Psychostimulants for cancer-related cognitive impairment in adult cancer survivors: a systematic review and meta-analysis

A pilot study of a targeted cognitive intervention for cancer survivors

PURPOSE

The primary aims of this four week pilot randomized clinical trial (RCT) involving a targeted cognitive intervention (TCI, n = 25) compared to an expectancy matched active control intervention (EMACI, n = 24), in a sample of cancer survivors were to: determine recruitment and retention rates; evaluate preliminary efficacy to improve three objective measures of cognitive function (i.e., attention, working memory, multi-tasking); evaluate adherence rates for and satisfaction with the interventions, and evaluate for treatment-related adverse events (e.g., nausea, motion sickness).

METHODS

Cancer survivors were recruited from previous studies through email. Following a screening call, survivors who consented to participate were oriented to the study measures and procedures via Zoom. Survivors were randomized to the TCI or EMACI and mailed an iPad with the software for their specific intervention and the Adaptive Cognitive Evaluation Explorer (ACE-X, the objective measure of cognitive function). Survivors used the intervention for 25 min per day at least 5 days per week. Differences in objective measures of attention, working memory, and multi-tasking were evaluated using multilevel regression analyses.

RESULTS

For the sustained attention measure, a significant cross-level interaction was found in favor of the TCI group. While improvements in multi-tasking occurred in both groups, while not statistically significant, the trend was larger for the TCI group. Equally important, in both groups, adherence with the intervention was high and adverse effects were minimal.

CONCLUSIONS

These preliminary findings provide promising evidence of feasibility, acceptability, and efficacy that warrant evaluation in a RCT with a larger sample of cancer survivors.

Improve the management of cancer-related cognitive impairment in clinical settings: a European Delphi study

PURPOSE

Cancer-related cognitive impairment (CRCI) is under-addressed by healthcare professionals owing to a lack of clinical management guidelines. This European Delphi study proposes recommendations to healthcare professionals for the management of CRCI in patients with non-central nervous system (non-CNS) cancers.

METHODS

Twenty-two recommendations were developed based on a literature review and authors' clinical experience, split into three categories: screening, cognitive assessment, intervention. The survey included European professionals, experts in CRCI. The Delphi method was used: experts rated the clinical relevancy of recommendations on a 9-point Likert scale in three rounds. A recommendation was accepted if all votes were between 7 and 9. Recommendations not accepted in round 1 and round 2 were deleted, or modified and rated in round 3.

RESULTS

Eighteen professionals (psychologists, physicians, researchers) voted and accepted 15 recommendations. Experts recommended the systematic screening of CRCI, followed by a short objective cognitive assessment, if complaints screened. A comprehensive evaluation is recommended if CRCI persists 6 months post-treatment. Cognitive rehabilitation, physical activity, meditative-movement therapy, and multimodal intervention should be offered. Recommendations about frequency and duration of interventions, the professional to administer cognitive rehabilitation and the use of meditation and cognitive training without psychoeducation were not accepted.

CONCLUSIONS

This survey provides 15 recommendations to assist healthcare professionals in detecting, assessing and offering interventions for CRCI.

IMPLICATIONS FOR CANCER SURVIVORS

These recommendations should be included in supportive care to help healthcare professionals to detect CRCI and propose the best available intervention for patients with cognitive complaints. Developing CRCI management in clinical settings would improve patients' quality of life.

Cancer-Related Cognitive Impairments (CRCIs) in Non-Central Nervous System Adult Patients: Outcome Measures and Methodology of Assessment: A Literature Review

BACKGROUND

Cancer-related cognitive impairment (CRCI) represents one of the most common and debilitating effects in patients surviving after cancer treatments. Neurocognitive deficits are important causes of disability and burden in cancer survivors. The true magnitude of CRCI is difficult to define due to significant heterogeneity of literature data. At present, there is no agreement on the gold standard for detection and grading of CRCI in clinical trials, and there is a lack of clear knowledge of its pathophysiology.

OBJECTIVES

In this review, we aim to discuss some perspectives for future research to pursue in order to cover the gaps in knowledge in the CRCI field.

METHODS

We focused our literature research on the following relevant issues: neuroradiological correlates of CRCI; objective neuropsychological evaluation and subjective complaint assessment and their correlation with objective measures; timing of assessment; and possible treatments.

RESULTS

The correct methodology for evaluating cognitive deficits induced by anti-tumor treatments still requires a definition based on quality scientific evidence, and literature data are currently scarce.

CONCLUSIONS

This review highlights the need for further research to understand the causes and consequences of cancer-related cognitive impairment using standardized and sensitive measures of cognitive functions and the long-term effects of chemotherapy on cognitive functions and to develop effective interventions.

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.

Randomized Controlled Trial of Virtually Delivered Cognitive Behavioral Therapy for Insomnia to Address Perceived Cancer-Related Cognitive Impairment in Cancer Survivors

PURPOSE

Comorbid insomnia and cancer-related cognitive impairment (CRCI) are experienced by up to 26% of individuals diagnosed with cancer. This study examined the efficacy and durability of cognitive behavioral therapy for insomnia (CBT-I) on perceived CRCI in cancer survivors.

METHODS

Atlantic Canadian cancer survivors with insomnia and CRCI were randomly assigned to receive seven weekly virtual CBT-I sessions (n = 63) or placed in a waitlist control group (n = 69) to receive treatment after the waiting period. Participants completed assessments at baseline, 1 month (mid-treatment), and 2 months (post-treatment). Age- and education-adjusted mixed-effects models using intention-to-treat principles assessed change at post-treatment. Data from both groups were then pooled to assess the durability of effects at 3 and 6 months. A mediation analysis examined whether change in insomnia symptoms mediated the effect of CBT-I on cognitive outcomes.

RESULTS

The mean age of the sample was 60 years, 77% were women, and breast cancer was the most common diagnosis (41%). The treatment group reported an 11.35-point reduction in insomnia severity, compared with a 2.67-point reduction in the waitlist control group (P < .001). The treatment group had a greater overall improvement than the waitlist control on perceived cognitive impairment (P < .001; d = 0.75), cognitive abilities (P < .001; d = 0.92), and impact on quality of life (P < .001; d = 1.01). These improvements were maintained at follow-up. Change in insomnia symptoms fully mediated the effect of CBT-I on subjective cognitive outcomes.

CONCLUSION

Treating insomnia with CBT-I produces clinically meaningful and durable improvements in CRCI. There is an urgent need increase access to evidence-based treatment for insomnia in cancer centers and the community.

Colon Cancer Survivorship in Patients Who Have Received Adjuvant Chemotherapy

The number of colon cancer survivors in the United States is increasing due to improved early detection, better treatments that extend survival, and the growing aging population who are at high risk for cancer. Following initial active treatment, colon cancer survivors experience a wide range of long-term physical, psychological, and socio-economic effects that impact their overall well-being. Healthcare providers caring for survivors need to prioritize not only monitoring for cancer recurrence but also optimizing their overall health through addressing these long-term effects; managing their comorbidities; promoting healthy behaviors (like exercise, nutrition, and weight loss); and screening for a second primary cancer depending on their risk. Personalized survivorship care plans should be formulated clearly outlining the roles of various healthcare providers involved in their care. Our review article focuses on these various aspects of colon cancer survivorship, including surveillance for cancer recurrence specific to those who received adjuvant chemotherapy with curative intent.

A self-administered immersive virtual reality tool for assessing cognitive impairment in patients with cancer

Objective

This study was aimed at exploring the feasibility and validity of a self-administered immersive virtual reality (VR) tool designed to assess cognitive impairment in patients with cancer.

Methods

In a cross-sectional survey study, an immersive tool was used to rate the previously recommended core assessment domains of cancer-related cognitive impairment-comprising attention, verbal learning memory, processing speed, executive function and verbal fluency-via an interactive VR scenario.

Results

A total of 165 patients with cancer participated in this study. The participants' mean age was 47.74 years (SD ​= ​10.59). Common cancer types included lung, liver, breast and colorectal cancer, and most patients were in early disease stages (n ​= ​146, 88.5%). Participants' performance in the VR cognition assessment showed a moderate to strong positive correlation with their paper-and-pencil neurocognitive test results (r ​= ​0.34-0.76, P ​< ​0.001), thus indicating high concurrent validity of the immersive VR cognition assessment tool. For all participants, the mean score for the VR-based cognition assessment was 5.41 (SD ​= ​0.70) out of a potential maximum of 7.0. The mean simulation sickness score for the VR-based tool, as rated by the patients, was 0.35 (SD ​= ​0.19), thereby indicating that minimal simulation sickness occurred during the VR-assisted cognition assessment.

Conclusions

Given its demonstrated validity, and the patients' high presence scores and minimal sickness scores, this VR-based cognition assessment tool is a feasible and acceptable instrument for measuring cognitive impairment in patients with cancer. However, further psychometric assessments should be implemented in clinical settings.

Neurocognition in adults with intracranial tumors: does location really matter?

OBJECTIVE

As preservation of cognitive functioning increasingly becomes important in the light of ameliorated survival after intracranial tumor treatments, identification of eloquent brain areas would enable optimization of these treatments.

METHODS

This cohort study enrolled adult intracranial tumor patients who received neuropsychological assessments pre-irradiation, estimating processing speed, verbal fluency and memory. Anatomical magnetic resonance imaging scans were used for multivariate voxel-wise lesion-symptom predictions of the test scores (corrected for age, gender, educational level, histological subtype, surgery, and tumor volume). Potential effects of histological and molecular subtype and corresponding WHO grades on the risk of cognitive impairment were investigated using Chi square tests. P-values were adjusted for multiple comparisons (p < .001 and p < .05 for voxel- and cluster-level, resp.).

RESULTS

A cohort of 179 intracranial tumor patients was included [aged 19-85 years, median age (SD) = 58.46 (14.62), 50% females]. In this cohort, test-specific impairment was detected in 20-30% of patients. Higher WHO grade was associated with lower processing speed, cognitive flexibility and delayed memory in gliomas, while no acute surgery-effects were found. No grading, nor surgery effects were found in meningiomas. The voxel-wise analyses showed that tumor locations in left temporal areas and right temporo-parietal areas were related to verbal memory and processing speed, respectively.

INTERPRETATION

Patients with intracranial tumors affecting the left temporal areas and right temporo-parietal areas might specifically be vulnerable for lower verbal memory and processing speed. These specific patients at-risk might benefit from early-stage interventions. Furthermore, based on future validation studies, imaging-informed surgical and radiotherapy planning could further be improved.

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.

Brain Tumor Rehabilitation: Symptoms, Complications, and Treatment Strategy

Brain tumors are receiving increasing attention in cancer rehabilitation due to their high rate of neurological deterioration. Motor dysfunction, cognitive deterioration, and emotional problems are commonly present in patients with brain tumors. Other medical complications, such as seizures, headache, and dysphagia are also common. An individualized multidisciplinary rehabilitation intervention is necessary to treat functional impairment due to the tumor itself and/or treatment-related dysfunction. Herein, we discuss rehabilitation treatment strategies in relation to the neurological and functional complications that commonly occur in patients with brain tumors.

Reduced prefrontal cortex and sympathetic nervous system activity correlate with fatigue after aHSCT

Long-term fatigue and cognitive dysfunction affects 35% of allogeneic haematopoietic stem cell transplantation (aHSCT) survivors, suggesting a dysfunctional prefrontal cortex. In this study, we assessed prefrontal cortex and sympathetic nervous system activity in aHSCT patients with fatigue (n = 12), non-fatigued patients (n = 12) and healthy controls (n = 27). Measurement of near-infrared spectroscopy and electrodermal activity was carried out at rest and during cognitive performance (Stroop, verbal fluency and emotion regulation tasks). Prefrontal cortex and sympathetic nervous system activity were also analyzed in response to dopamine and noradrenaline increase after a single dose of methylphenidate. Baseline cognitive performance was similar in the two patient groups. However, after methylphenidate, only non-fatigued patients improved in Stroop accuracy and had better verbal fluency task performance compared to the fatigued group. Task-related activation of prefrontal cortex in fatigued patients was lower compared to non-fatigued patients during all cognitive tests, both before and after methylphenidate administration. During the Stroop task, reaction time, prefrontal cortex activation, and sympathetic nervous system activity were all lower in fatigued patients compared to healthy controls, but similar in non-fatigued patients and healthy controls.Reduced prefrontal cortex activity and sympathetic arousal suggests novel treatment targets to improve fatigue after aHSCT.

Cognitive adverse effects of chemotherapy and immunotherapy: are interventions within reach?

One in three people will be diagnosed with cancer during their lifetime. The community of cancer patients is growing, and several common cancers are becoming increasingly chronic; thus, cancer survivorship is an important part of health care. A large body of research indicates that cancer and cancer therapies are associated with cognitive impairment. This research has mainly concentrated on chemotherapy-associated cognitive impairment but, with the arrival of immunotherapies, the focus is expected to widen and the number of studies investigating the potential cognitive effects of these new therapies is rising. Meanwhile, patients with cognitive impairment and their healthcare providers are eagerly awaiting effective approaches to intervene against the cognitive effects of cancer treatment. In this Review, we take stock of the progress that has been made and discuss the steps that need to be taken to accelerate research into the biology underlying cognitive decline following chemotherapy and immunotherapy and to develop restorative and preventive interventions. We also provide recommendations to clinicians on how to best help patients who are currently experiencing cognitive impairment.

Medical and Neurological Management of Brain Tumor Complications

PURPOSE OF REVIEW

The diagnosis of brain tumors often leads to complications that are either related to the tumor itself or the tumor-directed and supportive therapies, increasing the burden on the patients' quality of life and even survival. This article reviews the medical and neurological conditions that commonly complicate the disease course of brain tumors patients.

RECENT FINDINGS

Various mechanisms have been newly identified to be involved in the pathophysiology of seizures and brain edema and can help advance the treatment of such complications. There have also been new developments in the management of thromboembolic disease and cognitive impairment. Medical and neurological complications are being identified more often in brain tumor patients with the improved survival provided by therapeutic advances. Early and proper identification and management of such complications are crucial for a better survival and quality of life.

Neuropsychiatric effects of tamoxifen: Challenges and opportunities

Epidemiological, clinical, and basic research over the past thirty years have described the benefits of estrogen on cognition, mood, and brain health. Less is known about tamoxifen, a selective estrogen receptor modifier (SERM) commonly used in breast cancer which is able to cross the blood-brain barrier. In this article, we review the basic pharmacology of tamoxifenas well as its effects on cognition and mood. The literature reveals an overall impairing effect of tamoxifen on cognition in breast cancer patients, hinting at central antiestrogen activity. On the other hand, tamoxifen demonstrates promising effects in psychiatric disorders, like bipolar disorder, where its therapeutic action may be independent of interaction with estrogen receptors. Understanding the neuropsychiatric properties of SERMs like tamoxifen can guide future research to ameliorate unwanted side-effects and provide novel options for difficult to treat disorders.

Neurological and Medical Complications in Brain Tumor Patients

PURPOSE OF REVIEW

Patients with brain tumors are susceptible to multiple complications that can affect their survival or quality of life. The scope of these complications is widening due to prolonged overall survival and improved therapies. In this review, we discuss the most common complications in this patient population focusing on the recent literature. We specifically concentrated on tumor-related epilepsy, vasogenic edema, infectious, vascular, chemotherapeutic, radiation, endocrine, and cognitive complications.

RECENT FINDINGS

Molecular biomarkers play a role in epileptogenicity in brain tumor patients, and anti-epileptic drugs may cause neuro-cognitive side effects independent of other factors. The pathophysiology of vasogenic edema remains complex and poorly understood. Limited data suggest that newer oral anticoagulants appear to be safe and effective in venous and arterial thromboembolic complications. Brain tumor patients are prone to a wide variety of complications, including some related to new therapies. Optimal management of these complications improves quality of life, and in some cases overall survival.