Neuropsychological effects of treatments for adults with cancer: a meta-analysis and review of the literature

Nutritional Support of Crocin on Neurobehavioral Disabilities Induced by Cisplatin-Based Chemotherapy in Rats

Cisplatin, a chemotherapy drug containing platinum, is considered a neurotoxic agent. On the other hand, crocin, the primary component of saffron, possesses neuroprotective and antioxidant properties. In this study, 28 healthy adult male Wistar rats weighing 200-250 g were used (6-7 weeks old). Rats were divided into a control group (Ctr), a crocin group (Cro), a cisplatin group (Cis), and a crocin with cisplatin group (Cro + Cis). Rotarod, open field, and shuttle box tests were performed to assess balance, explorative behavior, and avoidance memory. After behavioral testing, the hippocampus was extracted to analyze oxidative stress parameters such as GPx (glutathione peroxidase), SOD (superoxide dismutase), CAT (catalase), and MDA (malondialdehyde) activity. Shuttle box, rotarod, and open field results showed that crocin can substantially mitigate the deleterious effects of cisplatin on avoidance memory, explorative behavior, motor coordination, and balance. Crocin was also able to effectively avoid the negative effects of cisplatin on MDA, GPx, and CAT during the assessment of oxidative indicators, while the beneficial effect of crocin on cisplatin was not statistically significant in terms of SOD level. In conclusion, since free radicals produced by cisplatin are a contributing factor to memory loss and movement disorders, crocin, owing to its antioxidant properties, improved passive avoidance learning as well as motor activity.

Cognitive impairments associated with chemotherapy in women with breast cancer: a meta-analysis and meta-regression

Chemotherapy is one of the most widely used treatments for breast cancer (BC). However, there is evidence of side effects like cognitive changes related to the chemotherapy treatment. The aim of the study was not only to summarize the existing evidence on the relationship between chemotherapy and cognitive performance in women with BC but also to identify additional consequences and aspects associated with these impairments. We conducted a systematic review with meta-analysis and meta-regression to present updated information on the matter. We retrieved data from the databases PubMed, Web of Science, PsycINFO, CINAHL, and Scopus. Twenty studies comprising over 2,500 women were examined and the results indicated that chemotherapy can compromise cognition in women with BC (-1.10 OR [95%CI: -1.81 to -0.74], P<0.01), with working memory (-0.49 OR [95%CI: -0.85 to -0.13], P=0.03) being the most affected among the domains. Furthermore, additional data indicated that cognitive impairment is most likely amid women with BC having a lower education level (Q=4.85, P=0.02). Our results suggested that chemotherapy affects cognitive functions in women with BC, and certain characteristics can worsen the deterioration. A comprehensive study of women with breast cancer and existing predictors contributes to optimized personal journeys, elevated life prospects, and advanced care that can also aid prognosis and therapeutic approaches.

Initial encoding deficits with intact memory retention in older long-term breast cancer survivors

PURPOSE

Cancer survivors frequently report significant forgetfulness, but standard neuropsychological tests often fail to detect primary memory deficits. Past research has suggested survivors may misattribute forgetfulness to memory decay rather than impairments in initial encoding, but no studies have tested whether this pattern is evident in older survivors, who are more vulnerable to age-related memory difficulties. We examined whether long-term breast cancer survivors treated in older adulthood demonstrate deficits in initial encoding, as opposed to increased rates of memory decay, relative to non-cancer controls.

METHODS

Three hundred twenty-eight breast cancer survivors age 60 and above, 5-15 years post-treatment, and 162 age-matched non-cancer controls completed list learning and narrative memory assessments at four time-points over 2 years. Performance on learning trials and delayed recall was analyzed at each time-point to assess group differences in memory encoding, and memory decay was assessed by analyzing changes in performance across delays.

RESULTS

Univariate ANCOVAs correcting for age and education showed that survivors had worse initial encoding performance across multiple time-points, which were compensated for with multiple learning trials to produce recall performance comparable to controls. There were no significant group differences in memory decay.

CONCLUSIONS

Older long-term breast cancer survivors exhibit a consistent pattern of initial encoding deficits, but memory retention was comparable to controls. Future research should consider the role of encoding deficits and age-related factors when evaluating cognitive function in older survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Commonly reported memory problems may stem from encoding deficits in older long-term cancer survivors.

Assessment of anxiety/depression among cancer patients before and during the COVID-19 pandemic

OBJECTIVE

To assess differences in the prevalence of anxiety/depression symptoms among cancer patients before (2019) and during the COVID-19 pandemic (2020); and the associations between anxiety/depression and sociodemographic and health behavior factors among cancer patients before and during the pandemic.

METHODS

We analyzed data from the 2019 (n = 856) and 2020 (n = 626) Health Information National Trends Survey, a nationally representative survey of United States adults aged ≥18 years. Only adults with a cancer diagnosis were used in the analyses. Anxiety/depression was assessed using the Patient Health Questionnaire-4 (low/none [0-2], mild [3-5], moderate [6-8], and severe [9-12]) and dichotomized as low/none and current anxiety/depression (mild/moderate/severe). Multivariate analysis was performed.

RESULTS

The prevalence of anxiety/depression symptoms among cancer patients was 32.7% before the COVID-19 pandemic and 31.1% during the pandemic. The odds of anxiety/depression among patients with fair/poor health status was higher during the pandemic relative to before (before: odds ratio [OR] = 1.85 vs. during: OR = 3.89). Participants aged 50-64 years (before: OR = 0.29, 95% confidence interval [95% CI] = 0.11-0.76; during: OR = 0.33, 95% CI = 0.11-0.97) and ≥65 years (before: OR = 0.13, 95% CI = 0.05-0.34; during: OR = 0.18, 95% CI = 0.07-0.47) had lower odds of anxiety/depression before and during the pandemic compared to those aged 35-49 years. Hispanics/Latinos had higher odds of anxiety/depression (OR = 2.70, 95% CI = 1.11-6.57) before the pandemic and lower odds of anxiety/depression during the pandemic (OR = 0.2, 95% CI = 0.05-1.01) compared to non-Hispanic Whites. Those who completed high school (before: OR = 0.08, 95% CI = 0.01-0.42), some college (before: OR = 0.10, 95% CI = 0.02-0.42), ≥college degree had lower odds of anxiety/depression symptoms (before: OR = 0.05, 95% CI = 0.01-0.26; during: OR = 0.06, 95% CI = 0.01-0.61) compared to those with less than a high school education.

CONCLUSION

Our results suggest the need to increase the provision of mental health services to cancer patients at high risk of developing anxiety/depression symptoms, particularly during public health emergencies, to alleviate further health burdens.

Cancer-related cognitive impairment in patients with newly diagnosed aggressive lymphoma undergoing standard chemotherapy: a longitudinal feasibility study

PURPOSE

Cancer-related cognitive impairment (CRCI) is a recognised adverse consequence of cancer and its treatment. This study assessed the feasibility of collecting longitudinal data on cognition in patients with newly diagnosed, aggressive lymphoma undergoing standard therapy with curative intent via self-report, neuropsychological assessment, peripheral markers of inflammation, and neuroimaging. An exploration and description of patterns of cancer-related cognitive impairment over the course of treatment and recovery was also undertaken and will be reported separately.

METHODS

Eligible participants completed repeated measures of cognition including self-report and neuropsychological assessment, and correlates of cognition including blood cell-based inflammatory markers, and neuroimaging at three pre-specified timepoints, time 1 (T1) - pre-treatment (treatment naïve), time 2 (T2) - mid-treatment, and time 3 (T3) - 6 to 8 weeks post-completion of treatment.

RESULTS

30/33 eligible patients (91%, 95% CI: 76%, 97%) were recruited over 10 months. The recruitment rate was 3 patients/month (95% CI: 2.0, 4.3 patients/month). Reasons for declining included feeling overwhelmed and rapid treatment commencement. Mean age was 57 years (SD = 17 years) and 16/30 (53%) were male. Most patients (20/30, 67%) had diffuse large B cell lymphoma or Hodgkin lymphoma (4/30, 13%). The neuroimaging sub-study was optional, 11/30 participants (37%) were eligible to take part, and all agreed. The remaining 19 participants were ineligible as their diagnostic PET/CT scan was completed prior. Retention and compliance with all assessments were 89 to 100% at all timepoints. Only one participant was withdrawn due to disease progression.

CONCLUSIONS

Findings from this study including excellent recruitment, retention, and compliance rates demonstrate it is feasible to longitudinally assess cognition in people with newly diagnosed aggressive lymphoma during their initial treatment and recovery to inform the development of future research to improve patient experiences and cognitive outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619001649101.

Melatonin Attenuates Methotrexate-Induced Reduction of Antioxidant Activity Related to Decreases of Neurogenesis in Adult Rat Hippocampus and Prefrontal Cortex

Previous studies have revealed that the side effects of anticancer drugs induce a decrease of neurogenesis. Methotrexate (MTX), one of anticancer drugs, can induce lipid peroxidation as an indicator of oxidative stress in the brain. Melatonin has been presented as an antioxidant that can prevent oxidative stress-induced neuronal damage via the activation of antioxidant enzymes associated with the increase of neurogenesis. The aims of the present study are to examine the neuroprotective effect of melatonin on the neurotoxicity of MTX on neurogenesis and the changes of protein expression and antioxidant enzyme levels in adult rat hippocampus and prefrontal cortex (PFC). Male Sprague-Dawley rats were assigned into four groups: vehicle, MTX, melatonin, and melatonin+MTX groups. The vehicle group received saline solution and 10% ethanol solution, whereas the experimental groups received MTX (75 mg/kg, i.v.) and melatonin (8 mg/kg, i.p.) treatments. After the animal examination, the brains were removed for p21 immunofluorescence staining. The hippocampus and PFC were harvested for Western blot analysis and biochemical assessments of malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase (SOD). The immunofluorescence result showed that coadministration with melatonin diminished p21-positive cells in the hippocampal dentate gyrus, indicating a decrease of cell cycle arrest. Melatonin reduced the levels of MDA and prevented the decline of antioxidant enzyme activities in rats receiving MTX. In the melatonin+MTX group, the protein expression results showed that melatonin treatment significantly upregulated synaptic plasticity and an immature neuron marker through enhancing brain derived neurotrophic factor (BDNF) and doublecortin (DCX), respectively. Moreover, melatonin ameliorated the antioxidant defense system by improving the nuclear factor erythroid 2-related factor 2 (Nrf2) in rats receiving MTX. These findings suggested that the effects of melatonin can ameliorate MTX toxicity by several mechanisms, including an increase of endogenous antioxidants and neurogenesis in adult rat hippocampus and PFC.

Evaluation of mild cognitive impairment and dementia in patients with metastatic renal cell carcinoma

BACKGROUND

Dementia and cancer are both more common in adults as they age. As new cancer treatments become more popular, it is important to consider how these treatments might affect older patients. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for older adults developing mild cognitive impairment or dementia (MCI/D) and the impact of mRCC-directed therapies on the development of MCI/D.

METHODS

We identified patients diagnosed with mRCC in a Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset from 2007 to 2015 and matched them to non-cancer controls. Exclusion criteria included age < 65 years at mRCC diagnosis and diagnosis of MCI/D within the year preceding mRCC diagnosis. The main outcome was time to incident MCI/D within one year of mRCC diagnosis for cases or cohort entry for non-cancer controls. Cox proportional hazards models were used to measure associations between mRCC and incident MCI/D as well as associations of oral anticancer agent (OAA) use with MCI/D development within the mRCC group.

RESULTS

Patients with mRCC (n = 2533) were matched to non-cancer controls (n = 7027). mRCC (hazard ratio [HR] 8.52, p < .001), being older (HR 1.05 per 1-year age increase, p < .001), and identifying as Black (HR 1.92, p = .047) were predictive of developing MCI/D. In addition, neither those initiating treatment with OAAs nor those who underwent nephrectomy were more likely to develop MCI/D.

CONCLUSIONS

Patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself or risk factors common to the two disease processes.

Neural Mechanisms Underlying Breast Cancer Related Fatigue: A Systematic Review of Neuroimaging Studies

Introduction: Fatigue and cognitive dysfunction commonly co-occur in breast cancer patients and survivors. However, the underlying neural mechanism is not clear. We performed a systematic review of studies that used neuroimaging methods to investigate structural and functional changes in the brain associated with fatigue in breast cancer patients and survivors.

Methods: We searched PubMed, Scopus, EmBase, and Cochrane CENTRAL from January 2009 to May 2021 for studies that reported brain neuroimaging findings in relationship to fatigue in breast cancer patients or survivors. Neuroimaging methods included magnetic resonance imaging (MRI), positron emission tomography (PET), and electroencephalogram (EEG). We summarized structural and functional neuroimaging changes associated with fatigue.

Results: Of the 176 articles retrieved, ten MRI studies reported neuroimaging findings in relationship to fatigue. Together these studies compared 385 breast cancer patients or survivors to 205 controls. Fatigue was associated with reduced white matter integrity and increased glutamate in the insula but changes in gray matter volume were not associated with fatigue score. Nine of the ten studies found significant associations between fatigue and functional changes in the frontoparietal cortex. In response to memory and planning tasks, fatigue was associated with increased activations in several regions of the frontoparietal cortex, however, overall performance on tasks was not reduced. Fatigue was also associated with extensive changes in the connectivity of brain networks that filter endogenous signals (salience network), internal attention (default mode network), and external attention (dorsal attention network). Subcortical regions associated with fatigue included insula (interoception), superior colliculus (sleep regulation), and thalamus (alertness). Functional brain changes before initiation of chemotherapy were a better predictor of post-treatment fatigue than chemotherapy itself.

Conclusions: Fatigue in breast cancer is associated with widespread functional changes of brain regions and networks that affect executive function including memory, planning, internal and external attention. Observed changes likely represent a compensatory mechanism through which breast cancer patients and survivors try to maintain adequate executive function. Breast cancer patients scheduled to undergo chemotherapy are at high risk for developing fatigue even before the start of treatment.

Health-Related Quality of Life: Longitudinal Analysis From the Time of Breast Biopsy Into the Post-treatment Period

Background: The physical, psychological, social, and spiritual quality of life (QoL) may be affected by breast cancer diagnosis and treatment, with mixed findings for psychological quality of life and cognitive ability performance. The present study aimed to evaluate QoL in women over 1 year from biopsy for a breast abnormality. Methods: Self-reported measures of physical, psychological, social, and spiritual QoL were obtained after biopsy results but prior to treatment initiation (baseline), 4 and 12 months later. CogState computerized neuropsychological screening battery also provided an evaluation of psychological QoL. Three groups of women including those with benign biopsy results, those with malignancy treated with chemotherapy, and those with malignancy not treated with chemotherapy were compared at 4 and 12 months after adjusting for baseline to isolate the effects of treatment. Additional covariates included are age, level of education, and income. Results: Benign biopsy results group included 72 women, whereas malignancy was found in 87 women of whom 33 were treated with chemotherapy and 54 without chemotherapy. At the time of diagnosis, women with cancer had worse psychological and social QoL but better spiritual QoL than those with benign biopsy results. Only CogState monitoring accuracy was worse for women with cancer compared with the controls at the time of biopsy results. After adjusting for QoL at baseline, women treated for cancer had worse physical and social QoL at 4 and 12 months later. Psychological well-being was worse for women with cancer at 4th month but improved at 1 year. No differences in cognition were found at 4 and 12 months when adjusted for baseline cognition and covariates. Discussion: Breast cancer is a traumatic life event for women, affecting psychological and social QoL domains, yet increasing spiritual QoL. Later, cancer treatment worsens physical, psychological, and social QoL compared with those without cancer. Conclusions: These findings suggest that interventions to improve psychological QoL may be especially important at the time of cancer diagnosis, while interventions to improve physical well-being are the most needed during and following cancer treatment. Support to improve social QoL is needed from the time of diagnosis into post-treatment survivorship.

Structural Neuroimaging Findings Related to Adult Non-CNS Cancer and Treatment: Review, Integration, and Implications for Treatment of Cognitive Dysfunction

Cancer- and treatment-related cognitive dysfunction (CRCD) is a common challenge faced by patients diagnosed with non-central nervous system (CNS) cancer. It has become increasingly recognized that multiple factors likely play a role in these symptoms, including the cancer disease process, systemic treatments (e.g., chemotherapy and endocrine therapies), and risk factors that may predispose an individual to both cancer and cognitive dysfunction. As the field has evolved, advanced neuroimaging techniques have been applied to better understand the neural correlates of CRCD. This review focuses on structural neuroimaging findings related to CRCD in adult non-CNS cancer populations, including examination of gray matter volume/density and white matter integrity differences between cancer patients and comparison groups, as well as emerging findings regarding structural network abnormalities. Overall, this literature has demonstrated consistent findings of reduced gray matter volume/density and white matter integrity in cancer patients relative to comparison groups. These are most prominent in individuals treated with chemotherapy, though alterations have also been noted in those treated with anti-estrogen and androgen-deprivation therapies. Alterations in gray and white matter structural network connectivity have also been identified. These structural abnormalities have been observed most prominently in frontal and temporal brain regions, and have been shown to correlate with subjective and objective cognitive function, as well as with physiological and clinical variables, helping to inform understanding of CRCD mechanisms. To date, however, structural neuroimaging techniques have not been utilized in systematic studies of potential CRCD treatments, suggesting a potentially fruitful avenue for future research.

Neurocognitive Effects of Chemotherapy for Colorectal Cancer: A Systematic Review and a Meta-Analysis of 11 Studies

Purpose

Chemotherapy-related cognitive impairment (CRCI) is a controversial concept not much explored on colorectal cancer patients.

Materials and Methods

We identified 11 prospective studies: eight studies on 696 colorectal cancer patients who received chemotherapy and three studies on 346 rectal cancer patients who received neoadjuvant chemoradiotherapy. Standardized mean differences (SMDs) of neuropsychological test results and the cognitive quality-of-life scale were calculated using random effect models. A meta-regression was conducted to investigate the association between mean study population age and effect sizes.

Results

The association between chemotherapy and cognitive impairment was not clear in colorectal cancer patients (SMD, 0.003; 95% confidence interval, −0.080 to 0.086). However, a meta-regression showed that older patients are more vulnerable to CRCI than younger patients (β=–0.016, p < 0.001).

Conclusion

Chemotherapy has an overall positive negligible effect size on the cognitive function of colorectal patients. Age is a significant moderator of CRCI.

A randomized trial of physical activity for cognitive functioning in breast cancer survivors: Rationale and study design of I Can! Improving Cognition After Cancer

INTRODUCTION

Difficulties with cognition are extremely common among breast cancer survivors and can significantly impact quality of life, daily functioning, and ability to return to work. One promising intervention is increasing physical activity, as it has been effective in improving cognition in non-cancer populations. Few physical activity intervention trials with cognition outcomes have included cancer survivors. This project builds upon our previous work indicating that increased physical activity can improve objectively measured processing speed and self-reported cognition among breast cancer survivors.

METHODS

The I Can! study will examine whether a physical activity intervention improves cognition among 250 post-treatment breast cancer survivors (Stages I-III, <5 years post-treatment) who are reporting cognitive difficulties. This 2-arm randomized controlled trial comparing a 6-month physical activity intervention (Exercise Group) to a health & wellness attention-comparison condition (Health & Wellness Group) will examine intervention effects on cognition (at 3 and 6 months) and maintenance of effects at 12 months. The primary aim is to investigate the impact of exercise on objectively measured processing speed and self-reported cognition. Secondary aims are to investigate maintenance of cognitive changes and examine candidate biological mechanisms and psychological mediators.

CONCLUSION

The I Can! study will contribute to the scientific, public health, and survivorship intervention literature by providing new information on the impact of physical activity for cognitive impairment in breast cancer survivors. Findings from this study will inform guidelines for physical activity to improve the lives of millions of breast cancer survivors.

Feasibility of an online cognitive rehabilitation programme in patients with a haematological malignancy undergoing autologous stem cell transplantation

BACKGROUND

Chemotherapy-related cognitive impairment (CRCI) is a known adverse event that can impact cancer survivors, resulting in long-standing effect on quality of life and activities of daily living. Currently, there is limited knowledge regarding the aetiology and therapy for CRCI. Although CRCI following autologous stem cell transplantation (AuSCT) is emerging as a potentially significant concern for patients with underlying haematological malignancies, it is an area that requires further research.

AIMS

This pilot study aimed to assess (i) the prevalence of CRCI in patients with haematological malignancies both pre-AuSCT and post-AuSCT and (ii) the feasibility of a cognitive rehabilitation programme (CRP) in survivorship care post-AuSCT.

METHODS

Over a 12-month period, consecutive patients planned for AuSCT were approached for the study. Enrolled patients were administered a 9-week course of CRP, commencing day 40 ± 5 post-AuSCT. Participants were evaluated using a neuropsychological tool and validated questionnaires at baseline, pre-CRP (day 40 ± 5 post-AuSCT), post-CRP and 6 months post-CRP.

RESULTS

Thirty-two patients were enrolled. The mean age was 59 years (SD = 11.5), 23 (72%) were male and 18 (56%) had multiple myeloma. Participants reported high satisfaction using the CRP, and most devoted significant amount of time as requested.

CONCLUSIONS

While there appeared to be a low incidence of significant CRCI in our patient population, the incorporation of CRP in survivorship care appeared to be feasible. A larger randomised study examining the efficacy of CRP should be further explored.

Relationship of perceived everyday cognitive function and work engagement in breast cancer survivors

INTRODUCTION

Breast cancer survivors (BCS) who represent approximately 3.5 million survivors in the USA frequently report ongoing cognitive dysfunction that may impact work outcomes. However, little is known about how perceived everyday cognitive function may affect work engagement (a measure of work efficacy and work well-being) in BCS who have completed treatment.

OBJECTIVES

The purpose of this study was to examine the relationship between perceived everyday cognitive function and work engagement in BCS.

METHODS

A convenience sample of 68 employed BCS seen at a Midwest NCI-Cancer Center who were at least 1-year post-treatment, completed a cross-sectional questionnaire assessing demographic and medical characteristics, and perceived everyday cognitive function (Everyday Cognition Scale) and work engagement (Utrecht Work Engagement Scale). Descriptive statistics, Pearson's r, and separate regression models controlling for age and education were used to analyze the data.

RESULTS

BCS who were on average 52 (SD = 8.6) years old, 5 (SD = 3.8) years post-treatment, and primarily employed full-time (79%) participated. A subset of BCS (12%) identified poorer everyday cognitive function after BC diagnosis and treatment. Everyday cognition, including subscales vigor and dedication, were correlated with work engagement (p˂0.01), controlling for age and education.

CONCLUSIONS

Findings indicate the important role of perceived everyday cognitive function in work engagement well into survivorship. Reducing cognitive dysfunction may be an important area for future intervention research to support BCS who return to work.

IMPLICATIONS TO PRACTICE

Healthcare providers need to assess and address perceived cognitive dysfunction to promote work-related outcomes in BCS well into survivorship.

Chemotherapy-Induced Brain Effects in Small-Cell Lung Cancer Patients: A Multimodal MRI Study

The golden standard of treating Small Cell Lung Cancer (SCLC) entails application of platinum-based chemotherapy, is often accompanied by Prophylactic Cranial Irradiation (PCI), which have been linked to neurotoxic side-effects in cognitive functions. The related existing neuroimaging research mainly focuses on the effect of PCI treatment in life quality and expectancy, while little is known regarding the distinct adverse effects of chemotherapy. In this context, a multimodal MRI analysis based on structural and functional brain data is proposed in order to evaluate chemotherapy-specific effects on SCLC patients. Data from 20 patients (after chemotherapy and before PCI) and 14 healthy controls who underwent structural MRI, DTI and resting state fMRI were selected in this study. From a structural aspect, the proposed analysis included volumetry and thickness measurements on structural MRI data for assessing gray matter dissimilarities, as well as deterministic tractography and Tract-Based Spatial Statistics (TBSS) on DTI data, aiming to investigate potential white matter abnormalities. Functional data were also processed on the basis of connectivity analysis, evaluating brain network parameters to identify potential manifestation of functional inconsistencies. By comparing patients to healthy controls, the obtained results revealed statistically significant differences, with the patients' brains presenting reduced volumetry/thickness and fractional anisotropy values, accompanied by prominent differences in functional connectivity measurements. All above mentioned findings were observed in patients that underwent chemotherapy.

A narrative review of risk factors and interventions for cancer-related cognitive impairment

Cancer-related cognitive impairment (CRCI) refers to a series of cognitive impairment symptoms associated with alternations in brain structure and function, caused by a non-central nervous system malignant tumor and its related treatment. CRCI may present as memory loss, impaired concentration, difficulty in multitasking and word retrieval, and reduced comprehension speed. CRCI has become one of the prevalent factors that compromise the quality of life for cancer survivors. Different treatments, including surgery, chemotherapy, radiotherapy, endocrine therapy, and targeted drugs, may contribute to CRCI. Meanwhile, patients’ factors, including emotional challenges and genetic makeup, also contribute to the development of CRCI. The condition can be treated with using stimulants methylphenidate and modafinil, metabolites of nicotine: cotinine, antidepressants of fluoxetine and fluvoxamine, dementia drug of donepezil, and antioxidants ZnSO4, n-acetyl cysteine, propofol, and Chinese herbal of silver leaf medicine. Psychotherapies, including meditation and relaxation, cognitive rehabilitation training, along with physical therapies, including aerobic exercise, resistance training, balance training, yoga, qigong, tai chi electroencephalogram biofeedback, and acupuncture, are also beneficial in alleviating cancer-related cognitive impairment symptoms. In recent years, researchers have focused on factors related to the condition and on the available interventions. However, most research was conducted independently, and no review has yet summarized the latest findings. This review details and discusses the status of related factors and potential treatments for CRCI. We also supply specific recommendations to facilitate future research and integration in this field.

Cancer-related cognitive impairment in patients with non-central nervous system malignancies: an overview for oncology providers from the MASCC Neurological Complications Study Group

Cancer-related cognitive impairment (CRCI) is commonly experienced by individuals with non-central nervous system cancers throughout the disease and treatment trajectory. CRCI can have a substantial impact on the functional ability and quality of life of patients and their families. To mitigate the impact, oncology providers must know how to identify, assess, and educate patients and caregivers. The objective of this review is to provide oncology clinicians with an overview of CRCI in the context of adults with non-central nervous system cancers, with a particular focus on current approaches in its identification, assessment, and management.

Longitudinal exploration of cancer-related cognitive impairment in patients with newly diagnosed aggressive lymphoma: protocol for a feasibility study

INTRODUCTION

Cancer-related cognitive impairment (CRCI) is a distressing and disabling side-effect of cancer treatments affecting up to 75% of patients. For some patients, their cognitive impairment may be transient, but for a subgroup, these symptoms can be long-standing and have a major impact on the quality of life. This paper describes the protocol for a study: (1) to assess the feasibility of collecting longitudinal data on cognition via self-report, neuropsychological testing, peripheral markers of inflammation and neuroimaging and (2) to explore and describe patterns of cancer-related cognitive impairment over the course of treatment and recovery in patients with newly diagnosed, aggressive lymphoma undergoing standard therapy with curative intent.

METHODS AND ANALYSIS

This is a prospective, longitudinal, feasibility study in which 30 newly diagnosed, treatment-naive patients with aggressive lymphoma will be recruited over a 12-month period. Patients will complete comprehensive assessments at three time points: baseline (time 1, pre-treatment) and two post-baseline follow-up assessments (time 2, mid-treatment and time 3, 6-8 weeks post-treatment completion). All patients will be assessed for self-reported cognitive difficulties and objective cognitive function using Stroop Colour and Word, Trail Making Test Part A and B, Hopkins Verbal Learning Test-Revised, Controlled Oral Word Association and Digit Span. Blood cell-based inflammatory markers and neuroimaging including a positron emission tomography (PET) with ¹⁸F-labelled fluoro-2-deoxyglucose (¹⁸F-FDG) and CT (¹⁸F-FDG-PET/CT) and a MRI will explore potential inflammatory and neuroanatomical or functional mechanisms and biomarkers related to CRCI. The primary intent of analysis will be to assess the feasibility of collecting longitudinal data on cognition using subjective reports and objective tasks from patients during treatment and recovery for lymphoma. These data will inform the design of a larger-scale investigation into the patterns of cognitive change over the course of treatment and recovery, adding to an underexplored area of cancer survivorship research.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Austin Health Human Rights Ethics Committee (HREC) in Victoria Australia. Peer reviewed publications and conference presentations will report the findings of this novel study.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619001649101).

Initial validation of the German version of the Attentional Function Index in a sample of haematological cancer survivors

OBJECTIVE

To date, no German instrument exists to assess subjective levels of cancer-related cognitive impairments (CRCI) in cancer survivors. We translated the validated Attentional Function Index (AFI) into German and explored its psychometric properties.

METHODS

The validation sample consisted of 1,111 haematological cancer survivors mainly recruited from two cancer registries. Factorial structure was explored using principal component analysis, internal consistency via Cronbach's α, construct validity through correlational analyses (Pearson's r) and associations of patient characteristics with the AFI score via regression analyses.

RESULTS

In line with the original version, we revealed three factors, that is "effective action" (seven items), "attentional lapses" (three items) and "interpersonal effectiveness" (three items). The overall reliability α was .91. Verifying construct validity, the AFI score correlated positively with cognitive functioning (r = .64, p ≤ .01) and global QoL (r = .44, p ≤ .01), but negatively with fatigue (r = -.60, p ≤ .01) and depressive symptomatology (r = -.6, p ≤ .01). Older age (β = .12, p < .001), higher comorbidity (β = -.07, p = .02) and being male patient (β = .07, p = .01) were significantly associated with the AFI scores, but effect sizes were small.

CONCLUSION

The German translation of the AFI shows good psychometric properties and thus may be reasonably applied to measure the subjective level of CRCI in German-speaking oncological populations.

Synergistic therapy with tangeretin and 5-fluorouracil accelerates the ROS/JNK mediated apoptotic pathway in human colorectal cancer cell

Synergistic therapy is emerging as a promising strategy for improving the chemotherapeutic efficacy of anticancer drugs. Addition of adjuvants with standard anticancer drugs has shown successful reduction of adverse side effects. The synthetic drug 5-Fluorouracil (5-FU) shows several side effects upon prolonged chemotherapy, thereby restricting its long-term clinical application. Several studies have reported anticancer potential and anti-inflammatory activity of tangeretin (TAN) towards mammalian cells. Therefore, we investigate whether the combination of TAN with 5-FU increases their anticancer potential against colorectal cancer. In this study, we examined the synergistic activity of TAN and 5-FU on the viability of several human cancer and normal cells. Several possible mechanistic pathways were screened, and found that co-exposure of TAN and 5-FU accelerates oxidative-stress and increases endogenous-ROS generation, which sequentially triggers the DNA damage response and activates the apoptotic pathway, by down-regulating autophagy and DNA repair system in HCT-116 cells. TAN and 5-FU co-treatment also remarkably reduces the mitochondrial membrane potential, and sequentially decreases ATPase activity. Collectively, results indicate that combination of TAN and 5-FU significantly accelerates apoptosis via JNK mediated pathway. To our knowledge gained from literature, this study is the first to describe synergistic activity of TAN and 5-FU against colorectal cancer cells.

Cognitive and brain structural changes in long-term oligodendroglial tumor survivors

BACKGROUND

We identify cognitive impairment and MRI structural brain changes in long-term oligodendroglial tumor survivors treated with radiation therapy (RT) alone (21%) or with chemotherapy (CT) (79%).

METHODS

Oligodendroglial tumor patients (based on the World Health Organization [WHO] 2007 classification) who completed RT ± CT at least 2 years before the study initiation, were classified into 3 groups according to the time treatment was completed: Group 1 = 2-5 years (n = 22), Group 2 = 6-10 years (n = 13), and Group 3 >10 years (n = 13). All patients had a cross-sectional neuropsychological evaluation (n = 48) and a longitudinal volumetric analysis (gray matter [GM; n = 34]) between postsurgical and last follow-up MRI. White matter (WM) changes on MRI were assessed using a qualitative scale.

RESULTS

There were no differences regarding tumor or treatment-related characteristics between groups. Six of 22 patients (27.3%) in Group 1; 5/13 (38.5%) in Group 2; and 9/13 (69.2%) in Group 3 had cognitive impairment that was considered severe in 3/22 patients (13.6%) in Group 1; 4/13 (30.8%) in Group 2; and 6/13 (46.2%) in Group 3. Patients in Groups 2 and 3 showed significant GM atrophy and more leukoencephalopathy than Group 1. Cognitive deficits were associated with brain atrophy and WM changes.

CONCLUSIONS

Long-term oligodendroglial tumor survivors who underwent standard RT ± CT treatment, mainly >5 years of its completion, present cognitive impairment, especially on memory and executive functions, associated with late GM and WM damage, thus highlighting the need of developing future strategies in patients with oligodendroglial tumor and long expected survival.

Understanding the Profile of Cancer-Related Cognitive Impairments: A Critique of Meta-Analyses

A large body of evidence indicates that cancer survivors who have undergone chemotherapy have cognitive impairments. Substantial disagreement exists regarding which cognitive domains are impaired in this population. We suggest that is in part due to inconsistency in how neuropsychological tests are assigned to cognitive domains. The purpose of this paper is to critically analyze the meta-analytic literature on cancer-related cognitive impairments (CRCI) to quantify this inconsistency. We identified all neuropsychological tests reported in seven meta-analyses of the CRCI literature. Although effect sizes were generally negative (indicating impairment), every domain was declared to be impaired in at least one meta-analysis and unimpaired in at least one other meta-analysis. We plotted summary effect sizes from all the meta-analyses and quantified disagreement by computing the observed and ideal distributions of the one-way χ2 statistic. The actual χ2 distributions were noticeably more peaked and shifted to the left than the ideal distributions, indicating substantial disagreement among the meta-analyses in how neuropsychological tests were categorized to domains. A better understanding of the profile of impairments in CRCI is essential for developing effective remediation methods. To accomplish this goal, the research field needs to promote better agreement on how to measure specific cognitive functions.

Non-pharmacological interventions for cognitive impairment in women with breast cancer post-chemotherapy: A systematic review

PURPOSE

Cognitive impairment is a well-reported side-effect of chemotherapy in persons with breast cancer. Whilst non-pharmacological interventions have proven efficacious in the management of cognitive impairment in high-risk groups, their efficacy in cognitive impairment post-chemotherapy in patients with breast cancer remains unclear.

METHODS

Medline, CINAHL, PsycINFO, Web of Science and Cochrane were searched for randomized controlled trials of non-pharmacological interventions for cognitive impairment post-chemotherapy in women with breast cancer.

RESULTS

Of 429 results, 83 full-texts were reviewed with ten meeting inclusion criteria. Interventions included cognitive training, exercise and complementary therapies. The non-pharmacological interventions assessed displayed variable benefits in subjective and/or objective cognitive assessments, with no strong evidence for beneficial effects across included studies. No studies assessed the efficacy of multi-domain interventions.

CONCLUSIONS

There is mixed evidence supporting non-pharmacological interventions for cognitive impairment post-chemotherapy in women with breast cancer. Moving forward, multidomain trials combining non-pharmacological interventions are imperative in this high risk cohort.

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.

Systematic review of cognitive sequelae of non-central nervous system cancer and cancer therapy

PURPOSE

The aim of this review is to provide an updated overview of chemotherapy-related cognitive impairment (CRCI) in patients with cancer outside central nervous system (CNS), its incidence and prevalence, the cognitive pattern in neuropsychological studies, neuroimaging findings, and the relationship between chemobrain and aging. Methodological limitations of studies are also discussed.

METHODS

This review was guided by the PRISMA statement. The MEDLINE and Scopus databases were employed to search articles about CRCI in non-CNS cancer patients published from January 2004 to September 2019. Two types of research were reviewed: prospective studies addressing the effects of chemotherapy on cognition and systematic reviews about factors related with CRCI, also as neuroimaging findings and current available treatments.

RESULTS

Fifty-nine studies meeting the criteria were analyzed: 47 were longitudinal studies on cancer and cognition and 12 were reviews on risk factors, neuroimaging, and treatment. The majority of studies find cognitive impairment in patients with cancer treated with chemotherapy. The body of the literature on breast cancer is the most abundant, but there are also studies on colorectal, testicular, and lung cancer. Neuroimaging studies show changes in structure and activation in patients undergoing chemotherapy. Non-pharmacological treatment is effective for improving cognition and quality of life.

CONCLUSIONS

The occurrence of CRCI during the course of treatment in people with different types of cancer is frequent. Some risk factors have been identified, but CRCI is a complex phenomenon, with mediating factors related to cancer and treatment and moderating factors related with lifestyle and health.

IMPLICATIONS FOR CANCER SURVIVORS

This review highlights the importance of recognizing that this cognitive dysfunction is frequent, mild to moderate in nature but with great impact on quality of life.

Systematic review of longitudinal studies on chemotherapy-associated subjective cognitive impairment in cancer patients

OBJECTIVES

This systematic review of longitudinal studies, assessing subjective cognitive impairment (SCI) reported by adult cancer patients, aimed to summarize evidence on the impact of chemotherapy on SCI, identify moderators of SCI, and evaluate methodological issues.

METHODS

Data accrued from Pubmed, EMBASE, CINAHL, PsychInfo, and the Cochrane library. Inclusion criteria were original studies, an exclusively adult sample, valid and reliable subjective cognitive measures, and at least one baseline data point prior to and another after the initiation of chemotherapy. Data were collected on the sample composition, data-collection time points, outcome measures, statistical analysis, and major findings (ie, longitudinal changes in prevalence, severity, and associated factors).

RESULTS

Forty articles published between 2004 and 2019 were retained: 21 examined chemotherapy-treated patients only, and 19 employed control groups. Findings were mixed, with slightly more studies supporting the impact of chemotherapy on SCI. SCI tended to be more prevalent and severe after initiating chemotherapy, compared with patients' own baseline and controls not treated with chemotherapy. Impact appeared to be acute and more likely limited to subsamples. Most studies examining non-breast-cancer samples reported the lack or limited impact of chemotherapy on SCI. The most consistent moderators were depression and fatigue. Methodological issues regarding sampling design, measurement, and statistical analysis were discussed.

CONCLUSION

More rigorously designed longitudinal studies would clarify direct and indirect effects of chemotherapy on SCI.

The effects of weight loss and metformin on cognition among breast cancer survivors: Evidence from the Reach for Health study

OBJECTIVE

Breast cancer survivors experience problems with cognition that interfere with daily life and can last for years. In the general population, obesity and diabetes are risk factors for cognitive decline, and weight loss can improve cognition; however, the impact of intentional weight loss on cancer survivors' cognition has not been tested. We investigated the impact of weight loss and metformin on changes in cognitive function in a sample of breast cancer survivors.

METHODS

Overweight/obese postmenopausal breast cancer survivors (n = 333) were randomized to a weight loss intervention versus control and metformin versus placebo in a 2 × 2 factorial design. Outcomes were changes in five cognitive domains from baseline to 6 months measured by objective neurocognitive tests.

RESULTS

There were no statistically significant intervention effects for the metformin or weight loss interventions in five neurocognitive domains. Baseline body mass index (BMI) was a significant effect modifier of the changes in verbal functioning for the weight loss (P = 0.009) and metformin interventions (P = 0.0125). These effect modifications were independent of percent weight loss achieved during the 6-month study period.

CONCLUSIONS

This randomized controlled trial of weight loss and metformin interventions that examined changes to cognition among breast cancer survivors suggests that these interventions may not improve cognitive functioning among breast cancer survivors in general. However, weight loss may improve verbal functioning among individuals with a higher BMI.

Cognitive impairment following chemotherapy for breast cancer: The impact of practice effect on results

Chemotherapy-Related Cognitive Impairment (CRCI) can be an adverse effect in women treated for breast cancer. Some longitudinal studies reported deficits in attention, memory, and executive function following treatment, but other studies did not find cognitive changes. It is known that practice effects (PE) on repeated assessments with cognitive tests contribute to the discrepancies in these results, but its influence on scores has not been systematically explored. The present study examines the impact of PE on retest scores in a group of women with breast cancer treated with chemotherapy and evaluated longitudinally.

METHOD

51 women with breast cancer treated with a combination of 5-fluorouracil, epirubicin, and cyclophosphamide with or without taxanes were assessed after surgery but before chemotherapy (T1), post-chemotherapy (T2), and at one year after T2 (T3). Longitudinal changes on cognitive performance were analyzed twice: when retest scores were not corrected for PE and when correction for PE was applied to T2 and T3 scores.

RESULTS

When PE was not corrected, progressive improvement over time in measures of memory and divided attention at T2 and T3 was observed. In contrast, when PE was corrected, worsening was found in measures of memory, fluency, executive function, and attention at T2 and in attention and executive function at T3. Results after correction for PE are in line with previous longitudinal studies that report cognitive impairment after treatment with chemotherapy for breast cancer.

CONCLUSION

Accounting for PE is recommended to identify true change on cognition through treatment with chemotherapy for breast cancer.

Breast cancer treatment and its effects on aging

Breast cancer is the most common cancer of women in the United States. It is also proving to be one of the most treatable. Early detection, surgical intervention, therapeutic radiation, cytotoxic chemotherapies and molecularly targeted agents are transforming the lives of patients with breast cancer, markedly improving their survival. Although current breast cancer treatments are largely successful in producing cancer remission and extending lifespan, there is concern that these treatments may have long lasting detrimental effects on cancer survivors, in part, through their impact on non-tumor cells. Presently, the impact of breast cancer treatment on normal cells, its impact on cellular function and its effect on the overall function of the individual are incompletely understood. In particular, it is unclear whether breast cancer and/or its treatments are associated with an accelerated aging phenotype. In this review, we consider breast cancer survivorship from the perspective of accelerated aging, and discuss the evidence suggesting that women treated for breast cancer may suffer from an increased rate of physical and cognitive decline that likely corresponds with underlying vulnerabilities of genome instability, epigenetic changes, and cellular senescence.

Comparing the effect of the subcategories of atypical antipsychotic medications on cognition in schizophrenia using a meta-analytic approach

OBJECTIVES

The aim of this study was to compare the two most commonly prescribed classes of atypical antipsychotic medications (i.e., -pines and -dones) with regard to their effects on cognition in patients with schizophrenia.

DATA SOURCES

Ovid Technologies web-based software was used to search the Medline and PsycINFO computerized databases to identify articles that met the inclusion criteria.

REVIEW METHODS

The search was limited to papers published after 1990, written in English, employing human subjects, using atypical antipsychotics, using a within-subjects design or control group of patients with schizophrenia for comparisons, using participants aged from 18-65, and employing standardized neuropsychological measures.

RESULTS

A total of 996 eligible studies were identified, and of these 19 were finally analyzed. Nine domains of cognitive functioning were assessed. The two groups of agents produced equivalent overall effects (-dones = .254 versus -pines = .202). The -pines were found to improve the domains of attention/working memory, executive functioning, fluency, nonverbal memory, processing speed, and verbal memory, each with a significant, small effect size. The -dones were found to improve attention/working memory, executive functioning, motor function, nonverbal memory, processing speed, and verbal memory, each with a significant, small effect size. Failsafe N was robust for all of the domains for the -pines, but only for the verbal memory domain for the -dones, suggesting that the significant findings for the other domains with the -dones are more tenuous.

CONCLUSION

The results indicate that the agents were largely equivalent and that there was no clear evidence that the pattern of cognitive effects differed as a result of the agent applied. The effects themselves, while statistically significant, were small, indicating that some or all of the differences may be attributable to practice effects on the instruments employed.

Cancer-related cognitive impairment in breast cancer survivors: An examination of conceptual and statistical cognitive domains using principal component analysis

There is a great deal of variability in the composition of neuropsychological test batteries used in the assessment of cancerrelated cognitive impairment (CRCI). Not only the development of a gold standard approach for CRCI assessment would allow for easier identification of women suffering from CRCI but it would also promote optimal care for survivors. As a first step towards the development of a valid and reliable unified test battery, the objective of this study was to verify whether the theoretical domains commonly used in CRCI assessment are statistically supported, before and after breast cancer treatment. Principal component analyses (PCA) were performed on the results from 23 neuropsychological tests grouped into eight conceptual domains. For baseline data, the Kaiser-Meyer-Olkin was .82 and Bartlett's X2(253, N=95) = 949.48, P<0.001. A five-component solution explained 60.94% of the common variance. For the post-treatment data, the Kaiser-Meyer-Olkin was .83 and Bartlett's X2(253, N=95) = 1007.21, P<0.001 and a five component solution explained 62.03% of the common variance. Although a visual comparison of the theoretical model with those determined via PCA indicated important overlap between conceptual domains and statistical components, significant dissimilarities were also observed.

Blood-based biomarkers of cancer-related cognitive impairment in non-central nervous system cancer: protocol for a scoping review

INTRODUCTION

Cancer-related cognitive impairment (CRCI) can have detrimental effects on quality of life, even among patients with non-central nervous system (CNS) cancers. Several studies have been conducted to explore different markers associated with CRCI to understand its pathobiology. It is proposed that the underlying mechanisms of CRCI are related to a cascade of physiological adaptive events in response to cancer and/or treatment. Hence, peripheral blood would be a logical source to observe and identify these physiological events. This paper outlines the protocol for a scoping review being conducted to summarise the extant literature regarding blood-based biomarkers of CRCI among patients with non-CNS cancer.

METHODS/ANALYSIS

Methods will be informed by the updated guidelines of Arksey and O'Malley. The systematic search for literature will include electronic databases, handsearching of key journals and reference lists, forward citation tracking and consultation with content experts. Study selection will be confirmed by duplicate review and calculation of inter-rater reliability. Data to be charted will include study design, sample size, cancer and treatment characteristics, demographic characteristics, cognitive variable/s and biomarkers assessed, associations between cognitive functioning and biomarkers (including statistics used), and rigour in biomarker sample collection and processing. Results will be presented through: (1) a descriptive numerical summary of studies, including a flow diagram based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, (2) a list of blood-based biomarkers associated with CRCI and (3) a narrative overview developed through collaboration among the research team and consultation with content experts.

DISSEMINATION

The findings of this review will highlight current directions and gaps in the current body of evidence that may lead to improved rigour in future CRCI investigations. The dissemination of this work will be facilitated through the involvement of clinicians and researchers on the research team, an external consultation process and the presentation of the results through scholarly publication and presentation.

Association of Neurocognitive Deficits With Radiotherapy or Chemoradiotherapy for Patients With Head and Neck Cancer

Importance

Neurocognitive deficits (NCD) have been observed in noncentral nervous system cancers, yet short- and long-term neurocognitive data on patients treated for head and neck cancer (HNC) are lacking.

Objective

To assess objective neurocognitive function before and after definitive radiation therapy for HNC.

Design, Setting, and Participants

In a prospective, longitudinal study, neurocognitive function and self-reported symptoms were assessed in 80 patients with histologically proven HNC requiring definitive chemoradiotherapy or radiotherapy and in 40 healthy controls 4 times (baseline, 6, 12, and 24 months after baseline) prior to commencing treatment at Princess Margaret Cancer Centre, Toronto, Canada.

Main Outcomes and Measures

Neurocognitive test scores were converted to age-corrected z scores (mean, 0; standard deviation, 1) and reported as mean scores, standardized regression-based scores, and frequencies of impairments in intellectual capacity, concentration, memory, executive function, processing speed, and motor dexterity. Multivariable analysis was used to identify factors associated with NCD 2 years after treatment.

Results

Eighty patients and 40 healthy controls enrolled. Analyses revealed significant differences between patient and control mean performance in some domains, with patient deficits increasing over time: intellectual capacity (Cohen d, effect sizes [95% CIs] of -0.46 [-0.64 to 0.30], -0.51 [-0.72 to -0.30], and -0.70 [-0.92 to -0.49] for time points 6, 12, and 24 months, respectively); concentration/short-term attention span (-0.19 [-0.37 to 0.00], -0.38 [-0.55 to -0.21], -0.54 [-0.71 to -0.37]); verbal memory (-0.16 [-0.33 to 0.02], -0.38 [-0.64 to -0.12], -0.53 [-0.74 to -0.32]); executive function (-0.14 [-0.27 to 0.00], -0.34 [-0.52 to -0.16], -0.43 [-0.64 to -0.22]), and global cognitive function composite (-0.38 [-0.55 to -0.22], -0.75 [-0.92 to -0.58], -1.06 [-1.26 to -0.86]). There was an increased rate of impaired global neurocognitive functioning among patients (38%) at 24 months compared with controls (0%). Neurocognitive deficits were not associated with baseline cytokines.

Conclusions and Relevance

Head and neck cancer survivors have neurocognitive sequelae up to 2 years after definitive chemoradiotherapy or radiation treatment. Patients and health care teams should know about such potential risks. Further research is warranted in search of strategies to avoid, reduce, and compensate for declines.

Changes in Cognition and Decision Making Capacity Following Brain Tumour Resection: Illustrated with Two Cases

Changes in cognition, behaviour and emotion frequently occur in patients with primary and secondary brain tumours. This impacts the ability to make considered decisions, especially following surgical resection, which is often overlooked in the management of patients. Moreover, the impact of cognitive deficits on decision making ability affects activities of daily living and functional independence. The assessment process to ascertain decision making capacity remains a matter of debate. One avenue for evaluating a patient’s ability to make informed decisions in the context of brain tumour resection is neuropsychological assessment. This involves the assessment of a wide range of cognitive abilities on standard measurement tools, providing a robust approach to ascertaining capacity. Evidence has shown that a comprehensive and tailored neuropsychological assessment has greater sensitivity than brief cognitive screening tools to detect subtle and/or specific cognitive deficits in brain tumours. It is the precise nature and severity of any cognitive deficits that determines any implications for decision making capacity. This paper focuses on cognitive deficits and decision making capacity following surgical resection of both benign and malignant, and primary and secondary brain tumours in adult patients, and the implications for patients’ ability to consent to future medical treatment and make decisions related to everyday activities.

Cognitive functioning and quality of life following chemotherapy in pre- and peri-menopausal women with breast cancer

PURPOSE

The purpose of the study was to prospectively examine changes in subjective and objective cognitive functions and quality of life (QOL) for pre- and peri-menopausal women receiving chemotherapy for breast cancer and to explore potential predictors of cognitive changes.

METHODS

Participants were assessed as follows: prior to chemotherapy (T1), after cycle 3 (T2), within 2-3 weeks of completing adjuvant chemotherapy (T3) (N = 20), and 8+ years later (T4; n = 18). Objective cognitive function was measured with the High Sensitivity Cognitive Screen (T1, T3, T4). Subjective measures for cognitive function, depressive symptoms, fatigue, and mental and physical QOL were assessed at all time points. Estradiol levels were measured at T1, T2, and T3. The Functional Assessment of Cancer Therapy-Cognition and the MD Anderson Cancer Symptom Inventory item for neuropathy were administered at T4.

RESULTS

No significant changes in objective cognitive function were found. However, participants reported decreased cognitive function over the course of treatment accompanied by depressive symptoms and fatigue. Depression and fatigue returned to near-baseline levels at T4, but over half of the participants continued to report mild to moderate depression. Estradiol levels were not associated with cognitive function. Neuropathy and higher body mass index (BMI) were associated with persistent cognitive complaints at T4 (adjusted R ² = 0.712, p = 0.001). Higher QOL was correlated with better subjective cognitive function (r = 0.705, p = 0.002) and lower body mass index (r = - 0.502, p = 0.017) at T4.

CONCLUSIONS

Further investigation of BMI, neuropathy, and depressive symptoms as predictors of persistent cognitive dysfunction following chemotherapy for breast cancer is warranted.

Altered Brain Functional Connectivity in Small-Cell Lung Cancer Patients after Chemotherapy Treatment: A Resting-State fMRI Study

Previous studies in small-cell lung cancer (SCLC) patients have mainly focused on exploring neurocognitive deficits associated with prophylactic cranial irradiation (PCI). Little is known about functional brain alterations that might occur due to chemotherapy treatment in this population before PCI is administered. For this reason, we used resting-state functional Magnetic Resonance Imaging (fMRI) to examine potential functional connectivity disruptions in brain networks, including the Default Mode Network (DMN), the Sensorimotor Network, and the Task-Positive Network (TPN). Nineteen SCLC patients after platinum-based chemotherapy treatment and thirteen controls were recruited in the current study. ROI-to-ROI and Seed-to-Voxel analyses were carried out and revealed functional connectivity deficits in patients within all the networks investigated demonstrating the possible negative effect of chemotherapy in cognitive functions in SCLC populations.

Executive functioning impairment in women treated with chemotherapy for breast cancer: a systematic review

PURPOSE

Women with breast cancer have reported adverse cognitive effects following chemotherapy. Evidence is mixed on whether executive functioning is particularly impaired in women treated with chemotherapy, in part due to the wide range of tasks used to measure executive processes. We performed a systematic review of the published literature to evaluate whether some subcomponents of executive functioning are more vulnerable to impairment than others among breast cancer survivors who had been treated with chemotherapy.

METHODS

Studies published as of April 2017 were identified using three electronic databases (MEDLINE, PsycINFO, and Web of Science) and a manual search of relevant reference lists. The methodological quality of included studies was assessed using a checklist of predefined criteria.

RESULTS

Of 1280 identified articles, a total of 41 were included for review. Study findings were categorized into three primary subdomains of executive functioning: inhibition, shifting, and updating. Although there was heterogeneity in the neuropsychological measures used to assess executive functioning, tests could be grouped into the subcomponents they assessed. Inhibition appears relatively spared from the effects of chemotherapy, whereas impairments in shifting and updating are more commonly found following chemotherapy.

CONCLUSIONS

Examination of subcomponents of executive functioning is recommended to better characterize the nature of executive dysfunction in women treated with chemotherapy. Future studies should include executive functioning tasks of varying complexity, use of multiple tasks to increase reliability, and alternative indices to capture performance, such as within-person variability.

Chemotherapy and Post-traumatic Stress in the Causation of Cognitive Dysfunction in Breast Cancer Patients

Background

Cancer-related cognitive dysfunction has mostly been attributed to chemotherapy; this explanation, however, fails to account for cognitive dysfunction observed in chemotherapy-naïve patients. In a controlled, longitudinal, multisite study, we tested the hypothesis that cognitive function in breast cancer patients is affected by cancer-related post-traumatic stress.

Methods

Newly diagnosed breast cancer patients and healthy control subjects, age 65 or younger, underwent three assessments within one year, including paper-and-pencil and computerized neuropsychological tests, clinical diagnostics of post-traumatic stress disorder (PTSD), and self-reported cognitive function. Analysis of variance was used to compare three groups of participants-patients who did or did not receive chemotherapy and healthy control subjects-on age- and education-corrected cognitive performance and cognitive change. Differences that were statistically significant after correction for false discovery rate were investigated with linear mixed-effects models and mediation models. All statistical tests were two-sided.

Results

Of 226 participants (166 patients and 60 control subjects), 206 completed all assessment sessions (attrition: 8.8%). Patients demonstrated overall cognitive decline (group*time effect on composite z -score: -0.13, P = .04) and scored consistently worse on Go/Nogo errors. The latter effect was mediated by PTSD symptoms (mediation effect: B = 0.15, 95% confidence interval = 0.02 to 0.38). Only chemotherapy patients showed declined reaction time on a computerized alertness test. Overall cognitive performance correlated with self-reported cognitive problems at one year ( T = -0.11, P = .02).

Conclusions

Largely irrespective of chemotherapy, breast cancer patients may encounter very subtle cognitive dysfunction, part of which is mediated by cancer-related post-traumatic stress. Further factors other than treatment side effects remain to be investigated.

Abnormal Development of Dendrites in Adult-Born Rat Hippocampal Granule Cells Induced by Cyclophosphamide

Although development of cognitive decline in cancer patients who receive chemotherapy is common, the underlying mechanism(s) remains to be identified. As abnormalities in adult hippocampal neurogenesis may serve as substrate for cognitive dysfunction, the present study examines the effect of cyclophosphamide (CPP), a widely prescribed chemotherapeutic agent, on dendritic development of adult-born hippocampal granule cells in the rat. CPP was intraperitoneally injected into male Sprague-Dawley rats once a week for four consecutive weeks. Four weeks and 1 week after the last dose of CPP, Morris water maze test and doublecortin (DCX) immunohistochemistry were carried out to determine the effects of CPP on cognitive function and the rate of hippocampal neurogenesis, respectively. Adult newborn hippocampal granule cells were labeled at the same day as the first dose of CPP and were examined 10 weeks after labeling. Results showed that cognitive decline induced by CPP was associated with both suppressed adult hippocampal neurogenesis and abnormal development of dendrites of newborn granule cells. The abnormalities of dendrites in newborn granule cells after CPP exposure included less dendritic branching, shorter total dendritic length, thinner and torturous dendritic shafts with intermittent appearances of varicosities, and lower spine densities of stubby and thin types along dendritic shafts, but an increased density of mushroom-like spines. Adult-born granule cells in the presence of CPP, a widely used anti-cancer medication, display abnormal dendritic morphologies and fewer dendritic spines which may underlie cognitive dysfunction.

Review paper. Chemobrain in patients suffering from cancer based on the example of multiple myeloma

Introduction: The incidence rate of cancers emphasizes the necessity to investigate not only patients’ somatic ailments but also their psychosocial functioning as well as the need to raise the quality standards of cancer patients. The improvement of the quality of life is one of the major challenges of psycho-oncology, which is the science created in the interface of two disciplines: psychology and medicine.

One of the important aspects of psycho-oncologists’ activity is the minimization of negative side-effects related to treatment, such as changes in patients’ cognitive functioning resulting from anti-cancer treatment.

Objective: The aim of this work is to provide the reader with the knowledge concerning the phenomenon of chemobrain in a very special group of patients with hemato-oncologic tumour. Few researches related to this topic have confirmed the occurrence of cognitive deficits resulting from the cancer process, taken cytotoxic drugs, other forms of anti-cancer therapy and the activeness of biochemical compounds in patients with multiple myeloma.

Methods: The author has done a literary review concerning the topic under study using the Google Scholar and EBSCO databases. The main part of this work consists of references to Polish and English research literature published after 2000. The review includes also classic works from the eighties and nineties of the 20th century.

Results: The present work has been divided into several sections. The part devoted to explanation of the term chemobrain describes the evolution of its definition over the years. The second section - ‘Heterogeneity of the phenomenon - causes’ - underlines the influence of biochemical etiological factors, such as the impact of the activity of proinflammatory cytokines on the cognitive state of the patients suffering from tumour. Next part - ‘Chemobrain and multiple myeloma’ is devoted to the clinical characteristics of this cancer and to the descriptions of the selected methods of chemotherapy. The review of researches concerning the deteriorated cognitive functioning of patients with multiple myeloma in relation to the probable aetiology of this disease has been also presented.

Conclusions: The review of Polish and English literature concerning the functioning of memory and attention processes in the patients suffering from multiple myeloma can serve as an inspiration for a search for objective biochemical factors conditioning the deterioration of cognitive processes of the patients undergoing anti-cancer treatment.

Development of an item bank for computerized adaptive testing of self-reported cognitive difficulty in cancer patients

Background

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group is developing computerized adaptive testing (CAT) versions of each scale of the EORTC Quality of Life Questionnaire (EORTC QLQ-C30). This study aims to develop an item bank for the EORTC QLQ-C30 cognitive functioning scale, which can be used for CAT.

Methods

The complete developmental approach comprised four phases: (I) conceptualization and literature search, (II) operationalization, (III) pretesting, and (IV) field-testing. This paper describes phases I-III.I) A literature search was performed to identify self-report instruments and items measuring cognitive complaints on concentration and memory. II) A multistep item-selection procedure was applied to select and generate items that were relevant and compatible with the 'QLQ-C30 item style.' III) Cancer patients from different countries evaluated the item list for wording (ie, whether items were difficult, confusing, annoying, upsetting or intrusive), and whether relevant issues were missing.

Results

A list of 439 items was generated by the literature search. In the multistep item-selection procedure, these items were evaluated for relevance, redundancy, clarity, and response format, resulting in an list of 45 items. A total of 32 patients evaluated this item list in the pretesting phase, resulting in a preliminary list of 44 items.

Conclusion

Phase I-III resulted in an item list of 44 items measuring self-reported cognitive complaints that was endorsed by international experts and cancer patients in several countries. This list will be evaluated for its psychometric characteristics in phase IV.