Monitoring neurocognitive functioning in childhood cancer survivors: evaluation of CogState computerized assessment and the Behavior Rating Inventory of Executive Function (BRIEF)

Baseline Neurocognitive Functioning Among Children Treated for Acute Lymphoblastic Leukemia (ALL): Dana Farber Cancer Institute ALL Consortium Study 16-001

BACKGROUND

This study describes neurocognitive functioning during the first month of induction chemotherapy for childhood acute lymphoblastic leukemia (ALL) and associations with age, sex, risk of relapse, maternal education, household material hardship (HMH), and oxidative stress.

METHODS

Patients treated on protocol 16-001 (NCT03020030) across eight North American sites (2017-2022) consented for optional testing using Cogstate at six timepoints throughout treatment. The baseline data presented were collected within the first month after diagnosis.

RESULTS

Among 406 eligible patients, 330 (81%) consented (53% males, mean age = 8.8 years, SD = 4.7). Over 63% of participants performed within normal limits for their age range. Additionally, no relationship was observed at baseline between neurocognition and maternal education, HMH, or oxidative stress. In contrast, a linear relationship was observed between older age and weaker psychomotor speed (p < 0.0001), attention (p < 0.0001), and working memory (p = 0.019). Males also demonstrated faster psychomotor speed (p = 0.0027), while females demonstrated stronger visual learning (p = 0.011). Furthermore, having a higher risk of relapse was associated with slower psychomotor speed (p = 0.006) and weaker attention (p = 0.033).

CONCLUSIONS

Our findings indicate that most ALL patients in this study who were assessed at baseline did not display cognitive impairments, except for a small subset of participants who were below age expectations across domains. These baseline findings also identify subgroups based upon age, sex, and ALL risk classification that begin medical treatment with neurocognitive delays, warranting monitoring to elucidate whether exposure to therapy further impacts these domains. Additionally, the lack of impact on neurocognitive functioning at baseline of maternal education, HMH, and/or oxidative stress enables subsequent assessments to effectively identify the potential emergence of deficits as a result of exposure to medical treatment.

The impact of academic pressure on mathematical academic achievement in middle school students: A perspective based on mediation effects

OBJECTIVE

This study explores how academic pressure affects middle school students' mathematical academic achievement, focusing on the mediating roles of academic self-concept and academic engagement.

RESULTS

A survey of 454 students from two schools in Yunnan province collected data on academic pressure, self-concept, engagement, and achievement. Mediation analysis was performed using Model 6 in the SPSS PROCESS macro. Results showed a significant negative correlation between academic pressure and mathematical academic achievement. Academic self-concept partially mediated this relationship, while a chain mediation effect involving both academic self-concept and engagement was also found. These findings suggest that reducing academic pressure, while strengthening students' academic self-concept and engagement, can improve mathematical academic achievement.

CONCLUSIONS

The study provides empirical support for educational strategies aimed at enhancing students' academic performance in mathematics.

Feasibility of Utilizing a Brief Neurocognitive Battery in 3-Year-Old Patients During Treatment for Acute Lymphoblastic Leukemia

Treatment of acute lymphoblastic leukemia (ALL) is associated with neurocognitive deficits in young children. While computerized measures have been utilized in pediatric oncology research, they exclude patients below the age of 4 years. Patients enrolled on "Treatment of Newly Diagnosed Acute Lymphoblastic Leukemia in Children and Adolescents" were offered participation in an optional neurocognitive study. Three-year old patients did not differ from 4-year-old patients in their ability to perform or complete the tests. Including patients diagnosed at age 3 will serve to improve our understanding of at-risk patients and their neurocognitive trajectory both during and after treatment.

Spanish Society of Medical Oncology recommendations for comprehensive assessment and care of cancer survivors' needs

This article reviews the contemporary and inclusive definition of cancer survivorship, including patients with and without disease who have completed or continue to undergo treatment. The Spanish Society of Medical Oncology (SEOM) describes in this article the needs of these patients and outlines a care model based on an estimation of cancer incidence and identification of patient needs, to enable the provision of practical actions to achieve effective care. The objectives of this review are to identify the main effects of cancer on survivors and to establish appropriate ways of measuring these effects, as well as discussing the management of physical, psychological and social, occupational, financial, and other health-related needs. We suggest a multidisciplinary care model and training programs for the different professionals involved in care, and highlight challenges and the future role of the SEOM and health-care policy in ensuring optimum care of cancer survivors.

An evaluation of computerized attention and executive function measures for use with school age children with neurofibromatosis type 1

The present study investigated the performance of children with neurofibromatosis type 1 on computerized assessments of attention and executive function. Relations to ADHD symptomatology were also examined. Participants included 37 children (20 male) with NF1 (9-13 years; Mage = 11.02). Participants completed the NIH Toolbox Dimensional Change Card Sort, List Sort Working Memory (LSWM), and Flanker tasks, as well as Cogstate Identification and One Back tests. ADHD symptomatology was assessed using the K-SADS. Average performance was significantly different from the normative mean on every measure, except LSWM. The NIH Toolbox Flanker and Cogstate Identification tasks detected the highest proportion of participants with at least mild difficulty, and the Cogstate Identification task detected the highest proportion of participants with severe difficulty. Analyses revealed significant relations with ADHD symptomatology for two NIH toolbox tasks. The various computerized measures of attention and executive function offer different information when working with school age children with NF1. The NIH Flanker may offer the most room for change and offers face validity, which may be beneficial for clinical trials research. However, the LSWM shows most support for relations with behavioral indicators of attention and executive challenges.

From Evidence-Based Guidelines to Clinical Practice: Pediatric Neuropsychology Care in Multidisciplinary Clinics

OBJECTIVE

High demand for pediatric neuropsychological care has highlighted the time- and resource-intensive nature of traditional comprehensive evaluations. Emerging care models address these constraints by facilitating tiered neuropsychological services provided in various contexts, including multidisciplinary clinics (MDCs). We aim to demonstrate feasibility and acceptability of tiered neuropsychological care in MDCs through examples from a single institution.

METHODS

A review of all current MDC practices at a tertiary pediatric care center was conducted to describe clinic workflow, services provided, and triage strategies. Pediatric neuropsychologists (n = 5) and other health care providers (n = 31) completed a survey focused on experience with neuropsychology consultation in MDCs.

RESULTS

Neuropsychologists provided care in 11 MDCs, including universal monitoring with consultative interviews and questionnaires, as well as targeted screening. Neuropsychologists (89%) and other health professionals (100%) reported that tiered neuropsychological services improved patient care within MDCs. Other health professionals reported utilizing results from neuropsychology MDC care to inform their clinical approach (48-90%), referrals (58%), and treatment or surveillance decisions (55-71%).

CONCLUSION

Tiered neuropsychological care in pediatric MDCs is feasible, and provider experience ratings indicate high acceptability. Practical steps for development of MDCs are provided, including identifying teams, clinic goals and outcomes, operational logistics, and billing.

Parent ratings of executive functioning in pediatric survivors of medulloblastoma and pilocytic astrocytoma

The present study compared parent-rated executive functioning in pediatric medulloblastoma (MB) and pilocytic astrocytoma (PA) survivors. Although standard care for both includes surgical resection, children with MB additionally receive chemotherapy and craniospinal irradiation. Given well-documented neurocognitive late effects associated with the latter, we anticipated poor parent-reported executive functioning in MB survivors. Parents/guardians of 36 MB survivors and 20 PA survivors completed the Behavior Rating Inventory of Executive Functioning (BRIEF). PA survivors were younger at diagnosis (t[51.97] = 3.07, p < .001, d = 0.86) and demonstrated higher IQ (t[54] = -3.51, p < .001, d = 0.95). However, relative to the MB group, the PA group was rated as having significantly more problems on all BRIEF scales (all p ≤ .05; d = 0.30 - 1.10), except the Shift scale. Additionally, all mean BRIEF scores for MB survivors were within normal limits, whereas for PA survivors, all mean BRIEF scores except for Organization of Materials were significantly discrepant from normative means. Overall, PA survivors were rated as demonstrating poorer executive function than MB survivors. Five theories are discussed as possible explanations for these surprising findings: two related to group differences, two related to potential sources of parental bias, and one related to the nature of questionnaire-based assessment. All these theories represent directions for future research. Parent questionnaires such as the BRIEF may have real-world implications for pediatric brain tumor survivors. Future research should explore factors affecting parent ratings of executive functioning in these populations, along with comparison to performance-based measures.

Processing efficiency in pediatric cancer survivors: A review and operationalization for outcomes research and clinical utility

OBJECTIVE

Childhood cancer and cancer-related treatments disrupt brain development and maturation, placing survivors at risk for cognitive late effects. Given that assessment tools vary widely across researchers and clinicians, it has been daunting to identify distinct patterns in outcomes across diverse cancer types and to implement systematic neurocognitive screening tools. This review aims to operationalize processing efficiency skill impairment-or inefficient neural processing as measured by working memory and processing speed abilities-as a worthwhile avenue for continued study within the context of childhood cancer.

METHODS

A comprehensive literature review was conducted to examine the existing research on cognitive late effects and biopsychosocial risk factors in order to conceptualize processing efficiency skill trends in childhood cancer survivors.

RESULTS

While a frequently reported pattern of neurobiological (white matter) and cognitive (working memory and processing speed) disruption is consistent with processing efficiency skill impairment, these weaknesses have not yet been fully operationalized in this population. We offer a theoretical model that highlights the impacts of a host of biological and environmental factors on the underlying neurobiological substrates of cancer survivors that precede and may even predict long-term cognitive outcomes and functional abilities following treatment.

CONCLUSION

The unified construct of processing efficiency may be useful in assessing and communicating neurocognitive skills in both outcomes research and clinical practice. Deficits in processing efficiency may serve as a possible indicator of cognitive late effects and functional outcomes due to the unique relationship between processing efficiency skills and neurobiological disruption following cancer treatment. Continued research along these lines is crucial for advancing childhood cancer outcomes research and improving quality of life for survivors.

Neuropsychological surveillance model for survivors of pediatric cancer: A descriptive report of methodology and feasibility

Objective: Neuropsychological late effects of pediatric cancer may not become apparent for years after therapy; therefore, serial monitoring is necessary for detecting changes to ensure timely intervention. Unfortunately, lack of access to neuropsychologists, increased patient volume, insurance authorization and reimbursement issues, time required for neuropsychological evaluation, and practice effects related to repeat testing present many challenges to provision of neuropsychological care for survivors of childhood cancer. Models involving surveillance and monitoring have been proposed, though minimal data exist related to the implementation and feasibility of such models. Method: In this descriptive feasibility study, the Neuropsychology Consult Clinic (NCC) at Children's Hospital Los Angeles is presented, outlining a methodology and algorithm for neuropsychological surveillance of survivors of non-CNS pediatric cancer and an account of the first three years of clinic implementation. Participants included 215 survivors (x̅ age = 5.6 years), including 75.3% Latinx patients. Results: The overall clinic implementation was found to be feasible, with approximately 75% of patients "passing" the screening and 25% "failing" the screening. Clinical judgment only conflicted with the algorithm 8.6% of the time. However, several limitations to feasibility were noted, including validity concerns and ability/time to complete parent-reported outcomes using Spanish forms, as well as access to bilingual examiners. Conclusions: These preliminary data support the feasibility of the NCC model with limitations as outlined above. This is the first phase in a multiphase plan to develop an appropriate screening clinic for survivors of pediatric cancer, with the next phase focusing on sensitivity/specificity of measures.

Longitudinal Trajectories of Neurocognitive Functioning in Childhood Acute Lymphoblastic Leukemia

OBJECTIVE

Children with acute lymphoblastic leukemia (ALL) are at risk for neurocognitive deficits, and examining individual variability is essential to understand these risks. This study evaluated latent longitudinal trajectories and risk factors of neurocognitive outcomes in childhood ALL.

METHODS

There were 233 participants with ALL who were enrolled on a phase 3, risk-stratified chemotherapy-only clinical trial (NCT00137111) and who completed protocol-directed neurocognitive assessments [47.6% female, mean (SD) = 6.6 (3.7) years]. Measures of sustained attention, learning/memory, and parent ratings of attention were completed during and after treatment. Longitudinal latent class analyses were used to classify participants into distinct trajectories. Logistic regression was used to identify predictors of class membership.

RESULTS

Within the overall group, attention performance was below age expectations across time (Conners Continuous Performance Test detectability/variability, p < 0.01); memory performance and parent ratings were below expectations at later phases (California Verbal Learning Test learning slope, p < 0.05; Conners Parent Rating Scale, Revised attention/learning, p < 0.05). Most participants (80-89%) had stable neurocognitive profiles; smaller groups showed declining (3-6%) or improving (3-11%) trajectories. Older age (p = 0.020), female sex (p = 0.018), and experiencing sepsis (p = 0.047) were associated with greater attention problems over time. Lower baseline IQ was associated with improved memory (p = 0.035) and fewer ratings of attention problems (p = 0.013) over time.

CONCLUSIONS

Most patients with ALL have stable neurocognitive profiles. Smaller groups have significant impairments shortly after diagnosis or have worsening performance over time. A tiered assessment approach, which includes consideration of individual and clinical risk factors, may be useful for monitoring neurocognitive functioning during treatment and survivorship.

Rate of radiation-induced microbleed formation on 7T MRI relates to cognitive impairment in young patients treated with radiation therapy for a brain tumor

BACKGROUND

Radiation therapy (RT) is essential to the management of many brain tumors, but has been known to lead to cognitive decline and vascular injury in the form of cerebral microbleeds (CMBs).

PURPOSE

In a subset of children, adolescents, and young adults recruited from a larger trial investigating arteriopathy and stroke risk after RT, we evaluated the prevalence of CMBs after RT, examined risk factors for CMBs and cognitive impairment, and related their longitudinal development to cognitive performance changes.

METHODS

Twenty-five patients (mean 17 years, range: 10-25 years) underwent 7-Tesla MRI and cognitive assessment. Nineteen patients were treated with whole-brain or focal RT 1-month to 20-years prior, while 6 non-irradiated patients with posterior-fossa tumors served as controls. CMBs were detected on 7T susceptibility-weighted imaging (SWI) using semi-automated software, a first use in this population.

RESULTS

CMB detection sensitivity with 7T SWI was higher than previously reported at lower field strengths, with one or more CMBs detected in 100% of patients treated with RT at least 1-year prior. CMBs were localized to dose-targeted brain volumes with risk factors including whole-brain RT (p = 0.05), a higher RT dose (p = 0.01), increasing time since RT (p = 0.03), and younger age during RT (p = 0.01). Apart from RT dose, these factors were associated with impaired memory performance. Follow-up data in a subset of patients revealed a proportional increase in CMB count with worsening verbal memory performance (r = -0.85, p = 0.03).

CONCLUSIONS

Treatment with RT during youth is associated with the chronic development of CMBs that evolve with memory impairment over time.

Pediatric oncology provider perspectives and practices: Supporting patients and families in schooling after cancer diagnosis

BACKGROUND

Cognitive limitations are common after childhood cancer and require assessment and support in the medical and school setting. Pediatric oncology providers are tasked with educating families about the side effects of disease/treatment, and supporting families as they navigate the associated challenges. Despite this important role, little is known about the training, practice, and knowledge of providers in the domain of cognitive/school impacts.

METHODS

An online survey was emailed to Children's Oncology Group (COG) member physicians in the United States. The survey consisted of 42 questions about training and practice, and 4 knowledge questions about neurocognitive impacts and school supports.

RESULTS

Surveys were completed by 282 physicians representing 64% of COG institutions and a diverse group of experience and institution size. The pediatric oncologist was reported most frequently (93%) as the person at their institution to provide information to families on this topic, yet 54% reported receiving no specific training in this area and the majority (66%) reported to only "somewhat" understand the issues pediatric oncology patients face when returning to school. A minority reported available institutional guidelines (42%) or screening tools (19%) to assist in making referrals or assessments. Knowledge questions concerning health conditions qualifying children for school supports received the fewest correct answers. The majority (77%) thought more training would be helpful.

CONCLUSIONS

Additional training about cognitive impacts and schooling challenges associated with childhood cancer is needed to prepare providers to support parents/children. In addition, establishing policy guidelines and screening procedures may help support providers in providing care.