxiety and fatigue.

PROSPERO REGISTRATION NUMBER

CRD42021264316.

Meta-analysis of neurocognitive rehabilitation for cognitive dysfunction among pediatric cancer survivors

Cancer and its treatment significantly affect the cognitive functioning of pediatric cancer survivors. This meta-analysis aimed to examine the effects of neurocognitive rehabilitation interventions on the cognitive functioning and intellectual performance of pediatric cancer survivors. Four databases were searched until December 15, 2021. RevMan 5.4 was used to analyze the effects of neurocognitive rehabilitation interventions on the cognitive functioning of pediatric cancer survivors. Ten eligible randomized controlled trials were initially identified, and nine of these were included in the meta-analysis. For the working memory outcome, the pooled effect results favored study interventions and had statistical significance at postintervention assessment (Z = 2.24, P = 0.03). For the attention outcome, there were significant statistical differences at postintervention and 3/6-month follow-up assessment (Z = 2.72, P = 0.007 and Z = 10.45, P < 0.001, respectively). For the executive functioning outcome, there were significant statistical differences at postintervention and 3/6-month follow-up assessment (Z = 2.90, P = 0.004 and Z = 14.75, P < 0.001, respectively). For the academic/intellectual performance secondary outcome, the pooled overall effects of study interventions on the academic/intellectual outcome were positive at postintervention and follow-up assessment (Ps < 0.001). No studies reported any adverse events related to neurocognitive and educational interventions. This meta-analysis found that neurocognitive rehabilitation interventions improve the working memory, attention, and executive functioning of pediatric cancer survivors at postintervention and short-term follow-up. Neurocognitive rehabilitation also has positive effects on the academic/intellectual performance of this study population during a vulnerable period in their development.

Neuropsychological Interventions for Cancer-Related Cognitive Impairment: A Network Meta-Analysis of Randomized Controlled Trials

The aim of this network meta-analysis was to evaluate the comparative effects of neuropsychological interventions for cancer-related cognitive impairment (CRCI), and to rank the best intervention options for adult cancer patients with CRCI. Twenty-seven eligible randomized controlled trials (RCTs) were searched, and a total of six interventions identified: cognitive behavioral therapies (CBT), cognitive rehabilitation (CR), cognitive training (CT), meditation/mindfulness-based interventions, psychoeducation, and supportive care. In terms of effectiveness, the relative effect size of CBT, CR, and CT in managing subjective cognition had statistically significant differences - 0.94 (0.43-1.44), 0.54 (0.03-1.05), and 0.47 (0.13-0.81), respectively. The most effective interventions to manage the objective cognition of attention were meditation or mindfulness-based interventions: intervention effect size was 0.58 (0.24-0.91). The relative effect size of CT had a statistically significant difference in managing verbal memory, and the intervention effect size was 1.16 (0.12-2.20). The relative effect size of psychoeducation in managing executive function compared with control had a statistically significant difference, which was 0.56 (0.26-0.86). For managing information processing speed, the most effective intervention was CT and the effect size was -0.58 (-1.09--0.06). This network meta-analysis found that CT is the most effective intervention for managing the objective cognition of verbal memory and processing speed; meditation/mindfulness-based interventions may be the best option for enhancing attention; psychoeducation is the most effective intervention for managing executive function; CT may be the best option for managing verbal fluency as the intervention ranking probability. For the management of subjective cognition, CBT may be the most effective intervention.

A Delphi technique toward the development of a cognitive intervention framework module for breast cancer survivors with cognitive impairment following chemotherapy

Objective

Chemotherapy-related cognitive impairment (CRCI) is a well-known phenomenon among breast cancer survivors. Cognitive impairment among breast cancer survivors can significantly affect their quality of life and ability to function independently. However, there is a lack of specific and focused cognitive intervention to improve their cognitive performances. This study aimed to develop a tailored cognitive intervention framework module by adapting the attention and memory interventions from the Cognitive Rehabilitation Manual of the Brain Injury Interdisciplinary Special Interest Group (BI-SIG) of the American Congress of Rehabilitation Medicine (ACRM) and incorporating them with the relevant exercises for cognitive rehabilitation for Malaysian breast cancer survivors with CRCI based on the consensus agreement of the expert panel.

Methods and analysis

The Delphi consensus technique was conducted online to review and evaluate the framework module. A panel of experts, including rehabilitation medicine physicians, occupational therapists, and clinical psychologists in Malaysia, was invited to participate in this study. For each round, the expert consensus was defined as more than 90% of the expert panel agreeing or strongly agreeing with the proposed items.

Results

A total of 33 practitioners completed the three Delphi rounds. 72.7% of the expert panel have been practising in their relevant clinical fields for more than six years (M = 10.67, SD = 5.68). In Round 1, 23% of the experts suggested that the framework module for attention training required further improvements, specifically in the language (M = 1.97, SD = 0.75) and instructions (M = 2.03, SD = 0.71) provided. In Round 2, 15% of the experts recommended additional changes in the instruction (M = 2.15, SD = 0.67) for attention training. Amendments made to the framework module in line with the recommendations provided by the experts resulted in a higher level of consensus, as 94% to 100% of the experts in Round 3 concluded the framework module was suitable and comprehensive for our breast cancer survivors. Following the key results, the objectives were practical, and the proposed approaches, strategies, and techniques for attention and memory training were feasible. The clarity of the instructions, procedures, verbatim transcripts, and timeframe further enhanced the efficacy and utility of the framework module.

Conclusions

This study found out that the cognitive intervention framework module for breast cancer survivors with cognitive impairment following chemotherapy can be successfully developed and feasible to be implemented using Delphi technique.

Randomized double-masked controlled trial of cognitive training in breast cancer survivors: a preliminary study

PURPOSE

To evaluate the acceptability, satisfaction, and preliminary efficacy of cognitive training for improving cognitive function and health outcomes in breast cancer survivors (BCS).

PATIENTS AND METHODS

BCS enrolled in this 2-group randomized, double-masked controlled trial of cognitive training. Primary outcomes included the acceptability and satisfaction of the interventions. Secondary outcomes included examining the effect size and reliable improvement of perceived cognitive function and health outcomes, including work ability, health perception (status and change), and quality of life. Exploratory outcomes were performance on neuropsychological tests and plasma levels of brain-derived neurotropic factor (BDNF). Data were collected at baseline and immediately post-intervention. Using ANCOVA models, the intervention was compared to attention control while adjusting for covariates and baseline values. The effect sizes for differences in means and the reliable improvement percentage were reported.

RESULTS

Thirty-six BCS completed the study and were on average 57.6 (SD = 8.0) years old, 59.4% Caucasian, and had some college education (74.5%). Both programs were reported to be satisfactory and acceptable. Non-significant small effect sizes were noted for the intervention on cognitive abilities (d = 0.26) and cognitive concerns (d =  - 0.32), with reliable improvement noted in 32% and 28% of BCS, respectively. Small to medium effect sizes were noted in improvement in work ability (d = 0.37) and health perception status (d = 0.30) and change (d = 0.60, p < 0.05).

CONCLUSIONS

Cognitive training was acceptable to BCS and resulted in improvement in perceived cognitive function and perceptions of "real-world" health benefits. A larger randomized controlled trial is warranted to determine its effectiveness for objective cognitive performance.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

The Use of Immersive Virtual Reality for Cancer-Related Cognitive Impairment Assessment and Rehabilitation: A Clinical Feasibility Study

Objective

This brief study aimed to examine the potential effects of virtual reality (VR)-assisted cognitive rehabilitation intervention on the health outcomes of patients with cancer.

Methods

A single group of pre-test and post-test study designs were used. An innovative VR system was developed to assess cancer-related cognitive impairment and provide cognitive rehabilitation. The potential effects of the system were determined by measuring changes in cognitive function (learning and memory, information processing speed, executive function, and verbal fluency) and the severity of depression, anxiety, and insomnia.

Results

Nine subjects completed the entire VR intervention and were included in the analysis. The participants’ mean age was 43.3 years (standard deviation, 8.9 years). The VR-based cognitive intervention significantly improved the subjective cognitive measures of perceived cognitive impairment and perceived cognitive ability (P ​= ​0.01 and P ​< ​0.01, respectively). The intervention also improved the objective cognitive measures of verbal learning memory as measured using the Auditory Verbal Learning Test (eg., P ​< ​0.01 for 5-min delay recall), information processing speed as measured using the trail-making test-A (P ​= ​0.02) and executive function as measured using the trail-making test-B (P ​= ​0.03). Only the subtest of delayed recall showed no statistically significant difference after the intervention (P ​= ​0.69). The VR-based psychological intervention significantly reduced the severity of sleep disorders (P ​< ​0.01).

Conclusions

The use of immersive VR was shown to have potential effects on improving cognitive function for patients with cancer. Future studies will require a larger sample size to examine the effects of immersive VR-assisted cognitive rehabilitation on the health outcomes of patients with cancer.

Management of common clinical problems experienced by survivors of cancer

Improvements in early detection and treatment have led to a growing prevalence of survivors of cancer worldwide. Models of care fail to address adequately the breadth of physical, psychosocial, and supportive care needs of those who survive cancer. In this Series paper, we summarise the evidence around the management of common clinical problems experienced by survivors of adult cancers and how to cover these issues in a consultation. Reviewing the patient's history of cancer and treatments highlights potential long-term or late effects to consider, and recommended surveillance for recurrence. Physical consequences of specific treatments to identify include cardiac dysfunction, metabolic syndrome, lymphoedema, peripheral neuropathy, and osteoporosis. Immunotherapies can cause specific immune-related effects most commonly in the gastrointestinal tract, endocrine system, skin, and liver. Pain should be screened for and requires assessment of potential causes and non-pharmacological and pharmacological approaches to management. Common psychosocial issues, for which there are effective psychological therapies, include fear of recurrence, fatigue, altered sleep and cognition, and effects on sex and intimacy, finances, and employment. Review of lifestyle factors including smoking, obesity, and alcohol is necessary to reduce the risk of recurrence and second cancers. Exercise can improve quality of life and might improve cancer survival; it can also contribute to the management of fatigue, pain, metabolic syndrome, osteoporosis, and cognitive impairment. Using a supportive care screening tool, such as the Distress Thermometer, can identify specific areas of concern and help prioritise areas to cover in a consultation.

Cannabinoid drugs against chemotherapy-induced adverse effects: focus on nausea/vomiting, peripheral neuropathy and chemofog in animal models

Although new drugs are being developed for cancer treatment, classical chemotherapeutic agents are still front-line therapies, despite their frequent association with severe side effects that can hamper their use. Cannabinoids may prevent or palliate some of these side effects. The aim of the present study is to review the basic research which has been conducted evaluating the effects of cannabinoid drugs in the treatment of three important side effects induced by classical chemotherapeutic agents: nausea and vomiting, neuropathic pain and cognitive impairment. Several published studies have demonstrated that cannabinoids are useful in preventing and reducing the nausea, vomits and neuropathy induced by different chemotherapy regimens, though other side effects can occur, such as a reduction of gastrointestinal motility, along with psychotropic effects when using centrally-acting cannabinoids. Thus, peripherally-acting cannabinoids and new pharmacological options are being investigated, such as allosteric or biased agonists. Additionally, due to the increase in the survival of cancer patients, there are emerging data that demonstrate an important cognitive deterioration due to chemotherapy, and because the cannabinoid drugs have a neuroprotective effect, they could be useful in preventing chemotherapy-induced cognitive impairment (as demonstrated through studies in other neurological disorders), but this has not yet been tested. Thus, although cannabinoids seem a promising therapeutic approach in the treatment of different side effects induced by chemotherapeutic agents, future research will be necessary to find pharmacological options with a safer profile. Moreover, a new line of research awaits to be opened to elucidate their possible usefulness in preventing cognitive impairment.

Effects of Endocrine Therapy on Cognitive Function in Patients with Breast Cancer: A Comprehensive Review

Simple Summary

Many persons diagnosed with breast cancer are treated with endocrine therapy and will experience the side effects of endocrine therapy. Cognitive adverse effects of endocrine therapy are increasingly being recognised, and can significantly affect quality of life, adherence and treatment outcome. This review aims to discuss the nature of cognitive dysfunction associated with endocrine therapy, the mechanisms underpinning its development, and evidence-based management strategies.

Abstract

Endocrine therapy forms the backbone of systemic therapy for the majority of persons with early and late-stage breast cancer. However, the side effects can negatively affect quality of life, and impact treatment adherence and overall oncological outcomes. Adverse effects on cognition are common, underreported and challenging to manage. We aim to describe the nature, incidence, risk factors and underlying mechanisms of endocrine therapy-induced cognitive dysfunction. We conducted a comprehensive literature review of the studies reporting on cognitive dysfunction associated with endocrine therapies for breast cancer. We also summarise prevention and treatment strategies, and ongoing research. Given that patients are taking endocrine therapies for longer durations than ever before, it is essential that these side effects are managed pro-actively within a multi-disciplinary team in order to promote adherence to endocrine therapy and improve patients’ quality of life.

Effects of Vigorous Versus Restorative Yoga Practice on Objective Cognition Functions in Sedentary Breast and Ovarian Cancer Survivors: A Randomized Controlled Pilot Trial

PURPOSE

Many cancer survivors experience cancer-related cognitive impairment (CRCI). We conducted a randomized controlled pilot trial of 2 types of yoga practice and evaluated their effects on participants' objective cognitive function.

METHODS

Sedentary breast or ovarian cancer survivors were randomized to practice either restorative yoga (with more meditative practice and minimal physical exertion) or vigorous yoga (with considerable physical exertion and minimal meditative practice) in 60-minute supervised sessions 3 times a week for 12 weeks, followed by 12 weeks of home practice. We used the NIH Toolbox Cognition Domain to evaluate participants at baseline, week 12, and week 24.

RESULTS

We enrolled 35 participants. For women in the restorative yoga group, overall cognitive function was statistically significantly improved at weeks 12 and 24 compared to baseline (P = .03 and 0.004; Cohen's D = 0.3 and 0.5). Fluid cognitive function also significantly improved at weeks 12 and 24 (P = .02 and 0.0007; Cohen's D = 0.3 and 0.6), whereas improvements in crystallized cognition were not significant. For women in the vigorous yoga group, significant improvement was only seen in tasks of crystallized cognition at week 24 (P = .03; Cohen's D = 0.5). Between-group comparisons showed that at week 24, women in the restorative yoga group had significantly higher scores on fluid cognition tasks.

CONCLUSIONS

Patients who participated in yoga practice demonstrated improvement in objective cognitive function over time. Restorative yoga may be more effective in improving fluid cognitive function at week 24 when compared to vigorous yoga. These promising findings should be confirmed in definitive studies.

TRIAL REGISTRATION

Clinicaltrials.gov; NCT02305498 (Date Registered: December 2, 2014).

Long-Term Cognitive Dysfunction in Cancer Survivors

Cancer-related cognitive impairment (CRCI) is a frequent side effect experienced by an increasing number of cancer survivors with a significant impact on their quality of life. Different definitions and means of evaluation have been used in available literature; hence the exact incidence of CRCI remains unknown. CRCI can be described as cognitive symptoms reported by cancer patients in self-reported questionnaires or as cognitive changes evaluated by formal neuropsychological tests. Nevertheless, association between cognitive symptoms and objectively assessed cognitive changes is relatively weak or absent. Studies have focused especially on breast cancer patients, but CRCI has been reported in multiple types of cancer, including colorectal, lung, ovarian, prostate, testicular cancer and hematological malignancies. While CRCI has been associated with various treatment modalities, including radiotherapy, chemotherapy, hormone therapy and novel systemic therapies, it has been also detected prior to cancer treatment. Therefore, the effects of cancer itself with or without the psychological distress may be involved in the pathogenesis of CRCI as a result of altered coping mechanisms after cancer diagnosis. The development of CRCI is probably multifactorial and the exact mechanisms are currently not completely understood. Possible risk factors include administered treatment, genetic predisposition, age and psychological factors such as anxiety, depression or fatigue. Multiple mechanisms are suggested to be responsible for CRCI, including direct neurotoxic injury of systemic treatment and radiation while other indirect contributing mechanisms are hypothesized. Chronic neuroinflammation mediated by active innate immune system, DNA-damage or endothelial dysfunction is hypothesized to be a central mechanism of CRCI pathogenesis. There is increasing evidence of potential plasma (e.g., damage associated molecular patterns, inflammatory components, circulating microRNAs, exosomes, short-chain fatty acids, and others), cerebrospinal fluid and radiological biomarkers of cognitive dysfunction in cancer patients. Discovery of biomarkers of cognitive impairment is crucial for early identification of cancer patients at increased risk for the development of CRCI or development of treatment strategies to lower the burden of CRCI on long-term quality of life. This review summarizes current literature on CRCI with a focus on long-term effects of different cancer treatments, possible risk factors, mechanisms and promising biomarkers.

Cognitive Dysfunction: Feasibility of a Brief Intervention to Help Breast Cancer Survivors

BACKGROUND

Many cancer survivors experience cancer-related cognitive dysfunction (CRCD), which is believed to be the result of multiple contributing biologic, situational, and personal factors. Efficacious, clinically implementable interventions addressing the multifactorial nature of CRCD are needed.

OBJECTIVES

This study evaluated the feasibility of an intervention to help breast cancer survivors mitigate the effects of modifiable factors that contribute to CRCD and improve cognitive functioning.

METHODS

A single-group pre-/post-test design was used. Treatment fidelity was tracked to evaluate implementability; attendance rates, experience surveys, and homework engagement were used to characterize acceptability. Pre- and post-test cognitive functioning, stress, fatigue, and mood were measured to evaluate preliminary efficacy.

FINDINGS

The intervention was implementable and acceptable to participants. Participants made statistically significant improvements.

Cannabinoid Drugs-Related Neuroprotection as a Potential Therapeutic Tool Against Chemotherapy-Induced Cognitive Impairment

In recent years, and particularly associated with the increase of cancer patients’ life expectancy, the occurrence of cancer treatment sequelae, including cognitive impairments, has received considerable attention. Chemotherapy-induced cognitive impairments (CICI) can be observed not only during pharmacological treatment of the disease but also long after cessation of this therapy. The lack of effective tools for its diagnosis together with the limited treatments currently available for alleviation of the side-effects induced by chemotherapeutic agents, demonstrates the need of a better understanding of the mechanisms underlying the pathology. This review focuses on the comprehensive appraisal of two main processes associated with the development of CICI: neuroinflammation and oxidative stress, and proposes the endogenous cannabinoid system (ECS) as a new therapeutic target against CICI. The neuroprotective role of the ECS, well described in other cognitive-related neuropathologies, seems to be able to reduce the activation of pro-inflammatory cytokines involved in the neuroinflammatory supraspinal processes underlying CICI. This review also provides evidence supporting the role of cannabinoid-based drugs in the modulation of oxidative stress processes that underpin cognitive impairments, and warrant the investigation of endocannabinoid components, still unknown, that may mediate the molecular mechanism behind this neuroprotective activity. Finally, this review points forward the urgent need of research focused on the understanding of CICI and the investigation of new therapeutic targets.

Management of Cancer-Related Cognitive Impairment: A Systematic Review of Computerized Cognitive Stimulation and Computerized Physical Activity

Cancer-related cognitive impairment (CRCI) occurs frequently in patients living with cancer, with consequences on quality of life. Recently, research on the management of these difficulties has focused on computerized cognitive stimulation and computerized physical activity programs. This systematic review presents the state of knowledge about interventions based on computerized-cognitive stimulation and/or physical activity to reduce CRCI. The review followed the PRISMA guidelines. A search was conducted in PUBMED and Web of Science databases. Risk of bias analysis was conducted using the Rob2 tool and the quality of evidence was conducted following the GRADE approach. A total of 3776 articles were initially identified and 20 of them met the inclusion criteria. Among them, sixteen investigated computerized-cognitive stimulation and four computerized-physical activity. Most of the studies were randomized controlled trials and assessed the efficacy of a home-based intervention on objective cognition in adults with cancer. Overall, cognitive improvement was found in 11/16 computerized-cognitive stimulation studies and 2/4 computerized-physical activity studies. Cognitive stimulation or physical activity improved especially cognitive complaints, memory, and attention. These results suggest the efficacy of both computerized-cognitive stimulation and physical activity. However, we report a high risk of bias for the majority of studies and a low level of quality of evidence. Therefore, further investigations are needed to confirm the efficacy of these interventions and to investigate the possible added benefit on cognition of a combined computerized-cognitive/physical intervention.

Multimodal Web-Based Intervention for Cancer-Related Cognitive Impairment in Breast Cancer Patients: Cog-Stim Feasibility Study Protocol

Simple Summary

Cognitive difficulties and their impact on patients’ quality of life are frequently reported by patients treated for breast cancer, who ask for support to improve these difficulties. Cognitive stimulation and physical activity resulted as beneficial for cognitive difficulties, but they are challenging to generalize in hospitals. To overcome this limitation, home-based computerized interventions have been proposed. In this study, the feasibility of a combined intervention of web-based cognitive stimulation and physical activity among breast cancer patients undergoing radiotherapy will be investigated. The overall goal is to develop interventions for cognitive difficulties adapted to supportive care units.

Abstract

Cancer-related cognitive impairment (CRCI) is a frequent side-effect of cancer treatment, with important consequences on patients’ quality of life. Cognitive stimulation and physical activity are the most efficient in improving cognitive impairment, but they are challenging to generalize in hospitals’ routine and to patients’ needs and schedules. Moreover, the added value of a combination of these interventions needs to be more investigated. The Cog-Stim study is an interventional study investigating the feasibility of a web-based multimodal intervention (combining cognitive stimulation and physical activity for the improvement of cognitive complaints among breast-cancer patients currently treated with radiotherapy (n = 20). Patients will take part in a 12-week program, proposing two sessions per week of web-based cognitive stimulation (20 min/session with HappyNeuron^®) and two sessions per week of web-based physical activity (30 min/session with Mooven^® platform). Cognitive complaints (FACT-Cog) and objective cognitive functioning (CNS Vital Signs^®), anxiety, depression (HADS), sleep disorders (ISI) and fatigue (FACIT-Fatigue) will be assessed before and after the intervention. The primary endpoint is the adherence rate to the intervention program. Patients’ satisfaction, reasons for non-attrition and non-adherence to the program will also be assessed. The overall goal of this study is to collect information to develop web-based interventions for cognitive difficulties in supportive care units.