Measurement, outcomes and interventions of cognitive function after breast cancer treatment: A narrative review

Subjective and Objective Cancer-Related Cognitive Impairments Among Systemic and Radiation Therapy-Naïve Female Cancer Patients

BACKGROUND

Cancer-related cognitive impairment (CRCI) is a frequent and burdensome problem that is still insufficiently understood and managed. We investigated subjective and objective measures of CRCI, as recommended by the International Cancer and Cognition Task Force (ICCTF) in cancer patients prior to systemic or radiation therapy with respect to potential influencing or associated psychosocial, demographic, or lifestyle factors.

METHODS

Female patients with breast or gynecological tumors (n = 239, mean age = 55.5, SD = 11.6) prior to any systemic or radiation therapy completed validated subjective (FACT-Cog: perceived cognitive impairment [PCI], perceived cognitive ability [PCA], impact on quality of life [IQoL]) and objective measures of CRCI (Trail Making Test [TMT-A and -B], Controlled Oral Word Association Test [COWA], and Hopkins Verbal Learning Test-Revised [HVLT-R]). Association with cross-sectionally assessed age, body mass index, education, smoking, alcohol intake, sleep problems, social support, anxiety, and pain was investigated using multiple linear regression models.

RESULTS

A quarter (25.1%) of patients showed indication for CRCI based on the PCI score. Subjective and objective CRCI measures showed no or only weak correlations, also when adjusting for age and education (partial Spearman correlations with each other, all |r| ≤ 0.21). Anxiety, sleep problems, and pain were significantly associated with low subjective cognitive function (PCI, PCA, and IQoL). Poor objective cognitive values (TMT, COWA, and HVLT-R) were mainly determined by higher age and lower education.

CONCLUSIONS

Cancer-related cognitive impairment is not solely (chemo-)therapy-induced but may be triggered or influenced by anxiety, sleep problems, and pain. Addressing these issues early in the treatment phase could potentially alleviate perceived CRCI. The ICCTF-recommended neuropsychological tests do not adequately capture this CRCI prior to systemic or radiation therapy, but could serve as complementary tools to monitor cognitive changes over time, independent of psychosocial influences.

Longitudinal study of cognitive and mental functions among adult Hodgkin-lymphoma survivors, based on data from a primary treatment center in Hungary

Introduction

Due to risk and response-adapted treatment strategies, more than 80% of newly diagnosed adult classical Hodgkin lymphoma (HL) patients at any stage can be cured and become long-term survivors. A well-known side effect is cognitive dysfunction that appears in HL patients after chemotherapy (chemobrain). In the present longitudinal study, we measured cognitive function in our HL patients, in search of potential correlations between patient-related factors, the signs and symptoms of their diseases, and therapeutic factors.

Methods

Patients underwent a computer-assisted assessment (CANTAB) of cognitive function (especially domains of visual memory, attention, working memory, and planning) and filled out psychological questionnaires (standardized, self-administered and validated for Hungarian language) before treatment (n=30, T1) and after the first-line treatment (n=25, T2), and 8.6 years after the end of chemotherapy (n=19, T3).

Results

The median age of 16 females and 14 males was 35 years (20-69), 35 years (21-63) after chemotherapy, and 43 years (29-70) at the end of the long-term follow-up, when the study was completed. 77% of all patients showed cognitive impairment before treatment. A close correlation was found between attention and unfavorable prognostic factors (III-IV. stage, age, bulky) baseline comorbidities (T2DM, psoriasis, HTN) and place of residence. Visual memory was affected by comorbidities and the place of residence. Working memory and planning was influenced by single marital status, and bulk disease. Post-treatment cognitive impairment was evaluated in 77% of the HL patients. In the working memory and planning domain, the Stockings of Cambridge (SOC) subtest significantly improved after treatment, while visual memory and attention remained unchanged. The cumulative dose of bleomycin associated with SOC.

Conclusion

The study highlights the fact that cognitive functions of HL patients were already impaired before treatment, especially attention, working memory, and planning. Long-term improvement in cognitive function was observed post-treatment. Employment status, place of residence and unfavorable prognosis have an impact on cognitive domains. Early diagnosis and intervention are essential to maintain patients' quality of life throughout and after treatment.

Factors associated with perceived cognitive function in breast cancer patients treated with chemotherapy: A multicenter cross-sectional study

PURPOSE

This study aimed to investigate the factors associated with perceived cognitive function among breast cancer patients treated with chemotherapy in China.

METHODS

The study was a multicenter cross-sectional design. Data were collected from 10 public hospitals in China between April 2022 and February 2023. A total of 741 participants completed questionnaires assessing sociodemographic and medical characteristics, perceived cognitive function, sleep quality, fatigue, anxiety, and depression. Hierarchical multiple regression analysis was used to assess the determinants of cognitive function.

RESULTS

The hierarchical multiple regression model accounted for 31.5% of variation in perceived cognitive function (sociodemographic 4.5%; medical 6.6%; exercise frequency 6.6%; sleep quality 2.1%; fatigue 2.8%; anxiety combined with depression 9.0%). Education level, chemotherapy type, number of chemotherapy cycles, and cyclophosphamide drug use were significant predisposing factors of perceived cognitive function (p < 0.001). Exercising ≥3 times/week (p < 0.001) was a significant factor positively influencing perceived cognitive function, meanwhile, anxiety (p < 0.001) and depression (p < 0 0.001) were negative factors.

CONCLUSION

Our findings suggest that patients with low education levels, postoperative chemotherapy, cyclophosphamide treatment, and a greater number of chemotherapy cycles need more assessment. Sedentary patients, those who have never exercised, and those with anxiety or depression all showed greater cognitive decline. By identifying susceptible populations, encouraging regular exercise, and addressing anxiety and depression, healthcare professionals can contribute significantly to prevent patients' cognitive decline throughout chemotherapy.

Association between Cognitive Function and Physical Function, Frailty, and Quality of Life in Older Breast Cancer Survivors

BACKGROUND

Older cancer survivors in general are at greater risk for cancer-related cognitive impairment (CRCI), yet few studies have explored its association with health outcomes. This study examined the association between subjective and objective measures of cognitive function and physical function, frailty, and quality of life (QoL) among older breast cancer survivors.

MATERIALS AND METHODS

Older breast cancer survivors who reported cognitive concerns completed surveys on patient-reported cognitive function, physical function, frailty, and QoL as well as objective tests of visuospatial working memory and sustained attention. Data were analyzed using descriptive statistics and separate linear regression models.

RESULTS

A total of 219 female breast cancer survivors completed the study. Perceived cognitive abilities were associated with better physical function, frailty, and QoL (p ≤ 0.001) while cognitive concerns were negatively related with these metrics (p ≤ 0.001). Poorer visuospatial working memory and sustained attention were linked to increased frailty (p ≤ 0.001-0.01), whereas poorer sustained attention was associated with poorer physical function (p < 0.01).

CONCLUSIONS

Older breast cancer survivors with perceived cognitive impairment and poorer cognitive performance reported poorer physical functioning, increased frailty, and poorer QoL. These findings underscore the importance of assessing cognitive concerns and their associated outcomes in older breast cancer survivors.

Impact of Short-Term Creatine Supplementation on Muscular Performance among Breast Cancer Survivors

Breast cancer (BC) is one of the most common cancers in the United States. Advances in detection and treatment have resulted in an increased survival rate, meaning an increasing population experiencing declines in muscle mass and strength. Creatine supplementation has consistently demonstrated improvements in strength and muscle performance in older adults, though these findings have not been extended to cancer populations.

PURPOSE

The purpose of this study was to investigate the effects of short-term creatine supplementation on muscular performance in BC survivors.

METHODS

Using a double-blind, placebo-controlled, randomized design, 19 female BC survivors (mean ± SD age = 57.63 ± 10.77 years) were assigned to creatine (SUPP) (n = 9) or dextrose placebo (PLA) (n = 10) groups. The participants completed two familiarization sessions, then two test sessions, each separated by 7 days, where the participants supplemented with 5 g of SUPP or PLA 4 times/day between sessions. The testing sessions included sit-to-stand power, isometric/isokinetic peak torque, and upper/lower body strength via 10 repetition maximum (10RM) tests. The interaction between supplement (SUPP vs. PLA) and time (Pre vs. Post) was examined using a group × time ANOVA and effect sizes.

RESULTS

No significant effects were observed for sit-to-stand power (p = 0.471; ηp2 = 0.031), peak torque at 60°/second (p = 0.533; ηp2 = 0.023), peak torque at 120°/second (p = 0.944; ηp2 < 0.001), isometric peak torque (p = 0.905; ηp2 < 0.001), 10RM chest press (p = 0.407; ηp2 = 0.041), and 10RM leg extension (p = 0.932; ηp2 < 0.001). However, a large effect size for time occurred for the 10RM chest press (ηp2 = 0.531) and leg extension (ηp2 = 0.422).

CONCLUSION

Seven days of creatine supplementation does not influence muscular performance among BC survivors.

Construction and validation of a risk-prediction model for chemotherapy-related cognitive impairment in patients with breast cancer

PURPOSE

To identify risk factors of chemotherapy-related cognitive impairment (CRCI) and construct and validate a visual prediction model of such for patients with breast cancer.

METHODS

A multicenter, descriptive, and cross-sectional design was adopted. Data were collected from ten public tertiary hospitals in China. Cognitive function was assessed by using Functional Assessment of Cancer Therapy-cognitive function. Socio-demographic, clinical, psychological, and physical indicators were also assessed. The logistic prediction model was constructed by fivefold cross-validation. Then, a nomogram was utilized to visualize the prediction model, which was also evaluated via discrimination, calibration, and decision curve analysis.

RESULTS

A total of 71 breast cancer patients had CRCI with a prevalence of 9.58%. This visual prediction model was constructed based on education background, exercise frequency, chemotherapy times, and fatigue and demonstrated good discrimination, with an area under the receiver operating characteristic curve of 0.882. The calibration curve indicated good agreement between experimental and projected values, and the decision curve proved good clinical applicability.

CONCLUSION

Education background, exercise frequency, chemotherapy times, and fatigue were associated with high incidence of CRCI. The prediction model exhibits superior performance and has promise as a useful instrument for assessing the likelihood of CRCI in breast cancer patients.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings could provide breast cancer survivors with risk screening based on CRCI predictors to implement prevention and early intervention, and help patients integrate into society and achieve comprehensive recovery.

A Clinically Relevant Dosage of Mitoxantrone Disrupts the Glutathione and Lipid Metabolic Pathways of the CD-1 Mice Brain: A Metabolomics Study

Long-term cognitive dysfunction, or "chemobrain", has been observed in cancer patients treated with chemotherapy. Mitoxantrone (MTX) is a topoisomerase II inhibitor that binds and intercalates with DNA, being used in the treatment of several cancers and multiple sclerosis. Although MTX can induce chemobrain, its neurotoxic mechanisms are poorly studied. This work aimed to identify the adverse outcome pathways (AOPs) activated in the brain upon the use of a clinically relevant cumulative dose of MTX. Three-month-old male CD-1 mice were given a biweekly intraperitoneal administration of MTX over the course of three weeks until reaching a total cumulative dose of 6 mg/kg. Controls were given sterile saline in the same schedule. Two weeks after the last administration, the mice were euthanized and their brains removed. The left brain hemisphere was used for targeted profiling of the metabolism of glutathione and the right hemisphere for an untargeted metabolomics approach. The obtained results revealed that MTX treatment reduced the availability of cysteine (Cys), cysteinylglycine (CysGly), and reduced glutathione (GSH) suggesting that MTX disrupts glutathione metabolism. The untargeted approach revealed metabolic circuits of phosphatidylethanolamine, catecholamines, unsaturated fatty acids biosynthesis, and glycerolipids as relevant players in AOPs of MTX in our in vivo model. As far as we know, our study was the first to perform such a broad profiling study on pathways that could put patients given MTX at risk of cognitive deficits.

Distinct Cognitive Function Profiles Are Associated With a Higher Presurgery Symptom Burden in Patients With Breast Cancer

BACKGROUND

Cancer-related cognitive impairment (CRCI) is a common symptom in patients with breast cancer. In our previous study of 397 women with breast cancer, we identified 3 groups of patients with distinct CRCI profiles (ie, high, moderate, and low-moderate attentional function). Compared with the other 2 classes, the low-moderate class was younger, had more comorbidities, and with lower functional status.

OBJECTIVES

In this study, we expand on this work and evaluate for differences among these latent classes in the severity of psychological (depression and anxiety) and physical (fatigue, decrements in energy, sleep disturbance, and pain) symptoms before surgery.

METHODS

Cancer-related cognitive impairment was assessed using the Attentional Functional Index from before through 6 months after surgery. Lower Attentional Functional Index scores indicate higher levels of CRCI. Psychological and physical symptoms were assessed with valid instruments. Parametric and nonparametric tests were used to evaluate for differences in symptom severity scores among the latent classes.

RESULTS

Approximately 60% of patients experienced CRCI (ie, moderate and low-moderate classes). Significant differences were found among the 3 classes in the severity of trait and state anxiety, depressive symptoms, fatigue, and sleep disturbance (ie, high < moderate < low-moderate). In addition, compared with the other 2 classes, the low-moderate class reported higher pain interference scores.

CONCLUSIONS

These findings suggest that women with clinically meaningful levels of persistent CRCI have a relatively high symptom burden before surgery.

IMPLICATIONS FOR PRACTICE

Clinicians need to routinely perform preoperative assessments of CRCI and associated symptoms and initiate therapeutic interventions.

Effectiveness of the Unified Barlow Protocol (UP) and neuropsychological treatment in cancer survivors for cognitive impairments: study protocol for a randomized controlled trial

Background

Cancer survivors frequently develop cognitive impairment, which negatively affects their quality of life and emotional well-being. This study compares the effectiveness of a well-established treatment (neuropsychological treatment) with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) to reduce these cognitive deficits and evaluate the effect of both treatments on anxiety-depressive symptoms and the quality of life of cancer survivors.

Methods

A three-arm, randomized superiority clinical trial with a pre-post and repeated follow-up measures intergroup design using a 1:1:1 allocation ratio will be performed. One hundred and twenty-three cancer survivors with mild to moderate cognitive impairment will be randomly assigned to one of the study interventions: a cognitive rehabilitation intervention group, an intervention group with UP intervention, or a control group on the waiting list. The primary outcome is to observe a significant improvement in cognitive function in both intervention groups and a significant decrease in emotional impairments in comparison with the waitlist group. Improvements in anxiety, depression, and quality of life are also expected as secondary outcomes. These results will be maintained at 6 months of follow-up.

Discussion

The aim of this trial is to test the efficacy of the UP intervention in reducing cognitive deficits in breast cancer survivors. The results of this trial may be useful in reducing the presence of cognitive problems in cancer survivors and improving their emotional state and quality of life.

Trial registration

ClinicalTrials.gov NCT05289258. Registered 12 March 2022, v01.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06731-w.

Actual, Personalized Approaches to Preserve Cognitive Functions in Brain Metastases Breast Cancer Patients

Breast cancer (BC) is the most often diagnosed cancer among women worldwide and second most common cause of brain metastases (BMs) among solid malignancies being responsible for 10-16% of all BMs in oncological patients. Moreover, BMs are associated with worse prognosis than systemic metastases. The quality of life (QoL) among brain metastases breast cancer (BMBC) patients is significantly influenced by cognitive functions. Cancer-related cognitive deficits and the underlying neural deficits in BMBC patients can be caused via BMs per se, chemotherapy administration, brain irradiation, postmenopausal status, or comorbidities. Brain RT often leads to cognitive function impairment by damage of neural progenitor cells of the hippocampus and hence decreased QoL. Sparing the hippocampal region of the brain during RT provides protective covering of the centrally located hippocampi according to the patient's clinical requirements. This article discusses the personalized strategies for treatment options to protect cognitive functions in BMBC patients, with special emphasis on the innovative techniques of radiation therapy.

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

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

Effects of Baduanjin exercise on cognitive function and cancer-related symptoms in women with breast cancer receiving chemotherapy: a randomized controlled trial

PURPOSE

Cognitive decline is one of the main side effects of breast cancer patients after relevant treatment, but there is a lack of clear measures for prevention and management without definite mechanism. Moreover, postoperative patients also have a need for limb rehabilitation. Whether the cognitive benefits of Baduanjin exercise can improve the overall well-being of breast cancer patients remains unknown.

METHODS

This randomized controlled trial was conducted on 70 patients with breast cancer receiving chemotherapy who were randomly assigned and allocated to (1:1) a supervised Baduanjin intervention group (5 times/week, 30 min each time) or a control group for 3 months. The effects of Baduanjin exercise intervention were evaluated by outcome measures including subjective cognitive function, symptoms (fatigue, depression, and anxiety), and health-related quality of life at pre-intervention (T0), 4 weeks (T1), 8 weeks (T2), and 12 weeks (T3). The collected data were analyzed by using an intention-to-treat principle and linear mixed-effects modeling.

RESULTS

Participants in the Baduanjin intervention group had a significantly greater improvement in terms of FACT-Cog (F = 14.511; p < 0.001), PCI (F = 15.789; p < 0.001), PCA (F = 6.261; p = 0.015), and FACT-B scores (F = 8.900; p = 0.004) compared with the control group over the time. The exercise-cognition relationship was significantly mediated through the reduction of fatigue (indirect effect: β = 0.132; 95% CI 0.046 to 0.237) and the improvement of anxiety (indirect effect: β =  - 0.075; 95% CI - 0.165 to -0.004).

CONCLUSIONS

This pilot study revealed the benefits of Baduanjin exercise for subjective cognition and health-related quality of life of Chinese breast cancer patients receiving chemotherapy and outlined the underlying mediating mechanism of exercise-cognition. The findings provided insights into the development of public health initiatives to promote brain health and improve quality of life among breast cancer patients.

TRIAL REGISTRATION NUMBER

ChiCTR 2,000,033,152.

Changes and Influencing Factors of Cognitive Impairment in Patients with Breast Cancer

OBJECTIVE

To investigate the changes in cognitive function and its influencing factors in patients with breast cancer after chemotherapy, to provide a scientific basis for further cognitive correction therapy.

METHODS

In this study, general information on age, marital status, and chemotherapy regimen was collected from 172 breast cancer chemotherapy patients. 172 patients with breast cancer undergoing chemotherapy were investigated by convenience sampling method, and the subjects were tested one-on-one using the Chinese version of the MATRICS Consensus Cognitive Battery (MCCB) computer system.

RESULTS

The mean value of standardized t-value of cognitive function and its abnormal dimensions in breast cancer patients undergoing chemotherapy were MCCB total cognition (66.3%, 36.99 ± 13.06, abnormal), working memory (73.3%, 36.84 ± 10.25), attention and alertness (70.3%, 37.20 ± 12.50), social cognition (65.1%, 39.54 ± 10.17), and visual memory (61.6%, 42.19 ± 9.38). A comparison of cognitive function among breast cancer chemotherapy patients with different demographic characteristics showed that differences in place of residence, educational level, monthly income, timing of chemotherapy, chemotherapy regimen, and chemotherapy times may be associated with abnormal cognitive function. Further multiple linear regression analysis was performed and the results showed that there was a linear regression between literacy, number of chemotherapy sessions, monthly personal income, and cognitive function.

CONCLUSION

Cognitive impairment is common in patients with breast cancer after chemotherapy. Nurses should pay attention to the cognitive function changes and intervention of patients with breast cancer after chemotherapy, to prevent the changes of cognitive function and promote the rehabilitation of patients.