Psychometric properties and measurement equivalence of the English and Chinese versions of the functional assessment of cancer therapy-cognitive in Asian patients with breast cancer

Perceived cognitive functioning difficulties in individuals living with endometriosis

Difficulties in cognitive functioning (e.g., memory, attention) are common in chronic conditions characterized by physical pain, fatigue and depression. Yet investigations in endometriosis are lacking. We aimed to assess: (1) perceived cognitive functioning, (2) the association of cognitive functioning with fatigue, pain and depressive symptoms, and (3) whether endometriosis treatments moderated these relationships. Participants (n = 1239) with diagnosed endometriosis completed an online survey assessing perceived cognitive functioning [Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog)], pain, fatigue and depression. FACT-Cog scores indicated cognitive impairments in 80% of participants. Hierarchical regression analyses demonstrated that greater pain, fatigue, and depressive symptoms were associated with poorer perceived cognitive functioning. Moderation analyses indicated that taking hormonal treatments or pain medications diminished the adverse effects of depression, but exacerbated the adverse effects of pain, on cognitive functioning. The extensive perceived cognitive difficulties evident in this sample suggests that supportive interventions to enhance cognitive functioning may be warranted.

HEalth-Related Quality of Life-Intervention in Survivors of Breast and Other Cancers Experiencing Cancer-Related Fatigue and Associated Cognitive Symptoms Using TraditionAL Chinese Medicine: The 'HERBAL' Trial

INTRODUCTION

As pharmacological strategies remain limited for relieving fatigue and associated cognitive symptoms, integrative modalities such as traditional Chinese medicine (TCM) could be explored as therapeutic strategies in cancer survivors. Here, we evaluate and report the efficacy and safety of a TCM concoction, modified Xiang Bei Yang Rong Tang (XBYRT), on quality of life (QOL), cancer-related fatigue (CRF), and cognitive symptoms, compared to placebo.

METHODS

In a single-centered, randomized, double-blinded, placebo-controlled pilot trial conducted from 2019 to 2022, fatigued cancer survivors ≥21 years old were recruited to receive the XBYRT intervention or placebo (5% diluted) once daily for the duration of 8 weeks. Patient-reported outcomes for QOL, CRF, cognition, blood samples for biomarker testing, and adverse events were collected at baseline (T0), 4 weeks (T1), 8 weeks (T2), and 10 weeks (T3) after baseline. Linear regression was performed to evaluate differences between groups at T2 and T3.

RESULTS

A total of 1502 patients were screened, with 672 patients considered eligible. Of the eligible, 15 XBYRT and 13 placebo subjects with similar mean ages (58.5 vs 58.4) were recruited. Both groups were predominantly Chinese (93% vs 62%), breast cancer patients (87% vs 62%), and diagnosed with stage 2 cancer (60% vs 46%). Although no significant difference was found in QOL between groups, the XBYRT group exhibited improved emotional fatigue at T3 (P = .045) and higher BDNF levels at T2 (P = .047) and T3 (P = .029). After baseline adjustment, XBYRT was associated with better perceived cognitive impairment at T2 (P = .011) and T3 (P = .017), as well as overall perceived cognitive function at T3 (P = .028). XBYRT is well tolerated, with grade 3 adverse events reported in three XBYRT (20%) and two placebo (15%) subjects.

CONCLUSION

In this pilot study, XBYRT as an integrative therapy is safe and generates encouraging improvements in cognitive and fatigue symptoms. Difficulties with recruitment limited the generalizability of trial findings, thus findings should be verified through a larger, multi-centered trial.

Relationship between δ-catenin expression and whole-brain small-world network in breast cancer patients before chemotherapy

Our study aimed to investigate the relationship between δ-catenin expression and whole-brain small-world network in breast cancer patients before chemotherapy using rs-fMRI. The study was based on the hypothesis that different δ-catenin expression levels correspond to distinct brain imaging characteristics. A total of 105 pathologically confirmed breast cancer patients were collected and categorized into high δ-catenin expression (DH, 52 cases) and low expression (DL, 53 cases) groups. Additionally, 36 age-matched healthy women were enrolled as a healthy control group (HC). The results demonstrated differences in several network topology attributes among the three groups. Furthermore, in addition to differences in nodal efficiency, betweenness, and degree centrality metrics observed between the patient groups and HCs across multiple brain regions, significant alterations were also identified between the DL and DH groups, particularly in the supramarginal gyrus and inferior frontal gyrus. Correlation analysis revealed associations between cognitive and memory-related brain regions, such as the caudate nucleus and frontal lobe, and scores on cognitive and verbal memory scales (all P < 0.05). This study concludes that high and low expression levels of δ-catenin in breast cancer patients are associated with distinct whole-brain network topology patterns, and that these differences in network segregation and integration functions are associated with alterations in cognition and verbal memory.

The Congruence and Interrelationship: A Dyadic Perspective on the Subjective Cognitive Impairment in the Patients with Colorectal Cancer and Their Spousal Caregivers

OBJECTIVES

Patients with colorectal cancer (CRC) reported experiencing subjective cognitive impairment (SCI), and their spousal caregivers perceived the patients' SCI. This cross-sectional study assessed the congruence of SCI between the patients' self-reports and the spousal caregivers' perceptions and examined the factors affecting SCI from the dyadic perspective.

METHODS

A total of 200 dyads of patients with CRC and their spousal caregivers were invited to complete the survey, which evaluated the SCI, dyadic coping (DC), quality of life, anxiety, and depression for the dyads. Congruence was analyzed using the intraclass correlation coefficient (ICC) and paired-sample t test. Impacting factors analysis was conducted using Pearson correlations, hierarchical multiple regression, and actor-partner interdependence mediation model.

RESULTS

The congruency of SCI between the patient-reported and the spouse-perceived ranged from moderate to good (ICC = 0.75 to 0.86). After controlling demographic variables (the patients' gender and spouses' work status), the DC of both patients and spousal caregivers, and the emotional health of patients were significant predictors for patients' SCI (all P < .05). In the actor-partner interdependence mediation model, there was an actor effect between DC and SCI for both patients and spousal caregivers and a partner effect between DC and SCI for patients. Moreover, patients' emotional health (anxiety and depression) had the mediating effect between DC and SCI for both patients and spousal caregivers.

CONCLUSION

Spousal caregivers played a vital role in assessment and management in the SCI of patients. The DC of patients and spousal caregivers and the emotional health of patients (eg, anxiety and depression) were major predictors for the SCI of patients.

IMPLICATIONS FOR NURSING

Nursing providers should consider the importance of patients' and spousal caregivers' perspectives in assessing and managing SCI. This study supports nurses focusing on the congruence and interrelationship of SCI to enhance DC for CRC patients and their spousal caregivers. This approach aims to reduce emotional distress and develop cognitive interventions from a dyadic perspective.

Patient reported outcomes and short-term adjustment trajectories following gamma knife radiosurgery for benign brain tumor

PURPOSE

Patient reported outcomes (PROs) in the context of Gamma Knife Stereotactic Radiosurgery (GKSRS) for benign brain tumor have been under-researched. This study examined changes in PROs and adjustment trajectories post-GKSRS.

METHOD

50 adults (54% female) aged on average 53.18 (SD = 14.76) years with benign brain tumor were assessed 1 week before GKSRS, 1-2 weeks post-GKSRS, and at 3-month follow-up. Telephone-based questionnaires of anxiety and depressive symptoms, cognitive function, symptom burden, and health-related quality of life (HRQoL) were completed.

RESULTS

Significant improvements in HRQoL, perceived cognitive ability, anxiety, and total brain tumor symptoms were evident between pre-GKSRS and 3-month follow-up. Conversely, there was a significant short-term increase in depressive symptoms at post-GKSRS; however, levels did not differ from pre-GKSRS at follow-up. No significant changes were evident on PROs of headaches or fatigue. About half of the participants (46-51%) experienced reliable improvement in global HRQoL, and one-third (31-34%) reported improved anxiety symptoms. Increased depressive symptoms was seen in 34% of participants post-GKSRS and 18% at follow-up.

CONCLUSIONS

At 3 months post-GKSRS, improvements in HRQoL, anxiety, perceived cognitive ability, and total brain tumor symptoms were evident. Routine monitoring and support for pre-GKSRS anxiety and depressive symptoms post-GKSRS is recommended.

Toward better understanding and management of chemobrain: the potential utilities of the MemTrax memory test

OBJECTIVE

To study the effects of chemotherapy on cognitive function in breast cancer patients, and to investigate the relationship of MemTrax test of memory and related functions to the FACT-Cog functional self-assessment for the evaluation and management of chemobrain.

METHODS

In this prospective cohort study, clinical information of pathologically confirmed female breast cancer patients who decided to receive chemotherapy were collected in a questionnaire which was developed for this study and provided as a supplementary file. The FACT-Cog self-assessment and MemTrax test were administered before and after the chemotherapy treatments. Patients with chemobrain were identified using published criteria based on FACT-Cog scores, and MemTrax scores from chemobrain patients were analyzed.

RESULTS

Fifty-six patients participated in this study, of which 41 participants completed 4 or more cycles of chemotherapy and were included in the final analyses here. Using the reported high end of minimal clinical differences (10.6 points) of FACT-Cog before and after chemotherapy, 18 patients suffered from chemobrain in this study. In these 18 chemobrain patients, no cognitive impairments were detected by MemTrax, which paradoxically demonstrated an improvement in the normal cognitive range.

CONCLUSION

The cognitive impairment induced by chemotherapy in breast cancer patients is detectable by the FACT-Cog in a Chinese cohort but is not detected by the MemTrax memory test. The fact that the more objective MemTrax could not detect the impairment could alleviate patients' concerns which in turn would be beneficial for patients' mental health.

Comparing the efficacy of a multi-dimensional breast cancer rehabilitation programme versus a home-based exercise programme during adjuvant cancer treatment

BACKGROUND

Breast cancer is the most common female malignancy worldwide and a major cause of morbidity and mortality. Exercise during adjuvant treatment improves function and relieves symptoms in breast cancer survivors. However, it is unclear if an unsupervised exercise programme may be as effective as a supervised multimodal group. We investigated the feasibility and efficacy of a centre-based multidimensional rehabilitation (MDR) programme for breast cancer survivors undergoing adjuvant treatment and compared it to an unsupervised home-based exercise (HE) programme.

METHODS

Participants were self-allocated to either MDR or HE group. MDR participants underwent 24 supervised exercise classes and 10 education classes over 12 weeks. HE participants were instructed on a home exercise regime. Outcome measures, including the 6-min walk test (6MWT) and Frenchay Activities Index (FAI), FACT-Cognitive Function scale, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, were conducted at baseline (W0), post-intervention (W12) and 6-months post-intervention (M6). Variance between time points and the 2 groups were analysed using a linear mixed model (unstructured covariance matrix) and adjusted with Bonferroni.

RESULT

Twenty-five participants attended at least half of the MDR interventions, while 21 completed the HE interventions. The former showed significant improvement in 6MWT, from 406.88 m (W0) to 443.34 m (W12) to 452.81 m (M6), while the improvement in the HE group was not significant (407.67 m (W0) to 433.14 m (W12) to 430.96 m (M6)). Both groups showed a significant improvement in FAI, with earlier significant improvement noted at W12 in the MDR group (22.71 (W0) to 27.65 (W12) to 28.81 (M6)) compared to the HE group (23.16 (W0) to 26.47 (W12) to 29.85 (M6)). Dropout rate was 16% in the MDR group and 34% in HE group. Overall satisfaction with the MDR programme was high.

CONCLUSION

Both MDR and HE programmes were feasible. MDR was superior in improving endurance and earlier return to instrumental activities for those who completed at least half of the sessions. Future studies could explore use of technology to improve adherence to exercise.

TRIAL REGISTRATION

The study was registered with ClinicalTrial.gov on 01/04/2022 with the registration number NCT05306808.

The association between inflammation-related biomarkers and the subtypes of cancer-related cognitive impairment in colorectal cancer patients: A latent profile analysis

PURPOSE

Cancer-related cognitive impairment (CRCI) has garnered considerable attention, yet limited research has delved into nuanced distinctions among varying degrees of CRCI in colorectal cancer survivors. This study aimed to identify distinct subgroups based on the patterns of CRCI, assess the heterogeneity among different subgroups, and investigate the potential correlations between the subgroups of CRCI and inflammation-related biomarkers.

METHODS

268 colorectal cancer patients were enrolled in this cross-sectional study, followed by the Functional Assessment of Cancer Therapy-Cognitive Function. The determination of CRCI subgroups was accomplished by the latent profile analysis (LPA). The effects of inflammation-related biomarkers on CRCI were examined using the binary logistic regression analysis. The receiver operating characteristic (ROC) curves assessed the diagnostic efficacy of inflammation-related biomarkers.

RESULTS

Two latent profiles were identified: CRCI (n = 64, 23.88%) and non-CRCI (n = 204, 76.12%). Independent factors for CRCI in colorectal cancer patients were SIRI (OR = 3.248, 95%CI [1.197-8.807], P = 0.021) and ALI (OR = 0.962, 95%CI [0.937-0.989], P = 0.005). The areas under the curve (AUCs) for SIRI and ALI in predicting CRCI were 0.781 and 0.774, with the optimal cut-off values being 0.70 and 37.04, respectively.

CONCLUSIONS

Colorectal cancer patients exhibited divergent cognitive performance profiles, categorized into two subgroups based on LPA. SIRI and ALI were identified as independent factors for CRCI, demonstrating strong diagnostic accuracy. These two inflammation-related biomarkers may potentially be novel indicators to identify and manage the development of CRCI among colorectal cancer patients.

Longitudinal trajectory of amplitude of low-frequency fluctuation changes in breast cancer patients during neoadjuvant chemotherapy-A preliminary prospective study

There is growing evidence that the amplitude of low-frequency fluctuation (ALFF) changes in breast cancer patients after chemotherapy. However, longitudinal changes in ALFF during chemotherapy are unclear. To assess the trajectory of ALFF changes during chemotherapy, 36 breast cancer patients underwent both resting-state functional magnetic resonance imaging and neuropsychological testing at three time points, including before neoadjuvant chemotherapy (NAC) (time point 0, TP0), after one cycle of NAC (before the second cycle of NAC, TP1), and upon completion of NAC (pre-operation, TP2). Healthy controls (HC) received the same assessments at matching time points. We compared the longitudinal changes of ALFF in the NAC and two HC groups. In the NAC group, compared with TP0, ALFF values in the right orbital part of the inferior frontal gyrus, left medial orbital part of the superior frontal gyrus, right insula, left medial part of the superior frontal gyrus, and right middle frontal gyrus declined significantly at TP1 and TP2. Compared with TP1, there were no significant changes in ALFF values at TP2. In the two HC groups, there were no significant changes in ALFF at corresponding intervals. We concluded that for breast cancer patients receiving NAC, ALFF values declined significantly in some brain regions after one cycle of NAC and then remained stable until the completion of NAC, and most of the brain regions with ALFF changes were located in the frontal lobe.

Cognitive impairment experienced by Chinese breast cancer survivors

To identify cognitive function in Chinese breast cancer survivors. Research questions were: is cognitive function was associated with breast cancer and/or chemotherapy treatment and/or psychological functioning:? and did women with breast cancer experience more cognitive and psychological issues than age-matched women without cancer? Breast cancer survivors with chemotherapy (n = 106, mean age = 50.2 ± 9.5), breast cancer survivors without chemotherapy (n = 100, mean age = 50.5 ± 10.0) and matched healthy controls (n = 96, mean age = 47.9 ± 9.1) completed a battery of cognitive and psychosocial functioning. Demographic characteristics were also collected. The Perceived Cognitive Impairment score for cancer groups was significantly higher than for the healthy group (p = 0.04), but not between the cancer groups. Processing speed was significantly slower in the cancer groups than in the healthy group (both p < 0.001), but not between the cancer groups. Age, living status and education were significantly associated with the FACT-Cog (all p < 0.05). The correlations between the FACT-Cog score and BSI score were strong (r = 0.60 p < 0.01), and between the HADS anxiety and depression scales were strong (r = 0.53 and 0.50, p < 0.01) but correlations were weaker between performance based cognitive tests and measures of psychological functioning. Breast cancer groups indicated more cognitive impairment and reduced psychological functioning compared to the healthy group. However, there was no differences between the breast cancer groups. Chinese breast cancer survivors experienced excess cognitive impairment not associated with usual ageing. Assessment and intervention to address cognitive impairment should be made available to breast cancer survivors.

Hula as a physical activity and social support intervention for sustained activity in female breast and gynecologic cancer survivors

Background

Physical activity improves health and psychosocial functioning for people who have been diagnosed with cancer. Native Hawaiians face disparities for some cancers, including breast cancer. Delivering culturally grounded interventions has the potential to improve enjoyment and adherence to the intervention. We sought to test the adherence and impact of a 6 month randomized wait-list controlled trial of hula.

Methods

In this randomized wait-list controlled design people who had been diagnosed with breast or gynecologic cancers were invited to participate with other cancer survivors in a group based setting. Participants were randomized to begin hula immediately or after six months. Attendance was collected and heart-rate measured three times per session. In addition, demographic data, self-report psychosocial data, and biological data (findings will be reported elsewhere) were collected at three time points: baseline, 6 months, and 12 months. The study included six months of hula, twice per week, 60 min each session. In addition, participants committed to practice 60 min per week at home.

Results

Participants in the study (n = 42) attended, on average, 72% of the sessions. Significant increase in moderate physical activity (d = 0.50, p = 0.03) was observed in the intervention versus control group. For the measures of intra-individual changes pre-and post-intervention, an increase in total physical activity were seen in the intervention group (d = 0.69, p = 0.003), daily caloric intake decreased (d = -0.62, p = 0.007), and a reduction in waist circumference (d = -0.89, p = 0.0002) that was sustained six months after completion of the intervention. Psychosocially, cognitive functioning significantly declined from baseline to 12 months (d = -0.50, p = 0.03), with role functioning improving (d = 0.55, p = 0.02), social constraints increasing (d = 0.49, p = 0.03), and financial difficulties improving (d = -0.55, p = 0.02).

Conclusion

Sustainable physical activity is crucial to improve both the survival and quality of life of cancer survivors. Culturally grounded interventions, such as hula have the potential to increase the maintenance of physical activity. In addition, they create a support group where the benefits of people who have all experienced cancer can gather and garner those benefits of social support, too. This study was registered as a clinical trial through the National Cancer Institute (NCT02351479).

Clinical trial registration

Clinicaltrails.gov, NCT02351479.

Quality of working life can protect against cognitive and emotional vulnerability in women living with metastatic breast cancer: a cross-sectional study

PURPOSE

Research focusing on the cognitive and emotional health of women with metastatic breast cancer (MBC) is limited. The focal aim of the current study was to explore how quality of working life was related to global health, perceived cognitive function, anxiety and depression. To this end, women's experience of employers after MBC diagnosis and its relationship to quality of working life was also explored.

METHODS

Women living with MBC (N = 88) completed online questionnaires assessing their global health status, perceived cognitive and emotional vulnerability and their experience of employers following diagnosis. Women working at the time of the study also reported on their quality of working life.

RESULTS

Women's experience of employers after MBC diagnosis was positively related to their quality of working life. Importantly, greater quality of working life met with better perceived cognitive function and global health, as well as lower levels of depression in working women.

CONCLUSIONS

Our study is the first to establish the role of quality of working life in protecting against levels of cognitive vulnerability and emotional vulnerability to depression in women with MBC. We also highlight the importance of having a positive experience with employers. Our findings suggest that educational programmes can be provided to employers to enhance their understanding and awareness of the needs of women with MBC.

IMPLICATIONS FOR CANCER SURVIVORS

Women with MBC may benefit from employers accessing educational (or support) programmes that can increase their awareness of the treatment-related sequelae and needs of women with MBC in the workplace.

Brain-derived neurotrophic factor as a biomarker in cancer-related cognitive impairment among adolescent and young adult cancer patients

Brain-derived neurotrophic factor (BDNF) improves cognitive function by stimulating neurogenesis and neuroplasticity. We hypothesize that higher plasma BDNF levels are protective against cognitive toxicity among adolescent and young adult cancer patients (15-39 years old). In a prospective, longitudinal study, we recruited 74 newly diagnosed cancer and 118 age-matched non-cancer controls who completed the Cambridge Neuropsychological Test Automated Battery (CANTAB), Functional Assessment of Cancer Therapy-Cognitive Function questionnaire (FACT-Cog) and blood draws. Plasma BDNF was quantified using an enzyme-linked immunosorbent assay. Genomic DNA from buffy coat was genotyped for BDNF Val66Met. Most cancer participants were diagnosed with breast (24%) and head/neck (22%) cancers. After adjusting for sociodemographic variables (age, gender, race, marital status, education years), cancer participants had lower BDNF levels (ng/mL) at baseline (median: 10.7 vs 21.6, p < 0.001) and 6-months post-baseline (median: 8.2 vs 15.3, p = 0.001) compared to non-cancer controls. Through linear mixed modelling adjusted for sociodemographic variables, baseline cognition, fatigue, psychological distress, and time, we observed that among cancer participants, lower baseline BDNF levels were associated with worse attention (p = 0.029), memory (p = 0.018) and self-perceived cognitive abilities (p = 0.020) during cancer treatment. Met/Met was associated with enhanced executive function compared to Val/Val (p = 0.012). Plasma BDNF may serve as a predictive biomarker of cancer-related cognitive impairment.

Managing Cancer and Living Meaningfully (CALM) alleviates chemotherapy related cognitive impairment (CRCI) in breast cancer survivors: A pilot study based on resting-state fMRI

BACKGROUND

Chemotherapy related cognitive impairment (CRCI) is a type of memory and cognitive impairment induced by chemotherapy and has become a growing clinical problem. Breast cancer survivors (BCs) refer to patients from the moment of breast cancer diagnosis to the end of their lives. Managing Cancer and Living Meaningfully (CALM) is a convenient and easy-to-apply psychological intervention that has been proven to improve quality of life and alleviate CRCI in BCs. However, the underlying neurobiological mechanisms remain unclear. Resting-state functional magnetic resonance imaging (rs-fMRI) has become an effective method for understanding the neurobiological mechanisms of brain networks in CRCI. The fractional amplitude of low-frequency fluctuations (fALFF) and ALFF have often been used in analyzing the power and intensity of spontaneous regional resting state neural activity.

METHODS

The recruited BCs were randomly divided into the CALM group and the care as usual (CAU) group. All BCs were evaluated by the Functional Assessment of Cancer Therapy Cognitive Function (FACT-Cog) before and after CALM or CAU. The rs-fMRI imaging was acquired before and after CALM intervention in CALM group BCs. The BCs were defined as before CALM intervention (BCI) group and after CALM intervention (ACI) group.

RESULTS

There were 32 BCs in CALM group and 35 BCs in CAU group completed the overall study. There were significant differences between the BCI group and the ACI group in the FACT-Cog-PCI scores. Compared with the BCI group, the ACI group showed lower fALFF signal in the left medial frontal gyrus and right sub-gyral and higher fALFF in the left occipital_sup and middle occipital gyrus. There was a significant positive correlation between hippocampal ALFF value and FACT-Cog-PCI scores.

CONCLUSIONS

CALM intervention may have an effective function in alleviating CRCI of BCs. The altered local synchronization and regional brain activity may be correlated with the improved cognitive function of BCs who received the CALM intervention. The ALFF value of hippocampus seems to be an important factor in reflect cognitive function in BCs with CRCI and the neural network mechanism of CALM intervention deserves further exploration to promote its application.

Cognitive Function in Patients at Different Stages of Treatment for Colorectal Cancer: A Comparative Cross-Sectional Study

OBJECTIVES

To compare subjective and objective cognitive functions among patients at the following three stages of treatment for colorectal cancer (CRC): new diagnosis (Group A), ≤2 years since chemotherapy completion (Group B), and >2 years since chemotherapy completion (Group C).

DATA SOURCES

A comparative cross-sectional approach was used in this study. The Functional Assessment of Cancer Therapy-Cognitive Function questionnaire and neuropsychological assessments were used to assess patients' subjective cognitive function, attention, memory, and executive functions. A total of 63 patients with stage I to III CRC were recruited from a medical center in northern Taiwan. We performed one-to-one-to-one propensity score matching to identify 36 individuals as eligible for this study. A generalized estimating equation was used to compare subjective and objective cognitive functions.

CONCLUSION

We observed no significant between-group differences in subjective cognitive function and objective performance in overall cognition and memory. Group B had significantly longer reaction time in attention and processing speed than did Group A. Adjuvant chemotherapy had significantly deleterious effects on attention and processing speed in patients with CRC. These cognitive symptoms last for approximately 2 years after the completion of chemotherapy.

IMPLICATIONS FOR NURSING PRACTICE

The early detection of cancer-related cognitive impairment is necessary for managing symptom distress. Future studies with a large sample size and longitudinal design may elucidate the trajectory of specific cognitive functions. Developing nursing interventions aimed at improving attention and executive function in patients with CRC are needed.

Cognitive functioning in women with breast cancer: psychometric properties of the Arabic version of the Functional Assessment of Cancer Therapy-Cognitive Function Tool

BACKGROUND

The Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) evaluates perceived cognitive functioning and their impact on quality of life. This study was designed to evaluate the factors associated with cognitive functioning in a sample of women with breast cancer (BC) in Lebanon. We also sought to explore the psychometric properties of the FACT-Cog Arabic version.

METHODS

A cross-sectional study was carried out between March and August 2020 among women with BC. Socio-demographic and clinical characteristics were collected. In addition, patients were asked to complete the FACT-Cog Arabic version as well as the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30, the Patient Health Questionnaire (PHQ-9), and the Generalized Anxiety Disorder (GAD-7). The internal consistency of the FACT-Cog tool was evaluated using Cronbach's alpha. Content, convergent, and known group validity of the FACT-Cog Arabic version were also evaluated. All statistical analyses were performed using SPSS version 23.0.

RESULTS

A sample of 134 women with BC was collected. Internal consistencies of the FACT-cog total scale and its subscales were high (Cronbach's α between 0.83 and 0.95). The convergent validity of the FACT-Cog Arabic version was supported by the positive correlation with the EORTC-cognitive functioning subscale. Moreover, negative correlations were found between FACT-Cog scale and fatigue, pain, anxiety, as well as depression. Known-group validity was supported by the statistically significant mean differences of the FACT-Cog total scale between patients in early (I &II) and late (III & IV) BC stages. Unmarried BC patients as well as those having higher depressive symptoms and a lower quality of life were found to be at higher risk of cognitive impairment.

CONCLUSION

The FACT-Cog Lebanese Arabic version is a valid and reliable tool for assessing perceived cognitive functioning in BC women. Higher level of depression and impaired quality of life were associated with a decline in cognitive functioning.

Psychometric properties of the Chinese version of the Cognitive Reserve Assessment Scale in Health in patients with cancer

BACKGROUND

Cognitive reserve is a modifiable factor that could prevent cognitive decline in patients with cancer. The Cognitive Reserve Assessment Scale in Health (CRASH) is an instrument used to assess cognitive reserve. This study aims to develop and examine the psychometric properties of the Chinese version of the CRASH for patients with cancer.

METHODS

A cross-sectional survey was conducted with 167 cancer patients from four wards of two hospitals in China. Thirty-one patients were re-assessed to examine the test-retest reliability. Four translators and three reviewers developed the Chinese version of the scale. We assessed its structural validity, concurrent validity, internal consistency, test-retest reliability, measurement error, and floor/ceiling effects.

RESULTS

Confirmatory factor analysis showed a good model fit with the four-factor structure of the original CRASH. The CRASH scores were statistically significantly associated with neuropsychological test scores, indicating sufficient concurrent validity. The internal consistency was acceptable, except for leisure activities, with standardized Cronbach's alphas (0.64-0.94) and standardized Omega (0.66-0.95). There was excellent test-retest reliability, with a high intraclass correlation coefficient (0.914-0.993) of total scores and scores for each domain. The measurement error was acceptable, and no floor or ceiling effects were observed.

CONCLUSIONS

The Chinese version of the CRASH is a valid and reliable instrument to assess cognitive reserve in patients with cancer. Moreover, cognitive reserve measured by the CRASH was associated with low cognitive performance in cancer patients.

Validation study of the Functional Assessment of Cancer Therapy-Cognitive Function-Version 3 for the Portuguese population

Background

Cancer-related cognitive impairment is a common and potentially debilitating symptom experienced by patients with non-central nervous system (CNS) cancers, with negative impact on their quality of life. The Functional Assessment of Cancer Therapy-Cognitive Function-Version 3 (FACT-Cog-v3) is the most extensively used instrument specifically developed to evaluate cognitive complaints in adult cancer patients. Nevertheless, this self-report measure is not yet validated for the Portuguese population. Therefore, the purpose of this study was to evaluate the psychometric properties of the FACT-Cog-v3 among patients with non-CNS cancers in Portugal.

Methods

The validation study was conducted based on a convenience sample of 281 patients with non-CNS cancers, aged between 18 and 65 years, recruited online. A confirmatory factor analysis (CFA) was used to test the factor structure of the Portuguese FACT-Cog-v3 version; internal consistency analysis was also conducted. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30–version 3) and the Hospital Anxiety and Depression Scale (HADS) were also used to test the concurrent, convergent, and discriminant validity of the scale.

Results

CFA supported a four-factor model with good fix indexes and internal consistencies: perceived cognitive impairments (α = 0.97), comments from others (α = 0.92), perceived cognitive abilities (α = 0.93), and impact on quality of life (α = 0.92). Concurrent, convergent, and discriminant validities were confirmed. Moderate and strong correlations were found between the FACT-Cog-v3 subscales and the QLQ-C30 cognitive functioning subscale. Good convergent validity, with moderate correlations, was found between the FACT-Cog-v3 subscales and the HADS-A, HADS-D, and QLQ-C30 fatigue, sleep disturbance, and global health status subscales. Acceptable discriminant validity, with weak and moderate correlations, was demonstrated between the FACT-Cog-v3 subscales and the QLQ-C30 pain and nausea/vomiting subscales.

Conclusions

The Portuguese FACT-Cog-v3 version can be considered a reliable and valid measure to assess cognitive concerns of patients with non-CNS cancers, with relevance for research and clinical practice.

Changes in Degree Centrality and Functional Connectivity after the First Cycle of Neoadjuvant Chemotherapy in Newly Diagnosed Breast Cancer: A Longitudinal Study

Purpose

To evaluate the longitudinal changes of brain degree centrality (DC) and functional connectivity (FC) in breast cancer patients after the first cycle of neoadjuvant chemotherapy (NAC).

Methods

Thirty-five breast cancer patients were included in the NAC group. Resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological test were performed at baseline before NAC (time point 0, TP0) and after the first cycle of NAC (time point 1, TP1). The healthy controls (HC) included 30 healthy subjects and received the same rs-fMRI scan and neuropsychological test as the above-mentioned NAC group at one time point. DC and FC analyses were conducted to assess brain connectivity of all participants. Receiver operating characteristic (ROC) curve was used to assess the ability of DC and FC in distinguishing patients before and after chemotherapy.

Results

In the NAC group, the Self-Rating Anxiety Scale scores decreased significantly over time. At TP0 and TP1, the Digital Span Test forward score of the NAC group was significantly lower than that of the HC group. In the NAC group, DC in the right middle frontal gyrus and left precentral gyrus/middle frontal gyrus decreased significantly at TP1, and FC between the left precentral gyrus/middle frontal gyrus and bilateral precuneus was significantly reduced at TP1. Through ROC analysis, we found that the area under the curve (AUC) of DC, FC, and the combined model in distinguishing patients in TP0 or TP1 was 0.7886, 0.7665, and 0.8278, respectively.

Conclusions

Brain connectivity, involving executive and motor function related brain areas, changes in the short term after NAC treatment in breast cancer patients.

Impacts of breast cancer and chemotherapy on gut microbiome, cognitive functioning, and mood relative to healthy controls

Women diagnosed with breast cancer undergoing chemotherapy experience cognitive impairment, symptoms of anxiety and depression, and physical side effects including disruption in the diversity and community composition of the gut microbiome. To date, there is limited research exploring the associations among these specific challenges. The present cross-sectional study explored the associations of self-reported cognitive functioning, depression, and anxiety symptoms, and gut microbiome diversity and community composition in women who were diagnosed with and undergoing chemotherapy treatment for breast cancer (BC) compared to cancer-free healthy controls (HC). The BC group displayed higher rates of cognitive dysfunction (p < 0.001) and depressive symptoms (p < 0.05) relative to HC. There was a significant difference in microbiome community composition between BC and HC, particularly characterized by a decreased relative abundance of the mucin-degrading genus Akkermansia in BC compared to HC (p < 0.05). Association models identified significant associations among group, cognitive, depression, and microbiome variables (p < 0.001). Overall, the study identified that BC participants experienced significant differences in self-reported cognitive functioning, self-reported depression symptoms, microbiome community composition, and mucin-degrading bacteria of the gut-mucosal barrier, relative to HC. The present study is consistent with the hypothesis that gut microbiome community composition impacts a woman's experience with breast cancer and treatment suggesting that microbiome-based interventions have potential for improving quality of life outcomes in individuals with breast cancer.

Impact of psychosocial, behavioral and lifestyle factors on subjective cognitive complaints and perceived quality of life in a large cohort of Italian breast cancer patients

The impact of psychosocial and behavioral factors on Cancer Related Cognitive Impairment manifestations is still under debate. Study's purpose is to determine the prevalence rate of cancer related cognitive impairment in a cohort of Italian breast cancer patients and to evaluate the implication of specific behavioral factors. For these purposes, a total of 233 women (106 breast cancer patients and 127 age-matched controls without oncological diagnosis) completed a questionnaire investigating cognitive functionality (FACT-Cog v3.0), sociodemographic characteristics, clinical information, psychosocial and behavioral factors (cognitive reserve, sleep quality, dietary habits, physical activity). The results indicated a higher prevalence rate of subjective cognitive complaints in breast cancer patients (37%) compared to a representative sample of women in the same age group without an oncological diagnosis (p < 0.001). Moreover, breast cancer patients showed significantly lower levels of cognitive reserve (p < 0.05) and worse sleep quality (p < 0.01) compared to age-matched controls. Further analysis revealed that breast cancer patients reporting subjective cognitive complaints differed significantly from breast cancer patients without subjective cognitive complaints on measures of perceived cognitive abilities (p < 0.001) and on the impact of cognitive difficulties on perceived quality of life (p < 0.01). Future studies are needed to examine behavioral directed interventions to prevent subjective cognitive deficits in breast cancer patients.

Longitudinal evaluation of dehydroepiandrosterone (DHEA), its sulfated form and estradiol with cancer-related cognitive impairment in early-stage breast cancer patients receiving chemotherapy

The purpose of this study is to elucidate how patient-reported cognitive symptoms manifest from variations in hormone levels or precursors such as dehydroepiandrosterone (DHEA) and its sulfated form [collectively termed as DHEA(S)] and to investigate their association in breast cancer survivors. Levels of estradiol and DHEA(S) were compared between early-stage breast cancer patients with and without cancer-related cognitive impairment (CRCI) during adjuvant chemotherapy. Data were analyzed from 242 patients (mean age ± SD = 50.8 ± 9.2 years) who had completed FACT-Cog v.3.0, blood draws and questionnaires. Regression model was used to fit the magnitude of change in each respective biomarker levels against overall cognitive impairment status while adjusting for clinically important covariates. There was reduction in mean plasma levels of estradiol and DHEAS during and towards the end of chemotherapy (p-values < 0.001). Compared to non-impaired patients, smaller magnitude of decline was observed in DHEA(S) levels in patients reporting CRCI, with significant association between decline in DHEAS levels and acute onset of CRCI at 6 weeks from baseline (adjusted β of 0.40, p-value of 0.02). In contrast, patients reporting CRCI showed greater magnitude of decline in estradiol compared to non-impaired patients, although this was not found to be statistically significant. There was an association between magnitude of change in biomarker levels with self-reported CRCI which suggests that the hormonal pathway related to DHEAS may be implicated in acute CRCI for breast cancer survivors. Our findings help to improve biological understanding of the pathway from which DHEAS may correlate with cognitive dysfunction and its impact on cancer survivors.

Psychometric properties of the 37-item Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) scale

Aim: To validate the French version of the 37-item Functional Assessment of Cancer Therapy-Cognitive Function, including the four items related to multitasking, previously excluded from the scoring algorithm. Materials & methods: A cross-sectional study was carried out among 261 cancer patients. Validity was confirmed by factor analyses using the principal component analysis technique. Results: Construct validity was demonstrated, and items loaded on subscales with adequate sample adequacy to factor analyses outcomes. Better cognitive functioning was noted with age and in working patients, whereas lower functioning was observed in metastatic patients. Conclusion: The 37-item French tool is valid and reliable; questions related to multitasking could be included in the score.

A Telehealth-Based Cognitive-Adaptive Training (e-OTCAT) to Prevent Cancer and Chemotherapy-Related Cognitive Impairment in Women with Breast Cancer: Protocol for a Randomized Controlled Trial

Background: Many women with breast cancer experience a great number of side effects, such as cognitive impairment, during and after chemotherapy that reduces their quality of life. Currently, research focusing on the use of non-pharmacological, and specifically telehealth interventions to prevent or mitigate them has been insufficient. Methods: This protocol describes a randomized controlled trial aimed at studying the preventive effects of a videoconferenced cognitive-adaptive training (e-OTCAT) program (ClinicalTrials.gov NCT04783402). A number of 98 eligible participants will be randomized to one of the following groups: (a) the experimental group receiving the e-OTCAT program during 12 consecutive weeks since the beginning of chemotherapy; and (b) the control group receiving and educational handbook and usual care. The primary outcome will be the cognitive function. Secondary measures will be psychological distress, fatigue, sleep disturbance, quality of life and occupational performance. The time-points for these measures will be placed at baseline, after 12 weeks and six months of post-randomization. Conclusion: This trial may support the inclusion of multidimensional interventions through a telehealth approach in a worldwide growing population suffering from breast cancer, emphasizing the prevention of cognitive impairment as one of the side effects of cancer and its treatments.

A Preliminary Study on the Relationship between Serum Heparan Sulfate and Cancer-Related Cognitive Impairment: The Moderating Role of Oxidative Stress in Patients with Colorectal Cancer

Cancer-related cognitive impairment (CRCI) has been frequently reported in colorectal cancer survivors. Heparan sulfate (HS) was gradually considered to be related to cognitive disorders. The effect and potential mechanism of HS on CRCI in colorectal cancer patients were unexplored. In this study, all participants were divided into a cognitive impaired group and a cognitive normal group. The concentrations of oxidative stress factors and HS in serum were detected. Associations among HS, oxidative stress factors and CRCI were evaluated. Participants with cognitive impairment exhibited increased levels of HS, GSH, SOD and MDA, compared to the patients with normal cognitive performance. The independent significant association was found between HS and CRCI after controlling for various covariates. The higher concentrations of HS were related to the decreased cognitive performance among survivors who reported higher levels of GSH (β = 0.080, p = 0.002). Moreover, the nonlinear association between the level of HS and cognitive scores was confirmed using the restricted cubic splines (p < 0.001). These results indicated that the increased concentrations of circulating HS had a nonlinear negative connection with cognitive performance in colorectal cancer survivors, which was moderated by GSH. HS might be a new biomolecule for the identification and management of patients with CRCI.

Mindfulness-based stress reduction and cognitive function among breast cancer survivors: A randomized controlled trial

BACKGROUND

Breast cancer (BC) survivors frequently report changes in cognition after chemotherapy. Mindfulness may benefit survivors by mitigating cancer-related cognitive impairment. As part of a larger study investigating the effects of mindfulness-based stress reduction (MBSR) for BC survivors living with neuropathic pain, the authors assessed whether MBSR would have an effect on cognitive outcomes.

METHODS

Participants were randomized to an MBSR intervention group (n = 30) or a waitlist control group (n = 30). Cognitive assessments were administered at 3 time points: at baseline, 2 weeks, and 3 months post-MBSR in the intervention group and at equivalent time intervals for the control group. Multilevel models were used to assess whether MBSR significantly improved task performance at each time point.

RESULTS

MBSR participants showed a significantly greater reduction in prospective and retrospective memory failures at 2 weeks postintervention. No effects of MBSR were noted for objective assessments.

CONCLUSIONS

These results suggest that MBSR training reduces subjective (but not objective) memory-related impairments in BC survivors who receive treatment with chemotherapy. This study provides insight into a noninvasive intervention to ameliorate memory difficulties in BC survivors.

Effects of cognitive behavior therapy combined with Baduanjin in patients with colorectal cancer

BACKGROUND

Cancer-related fatigue (CRF) is the most common concomitant symptom in the treatment of colorectal cancer (CRC). Such patients often present with subjective fatigue state accompanied by cognitive dysfunction, which seriously affects the quality of life of patients.

AIM

To explore the effects of cognitive behavior therapy (CBT) combined with Baduanjin exercise on CRF, cognitive impairment, and quality of life in patients with CRC after chemotherapy, and to provide a theoretical basis and practical reference for rehabilitation of CRC after chemotherapy.

METHODS

Fifty-five patients with CRC after radical resection and chemotherapy were randomly divided into either an experimental or a control group. The experimental group received the intervention of CBT combined with exercise intervention for 6 mo, and indicators were observed and measured at baseline, 3 mo, and 6 mo to evaluate the intervention effect.

RESULTS

Compared with the baseline values, in the experimental group 3 mo after intervention, cognitive function, quality of life score, and P300 amplitude and latency changes were significantly better (P < 0.01). Compared with the control group, at 3 mo, the experimental group had significant differences in CRF, P300 amplitude, and quality of life score (P < 0.05), as well as significant differences in P300 latency and cognitive function (P < 0.01). Compared with the control group, at 6 mo, CRF, P300 amplitude, P300 latency, cognitive function and quality of life score were further improved in the experimental group, with significant differences (P < 0.01). The total score of CRF and the scores of each dimension were negatively correlated with quality of life (P < 0.05), while the total score of cognitive impairment and the scores of each dimension were positively correlated with quality of life (P < 0.05).

CONCLUSION

CBT combined with body-building Baduanjin exercise can improve CRF and cognitive impairment in CRC patients after chemotherapy, and improve their quality of life.

The Managing Cancer and Living Meaningfully (CALM) Intervention Alleviates Chemotherapy-Related Cognitive Impairment in Patients with Breast Cancer by Modulating Pan-Immune-Inflammation Values

Background:

The number of patients with breast cancer is increasing worldwide, resulting in a growing number of patients with chemotherapy-related cognitive impairment (CRCI), which seriously affects their quality of life. CRCI is associated with inflammatory factors and systemic inflammatory markers such as pan-immune-inflammation value (PIV) and monocyte-to-lymphocyte ratio (MLR), which can reflect the level of inflammation in the body. While the Managing Cancer and Living Meaningfully (CALM) intervention has been demonstrated to alleviate CRCI in patients with breast cancer, the specific mechanism remains unclear.

Objective:

This study evaluated the impact of the CALM intervention on systemic inflammation.

Methods:

Ninety patients with breast cancer with CRCI were enrolled and randomized into care as usual (CAU) and CALM intervention groups. All patients were assessed using the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog), Mini-Mental State Exam (MMSE), and Functional Assessment of Cancer Therapy-Breast (FACT-B) before and after the CAU/CALM intervention. The blood levels of inflammatory markers were also analyzed before and after the intervention.

Results:

Compared to the CAU group, the CALM group showed significantly improved cognitive function and significantly decreased PIV ( P < .05). PIV was significantly negatively correlated with FACT-Cog ( P < .05). The levels of other inflammatory markers, including MLR, neutrophil-to-lymphocyte ratio (NLR), granulocyte-to-lymphocyte ratio (GLR), and systemic immune-inflammation index (SII), were also reduced in the CALM group.

Conclusion:

PIV is an important marker of inflammation. The CALM intervention may improve the cognitive function of patients by regulating the systemic inflammation marker PIV through the neuroimmune axis.

Exploring the Effects of Yoga Therapy on Heart Rate Variability and Patient-Reported Outcomes After Cancer Treatment: A Study Protocol

BACKGROUND

Following cancer treatment, adults commonly report worsened patient-reported outcomes (PROs) such as anxiety, stress, depression, persistent and upsetting cognitive complaints, unrelenting fatigue, and reduced quality of life. Poorer PROs are associated with disrupted autonomic nervous system functioning as measured by heart rate variability (HRV), both of which have been associated with greater morbidity and mortality. Interventions to improve HRV and PROs among adults following cancer treatment are needed. Yoga therapy holds promise as an intervention to improve HRV and PROs. Therefore, we conducted a single-subject exploratory experimental study to investigate the effects of yoga therapy on HRV and specific PROs (ie, cancer-related fatigue, anxiety, cognitive function, depression, stress, quality of life) in adults treated for cancer. To reduce publication bias, improve reproducibility, and serve as a reference for forthcoming reporting of study results, we present the study protocol for this study herein.

METHODS

Participants were adults who completed cancer treatment that were recruited from the Ottawa Integrative Cancer Centre. Consenting and eligible participants received one 1:1 yoga therapy session (ie, 1 participant, 1 Yoga Therapist) and 6 weekly group-based yoga therapy sessions (ie, 2-3 participants, 1 Yoga Therapist). Participants completed assessments 7 times: 3 times prior to the program (ie, -6 weeks, -3 weeks, immediately prior to the 1:1 yoga therapy session), immediately following the 1:1 yoga therapy session, prior to the first group-based yoga therapy session, after the last group-based yoga therapy session, and at a 6-week follow-up. Hierarchical linear modeling will be used to test the average effects of the yoga therapy program across participants.

DISCUSSION

This study will explore several novel hypotheses, including whether yoga therapy can improve HRV and/or specific PROs among adults treated for cancer acutely (ie, during a 1:1 yoga therapy session) and/or through repeated exposure (ie, after completing 6 weeks of group-based yoga therapy). Although the findings will require confirmation or refutation in future trials, they may provide initial evidence that YT may benefit adults treated for cancer.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN64763228. Registered on December 12, 2021. This trial was registered retrospectively. URL of trial registry record: https://www.isrctn.com/ISRCTN64763228.

What Matters Most? Predictors of Quality of Life and Life Satisfaction Among Young Breast Cancer Survivors

BACKGROUND

Younger breast cancer survivors face unique challenges, and research is needed to better understand how to optimize their quality of life (QoL) and satisfaction with life (SwL).

OBJECTIVE

The aim of this study was to examine a biopsychosocial model of QoL and SwL in young breast cancer survivors. Biological, psychological, and social/practical factors were hypothesized to be associated with both distressing and adaptive reactions during survivorship, which in turn were hypothesized to be associated with QoL and SwL.

METHODS

Young (age = 19-45 years at diagnosis) breast cancer survivors (N = 284) completed an online survey assessing demographic and biopsychosocial factors, QoL, and SwL. Latent variables were created for adaptive and distressing reactions, and structural equation modeling was used to test the hypothesized relationships.

RESULTS

The model fit the data (χ2(100) = 332.92, P < .001, comparative fit index = 0.86, root mean square error of approximation = 0.09, standardized root mean square residual = 0.05) and accounted for large proportions of variance in QoL (R2 = 0.86) and SwL (R2 = 0.62). Social support, parenting concerns, and fertility concerns each significantly predicted adjustment. Adaptive reactions positively predicted SwL (β = 0.58, P < .001) but not QoL. Distressing reactions negatively predicted SwL (β = -0.26, P < .01) and QoL (β = -0.87, P < .001).

CONCLUSIONS

Adjustment in survivorship mediated the association of social support, parenting concerns, and fertility concerns on QoL and SwL in young breast cancer survivors.

IMPLICATIONS FOR PRACTICE

To support the psychological adjustment of young breast cancer survivors, attention should be given to survivors' social context including survivors' available social support and their concerns about fertility and parenting.

Outcome Measures in Cancer Rehabilitation: Pain, Function, and Symptom Assessment

Assessment of cancer rehabilitation outcome measures is integral for patient assessment, symptom screening, and advancing scientific research. In the broad field of cancer rehabilitation, outcome measures can cross-cut across many different branches of oncologic care including clinician-reported, patient-reported, and objective measures. Specific outcome measures that apply to cancer rehabilitation include those pertinent to pain, function, quality of life, fatigue, and cognition. These outcome measures, when used in cancer rehabilitation, can be utilized to evaluate the effectiveness of an intervention and to triage to the appropriate supportive care service. This review article summarizes some of the commonly used outcome measures that can be applied in the cancer rehabilitation setting to support scholarly work and patient care.

Drum-Assisted Recovery Therapy for Native Americans (DARTNA): Results from a feasibility randomized controlled trial

Alcohol and other drug (AOD) use among American Indians and Alaska Natives (AI/ANs) is a significant health issue in the United States. However, few evidence-based substance use interventions that utilize AI/AN traditional practices, such as drumming, exist. The current study is a feasibility randomized controlled trial (RCT) analyzing the potential benefits of DARTNA (Drum-Assisted Recovery Therapy for Native Americans) among 63 AI/AN adults seeking substance use treatment within an urban area in southern California. We compared DARTNA participants to usual care plus, which involved an integrated multimedia health educational program and usual care from providers for AOD use. At end of treatment, DARTNA participants reported significantly lower cognitive impairment and lower counts of physical ailments. Given that this was a feasibility trial, we also used Cohen's d = 0.20 or odds ratio = 2 or 0.5 to determine clinical significance. At end of treatment, we found promising benefits for DARTNA participants related to better physical health, fewer drinks per day, and lower odds of marijuana use in the past 30 days compared to the control group. Using these criteria, at 3-month follow-up, DARTNA participants reported less adoption of 12-step principles, less cognitive impairment, and lower anxiety with relationships. However, DARTNA participants reported more drinks per day and more cigarettes compared to the control group. Overall, this study demonstrates feasibility of conducting an RCT with AI/AN people in urban settings and highlights how a substance use treatment intervention utilizing drumming may help to meet the diverse needs of AI/AN people seeking substance use treatment.

Mental Health, Physical Health, and Cultural Characteristics Among American Indians/Alaska Natives Seeking Substance Use Treatment in an Urban Setting: A Descriptive Study

Although approximately 70% of American Indians/Alaska Natives (AI/ANs) reside in urban areas, our knowledge of risk and protective factors among AI/ANs seeking substance use treatment within urban areas is limited. We analyze substance and commercialized cigarette use, AI/AN cultural identity and involvement, physical health and cognitive functioning, and mental health symptoms among 63 AI/AN adults seeking substance use treatment within an urban area in California. Alcohol (37%), marijuana (27%), and methamphetamine (22%) were the most commonly reported substances. Sixty-two percent used commercialized tobacco use. The majority of AI/AN adults (78%) engaged in at least one traditional practice during the past month and endorsed high levels of spiritual connectedness. Those who engaged in traditional practices demonstrated significantly less depression (p = 0.007) and anxiety (p = 0.04). Medical and mental health issues were not prominent, although participants revealed high levels of cognitive impairment. Results highlight the importance of utilizing AI/AN traditional practices for AI/AN adults seeking substance use treatment within urban areas. Clinical Trials Registry Number NCT01356667.

Effect of Baduanjin exercise intervention on cognitive function and quality of life in women with breast cancer receiving chemotherapy: study protocol of a randomized controlled trial

BACKGROUND

More than 50% cognitive impairment was reported by cancer patients before and after medical treatment. However, there are no effective interventions to manage the cognitive problem in women with breast cancer. This pilot study was designed to evaluate the protective effect of Baduanjin exercise on cognitive function and cancer-related symptoms in women with early-stage breast cancer undergoing chemotherapy.

METHOD

A single-blinded, randomized control trial was designed. The trial will recruit 70 patients with early-stage breast cancer scheduled to receive chemotherapy from Shanghai in China. All participants will be randomly assigned to (1:1) the supervised Baduanjin group (5 times/week, 30 min each time) or the wait-list control group for 3 months. The effect of Baduanjin exercise intervention will be evaluated by outcome measures including subjective and objective cognitive function, symptoms (fatigue, depression, and anxiety), and health-related quality of life at pre-intervention (T0), 8 weeks (T1), and 12 weeks (T2). The PCI score in the FACT-Cog as the primary cognitive outcome will be reported descriptively, while effect sizes and 95% confidence intervals (CIs) will be calculated. The collected data will be analyzed by using an intention-to-treat principle and linear mixed-effects modeling.

DISCUSSION

This is the first randomized clinical trial to investigate whether Baduanjin exercise will have a positive role in improving cognitive function in women with breast cancer receiving chemotherapy. If possible, Baduanjin exercise will be a potential non-pharmacological intervention to manage cognitive dysfunction and promote survivorship care among breast cancer survivors.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) ChiCTR2000033152 . Registered on 22 May 2020.

Relationship between cytokines and brain-derived neurotrophic factor (BDNF) in trajectories of cancer-related cognitive impairment

Cytokines facilitate the peripheral immune and cerebral response, through their ability to modulate the expression of brain derived neurotrophic factor (BDNF). Cytokines and BDNF are implicated in cancer-related cognitive impairment (CRCI), but their relationship has not been clearly defined for this condition. The aim of this study was to evaluate the associations of cytokines and BDNF among early stage breast cancer (ESBC) patients with different CRCI trajectories. This was a multicenter longitudinal study involving 136 ESBC patients. CRCI was assessed using the FACT-Cog (V3) questionnaire. Plasma cytokines and BDNF levels were quantified at three time points throughout chemotherapy. The associations between cytokines and BDNF were analyzed using linear mixed models, with interaction terms for CRCI status. All cytokines analyzed showed inverse associations with BDNF levels. There was a significant interaction between IL-6 and the persistent impairment trajectory, which would impact on BDNF levels (p = 0.026). The inverse associations with BDNF were more pronounced for IFN-γ, IL-1β, IL-4, IL-8, and GM-CSF in patients with persistent CRCI. The coefficient values for IL-2, IL-4, and TNF-α also indicate that there was a greater magnitude of decrease in BDNF level for every unit of cytokine increase in patients with acute and persistent CRCI, compared to patients without CRCI. The differential associations between cytokines and BDNF may be indicative of probable susceptibility to the elevation of cytokines. Further research is required to elucidate the specific associations of cytokines and BDNF, along with their contributions to acute and persistent CRCI.

A Web-Based Lifestyle Intervention Aimed at Improving Cognition in Patients With Cancer Returning to Work in an Outpatient Setting: Protocol for a Randomized Controlled Trial

Background

A high percentage of patients with cancer experience cognitive impairment after cancer treatment, resulting in a decreased health-related quality of life and difficulty returning to work. Consequently, there is a need for effective treatment options to improve cognitive functioning in these patients. In a healthy aging population, multidomain web-based lifestyle interventions have been found to be effective in preventing cognitive decline and improving cognitive functioning.

Objective

This study aims to investigate the feasibility and effectiveness of the web-based lifestyle intervention Mijn Fitte Brein (My Fit Brain [MFB]) on cognitive functioning in patients with cancer returning to work.

Methods

The study consists of a feasibility study (N=10), followed by a randomized controlled trial (RCT; N=220). Patients will be recruited by their occupational physicians after their return to work following cancer treatment. Mijn Fitte Brein is organized into 4-week cycles in which patients set a lifestyle goal using the Goal Attainment Scale, receive weekly tips and support, and finally evaluate whether they succeeded in achieving this goal. Lifestyle goals are based on 6 domains: physical exercise, diet, sleep, stress, alcohol use, and smoking. In the feasibility study, data on user experience (structured interview) and usability, assessed with the Post-Study System Usability Scale, will be collected and used to optimize Mijn Fitte Brein. In the RCT, patients will be randomized 1:1 between an intervention group and a control group. Patients will be assessed at baseline, 3 months, and 6 months. The primary outcome measure is subjective cognitive functioning, assessed with the Functional Assessment of Cancer Therapy–Cognitive Function (FACT-Cog). Secondary outcome measures are lifestyle, objective cognitive functioning, and work and psychosocial factors.

Results

Recruitment for the feasibility study has started in February 2020. As of July 2020, however, no patients have been enrolled (due to COVID-19 restrictions). The findings of the feasibility study will be used to optimize the Mijn Fitte Brein intervention. Enrollment for the RCT will continue when possible. The feasibility study will take 6 months (including making adjustments to the intervention), and the RCT will take 2 years. The final results are expected in 2024. The results of the feasibility study and the RCT will be published in peer-reviewed journals.

Conclusions

This is the first time the feasibility and efficacy of a multidomain web-based lifestyle intervention will be studied in patients with cancer. If Mijn Fitte Brein is found to be effective in decreasing cognitive complaints in these patients returning to work, it will be a promising treatment option because of being both affordable and accessible.

Trial Registration

Netherlands Trial Register NL8407; https://www.trialregister.nl/trial/8407

International Registered Report Identifier (IRRID)

DERR1-10.2196/22670

Effects of brief acceptance and commitment therapy (ACT) on subjective cognitive impairment in breast cancer patients undergoing chemotherapy

PURPOSE

This study examined the efficacy of a brief acceptance and commitment therapy (ACT) on subjective cognitive impairment in breast cancer patients undergoing chemotherapy.

METHODS

Data collection was carried out in 3-time points: baseline (T1), screening (T2), and post-treatment (T3). Respondents who had significant subjective cognitive impairment were randomly divided into two groups: intervention (n = 30) and waitlist (n = 30). Respondents in the intervention group received 4 sessions of 1 hour of ACT therapy.

FINDINGS

Respondents in the intervention group showed significant improvement in subjective cognitive impairment, depression, anxiety, and psychological inflexibility after the ACT intervention (p < 0.05). After controlling the covariates, group differences in all variables were significant except for fatigue and psychological inflexibility has the highest effect size (d = 4.69).

CONCLUSION

ACT could be considered as an effective intervention to ameliorate subjective cognitive impairment, anxiety, depression, and psychological inflexibility in breast cancer patients undergoing chemotherapy.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

This study highlights the importance of screening for subjective cognitive impairment in breast cancer patients undergoing chemotherapy and heightens their opportunity to receive proper management as earlier as possible.

A study protocol for HEalth-Related quality of life-intervention in survivors of Breast and other cancers experiencing cancer-related fatigue using TraditionAL Chinese Medicine: the HERBAL trial

BACKGROUND

Cancer-related fatigue (CRF) is a debilitating condition which commonly affects cancer survivors. The management of CRF remains a challenge due to the lack of effective pharmacological interventions. Traditional Chinese medicine (TCM) could be a potential therapeutic option for CRF. The modified Xiang Bei Yang Rong Tang (XBYRT) is a TCM herbal decoction, formulated to improve fatigue symptoms in cancer survivors. This clinical trial aims to evaluate the efficacy and safety of XBYRT in improving CRF and quality of life (QOL) of cancer survivors.

METHODS

This is a single centre, randomized, double-blind, placebo-controlled, parallel trial. Eighty cancer survivors will be recruited and randomized to receive the XBYRT or placebo decoction, in a ratio of 1:1. Participants will consume the XBYRT/placebo decoction daily for 8 weeks and undergo assessments at baseline and 4, 8 and 10 weeks after baseline. The participants will be assessed for patient-reported outcomes (PRO), blood biomarkers and adverse events at each time point. The primary outcome is the overall health and QOL status, at 8 weeks follow-up. The secondary outcomes are the effects of XBYRT on fatigue levels, cancer-related cognitive impairment and QOL, as assessed by PRO. The incidence of adverse events and the effects of the XBYRT decoction on blood biomarkers associated with CRF will also be evaluated.

DISCUSSION

Efficacy and safety outcomes from this trial will provide important clinical data to guide future large-scale randomized controlled trials, and the evaluation of the objective blood biomarkers can help to delineate the biological mechanisms of CRF.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04104113 . Registered on 26 September 2019.

Chemotherapy-related cognitive impairment in patients with breast cancer based on MRS and DTI analysis

The purpose of this study is to investigate chemotherapy-related cognitive impairment (CRCI) in breast cancer patients, analyze absolute concentration and structural changes of metabolites in different brain regions by multimodal neuroimaging technology, and explore correlation between them. Breast cancer patients with chemotherapy treatment group (Ctx+, N = 24) and control group without treatment (Ctx-, N = 20) underwent neuropsychological tests, multivoxel magnetic resonance spectroscopy (MRS), and diffusion tensor imaging (DTI) before and after chemotherapy. Regions of interest (ROls) in magnetic resonance scan include bilateral posterior cingulate gyrus (PCG), bilateral dorsal thalamus (DT), bilateral lenticular nucleus (LN), bilateral posterior horn of the lateral ventricle paratrigonal white matter (PWM). In MRS, absolute concentrations of N-acetylaspartate (NAA), myo-inositol (MI), choline-containing compounds (Cho), total creatine (tCr), glutamine + glutamate (Glx) were quantified using LC Model and SAGE software. In DTI, we used fractional anisotropy (FA) and mean diffusivity (MD) to reflect white matter integrity. In Ctx+ patients, scores of functional assessment of cancer treatment cognition test (FACT-Cog), perceived cognitive impairments (PCI), impact of perceived impairments on quality of life (QOL), perceived cognitive abilities (PCA), auditory-verbal learning test (AVLT) recognition and clock drawing test (CDT) were lower than those before chemotherapy (p < 0.05). In MRS, Ctx+ patients had significantly lower NAA values in bilateral PCG, DT, respectively. The concentrations of tCr were observed to decline in bilateral PCG and right DT. Glx values decreased in right DT. Cho values decreased significantly in bilateral DT. In DTI, Ctx+ patients had lower FA values in bilateral PCG compared with patients before chemotherapy. Among imaging metrics and cognitive scores, positive correlations were observed between changes in AVLT recognition scores and changes in NAA values in bilateral PCG (left PCG: r = 0.470, p < 0.01; right PCG: r = 0.500, p < 0.01). Positive correlations were also found between changes in AVLT recognition and changes in FA values in bilateral PCG (left PCG: r = 0.513, p < 0.01; right PCG: r = 0.563, p < 0.01). Chemotherapy can lead to a decrease in memory function, accompanied by changes in brain metabolite concentration and white matter integrity in some parts of brain.

Exploring the Score Equivalence of the English and Chinese Versions of the Brief Assessment Scale for Caregivers

Background:

Multilingual outcome measures are used so that research studies are more generalizable across language contexts.

Objective:

To determine the score equivalence of the English and Chinese versions of Brief Assessment Scale for Caregivers (BASC) in Singapore.

Method:

Caregivers of patients with advanced cancer completed the BASC in either English or Chinese. Multivariable linear regression analysis was used to compare the mean BASC total and factor scores between the 2 language versions, with adjustment for possible confounding variables. Equivalence was declared if the 90% confidence interval of the mean scores fell entirely within an equivalence zone of ±0.5 standard deviation.

Results:

There were 521 ethnic Chinese participants, of whom 214 answered the English version and 307 answered the Chinese version. The BASC total and factor scores met the criteria for equivalence. Cronbach α coefficients were similar and exploratory factor analysis showed similar 2-factor structures for both language versions.

Conclusion:

The English and Chinese versions of the BASC were found to be equivalent in terms of similar adjusted mean scores, Cronbach α, and factor structures.

Managing Cancer and Living Meaningfully (CALM) Intervention on Chemotherapy-Related Cognitive Impairment in Breast Cancer Survivors

Objective: To evaluate the effectiveness and feasibility of Managing Cancer and Living Meaningfully (CALM), which is used to reduce chemotherapy-related cognitive impairment (CRCI), relieve psychological distress, and improve quality of life (QOL) in Chinese breast cancer survivors (BCs). Methods: Seventy-four BCs were enrolled in this study. All patients were randomly assigned to either the CALM group or the care as usual (CAU) group. All patients were evaluated by the Functional Assessment of Cancer Therapy–Cognitive Function (FACT-Cog), Distress Thermometer (DT), and the Functional Assessment of Cancer Therapy–Breast (FACT-B) before and after CALM or CAU application to BCs with CRCI. We compared the differences in all these scores between the CALM group and the control group and analyzed the correlation between cognitive function and QOL. Results: Compared with the CAU group, the performance of the CALM group on the FACT-Cog, DT, and FACT-B showed significant differences before and after CALM (t = −18.909, −5.180, −32.421, P = .000, .000, .000, respectively). Finally, there was a positive correlation between cognitive function and QOL in breast cancer patients before (r = 0.579, P = .000) and after (r = 0.797, P = .000) treatment. Conclusions: The present results indicated that CALM has salutary effects on the improvement of cognitive impairment and QOL and relieves psychological distress in breast cancer patients, which may be due to a positive correlation between psychological distress and cognitive function or QOL.

Self-reported cognitive outcomes among adolescent and young adult patients with noncentral nervous system cancers

Objective

Cancer‐related cognitive impairment (CRCI) among adolescent and young adult (AYA) cancer patients with noncentral nervous system (CNS) cancers has not been well studied. In this study, we aimed to describe CRCI‐associated trends and characteristics among AYA cancer patients.

Methods

In a longitudinal cohort of AYA cancer patients without CNS disease, CRCI was evaluated over 1 year using the Functional Assessment of Cancer Therapy‐Cognitive Function Instrument, a self‐reported cognitive outcome measure. CRCI prevalence was quantified using the previously established minimal clinically important difference. CRCI‐associated longitudinal trends and factors were evaluated with mixed‐effects model analysis.

Results

Ninety‐one patients (mean age = 28.4 ± 6.7 years) were included. Approximately one‐third (34.1%) experienced CRCI at least once during the study follow‐up. Female gender (P = .02), Indian ethnicity (P < .01), current smokers (P < .01), anxiety/depressive symptoms (P < .01) and fatigue (P < .01) were found to be associated with poorer cognitive function among AYAs.

Conclusions

Although AYA cancer patients were relatively young and without CNS disease involvement, a significant proportion of them experienced clinically important decline in cognitive function. With improved understanding of this subject, effective strategies can be formulated to promote awareness of CRCI and mitigate its negative effects among AYA cancer patients.

Validation of the Japanese Version of the Functional Assessment of Cancer Therapy-Cognitive Function Version 3

CONTEXT

Cancer therapy-induced cognitive impairment adversely affects the quality of life of patients with cancer but cannot be detected by neuropsychological tests.

OBJECTIVES

This study aimed to validate a Japanese version of the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) version 3, which is a self-report measure of the cognitive concerns of patients with cancer.

METHODS

The FACT-Cog was translated into Japanese and pilot tested with five patients with breast cancer and five patients with hematologic malignancy. Study participants were recruited in Hiroshima University Hospital and Kagawa Breast Clinic in Hiroshima, Japan. Patients with breast cancer (N = 236) responded to the resultant assessment and Functional Assessment of Cancer Therapy-General version 4. The internal consistency and concurrent and construct validity of the FACT-Cog were examined.

RESULTS

The Cronbach's alphas of the four FACT-Cog subscales, namely, CogPCI, CogOth, CogPCA, and CogQOL, were 0.95, 0.73, 0.93, and 0.88, respectively. The item-to-domain correlations ranged from 0.211 to 0.920. Most of the FACT-Cog subscales were significantly correlated with other subscale and total scores (r = 0.133-0.425). Structural equation modeling was barely acceptable (χ2 = 1361.8, df = 489, P < 0.001; goodness of fit index = 0.731, adjusted goodness of fit index = 0.691, comparative fit index = 0.848, root-mean-square error of approximation = 0.087).

CONCLUSION

The Japanese version of the FACT-Cog is a valid and reliable self-report measure of the cognitive function of patients with breast cancer. Its utility to clinicians and researchers in measuring the cognitive concerns of patients with cancer in Japan will serve as a further test of its validity.

An Evaluation of DNA Methyltransferase 1 (DNMT1) Single Nucleotide Polymorphisms and Chemotherapy-Associated Cognitive Impairment: A Prospective, Longitudinal Study

Strong evidence suggests that genetic variations in DNA methyltransferases (DNMTs) may alter the downstream expression and DNA methylation patterns of neuronal genes and influence cognition. This study investigates the association between a DNMT1 polymorphism, rs2162560, and chemotherapy-associated cognitive impairment (CACI) in a cohort of breast cancer patients. This is a prospective, longitudinal cohort study. From 2011 to 2017, 351 early-stage breast cancer patients receiving chemotherapy were assessed at baseline, the midpoint, and the end of chemotherapy. DNA was extracted from whole blood, and genotyping was performed using Sanger sequencing. Patients' self-perceived cognitive function and cognitive performance were assessed at three different time points using FACT-Cog (v.3) and a neuropsychological battery, respectively. The association between DNMT1 rs2162560 and cognitive function was evaluated using logistic regression analyses. Overall, 33.3% of the patients reported impairment relative to baseline in one or more cognitive domains. Cognitive impairment was observed in various objective cognitive domains, with incidences ranging from 7.2% to 36.9%. The DNMT1 rs2162560 A allele was observed in 21.8% of patients and this was associated with lower odds of self-reported cognitive decline in the concentration (OR = 0.45, 95% CI: 0.25-0.82, P = 0.01) and functional interference (OR = 0.48, 95% CI: 0.24-0.95, P = 0.03) domains. No significant association was observed between DNMT1 rs2162560 and objective cognitive impairment. This is the first study to show a significant association between the DNMT1 rs2162560 polymorphism and CACI. Our data suggest that epigenetic processes could contribute to CACI, and further studies are needed to validate these findings.

Individualized Piano Instruction for Improving Cognition in Breast Cancer Survivors

PURPOSE

To evaluate the use of individualized piano instruction (IPI) for improving cognition among breast cancer survivors.

PARTICIPANTS & SETTING

Six participants were included in an eight-week piano program with three data collection time points at baseline, midpoint, and postintervention. Participants were recruited from the breast cancer clinic of a university cancer center in South Florida.

METHODOLOGIC APPROACH

Neurocognitive, psychosocial, and self-report assessments were conducted to determine potential benefits and program feasibility, including the NIH Toolbox® Cognition Battery, the Functional Assessment of Cancer Therapy (FACT)-Cognitive Function, the FACT-Breast, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and a participant questionnaire.

FINDINGS

Results related to potential benefits suggest that IPI may significantly improve overall cognition in breast cancer survivors, with fluid cognition showing improvement. In addition, IPI may improve quality of life and self-reported measures of depression and anxiety, with large to moderate effect sizes, respectively.

IMPLICATIONS FOR NURSING

Nurses should explore different treatment options for chemotherapy-related cognitive impairment and consider including IPI in survivorship care plans.

Subjective cognitive functioning and associations with psychological distress in adult brain tumour survivors

PURPOSE

The impact of brain tumour on subjective cognitive function (SCF) has received little attention despite the implications of these perceptions for quality of life. SCF consists of two related yet distinct components, perceived cognitive impairment (PCI) and perceived cognitive abilities (PCA). This study compared the SCF of adult brain tumour survivors and healthy controls and examined demographic, illness-related, and psychological factors associated with SCF.

METHOD

Sixty-five adult survivors with primary brain tumour (age, 22-75 years), and 65 age- and sex-matched controls were recruited. Participants with brain tumour completed the Brief Test of Adult Cognition by Telephone, Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog), ratings of physical symptoms, Depression Scale of the Depression Anxiety Stress Scales-21 (DASS-Depression), and Generalized Anxiety Disorder-7 (GAD-7) scale. Controls completed the FACT-Cog, DASS-Depression, and GAD-7.

RESULTS

Adult brain tumour survivors reported significantly greater PCI and lower PCA than controls, after accounting for anxiety. Higher PCI was significantly related to fatigue, pain, treatment-related side-effects, anxiety, and depression. Lower PCA was significantly associated with fatigue, pain, poorer objective cognitive function, lower education, anxiety, and depression. Anxiety uniquely accounted for 9-14% of variance in SCF.

CONCLUSIONS

Adult brain tumour survivors were found to experience poorer SCF than healthy controls after accounting for anxiety. SCF was related to multiple factors after brain tumour; however, an independent association with anxiety was identified.

IMPLICATIONS FOR CANCER SURVIVORS

These findings highlight the potential value of psychological interventions targeting anxiety and cognitive effects to improve quality of survivorship after brain tumour.

Health Technology Assessment Challenges in Oncology: 20 Years of Value in Health

BACKGROUND

Oncology treatments have changed from chemotherapies to targeted therapies and more recently immuno-oncology. This has posed special challenges in the field of health technology assessment (HTA): capturing quality of life (QOL) associated with toxicity due to chemotherapy, crossover upon progression in targeted therapy trials, and survival extrapolation for immuno-oncology drugs.

OBJECTIVES

To showcase 20 years of Value in Health (ViH) publications in oncology.

METHODS

A review was undertaken of oncology articles published in ViH from May 1998 to August 2018. Full-length articles published in ViH with the keywords "oncology," "cancer," "h(a)ematology," and "malignancy" were included for review. Conference abstracts were excluded.

RESULTS

Four major themes were identified: (1) QOL and the development of multiple functional assessment of cancer therapy tools and mapping instruments; (2) analysis of clinical evidence using indirect comparisons, network analyses, and adjustment for crossovers; (3) modeling, Markov models, partitioned survival models, and extrapolation methods; and (4) financial implications and how to deal with uncertainty, introduction of conditional reimbursement, managed entry, and risk share agreements.

DISCUSSION

This review article highlights the important role ViH has played in disseminating HTA research in oncology. A few key issues loom on the horizon: precision medicine, further development and practical application of new QOL measures, methods for translating clinical evidence, and exploration of modeling techniques. For a better understanding of the complex interplay between access and financial risk management, ViH will no doubt continue to promote pioneering research in HTA and oncology.