Adjuvant breast cancer treatment and cognitive function: current knowledge and research directions

Impact of integrated yoga therapy on cognitive impairment and cardiac dysfunction in relation to quality of life in breast cancer patients undergoing chemotherapy: Study protocol for a two-arm randomized controlled trial

Background

Chemotherapy-related cognitive impairment (CRCI) and cardiac dysfunction (CRCD) are common adverse effects seen in breast cancer patients undergoing chemotherapy. Even though these effects significantly influence daily functioning and overall quality of life, effective strategies to avoid and/or mitigate these adverse effects remain elusive. Yoga as a Mind-body intervention has been used increasingly by cancer patients and has undergone empirical investigations as a potential intervention for patients with cancer. Furthermore, yoga is associated with improved cognition and cardiac functioning in healthy older adults and subjects with cognitive and cardiac impairments. Accordingly, in the current study, yoga holds promise as an intervention to prevent/manage CRCI and CRCD with improved overall QOL in women receiving chemotherapy for breast cancer.

Methods

The study is a two-arm, randomized controlled trial. Women diagnosed with stage I-III breast cancer and awaiting neo-adjuvant or adjuvant chemotherapy will be recruited from a tertiary care center in Bangalore, India. Following recruitment, subjects are randomized to the intervention group (integrated yoga therapy intervention during chemotherapy) or the control group (standard care during chemotherapy). The study’s primary outcome is to measure the quality of life (cognitive domain) using European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The other primary objectives will include cognitive functioning using neuropsychological test battery and cardiac autonomic function testing using heart rate variability. Secondary outcomes are Brain-derived neurotrophic factor (BDNF), brain function (functional MRI), Echocardiography, serum cortisol, Functional assessment of cancer therapy-cognition (FACT-Cog V3), perceived stress scale and Ryff Scales of Psychological Well-Being. Assessments take place before, during and after chemotherapy; 16-weeks post chemotherapy and 1-year post-baseline.

Discussion

Yoga is a promising intervention for preventing and/or managing chemotherapy-related adverse effects (CRAE) and enhancing the quality of life among breast cancer patients. The findings from this study may also help understand the inner mechanisms involved in the protective and restorative effects of yoga on CRAE and support the use of yoga prophylactically for breast cancer patients. In addition, the results of this study could help chemotherapy-exposed individuals with other solid cancer types who have cognitive and cardiac issues.

Ethics and Dissemination

The study is approved by the ethics committee of the HealthCare Global Enterprises Ltd. Hospital (EC/434/19/01) and National Institute of Mental Health and Neurosciences (NIMH/DO/ETHICS SUB-COMMITTEE (BS&NS) 9th MEETING/2018).

Clinical Trial Registration

http://ctri.nic.in/Clinicaltrials/advancesearchmain.php, identifier CTRI/2020/10/028446.

Stem cell therapies as a therapeutic option to counter chemo brain: a negative effect of cancer treatment

Chemo brain, a constellation of cognitive deficiencies followed by chemotherapy drugs, used to treat different types of cancers and adversely impacts the quality of life of a cancer survivor. The underlying mechanism of chemo brain remains vague, thus delaying the advancement of efficient treatments. Unfortunately, there is no US FDA approved medicine for chemo brain and often medicines considered for chemo brain are already the ones approved for other diseases. Nevertheless, researches exploring stem cell transplantation in different neurodegenerative diseases demonstrate that cellular transplantation could reverse chemotherapy-induced chemo brain. This review talks about the mechanism behind the cognitive impairments instigated by different chemotherapy drugs used in cancer treatment, and how stem cell therapy could be advantageous to overcome this disease.

The added value of geriatric assessment in evaluating a patient's Health-Related Quality-of-Life: A study in ≥70-year-old early-stage invasive breast cancer patients

OBJECTIVE

The objective of this study was to assess the relationship between geriatric assessment (GA) and health-related Quality-of-Life (HRQOL) in older patients with breast cancer.

METHODS

Patients were assigned either to adjuvant chemotherapy (CTG) or to a control group (CG). Spearman rank coefficients (ρ) calculated correlations between HRQOL and GA at baseline, 3 months and 1 year. Multivariate regressions modelled the prognostic value of GA in evaluating of a patient's HRQOL and the accuracy of baseline GA in predicting HRQOL decline (change of ≥10 points).

RESULTS

The analysis included 57 patients in the CTG and 52 in the CG. Strong correlations (ρ ≥ 0.5) were reported between the EORTC QLQ-C30 Physical Functioning Scale and Activities of Daily Living (ADL), Instrumental ADL (iADL) and Leuven Oncogeriatric Frailty Score Scale (LOFS). Multivariate models demonstrated that poor iADL, ADL and LOFS (CG) and ADL and iADL (CTG) contributed to a statistically (all p < .05) worse HRQOL. The relative gain in predicting 3-month and 1-year HRQOL decline was 24.1% and 4.7% (CG) and 6.1% and 18.3% (CTG).

CONCLUSION

Our results show that the functional measures in the GA are strongly correlated with patient self-reported functioning. Poor baseline GA has a modest probability of predicting HRQOL deterioration.

Mechanisms underlying select chemotherapeutic-agent-induced neuroinflammation and subsequent neurodegeneration

This review demonstrates the importance of uncovering the mechanisms that underlie chemotherapy-induced neuroinflammation. It builds upon the well-established connection between chemotherapeutic-agents and neurotoxicity along with widespread peripheral toxicities. This article summarises the major studies which have linked chemotherapy-induced neurodegeneration with direct evidence of neuroinflammation. Cancer and chemotherapy-related adverse effects impact a large proportion of the population. A better understanding of the link between chemotherapy, neurotoxicity and specifically the mechanisms of neuroinflammation, will allow the development of strategies to improve the management of side effects, and overall to reduce the burden on cancer patients receiving chemotherapy. This review has developed a summary schematic of the relationship between different chemotherapeutic agents and inflammatory markers within the central nervous system and links this correlation with some major ailments associated with chemotherapy use.

Dimensions of sedentary behavior and objective cognitive functioning in breast cancer survivors

PURPOSE

To examine associations between dimensions of sedentary behavior and cognitive function in breast cancer survivors.

METHODS

Sedentary behavior variables were measured using thigh-worn activPALs, and included total daily sitting time, time in long sitting bouts, sit-to-stand transitions, and standing time. Cognitive function was assessed using the NIH Toolbox Cognitive Domain. Separate multivariable linear regression models were used to examine associations between sedentary behavior variables with the cognitive domain scores of attention, executive functioning, episodic memory, working memory, and information processing speed.

RESULTS

Thirty breast cancer survivors with a mean age of 62.2 (SD = 7.8) years who were 2.6 (SD = 1.1) years since diagnosis completed study assessments. In multivariable linear regression models, more time spent standing was associated with faster information processing (b: 5.78; p = 0.03), and more time spent in long sitting bouts was associated with worse executive function (b: -2.82; p = 0.02), after adjustment for covariates. No other sedentary behavior variables were statistically significantly associated with the cognitive domains examined in this study.

CONCLUSIONS

Two important sedentary constructs that are amenable to intervention, including time in prolonged sitting bouts and standing time, may be associated with cognitive function in breast cancer survivors. More research is needed to determine whether modifying these dimensions of sedentary behavior will improve cognitive function in women with a history of breast cancer, or prevent it from declining in breast cancer patients.

Psychosocial distress and its effects on the health-related quality of life of primary brain tumor patients

All cancer patients experience distress from the diagnosis, the effects of the disease or the treatment. Clinically significant distress decreases overall quality of life and the recognition of distress with prompt intervention is essential. The National Comprehensive Cancer Network distress thermometer (NCCN-DT) is a validated measuring tool that has been utilized in the primary brain tumor population to detect psychologic distress thereby provoking a referral process to the appropriate support system. Brain tumor patients commonly reported emotional and physical distress encompassing: fatigue, fears, memory and concentration and worry. More research is needed to identify the stressors of all primary brain tumor patients and their caretakers and integrate appropriate interventions to improve health-related quality of life in both groups.

PET Evidence of the Effect of Donepezil on Cognitive Performance in an Animal Model of Chemobrain

A considerable number of patients with breast cancer complain of cognitive impairment after chemotherapy. In this study, we showed that donepezil enhanced memory function and increased brain glucose metabolism in a rat model of cognitive impairment after chemotherapy using behavioral analysis and positron emission tomography (PET). We found that chemotherapy affected spatial learning ability, reference memory, and working memory and that donepezil improved these cognitive impairments. According to PET analysis, chemotherapy reduced glucose metabolism in the medial prefrontal cortex and hippocampus, and donepezil increased glucose metabolism in the bilateral frontal lobe, parietal lobe, and hippocampus. Reduced glucose metabolism was more prominent after treatment with doxorubicin than cyclophosphamide. Our results demonstrated the neural mechanisms for cognitive impairment after chemotherapy and show that cognition was improved after donepezil intervention using both behavioral and imaging methods. Our results suggested that donepezil can be employed clinically for the treatment of cognitive deficits after chemotherapy.

Acupuncture for Chemotherapy-Associated Cognitive Dysfunction: A Hypothesis-Generating Literature Review to Inform Clinical Advice

There is an emerging consensus that between one fifth and one half of breast cancer patients experience chemotherapy-associated cognitive dysfunction. Research shows that patients with cancer are often interested in acupuncture for symptom relief. A clinical question thus arises: What should physicians advise their patients regarding the use of acupuncture to alleviate or ameliorate chemotherapy-associated cognitive dysfunction? The authors review and synthesize 2 bodies of relevant research literature: (1) the developing literature on the etiology and nature of chemotherapy-associated cognitive dysfunction and (2) the literature concerning acupuncture for neurological diseases and psychological issues. There is evidence that acupuncture may be effectively used to manage a range of psychoneurological issues, some of which are similar to those experienced by patients with chemotherapy-associated cognitive dysfunction. The evidence of efficacy is more promising for psychological than neurological conditions. Given evidence of possible efficacy combined with evidence of demonstrated safety, we suggest that physicians should support patient decisions to use acupuncture services for chemotherapy-associated cognitive dysfunction, especially given the lack of proven alternatives.

What is known and unknown about chemotherapy-related cognitive impairment in patients with haematological malignancies and areas of needed research

Cancer-related cognitive impairment (CRCI) is an important clinical problem for cancer patients and survivors. In this review, we summarize studies investigating the occurrence of impaired cognition in patients with haematological malignancies. Most published studies focus on survivors of childhood acute lymphoblastic leukaemia and primary central nervous system lymphoma. We also discuss studies conducted in acute myeloid leukaemia, myelodysplastic syndromes, chronic myeloid leukaemia, Hodgkin lymphoma (HL), non-HL and chronic lymphocytic leukaemia. Although research in this area is still emerging, it appears that a subset of chemotherapy-treated haematological malignancy survivors experience CRCI. Future research should focus on expanding the literature reviewed here with larger studies appropriately powered to assess cognition via objective and subjective measures in a longitudinal fashion to tease apart the impact of disease and the various forms of cancer treatment.

Cancer Related Fatigue and Quality of Life in Patients with Advanced Prostate Cancer Undergoing Chemotherapy

Cancer related fatigue (CRF) is a common and debilitating symptom that can influence quality of life (QoL) in cancer patients. The increase in survival times stresses for a better understanding of how CRF affects patients' QoL. This was a cross-sectional descriptive study with 148 randomly recruited prostate cancer patients aiming to explore CRF and its impact on QoL. Assessments included the Cancer Fatigue Scale, EORTC QLQ-C30, and EORTC QLQ-PR25. Additionally, 15 in-depth structured interviews were performed. Quantitative data were analyzed with simple and multiple regression analysis and independent samples t-test. Qualitative data were analyzed with the use of thematic content analysis. The 66.9% of the patients experienced CRF with higher levels being recorded for the affective subscale. Statistically significant differences were found between the patients reporting CRF and lower levels of QoL (mean = 49.1) and those that did not report fatigue and had higher levels of QoL (mean = 72.1). The interviews emphasized CRF's profound impact on the patients' lives that was reflected on the following themes: “dependency on others,” “loss of power over decision making,” and “daily living disruption.” Cancer related fatigue is a significant problem for patients with advanced prostate cancer and one that affects their QoL in various ways.

Cognitive function in cancer survivors: analysis of the 1999-2002 National Health and Nutrition Examination Survey

PURPOSE

Cancer and its treatment may affect cognitive function through a number of direct and indirect pathways including inflammation, lipid metabolism, vascular damage, and changes in the blood-brain barrier. While short-term treatment-related cognitive changes are well recognized, only limited research is available in older, long-term survivors of cancer.

METHODS

Using NHANES data from 1999 to 2002, 408 cancer survivors and 2639 non-cancer participants aged 60 years old and above were identified. Cognitive function of these groups were compared using the Digit Symbol Substitution Test (DSST) and self-reported problems with memory or confusion.

RESULTS

After adjustment for covariates, cancer survivors scored, on average, 1.99 points lower on the DSST compared to non-cancer survivors (-1.99, 95 % CI -3.94, -0.05). Cancer survivors also had 17 % higher odds of self-reporting problems with memory or confusion (OR 1.17, 95 % CI 0.89, 1.53).

CONCLUSION

In this nationally representative sample of older US adults, cancer survivors had lower DSST scores than non-survivors and had more self-reported problems with memory or confusion.

Coping with cancer-related cognitive dysfunction: a scoping review of the literature

PURPOSE

Cancer-related cognitive dysfunction (CRCD) impacts memory, attention, concentration, language, multi-tasking, and organizational skills and decreases participation and quality of life for cancer survivors. The objectives of this article are: (1) to outline the neuroscience of CRCD, its risk factors, and its effect on participation; and (2) to identify and summarize the literature on rehabilitation interventions and coping techniques for CRCD in cancer survivors.

METHODS

A scoping review of articles cited in PubMed, MEDLINE, PsychINFO, and CINAHL was performed. To be included, articles must have been published in a peer-reviewed scientific journal between 1996 and 2014, written in English, and included a quantitative or qualitative non-pharmacological study of interventions and/or coping strategies for adult cancer survivors experiencing CRCD.

RESULTS

Ten articles met the inclusion criteria for final review. Six studies tested the efficacy of rehabilitation treatments on CRCD. Three involved cognitive-behavioral therapy (CBT), while three tested neuropsychological and/or cognitive training interventions. Four qualitative studies investigated coping strategies used by survivors with CRCD.

CONCLUSIONS

CBT-based treatments and neuropsychological/cognitive training methods may ameliorate symptoms of CRCD. The most commonly-reported coping strategy is utilization of assistive technology and memory aids. Further research is needed about efficacious rehabilitation techniques for this population. Implications for Rehabilitation Cancer-related cognitive dysfunction (CRCD) may impact up to 50% of cancer survivors. CRCD can significantly decrease participation and quality of life during survivorship. Cognitive-behavioral therapy (CBT) and neuropsychological/cognitive training methods may ameliorate symptoms of CRCD. The most common coping strategy reported by cancer survivors with CRCD is the use of assistive technology and memory aids.

Redox biology in normal cells and cancer: restoring function of the redox/Fyn/c-Cbl pathway in cancer cells offers new approaches to cancer treatment

This review discusses a unique discovery path starting with novel findings on redox regulation of precursor cell and signaling pathway function and identification of a new mechanism by which relatively small changes in redox status can control entire signaling networks that regulate self-renewal, differentiation, and survival. The pathway central to this work, the redox/Fyn/c-Cbl (RFC) pathway, converts small increases in oxidative status to pan-activation of the c-Cbl ubiquitin ligase, which controls multiple receptors and other proteins of central importance in precursor cell and cancer cell function. Integration of work on the RFC pathway with attempts to understand how treatment with systemic chemotherapy causes neurological problems led to the discovery that glioblastomas (GBMs) and basal-like breast cancers (BLBCs) inhibit c-Cbl function through altered utilization of the cytoskeletal regulators Cool-1/βpix and Cdc42, respectively. Inhibition of these proteins to restore normal c-Cbl function suppresses cancer cell division, increases sensitivity to chemotherapy, disrupts tumor-initiating cell (TIC) activity in GBMs and BLBCs, controls multiple critical TIC regulators, and also allows targeting of non-TICs. Moreover, these manipulations do not increase chemosensitivity or suppress division of nontransformed cells. Restoration of normal c-Cbl function also allows more effective harnessing of estrogen receptor-α (ERα)-independent activities of tamoxifen to activate the RFC pathway and target ERα-negative cancer cells. Our work thus provides a discovery strategy that reveals mechanisms and therapeutic targets that cannot be deduced by standard genetics analyses, which fail to reveal the metabolic information, isoform shifts, protein activation, protein complexes, and protein degradation critical to our discoveries.

Neurologic complications of chemotherapy and other newer and experimental approaches

Neurologic complications of conventional cytototxic agents as well as those from monoclonal antibodies and targeted therapies are increasingly observed in patients with cancer. The major categories are represented by alkylating agents (platinum compounds, ifosfamide, procarbazine, thiotepa), mitotic spindle inhibitors (vinca alkaloids, taxanes, etoposide, teniposide), proteasome inhibitors (bortezomib), antibiotics, antimetabolites, thalidomide, lenalidomide, topoisomerase inhibitors, interferon-α, hormones, bevacizumab, trastuzumab, and small tyrosine kinase inhibitors. Peripheral neuropathy is a common adverse effect of a number of chemotherapeutic drugs and often represents a critical factor limiting an adequate dose-intensity of chemotherapy. Regarding the central nervous system (CNS), it is vulnerable to many forms of toxicity from chemotherapeutic agents, including encephalopathy syndromes and confusional states, seizures, headache, cerebrovascular complications, visual loss, cerebellar syndromes, and myelopathy. For a given drug, the occurrence of CNS toxicity depends on several factors, including the total dose, route of administration, presence of structural brain lesions, exposure to prior or concurrent irradiation, and interactions with other drugs. However, many of the neurotoxic reactions are rare and idiosyncratic, and remain unpredictable. Several forms of neuroprotection and rehabilitation are being investigated. Last, the so-called "chemobrain" is an emerging issue, as it is a model of a subtle of and long-lasting damage to neuronal structures from some antineoplastic agents.

Common biological pathways underlying the psychoneurological symptom cluster in cancer patients

BACKGROUND

A symptom cluster is a group of symptoms that occur together and are interrelated. The clinical implication of symptom cluster research is to use the clustering patterns of symptoms to understand the mechanisms for these symptoms and develop management strategies targeted at multiple symptoms.

OBJECTIVE

The purposes of this review were to summarize the evidence for a psychoneurological symptom cluster in cancer patients, to provide information regarding the underlying biological mechanisms for each of the psychoneurological symptoms within the cluster, and to propose possible common biological pathways that may underlie this cluster.

METHODS

A systematic review of the literature was conducted.

RESULTS

Empirical evidence exists to support a cluster of psychoneurological symptoms (ie, depressive symptoms, cognitive disturbance, fatigue, sleep disturbance, pain). At a molecular level, common biological pathways (ie, proinflammatory cytokines, hypothalamic-pituitary-adrenal axis, and monoamine neurotransmission system) may underlie the development of symptoms within this cluster. Activation of proinflammatory cytokines is proposed as a first stage of mechanistic pathway. However, other biological factors, such as lowered estrogen or hemoglobin levels, may influence psychoneurological cluster.

CONCLUSION

Additional studies are needed to confirm the roles of cytokines as well as other biological factors in the development of the psychoneurological cluster and to determine the biomarkers to identify the subgroups of cancer patients who are at greatest risk for this cluster.

IMPLICATIONS FOR PRACTICE

This information can be used by researchers and clinicians to guide the selection of symptom management strategies that are ideally targeted to the biological mechanisms that underlie this symptom cluster.

Self-reported cognitive impairment in patients with cancer

PURPOSE

Cancer patients often report cognitive impairment, manifested as problems with concentration and memory, following cancer therapy. As part of a large multicenter survey of cancer patients undergoing treatment, we investigated the frequency and severity of self-reported problems with memory and concentration over time.

METHODS

A total of 595 patients undergoing treatment for solid tumors self-rated problems with memory and concentration, using an 11-point Likert scale (0 = "not present" to 10 = "as bad as you can imagine") at baseline before treatment began (T1), at their worst during treatment (T2), and at 6 months following treatment (T3). Any symptom level ≥ 7 was classified as "severe." Paired or independent t tests (as appropriate) with a Bonferroni correction were used to examine differences in symptoms over time and between patients treated with chemotherapy, radiation therapy, or both.

RESULTS

Concentration problems were reported by 48% of the 595 participants at T1 (5% severe), 67% at T2 (18% severe), and 58% (8% severe) at T3. Problems with memory were reported by 53% at T1 (4% severe), 67% (18% severe) at T2, and 68% (11% severe) at T3. The average frequency and severity of both symptoms in patients receiving chemotherapy, with or without radiation, increased significantly between T1 and T2 (P < .001). Both symptoms were less severe in patients receiving radiation alone at all three measurements than in either of the chemotherapy groups (all P values < .001). Symptoms at T3 were significantly higher than T1 for all groups (P < .001).

CONCLUSION

A significant proportion of patients undergoing cancer therapy self-report problems with memory and concentration. Cognitive problems get worse during treatment and are still in evidence 6 months following the conclusion of treatments.

Cognitive function in older women with breast cancer treated with standard chemotherapy and capecitabine on Cancer and Leukemia Group B 49907

Cognitive changes in older women receiving chemotherapy are poorly understood. We examined self-reported cognitive function for older women who received adjuvant chemotherapy on Cancer and Leukemia Group B (CALGB) 49907. CALGB 49907 randomized 633 women aged ≥65 with stage I-III breast cancer to standard adjuvant chemotherapy (cyclophosphamide-methotrexate-5-fluorouracil or doxorubicin-cyclophosphamide) versus capecitabine. We examined self-reported cognitive function in 297 women (CALGB 361002) who enrolled on the quality of life substudy and had no gross impairment on cognitive screening. Women were evaluated using an 18-item instrument at six time points (baseline through 24 months). At each time point for each patient, we calculated a cognitive function score (CFS) defined as the mean response of items 1-18 and defined impairment as a score >1.5 standard deviations above the overall average baseline score. Differences in scores by patient characteristics were evaluated using a Kruskal-Wallis test. A linear mixed-effects model was used to assess CFSs by treatment over time. Among 297 women, the median age was 71.5 (range 65-85) and 73 % had performance status of 0. Baseline depression and fatigue were reported in 6 and 14 % of patients, respectively. The average CFS at baseline was 2.08 (corresponding to "normal ability"), and baseline cognitive function did not differ by treatment regimen (p = 0.350). Over 24 months, women reported minimal changes at each time point and insignificant differences by treatment arm were observed. In a healthy group of older women, chemotherapy was not associated with longitudinal changes in self-reported cognitive function.

Exploring the use of the survivorship consult in providing survivorship care

PURPOSE

Advances in breast cancer treatment have increased survival and contributed to longer periods of survivorship as reported by the Committee CCSsS (Canadian Cancer Statistics) (2011) and Hewitt et al. (2005), increasing the relevance of survivorship care. Survivorship care includes encouraging survivors to acquire the knowledge, skills and confidence to manage their life, as well as engaging survivors through post-diagnosis disease self-management and self-care strategies. The Survivorship Consult (SC) was designed to help survivors reflect on their needs, establish goals and create an action plan.

METHODS

Twenty-six breast cancer survivors who participated in the SC at Princess Margaret Cancer Centre took part in semi-structured interviews to assess the survivor experience and effectiveness of the SC. Data from these interviews were coded, and themes were identified using a modified grounded theory approach.

RESULTS

Themes that emerged regarding the experience and effectiveness of the SC included (1) the supportive experience of collaborative dialogue with supportive care clinicians (i.e. nurses, social workers, occupational therapists, etc.), (2) the development of personalized goals that motivated individuals to implement recommendations, (3) an enhanced understanding of their health condition, team and options, (4) an improved ability to identify needs and (5) an increased sense of confidence to manage issues related to care.

CONCLUSIONS

The assessment of the SC improved the experience of breast cancer patients by providing a supportive environment where they could feel cared about, by increasing understanding of their condition and its treatment, by improving communication with the care team and by motivating patients to manage care issues. Further research is needed on survivors who conduct the SC before the treatment phase of their cancer trajectory.

Why, After Chemotherapy, is it Necessary to Assess Memory Using Translational Testing?

As the number of cancer survivors rises, so does the importance of understanding what happens post-chemotherapy. The evidence is clear that chemotherapy affects not only cancer cells, but also healthy cells including neurons, leading to long-term cognitive dysfunction in a large portion of survivors. In order to understand the mechanism of action and in the hope of reducing the potential neurocognitive side effects of chemotherapy, pre-clinical testing should be used more effectively. However, the field is lacking translation from clinical studies to animal models. Spatial learning and memory paradigms based on the water maze, the most commonly used rodent model, are available for translational testing in humans and could overcome this weakness. There is an overwhelming need in the field to understand whether the water maze is an adequate model for post-chemotherapy impairments or whether other paradigms should be used. This is of great importance for the understanding of the mechanisms, side effects of new drugs, appropriate pharmacotherapy, and confounding factors related to chemotherapy treatment regiments. This review is very important to both basic scientists and clinicians determining how translational paradigms are critical to future cancer research, as well as what type of paradigms are appropriate in our technically advancing society.

Lack of a chemobrain effect for adjuvant FOLFOX chemotherapy in colon cancer patients. A pilot study

PURPOSE

Chemotherapy improves the survival rate of stage III colon cancer patients. The combination of oxaliplatin, 5-fluorouracil, and leucovorin (the FOLFOX4 regimen) has emerged as the standard of care. This prospective study evaluates potential alterations in cognitive function in FOLFOX4-treated patients.

METHODS

We evaluated 57 consecutive colorectal cancer patients who received adjuvant chemotherapy with FOLFOX4. Patients underwent a complete battery of neuropsychological tests at three different times: before (T0), at the end (T1), and 6 months after treatment (T2).

RESULTS

We have analyzed cognitive impairment (Mini Mental State Examination, MMSE), visuo-spatial memory (Clock Drawing Test, CDT, Rey Complex Figure, copy and recall), information processing speed (Trial Making Test-A, TMT-A, and Trial Making Test-B, TMT-B), verbal memory (Rey Auditory Verbal Learning Test, call and recall), emotional distress (Psychological Distress Inventory, PDI), anxiety (State and Trait Anxiety Inventory, STAI-Y1 and Y2), and depression (Beck Depression Inventory, BDI). Then we have calculated, for each test and for each interval of time, mean ± standard deviation for the mean. In a subsequent phase, we tested the significance of different results through the ANOVA analysis for repeated measures. In this case, we could not find any statistically significant modification in cognitive function, but we could notice an improvement in emotional performance, anxiety and depression a short time after chemotherapy administration.

CONCLUSIONS

We found no effect on cognitive function related to chemotherapy, the only little modification is about some emotional performance during chemotherapy. These findings may be explained by the central role of the psychological adaptation process, which occurs during the period from diagnosis to completion of treatment and is characterized by anxiety and adjustment depression. Our results seem to rule out any significant cognitive impairment due to adjuvant FOLFOX4 chemotherapy in colon cancer patients.

Neurocognitive effects of chemotherapy and endocrine therapies in the treatment of breast cancer: recent perspectives

With an estimated 207,090 patients diagnosed with breast cancer in 2010, the role of chemotherapy-induced cognitive impairment is of growing importance. Studies to determine the impact of chemotherapy-induced cognitive impairment have been hindered by difficulties in study-design, in particular, study methodology. Here, we present a review of existing studies and discuss several mechanisms for chemotherapy-induced neurocognitive impairment in breast cancer patients, such as direct neurotoxic injury, telomere shortening, oxidative stress, cytokine dysregulation, estrogen-mediated effects, and the role of certain genetic polymorphisms. Decreased estrogen levels may serve as a link between multiple mechanisms potentiating the effects of the chemotherapy-induced cognitive impairment.

Neurological complications of chemotherapy to the central nervous system

One of the most common complications of chemotherapeutic drugs is toxicity to the central nervous system (CNS). This toxicity can manifest in many ways, including encephalopathy syndromes and confusional states, seizure activity, headache, cerebrovascular complications and stroke, visual loss, cerebellar dysfunction, and spinal cord damage with myelopathy. For many drugs, the toxicity is related to route of administration and cumulative dose, and can vary from brief, transient episodes to more severe, chronic sequelae. However, the neurotoxicity can be idiosyncratic and unpredictable in some cases. Among the antimetabolite drugs, methotrexate, 5-fluorouracil, and cytosine arabinoside are most likely to cause CNS toxicity. Of the alkylating agent chemotherapeutic drugs, the nitrosoureas (e.g., BCNU) and cisplatin most frequently cause toxicity to the CNS, especially when given via the intra-arterial route. Ifosfamide is also likely to cause neurotoxicity at high intravenous doses. Other alkylating agents, such as busulfan, cyclophosphamide, procarbazine, and temozolomide, are better tolerated by the CNS at moderate doses. The retinoid drugs are known to cause severe headaches at high doses. l-Asparaginase can induce an encephalopathy syndrome, as well as cerebrovascular complications such as stroke.

An evaluation on the neuropsychological tests used in the assessment of postchemotherapy cognitive changes in breast cancer survivors

OBJECTIVES

The choice of appropriate neuropsychological tests is important in evaluating the onset, severity, duration, and site of cognitive changes in postchemotherapy breast cancer survivors. This literature review is designed to evaluate and provide a summary of suitable neuropsychological tests to determine cognitive changes in breast cancer survivors.

METHOD

A literature search restricted to publications in English before June 2011 was performed using the following combination of keywords: "neuropsychological assessments," "breast cancer," "chemotherapy," and "cognitive impairment." Only observational studies that performed cognitive assessments on breast cancer survivors were included. The neuropsychological assessments were grouped as "objective" (traditional batteries and screening tests), "subjective," or "computerized."

RESULTS

Of the 43 studies extracted, memory (88 %) and attention/concentration (88 %) are the two most commonly assessed domains. A majority (63 %) employed the use of Wechsler Adult Intelligent Scale (an objective test), while only 49 % incorporated subjective assessments to assess perceived cognitive impairment. Computerized tests received low popularity (28 %) despite their numerous advantages, which include overcoming the language- and cultural-dependent limitations of traditional objective tests.

CONCLUSIONS

In the selection of a suitable neuropsychological tool to determine the onset, severity, site, and duration of cognitive changes in breast cancer survivors, incorporation of both subjective and objective tests is essential to facilitate a comprehensive assessment. With more validation work performed in future studies, it may be feasible to employ computerized neuropsychological assessments in both clinical and research settings.

Impact of mammography detection on the course of breast cancer in women aged 40-49 years

PURPOSE

To analyze trends in detection method related to breast cancer stage at diagnosis, treatments, and outcomes over time among 40-49-year-old women.

MATERIALS AND METHODS

i This study was institutional review board approved, with a waiver of informed consent, and HIPAA compliant. A longitudinal prospective cohort study was conducted of women aged 40-49 years who had primary breast cancer, during 1990-2008, and were identified and tracked by a dedicated registry database (n = 1977). Method of detection--patient detected (PtD), physician detected (PhysD), or mammography detected (MamD)--was chart abstracted. Disease-specific survival and relapse-free survival statistics were calculated by using the Kaplan-Meier method for stage I-IV breast cancer.

RESULTS

A significant increase in the percentage of MamD breast cancer over time (28%-58%) and a concurrent decline in patient and physician detected (Pt/PhysD) breast cancer (73%-42%) (Pearson x(2) = 72.72, P < .001) were observed over time from 1990 to 2008, with an overall increase in lower-stage disease detection and a decrease in higher-stage disease. MamD breast cancer patients were more likely to undergo lumpectomy (67% vs 48% of Pt/PhysD breast cancer patients) and less likely to undergo modified radical mastectomy (25% vs 47% of the Pt/PhysD breast cancer patients) (P < .001). Uncorrected for stage, 13% of MamD breast cancer patients underwent surgery and chemotherapy versus 22% of Pt/PhysD breast cancer patients (P < .001), and 31% of MamD breast cancer patients underwent surgery, radiation therapy, and chemotherapy versus 59% of Pt/PhysD breast cancer patients (x(2) = 305.13, P < .001). Analyzing invasive cancers only, 5-year relapse-free survival for MamD breast cancer patients was 92% versus 88% for Pt/PhysD patients (log-rank test, 12.47; P < .001).

CONCLUSION

Increased mammography-detected breast cancer over time coincided with lower-stage disease detection resulting in reduced treatment and lower rates of recurrence, adding factors to consider when evaluating the benefits of mammography screening of women aged 40-49 years.

Preserved learning and memory in mice following chemotherapy: 5-Fluorouracil and doxorubicin single agent treatment, doxorubicin-cyclophosphamide combination treatment

Clinical studies suggest that chemotherapy is associated with long-term cognitive impairment in some patients. A number of underlying mechanisms have been proposed, however, the etiology of chemotherapy-related cognitive dysfunction remains relatively unknown. As part of a multifaceted approach, animal models of chemotherapy induced cognitive impairment are being developed. Thus far, the majority of animal studies have utilized rats, however, mice may prove particularly beneficial in studying genetic risk factors for developing chemotherapy induced cognitive impairment. Thus, C57BL/6J mice were treated once a week for three weeks with saline, doxorubicin and cyclophosphamide (D&C), doxorubicin (Dox), or 5-fluorouracil (5-FU). Recent and remote contextual fear conditioning and novel object recognition (NOR) was assessed. Despite significant toxic effects as assessed by weight loss, the chemotherapy treated mice performed as well as control mice on all task. As are some humans, C57BL/6J mice may be resistant to at least some aspects of chemotherapy induced cognitive decline.

Weekly administration of epoetin alfa improves cognition and quality of life in patients with breast cancer receiving chemotherapy

Patients with breast cancer treated with adjuvant chemotherapy experience not only fatigue and menopausal symptoms but also documented cognitive dysfunction and reduced capacity to carry out activities of daily living. The role of epoetin alfa in improving cognition and functional capacity was assessed in a large randomized trial through patient self-reported outcomes. Patients with breast cancer (N = 354, adjuvant and metastatic) undergoing chemotherapy were randomized in a 1:1 ratio to receive epoetin alfa (40,000 IU once weekly) or the standard of care (SOC). Change in patient-reported Health Utilities Index Mark 3 (HUI3) from baseline to week 12 was compared between the epoetin alfa and SOC groups. In addition, correlations between the disease-nonspecific HUI3 utility scale and the cancer-specific quality of life instrument Functional Assessment of Cancer Therapy-Anemia (FACT-An) and Fatigue subscales were assessed. Epoetin alfa treatment significantly improved HUI3 scores compared with patients receiving SOC (P = 0.036). Three subscales within HUI3 were also significantly better for epoetin alfa-treated patients (emotion, P = 0.048; ambulation, P = 0.048; and cognition, P = 0.02). Moreover, a strong correlation (P = 0.0001) exists between the disease-nonspecific utility scale HUI3 and the disease-specific FACT-An and FACT-Fatigue scales in terms of overall scores and score changes. The findings of the study demonstrate for the first time in patients with breast cancer that epoetin alfa significantly enhances functional well-being, which translates into significantly better utility scores. In addition, epoetin alfa also significantly improved cognitive function of women undergoing chemotherapy, and this could have an important impact on their lives from a societal perspective.

Management of treatment-related symptoms in patients with breast cancer

Although the benefits of current treatment strategies are well established, many cancer survivors are at risk for developing physiologic and psychological late effects of cancer treatment that might lead to premature mortality and morbidity and compromise their quality of life. Psychological symptoms include anxiety, depression, fatigue, difficulty sleeping, and loss of self-esteem. Physiologic symptoms include pain, numbness, cognitive impairment, weight gain, loss of sexual interest, spontaneous menopause, and peripheral neuropathy. Both length and quality of survival are important end points. The goal of this review is to summarize the psychological and physiologic symptoms related to breast cancer treatment; the prevalence, contributing therapies, and inter-relatedness of these symptoms; current interventions to prevent, ameliorate, or treat these symptoms; and effectiveness and safety of these interventions. The results of this review will identify the gaps in knowledge and assist in the design of assessments and approaches to improve mortality and quality of life and provide the foundation for the development of evidence-based guidelines to standardize palliative care in cancer survivors.

'Like a sieve': an exploratory study on cognitive impairments in patients with multiple myeloma

The aim of this study was to obtain a more in-depth understanding of cognitive impairments and concerns as described by patients with multiple myeloma and the strategies used to cope with them. Semi-structured qualitative interviews were undertaken with 15 multiple myeloma patients of differing age ranges and at various stages of their disease. Various cognitive impairments, such as problems with short-term memory, poor recall and lack of concentration were observed and/or expressed in at least 10 out of 15 patients, all of them long(er)-term survivors. In some patients cognitive impairments significantly interfered with their personal and professional lives, and for some patients these were described as permanent. The patients used various coping strategies, from denial, taking notes, writing diaries, reading simpler texts, using talking books and videos, to using systems for counting medication to cope with the results of their cognitive impairment. Our findings differ from much of the contemporary literature which states that if cognitive impairments in cancer patients occur, they are mostly mild and transient. More proactive supportive care is needed to help patients with multiple myeloma to cope with poorer cognitive functioning.

Tailored chemotherapy doses based on toxicity in breast cancer result in similar quality of life values, irrespective of given dose levels

BACKGROUND

From March 1994 to March 1998, breast cancer patients (an estimated relapse risk with 70% or more within five years with standard therapy) were randomised to treatment with tailored fluorouracil, epirubicin, and cyclophosphamide (FEC) therapy or FEC followed by marrow-supported high dose therapy in the Scandinavian Breast Group 9401 study. The aim of the present paper was to investigate differences in toxicity and eight health-related quality of life (HRQoL) variables (physical functioning, role functioning, emotional functioning, social functioning, cognitive functioning, fatigue, nausea-vomiting, and global quality of life) between women in the six dose steps used in the tailored and granulocyte colony stimulating factor supported FEC-arm at the assessment point 16 weeks after random assignment to treatment.

METHODS

The European Organization and Treatment of Cancer Quality of Life Questionnaire EORTC QLQ-C30 were mailed to the patients.

RESULTS

A total of 157 (87%) in the tailored FEC-group responded to the questionnaire within the time frame 16 weeks after inclusion in the study. Overall, toxicity was low, reaching grade 1-2 also in the higher dose steps. There were no overall differences between the dose steps on any of the tested HRQoL variables. Patients at dose step 4 scored statistically significantly higher on physical functioning than patients at dose step 1 (p = 0.022) and compared to those at dose step 2 (p = 0.014). Patients at dose steps -2 and -1 (combined to one group) reported statistically significantly higher mean scores on cognitive functioning than patients at dose step 1 (p = 0.022).

CONCLUSION

Patients who received higher doses, based on the tailored dosing strategy, did not seem to have worse HRQoL than those who had lower doses.

'Chemobrain': concentration and memory effects in people receiving chemotherapy - a descriptive phenomenological study

There is an international literature which claims that there is a link between chemotherapeutic agents and cognitive impairment. Deficits in concentration and memory can have a major impact on decision making about education and careers, and on general quality of life. The literature to date is generally anecdotal, or reports on quantitative research that does not address patients' interpretations of impaired cognition. It was the intention of this study to capture experiences and perceptions of cognitive impairment as told by people receiving chemotherapy. A descriptive phenomenological approach was employed and four participants were interviewed twice. Analysis was conducted using Nvivo software alongside Hycner's analysis framework so that researchers could produce narratives to represent experiences for each case. The description for each case illuminates uniqueness and commonality. 'Chemobrain' is a significant and important issue for many patients but they are often unaware, prior to chemotherapy, that cognition may be affected. There is no shared understanding between patients and healthcare professionals and there is a lack of information about the phenomena which disempower patients. Healthcare professionals should develop knowledge and skills to recognise and address chemotherapy-induced cognitive impairment.

Designing conceptual model-based research in chemotherapy-related changes in cognitive function

Any well-designed biobehavioral research will begin with a comprehensive understanding and stated conceptual approach to the issue to be studied and the hypotheses to be tested. Following this conceptual orientation, the research protocol can be designed. This chapter reviews these factors to guide conceptual model-based research of chemotherapy-related changes in cognitive function.

Attitudes toward information about genetic risk for cognitive impairment after cancer chemotherapy: breast cancer survivors compared with healthy controls

PURPOSE

The trend toward personalized medicine will involve cancer treatment increasingly being tailored to the genetic characteristics of individuals. However, the availability of genetic information does not imply this information is desired or would impact treatment decision making.

METHODS

One hundred sixty breast cancer survivors (BC group) and 205 healthy controls (HC group) were randomly assigned to respond to two different clinical scenarios varying in genetic-related risk of cognitive impairment (CI; little v very likely) and severity of CI (little v moderate problem) after chemotherapy. Ratings of the importance of being told this genetic information (information importance) and the likelihood this information would affect their decision to receive chemotherapy (information impact) were obtained.

RESULTS

Results indicated the importance ascribed to genetic information was greatest when CI likelihood and severity were both high or low (P < .05). Information impact ratings were not sensitive to differences in CI likelihood or severity; the BC group was less likely to indicate genetic information would affect their decision to receive chemotherapy than the HC group (P < .001).

CONCLUSION

Results suggest lessened enthusiasm for genetic information that maintains or increases uncertainty about a specific course of action and highlight the importance of including clinically relevant groups in treatment decision-making research that employs hypothetical scenarios. Although women generally believe it is important to receive genetic information, they might benefit from assistance (eg, decision aid) in the difficult task of integrating information about survival and risk for adverse late effects from cancer treatment.

Cognitive function in postmenopausal women receiving adjuvant letrozole or tamoxifen for breast cancer in the BIG 1-98 randomized trial

Cognitive function in postmenopausal women receiving letrozole or tamoxifen as adjuvant endocrine treatment was compared during the fifth year of treatment in a substudy of the BIG 1-98 trial. In BIG 1-98 patients were randomized to receive adjuvant (A) 5-years tamoxifen, (B) 5-years letrozole, (C) 2-years tamoxifen followed by 3-years letrozole, or (D) 2-years letrozole followed by 3-years tamoxifen. The primary comparison was the difference in composite score for patients taking letrozole (B+C; N=65) vs. tamoxifen (A+D; N=55). The patients taking letrozole had better overall cognitive function than those taking tamoxifen (difference in mean composite z-scores=0.28, P=0.04, 95% CI: 0.02, 0.54, Cohen's D=0.40 indicating small to moderate effect). In this substudy, breast cancer patients taking adjuvant letrozole during the fifth year of treatment had better cognitive function than those taking tamoxifen, suggesting aromatase inhibitors do not adversely impact cognition compared with tamoxifen.

Chemo brain (chemo fog) as a potential side effect of doxorubicin administration: role of cytokine-induced, oxidative/nitrosative stress in cognitive dysfunction

Doxorubicin (ADRIAMYCIN, RUBEX) is a chemotherapeutic agent that is commonly administered to breast cancer patients in standard chemotherapy regimens. As true of all such therapeutic cytotoxic agents, it can damage normal, noncancerous cells and might affect biochemical processes in a manner that might lead to, or contribute to, chemotherapy-induced cognitive deficits when administered either alone or in combination with other agents.

Prechemotherapy alterations in brain function in women with breast cancer

Despite clinical reports of cognitive deficits associated with cancer chemotherapy, the underlying brain mechanisms are not clear. This research examined selective attention and working memory using functional magnetic resonance imaging (fMRI) in women before chemotherapy for localized breast cancer. Patients were tested with an established selective attention and working memory task during fMRI. Compared with healthy controls, patients showed (a) bilateral brain activation in high-demand task conditions with recruitment of additional components of attention/working memory circuitry, and (b) less accurate and slower task performance. Results indicate compromised cognitive functioning before any chemotherapy and raise key questions for further research.

The effects of chemotherapy on Useful Field of View (UFOV) in younger and older breast cancer patients

Chemotherapy is thought to cause cognitive deficits in some breast cancer patients, but the relative effects on older and younger breast cancer patients are unknown. The effects of chemotherapy on everyday cognitive tasks have not been examined. Thirty-eight female breast cancer survivors (3 to 45 months post chemotherapy) were compared to 55 age-matched control participants. Participants completed the Useful Field of View (UFOV), a computerized test of visual information processing that has been shown to decline with age, and which has been used to predict older adults' driving performance. Older chemotherapy patients performed more poorly than controls on the UFOV speed of processing, but not on the other two components. They also performed more poorly than younger chemotherapy patients. On the divided attention and selective attention components of the UFOV, older participants performed more poorly than younger participants, but there were no significant differences between chemotherapy patients and controls. These findings are explained in terms of brain changes thought to be caused by chemotherapy, which might have the most impact on older adults, already at risk for behavioral slowing.

Cognitive functioning in breast cancer survivors: a controlled comparison

BACKGROUND

The current study was performed to determine whether neuropsychologic functioning differs in breast cancer survivors 6 months after the completion of adjuvant treatment compared with women without cancer.

METHODS

Participants were 187 women who were diagnosed with ductal carcinoma in situ or stage I or stage II breast cancer and 187 age-matched and geographically matched women without cancer. Of the survivors, 97 had been treated after surgery with chemotherapy only or chemotherapy plus radiotherapy and 90 had been treated after surgery with radiotherapy only (grading determined according to the American Joint Committee on Cancer grading system).

RESULTS

Small but statistically significant differences in cognitive functioning and cognitive impairment were observed in those survivors who were treated with chemotherapy and their matched controls, as well as in survivors treated with radiotherapy only and their matched controls. No group differences were observed with regard to cognitive symptoms.

CONCLUSIONS

Data from the current study suggest that cognitive deficits are subtle and likely the result of the general effects of cancer diagnosis and treatment rather than systemic treatment.

Validity of the CogState brief battery: relationship to standardized tests and sensitivity to cognitive impairment in mild traumatic brain injury, schizophrenia, and AIDS dementia complex

This study examined the validity of the four standard psychological paradigms that have been operationally defined within the CogState brief computerized cognitive assessment battery. Construct validity was determined in a large group of healthy adults. CogState measures of processing speed, attention, working memory, and learning showed strong correlations with conventional neuropsychological measures of these same constructs (r's = .49 to .83). Criterion validity was determined by examining patterns of performance on the CogState tasks in groups of individuals with mild head injury, schizophrenia, and AIDS dementia complex. Each of these groups was impaired on the CogState performance measures (Cohen's d's = -.60 to -1.80) and the magnitude and nature of this impairment was qualitatively and quantitatively similar in each group. Taken together, the results suggest that the cognitive paradigms operationally defined in the CogState brief battery have acceptable construct and criterion validity in a neuropsychological context.