The effect of chemotherapy on subjective cognitive function in younger early-stage breast cancer survivors treated with chemotherapy compared to older patients

A scoping review evaluating physical and cognitive functional outcomes in cancer survivors treated with chemotherapy: charting progress since the 2018 NCI think tank on cancer and aging phenotypes

PURPOSE

The primary goal of this scoping review was to summarize the literature published after the 2018 National Cancer Institute think tank, "Measuring Aging and Identifying Aging Phenotypes in Cancer Survivors," on physical and cognitive functional outcomes among cancer survivors treated with chemotherapy. We focused on the influence of chemotherapy on aging-related outcomes (i.e., physical functional outcomes, cognitive functional outcomes, and frailty), given the known associations between chemotherapy and biologic mechanisms that affect aging-related physiologic processes.

METHODS

A search was conducted across electronic databases, including PubMed, Scopus, and Web of Science, for manuscripts published between August 2018 and July 2023. Eligible studies: 1) included physical function, cognitive function, and/or frailty as outcomes; 2) included cancer survivors (as either the whole sample or a subgroup); 3) reported on physical or cognitive functional outcomes and/or frailty related to chemotherapy treatment (as either the whole sample or a subgroup); and 4) were observational in study design.

RESULTS

The search yielded 989 potentially relevant articles, of which 65 met the eligibility criteria. Of the 65 studies, 49 were longitudinal, and 16 were cross-sectional; 30 studies (46%) focused on breast cancer, 20 studies (31%) focused on the age group 60 + years, and 17 (26%) focused on childhood cancer survivors. With regards to outcomes, 82% of 23 studies reporting on physical function showed reduced physical function, 74% of 39 studies reporting on cognitive functional outcomes found reduced cognitive function, and 80% of 15 studies reporting on frailty found increasing frailty among cancer survivors treated with chemotherapy over time and/or compared to individuals not treated with chemotherapy. Fourteen studies (22%) evaluated biologic mechanisms and their relationship to aging-related outcomes. Inflammation was consistently associated with worsening physical and cognitive functional outcomes and epigenetic age increases. Further, DNA damage was consistently associated with worse aging-related outcomes.

CONCLUSION

Chemotherapy is associated with reduced physical function, reduced cognitive function, and an increase in frailty in cancer survivors; these associations were demonstrated in longitudinal and cross-sectional studies. Inflammation and epigenetic age acceleration are associated with worse physical and cognitive function; prospective observational studies with multiple time points are needed to confirm these findings.

IMPLICATIONS FOR CANCER SURVIVORS

This scoping review highlights the need for interventions to prevent declines in physical and cognitive function in cancer survivors who have received chemotherapy.

Impact of non-pharmacological interventions on cognitive impairment in women with breast cancer: A systematic review and meta-analysis

Objective

This study aimed to examine the characteristics of research conducted on nonpharmacological interventions for cognitive impairment in patients with breast cancer and identify the primary effects of nonpharmacological interventions through a systematic review and meta-analysis.

Methods

Five electronic databases were searched to identify all randomized controlled trial studies until September 30, 2022, using the key terms "breast cancer," "cognitive disorders," and their possible variations. The Cochrane Risk of Bias tool was used to assess risk of bias. The effect sizes were calculated in Hedges' g. Potential moderators influencing the intervention effects were explored.

Results

Twenty-three studies were included in the systematic review, and 17 studies were included in the meta-analysis. Among the nonpharmacological interventions for patients with breast cancer, cognitive rehabilitation and physical activity were the most common, followed by cognitive behavioral therapy. The meta-analysis indicated that nonpharmacological interventions had a significant effect on attention (g ​= ​0.83; 95% CI: 0.14 to 1.52; I ² ​= ​76%), immediate recall (g ​= ​0.33; 95% CI: 0.18 to 0.49; I ² ​= ​0%), executive function (g ​= ​0.25; 95% CI: 0.13 to 0.37; I ² ​= ​0%), and processing speed (g ​= ​0.44; 95% CI: 0.14 to 0.73; I ² ​= ​51%) among objective cognitive functions, as well as subjective cognitive function (g ​= ​0.68; 95% CI: 0.40 to 0.96; I ² ​= ​78%). Intervention type and mode of delivery were potential moderators for the effects of nonpharmacological interventions on cognitive functions.

Conclusions

Nonpharmacological interventions can improve subjective and objective cognitive functioning among patients with breast cancer undergoing cancer treatment. Therefore, it is necessary to provide nonpharmacological interventions by screening patients at high risk of cancer-related cognitive impairment.

Systematic review registration

CRD42021251709.

Cognitive effects of chemotherapy: An integrative review

PURPOSE

An estimated 18.1 million new cancer cases (excluding nonmelanoma skin cancers) were diagnosed worldwide in 2020. Despite a rising incidence of cancers worldwide, in developed countries with strong healthcare systems, survival rates are improving as a result of early detection, improved treatments and survivorship care (World Health Organisation (WHO), 2021). Whilst living longer, cancer survivors are often living with side effects of treatment, including chemotherapy related cognitive impairment, often termed "chemobrain".

METHOD

An integrative review of contemporary literature answering the research question how does chemotherapy affect cognitive function? was undertaken utilising three computerised databases CINAHL, Medline and PUBMED, between 2015 and 2021. Data was thematically analysed to identify themes within published literature.

RESULTS

Thematic analysis identified four broad themes within the literature regarding chemotherapy induced cognitive impairment. Identified themes included; cognition as part of a complex scenario, proof of existence and searching for the cause, learning to play the game and timing of cognitive impairment.

CONCLUSIONS

Aggressive treatment with chemotherapy in the adjuvant setting has drastically improved the survival of cancer patients. Subsequent to aggressive treatments, side effects such as cognitive impairment have presented, which may persist in the long term. Despite the exact aetiology of chemotherapy induced cognitive impairment being largely unknown, the consequences of the condition are impacting cancer survivors and their quality of life.

Aging and CNS Myeloid Cell Depletion Attenuate Breast Cancer Brain Metastasis

PURPOSE

Breast cancer diagnosed in young patients is often aggressive. Because primary breast tumors from young and older patients have similar mutational patterns, we hypothesized that the young host microenvironment promotes more aggressive metastatic disease.

EXPERIMENTAL DESIGN

Triple-negative or luminal B breast cancer cell lines were injected into young and older mice side-by-side to quantify lung, liver, and brain metastases. Young and older mouse brains, metastatic and naïve, were analyzed by flow cytometry. Immune populations were depleted using antibodies or a colony-stimulating factor-1 receptor (CSF-1R) inhibitor, and brain metastasis assays were conducted. Effects on myeloid populations, astrogliosis, and the neuroinflammatory response were determined.

RESULTS

Brain metastases were 2- to 4-fold higher in young as compared with older mouse hosts in four models of triple-negative or luminal B breast cancer; no age effect was observed on liver or lung metastases. Aged brains, naïve or metastatic, contained fewer resident CNS myeloid cells. Use of a CSF-1R inhibitor to deplete myeloid cells, including both microglia and infiltrating macrophages, preferentially reduced brain metastasis burden in young mice. Downstream effects of CSF-1R inhibition in young mice resembled that of an aged brain in terms of myeloid numbers, induction of astrogliosis, and Semaphorin 3A secretion within the neuroinflammatory response.

CONCLUSIONS

Host microenvironmental factors contribute to the aggressiveness of triple-negative and luminal B breast cancer brain metastasis. CSF-1R inhibitors may hold promise for young brain metastasis patients.

Association of cognitive impairment and breast cancer survivorship on quality of life in younger breast cancer survivors

Purpose

Younger breast cancer survivors (BCS) often report cognitive impairment and poor quality of life (QoL), which could be interrelated. The purpose of this study was to examine the association of cognitive impairment and breast cancer status (BCS versus healthy control (HC)), with QoL, which included psychological (depressive symptoms, well-being, perceived stress, and personal growth) and physical well-being (physical functioning and fatigue).

Methods

Four hundred ninety-eight BCS (≤45 years at diagnosis) who were 3 to 8 years post-chemotherapy treatment and 394 HC completed subjective questionnaires and a one-time neuropsychological assessment, including tests of attention, memory, processing speed, and verbal fluency. For each test, cognitive impairment was defined as scoring 1.5 and 2.0 standard deviations below the mean of the HC group. Separate linear regression models for each outcome were ran controlling for known covariates.

Results

BCS reported significantly more memory problems than HC (p < 0.0001), with up to 23% having significant impairment. Cognitive performance did not differ significantly between BCS and HCs. BCS vs. HCs had greater depression and fatigue, yet more personal growth. Objective and subjective cognitive impairment were significantly related to greater depressive symptoms and perceived stress and lower well-being and physical functioning; whereas, objective impairment was related to less personal growth and subjective impairment was related to greater fatigue.

Conclusions

Younger BCS report significant cognitive impairment years after treatment which may relate to greater decrements in QoL.

Implications to Cancer Survivors

Assessment and interventions to address cognitive concerns may also influence QoL outcomes in younger BCS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01075-x.

Plainte cognitive à l’issue des traitements d’un lymphome

Objectif : Évaluer la prévalence de la plainte cognitive chez des personnes ayant été traitées pour un lymphome.

Matériel et méthode : Questionnaire diffusé auprès des participants de la Journée mondiale des lymphomes, en septembre 2017 et février 2018.

Résultats : Soixante-deux pour cent des participants (n = 396) rapportaient une plainte cognitive, et 39 % l’attribuaient aux traitements oncologiques reçus. Cinquantequatre pour cent d’entre eux auraient souhaité bénéficier de soins de support adaptés.

Conclusion : Les difficultés cognitives à la suite des traitements oncologiques doivent être mieux connues des professionnels de santé afin de proposer des soins de support adaptés.

Self-perceived cognitive functioning and quality of life among cancer survivors: results from the PROFILES registry

PURPOSE

The aim was to investigate the level of self-perceived cognitive functioning and its associated factors among a large population-based cohort of cancer survivors and their matched controls.

METHODS

Data were obtained from population-based PROFILES registry cohorts, including colon, rectum, prostate or thyroid cancer, Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL), chronic lymphocytic leukemia, multiple myeloma (MM), melanoma, or basal cell carcinoma (BCC)/squamous cell carcinoma (SCC). All patients completed the EORTC QLQ-C30 from which self-perceived cognitive functioning, fatigue, functioning, and global health status/quality of life (GHS/QoL) were used. The PROFILES registry data were linked with the Netherlands Cancer Registry to obtain sociodemographic and clinical data.

RESULTS

Six thousand seven hundred eighty-six survivors were included (response rate=76%). Survivors, except for melanoma and BCC/SCC, reported on average lower self-perceived cognitive functioning scores compared to their matched controls (all p's<0.01). Largest differences with the norm were observed in thyroid cancer, HL, NHL and MM, and younger survivors (<50 years). Survivors with lower emotional functioning and more fatigue were more likely to report impaired self-perceived cognitive functioning.

CONCLUSION

Self-perceived impaired cognitive functioning is prevalent among a wide range of cancer survivors, especially among survivors <50 years. Approaches targeting cognitive problems including attention for co-occurring symptoms such as fatigue and emotional impairments are needed to improve care for these patients.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors and clinicians should be aware that impaired self-perceived cognitive functioning is a frequently reported consequence of cancer and its treatment among survivors of various cancer types. Clinicians can redirect survivors to a relevant healthcare provider or program to target cognitive problems.

COVID-19 Lockdown and Its Adverse Impact on Psychological Health in Breast Cancer

The Coronavirus disease 2019 (COVID-19) outbreak generated an unprecedented set of emotional challenges for women diagnosed with breast cancer. In the United Kingdom (UK), the pandemic significantly disrupted oncology services as resources were reassigned to care for COVID-19 patients. In addition to service disruptions, many women received a UK Government letter advising them to shield for 12-weeks. We aimed to explore the effect of disruption to scheduled oncology services and the UK Government shielding letter on emotional and cognitive vulnerability. A further aim was to investigate the relationship between COVID-19 related emotional vulnerability (COVID-EMV) and anxiety, depression and perceived cognitive function. Women diagnosed with primary breast cancer (N = 234) completed a series of online questionnaires to assess their cognitive and emotional wellbeing as well as their COVID-EMV. Results indicated that disrupted oncology services had a significant impact on COVID-EMV, anxiety and depression, with those experiencing disruptions expressing higher general emotional vulnerability as well as COVID-EMV. Further, the UK Government letter had a significant effect on perceived cognitive function; those who received the letter reported poorer cognitive function. Regression analyses revealed that after allowing for the effects of sociodemographic and clinical variables, women’s COVID-EMV significantly predicted worse outcomes of anxiety, depression and perceived cognitive function. Our findings indicate that concerns about COVID-19 amongst women affected by breast cancer leads to increased risk of developing affective disorder, such as anxiety and depression symptomatology, among this sample. We advocate the rapid implementation of accessible interventions designed to promote emotional resilience in the breast cancer population.

ESO-ESMO 4th International Consensus Guidelines for Breast Cancer in Young Women (BCY4)

The 4th International Consensus Conference for Breast Cancer in Young Women (BCY4) took place in October 2018, in Lugano, Switzerland, organized by the European School of Oncology (ESO) and the European Society of Medical Oncology (ESMO). Consensus recommendations for the management of breast cancer in young women were updated from BCY3 with incorporation of new evidence to inform the guidelines. Areas of research priorities were also identified. This article summarizes the ESO-ESMO international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Changes in Attentional Function in Patients From Before Through 12 Months After Breast Cancer Surgery

CONTEXT

Although approximately 75% of patients with breast cancer report changes in attentional function, little is known about how demographic, clinical, symptom, and psychosocial adjustment (e.g., coping) characteristics influence changes in the trajectories of attentional function over time.

OBJECTIVES

This study evaluated interindividual variability in the trajectories of self-reported attentional function and determined which demographic, clinical, symptom, and psychosocial adjustment characteristics were associated with initial levels and with changes in attentional function from before through 12 months after breast cancer surgery.

METHODS

Before surgery, 396 women were enrolled. Attentional Function Index (AFI) was completed before and nine times within the first 12 months after surgery. Hierarchical linear modeling was used to determine which characteristics were associated with initial levels and trajectories of attentional function.

RESULTS

Given an estimated preoperative AFI score of 6.53, for each additional month, the estimated linear rate of change in AFI score was an increase of 0.054 (P < 0.001). Higher levels of comorbidity, receipt of adjuvant chemotherapy, higher levels of trait anxiety, fatigue, and sleep disturbance, and lower levels of energy and less sense of control were associated with lower levels of attentional function before surgery. Patients who had less improvements in attentional function over time were nonwhite, did not have a lymph node biopsy, had received hormonal therapy, and had less difficulty coping with their disease.

CONCLUSION

Findings can be used to identify patients with breast cancer at higher risk for impaired self-reported cognitive function and to guide the prescription of more personalized interventions.

Cognitive Functioning and Psychological Well-being in Breast Cancer Patients on Endocrine Therapy

BACKGROUND/AIM

Anti-cancer therapies may deteriorate cognitive functioning, affective functioning and psychological well-being.

MATERIALS AND METHODS

In this prospective longitudinal pilot study, premenopausal and postmenopausal patients received adjuvant endocrine therapy (ET) (tamoxifen with or without LHRH analog or aromatase inhibitor) or were observed only (control group). At baseline testing and 6, 12 and 24 months thereafter, cognitive, depression and anxiety tests and quality of life (QOL) measurements were performed.

RESULTS

Overall, 46 cases were evaluated. None of the studied cognitive parameters differed between the subgroups or changed by time. No differences were found regarding anxiety, depression or QOL measures either. Baseline cognitive test and QOL results were in association with later anxiety and depression.

CONCLUSION

No cognitive impairment was found during the two years of ET. Baseline cognitive scores and QOL dimensions proved good predictors of later anxiety and depression.