Chemotherapy was not associated with cognitive decline in older adults with breast and colorectal cancer: findings from a prospective cohort study

Quantifying chemotherapy-induced cognitive impairment in gastrointestinal cancer patients: A scoping review of methodological concerns in the literature

PURPOSE

Chemotherapy is one of the common treatments in cancer management. However, chemotherapy-induced cognitive impairment (CICI) is one notable side effect that can greatly impact a patient's quality of life. Literature on CICI in gastrointestinal (GI) cancers are few and inconsistent. This review aims to identify the methodological differences in such studies.

METHODS

A systematic search was performed in four electronic databases. All peer-reviewed primary literature published in English that evaluated cognitive-related functioning scores related to chemotherapy in GI cancer patients were included. Information about each study such as CICI findings, study limitations, methodology, and sample characteristics was extracted and synthesized.

RESULTS

A total of 19 studies were included. Evidence of CICI was found in 50.0% (8 of 16) and 62.5% (5 of 8) studies that used objective and subjective measures, respectively. Methodological differences such as groups used for comparison, instruments used, and assessment from the length of time since chemotherapy were highlighted between studies that did and did not find evidence of CICI.

CONCLUSIONS

This review suggests that the mixed findings can be attributed to the heterogeneous methodologies adopted in the evaluation of CICI in this field.

IMPLICATIONS FOR CANCER SURVIVORS

Further studies are necessary to establish the presence and chronicity of CICI, and in which groups of patients to facilitate targeted interventions and treatments.

A Systematic Review on the Potential Acceleration of Neurocognitive Aging in Older Cancer Survivors

As survival rates increase, more emphasis has gone to possible cognitive sequelae in older cancer patients, which could be explained by accelerated brain aging. In this review, we provide a complete overview of studies investigating neuroimaging, neurocognitive, and neurodegenerative disorders in older cancer survivors (>65 years), based on three databases (Pubmed, Web of Science and Medline). Ninety-six studies were included. Evidence was found for functional and structural brain changes (frontal regions, basal ganglia, gray and white matter), compared to healthy controls. Cognitive decline was mainly found in memory functioning. Anti-hormonal treatments were repeatedly associated with cognitive decline (tamoxifen) and sometimes with an increased risk of Alzheimer's disease (androgen deprivation therapy). Chemotherapy was inconsistently associated with later development of cognitive changes or dementia. Radiotherapy was not associated with cognition in patients with non-central nervous system cancer but can play a role in patients with central nervous system cancer, while neurosurgery seemed to improve their cognition in the short-term. Individual risk factors included cancer subtypes (e.g., brain cancer, hormone-related cancers), treatment (e.g., anti-hormonal therapy, chemotherapy, cranial radiation), genetic predisposition (e.g., APOE, COMT, BDNF), age, comorbidities (e.g., frailty, cognitive reserve), and psychological (e.g., depression, (post-traumatic) distress, sleep, fatigue) and social factors (e.g., loneliness, limited caregiver support, low SES). More research on accelerated aging is required to guide intervention studies.

Risk of Dementia in Cancer Survivors: A Meta-Analysis of Population-Based Cohort Studies

Background: A negative association between cancer and Alzheimer’s disease (AD) was revealed. Objective: We aimed to further explore the dementia risk among cancer survivors and then among cancer survivors who received cancer treatment in subsequent subgroup analyses. Methods: Databases of PubMed, Embase, and Cochrane Library were systematically searched from inception to April 1, 2021, following PRISMA and MOOSE guidelines. Relative risks (RR) of dementia were pooled by a random-effects model stratifying the data by potential confounding factors to explore the heterogeneity. This study is registered with PROSPERO, number CRD42021250654. Results: A total of 36 studies were included in this meta-analysis, of which 16 studies were about the risk of dementia in cancer survivors, and 20 studies were about the risk of dementia in survivors who accepted cancer treatment. The pooled RR reached 0.89 ([95% CI = 0.82–0.97], I2 = 97.9%) for dementia and 0.89 ([0.83–0.95], I2 = 92.6%) for AD in cancer survivors compared with non-cancer controls. Notably, both dementia risk and AD risk significantly decreased in survivors of colon, leukemia, small intestine, and thyroid cancers (RR ranged from 0.64 to 0.92). Furthermore, prostate cancer patients treated with androgen deprivation therapy exhibited a significantly increased risk of dementia (RR:1.18 [1.09–1.27], I2 = 89.5%) and AD (RR:1.17 [1.08–1.25], I2 = 81.3%), with evidence of between-study heterogeneity. Conclusion: Currently, available evidence suggests that the risk of dementia among cancer survivors is decreased. However, large-scale prospective cohort studies are warranted to further prove the association.

Investigating Relationship between Pre- and Post- Chemotherapy Cognitive Performance with Levels of Depression and Anxiety in Breast Cancer Patients: A Cross-Sectional Study

INTRODUCTION

Evidence suggests that cancer and chemotherapy-related cognitive impairments are an important clinical issue that can have a negative impact on the quality of life (QOL) of many cancer patients during and after treatment. The aim of the current study was to investigate the relationship between cognitive performance before and after chemotherapy with levels of depression and anxiety in patients with breast cancer.

MATERIALS AND METHODS

This cross-sectional descriptive-analytical study was performed on 100 women with breast cancer in south of Iran. Patients included in the study were evaluated for cognitive performance before chemotherapy and 1, 3, and 6 months after chemotherapy. Patients' cognitive performance was assessed by Mini-Mental State Examination (MMSE). Patients were also assessed for their level of anxiety and depression using Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Descriptive tests (percentage, frequency and mean) and ANOVA test used for statistical analysis.

RESULTS

Results of ANOVA test showed a significant difference between the cognitive performance of patients with breast cancer at 1, 3, and 6 months after chemotherapy compared to pre- chemotherapy phase. The above test also revealed a significant relationship between cognitive performance of patients and anxiety and depression.

CONCLUSION

The results showed that, due to the decrease in cognitive performance and increased anxiety and depression after initiation of chemotherapy in patients with breast cancer, it is necessary to closely monitor the mental and psychological status of these patients by their family and the treatment staffs so that the patient be able to cope with the disease more optimally and to recover.

Cancer-related cognitive impairment: an update on state of the art, detection, and management strategies in cancer survivors

BACKGROUND

Advances in diagnostic and therapeutic strategies in oncology have significantly increased the chance of survival of cancer patients, even those with metastatic disease. However, cancer-related cognitive impairment (CRCI) is frequently reported in patients treated for non-central nervous system cancers, particularly during and after chemotherapy.

DESIGN

This review provides an update of the state of the art based on PubMed searches between 2012 and March 2019 on 'cognition', 'cancer', 'antineoplastic agents' or 'chemotherapy'. It includes the most recent clinical, imaging and pre-clinical data and reports management strategies of CRCI.

RESULTS

Evidence obtained primarily from studies on breast cancer patients highlight memory, processing speed, attention and executive functions as the most cognitive domains impaired post-chemotherapy. Recent investigations established that other cancer treatments, such as hormone therapies and targeted therapies, can also induce cognitive deficits. Knowledge regarding predisposing factors, biological markers or brain functions associated with CRCI has improved. Factors such as age and genetic polymorphisms of apolipoprotein E, catechol-O-methyltransferase and BDNF may predispose individuals to a higher risk of cognitive impairment. Poor performance on neuropsychological tests were associated with volume reduction in grey matter, less connectivity and activation after chemotherapy. In animals, hippocampus-based memory and executive functions, mediated by the frontal lobes, were shown to be particularly susceptible to the effects of chemotherapy. It involves altered neurogenesis, mitochondrial dysfunction or brain cytokine response. An important next step is to identify strategies for managing cognitive difficulties, with primary studies to assess cognitive training and physical exercise regimens.

CONCLUSIONS

CRCI is not limited to chemotherapy. A multidisciplinary approach has improved our knowledge of the complex mechanisms involved. Nowadays, studies evaluating cognitive rehabilitation programmes are encouraged to help patients cope with cognitive difficulties and improve quality of life during and after cancer.

Depression involved in self-reported prospective memory problems in survivors of breast cancer who have received chemotherapy

To investigate the relationship between depression and the self-reported prospective memory (SPM) problems in breast cancer survivors who have received chemotherapy.Sixty-three breast cancer patients were administered with self-rating depression scale (SDS) and the prospective memory questionnaire as part of extensive neuropsychological assessments before and after chemotherapy. The performance of SDS and SPM were compared, with the level of significance set at P < .05.Compared with the group before chemotherapy, there is a significant difference on the SPM score (t = 6.069, P = .000) in breast cancer patients after chemotherapy. Further, there is also a significant difference on the SPM score (t = -4.348, P = .000) between the patients with and without depression group after chemotherapy.The present result indicated that the depression in breast cancer survivors after chemotherapy may be involved in their chemotherapy-induced SPM impairment.

Is Cancer a Risk Factor for Cognitive Decline in Late Life?

With advances in screening and early detection, coupled with improved treatment and care, the number of cancer survivors has risen exponentially over the past several decades. Moreover, because age is the most significant risk factor for cancer, the majority of cancer survivors are over 65 years of age. Finally, cancer survivors often experience significant health issues for many years after the treatment has subsided. In the current article, we describe select research that has focused on changes to cognitive performance associated with cancer and its treatment, i.e., alterations that have been colloquially referred to as chemobrain. Although understanding changes in cognitive performance following cancer treatment is an active area of inquiry, the experience of older adult cancer survivors has been somewhat neglected. For example, evidence is mixed as to whether changes in cognitive performance associated with normal aging are exacerbated by cancer survivorship status. It is also unclear whether a history of cancer makes it more or less likely that a person will be diagnosed with dementia or Alzheimer's disease in the future. Finally, we identify a number of areas where existing cognitive aging research can inform studies on cognitive performance following cancer treatment. Future efforts should be directed towards designing studies that focus on the experience of older adult cancer survivors and are informed by the clinical oncology and cognitive aging literature.

Cognition in breast cancer survivors: hormones versus depression

BACKGROUND

OBJECTIVE

Breast cancer survivors receiving hormone treatment and/or endorsing histories of receiving chemotherapy report changes in their cognitive capacity, which is often not supported by formal testing. To address these conflicting reports, this study examined survivors' applied cognitive capacity and its association with hormone treatment, depression, and selected demographics.

METHODS

A descriptive, correlational, cross-sectional survey design was employed. There were 357 women who completed a survey comprised of 69 questions. The survey included both investigator-developed questions and instruments from the PROMIS(®) system.

RESULTS

There were significant main effects for hormone therapy, race, and depression. Depression explained the largest portion of variance of the perceived decreases in cognitive function among breast cancer survivors.

CONCLUSIONS

Survivor complaints of changes in cognitive function may be a predictor for evaluating the presence of mood disorders and less a function of hormone therapy or chemotherapy history.

Cognitive impairment in older patients with breast cancer before systemic therapy: is there an interaction between cancer and comorbidity?

PURPOSE

To determine if older patients with breast cancer have cognitive impairment before systemic therapy.

PATIENTS AND METHODS

Participants were patients with newly diagnosed nonmetastatic breast cancer and matched friend or community controls age > 60 years without prior systemic treatment, dementia, or neurologic disease. Participants completed surveys and a 55-minute battery of 17 neuropsychological tests. Biospecimens were obtained for APOE genotyping, and clinical data were abstracted. Neuropsychological test scores were standardized using control means and standard deviations (SDs) and grouped into five domain z scores. Cognitive impairment was defined as any domain z score two SDs below or ≥ two z scores 1.5 SDs below the control mean. Multivariable analyses evaluated pretreatment differences considering age, race, education, and site; comparisons between patient cases also controlled for surgery.

RESULTS

The 164 patient cases and 182 controls had similar neuropsychological domain scores. However, among patient cases, those with stage II to III cancers had lower executive function compared with those with stage 0 to I disease, after adjustment (P = .05). The odds of impairment were significantly higher among older, nonwhite, less educated women and those with greater comorbidity, after adjustment. Patient case or control status, anxiety, depression, fatigue, and surgery were not associated with impairment. However, there was an interaction between comorbidity and patient case or control status; comorbidity was strongly associated with impairment among patient cases (adjusted odds ratio, 8.77; 95% CI, 2.06 to 37.4; P = .003) but not among controls (P = .97). Only diabetes and cardiovascular disease were associated with impairment among patient cases.

CONCLUSION

There were no overall differences between patients with breast cancer and controls before systemic treatment, but there may be pretreatment cognitive impairment within subgroups of patient cases with greater tumor or comorbidity burden.

Intra-individual variability in women with breast cancer

Studies assessing cognitive functioning in women treated for breast cancer have used primarily standardized neuropsychological tests and examined accuracy and/or reaction time as outcome measures: they have been inconsistent in identifying the cognitive domains affected and the severity of deficits. In other contexts of neural development and disorders, measures of Intra-individual variability (IIV) have proven useful in identifying subtleties in performance deficits that are not captured by measures of central tendency. This article presents proof of concept that assessing IIV may also increase understanding of the cognitive effects of cancer treatment. We analyzed mean accuracy and reaction time, as well as IIV from 65 women with breast cancer and 28 age and education matched controls who performed the Conner's Continuous Performance Test, a "Go-NoGo" task. Although there were no significant differences between groups using measures of central tendency, there was a group × inter-stimulus interval (ISI) interaction for IIV Dispersion (p < .001). Patient Dispersion was more variable at shorter ISI than controls and less variable at long ISI, suggesting greater sensitivity to presentation speed. Interpretation of IIV differences requires further investigation. Our results suggest that future studies would benefit from designs that allow analysis of IIV measures in studies assessing cognition in cancer survivors.

Self-Reported History of Chemotherapy and Cognitive Decline in Adults Aged 60 and Older: The PATH Through Life Project

BACKGROUND

There is a lack of data from cohort studies assessing cognitive function prior to and after chemotherapy. We evaluated the effect of self-reported cancer chemotherapy on cognitive function in a cohort assessed at baseline, 4 and 8 years.

METHODS

Participants were from the population-based PATH Through Life Study. Of the 2,551 participants aged 60-64 at baseline without cognitive impairment, 1,949 completed wave 3 and had data on cancer and chemotherapy and cognitive function. Linear mixed models were used to analyze the data.

RESULTS

At wave 3, participants reporting history of chemotherapy (n = 76) had lower scores on memory, processing speed, and executive function compared with those reporting cancer without chemotherapy (n = 289) and no cancer history (n = 1508). After adjustment for depression and disability, effects remained for processing speed and memory. Chemotherapy prior to the study commencement (n = 24), but not between waves 1 and 3 (n = 81), was associated with greater decline in delayed recall (β = -.21 [95% CI -0.38, -.03], p = .02) and digits backwards β = -.05 [95% CI -0.09, -.01], p = .02) over 8 years compared with those with no cancer history (n = 1562). Women reporting chemotherapy for breast cancer after wave 1 (n = 26) had slower choice reaction time (-0.81 (95% CI -1.28, -0.34), p = .001) but did not decline faster on this measure compared with those reporting no breast cancer history (n = 818).

CONCLUSIONS

Results suggest chemotherapy prior to old age is associated with faster decline in memory in late life but that it does not affect decline in other domains of cognitive function.

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.

A Chinese herbal formula, Yi-Qi-Fu-Sheng, inhibits migration/invasion of colorectal cancer by down-regulating MMP-2/9 via inhibiting the activation of ERK/MAPK signaling pathways

Background

A Chinese herbal formula, Yi-Qi-Fu-Sheng (YQFS), has long been employed clinically to treat cancer patients. We aimed to determine its effectiveness as a treatment method for colorectal cancer. We investigated the therapeutic effects of YQFS on colorectal cancer, as well as the underlying mechanisms, which have not previously been explored.

Methods

First, YQFS was extracted and chemically characterized. We then tested the effects of YQFS on proliferation and migration by MTT and transwell migration assays in vitro. Mouse xenograft models of colorectal cancer were established by inoculation with HCT-116 cells, and mice received one of three oral doses (200, 400 and 800 mg/kg/day) to evaluate the effects of YQFS extract. Metalloproteinase-2/9 (MMP-2/9) expression in mice was evaluated by gelatin zymography assay. Apoptosis was evaluated by flow cytometry (FCM) analysis in vitro and by TUNEL assay in vivo. ERK and p-ERK expression were evaluated by western blot analysis at the protein level in vitro, and by quantitative RT-PCR at mRNA level in vivo.

Results

Our results show that YQFS significantly inhibits colorectal cancer cell proliferation and induces apoptosis and cell cycle arrest at the G₁₋ and S-phase in HCT-116 cells. Furthermore, YQFS effectively retards tumor cell migration and invasion by inhibiting metalloproteinase-2/9 (MMP-2/9) expression, both in vitro and in vivo. Moreover, YQFS had an inhibitory effect on tumor growth in vivo, and induced apoptosis through the inhibition of the ERK1/2 pathway both in vitro and in vivo.

Conclusion

These findings demonstrate that YQFS extract has an anti-tumor effect in colorectal cancer, which could be attributed to ERK1/2-dependent inhibition of MMP-2/9 expression.