Cognitive function after the initiation of adjuvant endocrine therapy in early-stage breast cancer: an observational cohort study

Changes in Subjective Measures of Cognitive Function in Older Adults From the Initiation Through 12 Months After the Receipt of Chemotherapy

BACKGROUND

Cognitive impairment has a negative impact on older patients with cancer.

OBJECTIVES

The aim of this study was to evaluate for interindividual differences in 2 subjective measures of cognitive function in older patients (n = 112), as well as determine which demographic, clinical, and symptom characteristics, and levels of physical function, were associated with initial levels and with the trajectory of each of these 2 measures.

METHODS

Cognitive function was assessed using the cognitive function scale from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and the Attentional Function Index at the initiation of chemotherapy and at 1, 3, 6, 9, and 12 months after its initiation. Hierarchical linear modeling was used to assess for interindividual differences in and characteristics associated with initial levels and changes in cognitive function.

RESULTS

Characteristics associated with decreases in Quality of Life Questionnaire Core 30 scores at the initiation of chemotherapy were longer time since the cancer diagnosis and higher depression scores. Characteristics associated with poorer Attentional Function Index scores at enrollment were lower levels of education and higher depression scores. No characteristics were associated with worse trajectories of either cognitive function measure.

CONCLUSION

Some older patients undergoing chemotherapy experience decrements in cognitive function.

IMPLICATIONS FOR PRACTICE

Our findings suggest that clinicians need to assess for depressive symptoms in older patients before the initiation of chemotherapy. Evidence-based interventions (eg, cognitive stimulation, increased physical activity) can be recommended to maintain and increase cognitive function in older oncology patients.

Cognitive impairment after cancer treatment: mechanisms, clinical characterization, and management

Cognitive impairment is a debilitating side effect experienced by patients with cancer treated with systemically administered anticancer therapies. With around 19.3 million new cases of cancer worldwide in 2020 and the five year survival rate growing from 50% in 1970 to 67% in 2013, an urgent need exists to understand enduring side effects with severe implications for quality of life. Whereas cognitive impairment associated with chemotherapy is recognized in patients with breast cancer, researchers have started to identify cognitive impairment associated with other treatments such as immune, endocrine, and targeted therapies only recently. The underlying mechanisms are diverse and therapy specific, so further evaluation is needed to develop effective therapeutic interventions. Drug and non-drug management strategies are emerging that target mechanistic pathways or the cognitive deficits themselves, but they need to be rigorously evaluated. Clinically, consistent use of objective diagnostic tools is necessary for accurate diagnosis and clinical characterization of cognitive impairment in patients treated with anticancer therapies. This should be supplemented with clinical guidelines that could be implemented in daily practice. This review summarizes the recent advances in the mechanisms, clinical characterization, and novel management strategies of cognitive impairment associated with treatment of non-central nervous system cancers.

Longitudinal evaluation of dehydroepiandrosterone (DHEA), its sulfated form and estradiol with cancer-related cognitive impairment in early-stage breast cancer patients receiving chemotherapy

The purpose of this study is to elucidate how patient-reported cognitive symptoms manifest from variations in hormone levels or precursors such as dehydroepiandrosterone (DHEA) and its sulfated form [collectively termed as DHEA(S)] and to investigate their association in breast cancer survivors. Levels of estradiol and DHEA(S) were compared between early-stage breast cancer patients with and without cancer-related cognitive impairment (CRCI) during adjuvant chemotherapy. Data were analyzed from 242 patients (mean age ± SD = 50.8 ± 9.2 years) who had completed FACT-Cog v.3.0, blood draws and questionnaires. Regression model was used to fit the magnitude of change in each respective biomarker levels against overall cognitive impairment status while adjusting for clinically important covariates. There was reduction in mean plasma levels of estradiol and DHEAS during and towards the end of chemotherapy (p-values < 0.001). Compared to non-impaired patients, smaller magnitude of decline was observed in DHEA(S) levels in patients reporting CRCI, with significant association between decline in DHEAS levels and acute onset of CRCI at 6 weeks from baseline (adjusted β of 0.40, p-value of 0.02). In contrast, patients reporting CRCI showed greater magnitude of decline in estradiol compared to non-impaired patients, although this was not found to be statistically significant. There was an association between magnitude of change in biomarker levels with self-reported CRCI which suggests that the hormonal pathway related to DHEAS may be implicated in acute CRCI for breast cancer survivors. Our findings help to improve biological understanding of the pathway from which DHEAS may correlate with cognitive dysfunction and its impact on cancer survivors.

Multimodal MRI examination of structural and functional brain changes in older women with breast cancer in the first year of antiestrogen hormonal therapy

PURPOSE

Cancer patients are concerned about treatment-related cognitive problems. We examined effects of antiestrogen hormonal therapy on brain imaging metrics in older women with breast cancer.

METHODS

Women aged 60 + treated with hormonal therapy only and matched non-cancer controls (n = 29/group) completed MRI and objective and self-reported cognitive assessment at pre-treatment/enrollment and 12 months later. Gray matter was examined using voxel-based morphometry (VBM), FreeSurfer, and brain age calculations. Functional MRI (fMRI) assessed working memory-related activation. Analyses examined cross-sectional and longitudinal differences and tested associations between brain metrics, cognition, and days on hormonal therapy.

RESULTS

The cancer group showed regional reductions over 12 months in frontal, temporal, and parietal gray matter on VBM, reduced FreeSurfer cortical thickness in prefrontal, parietal, and insular regions, and increased working memory-related fMRI activation in frontal, cingulate, and visual association cortex. Controls showed only reductions in fusiform gyrus on VBM and FreeSurfer temporal and parietal cortex thickness. Women with breast cancer showed higher estimated brain age and lower regional gray matter volume than controls at both time points. The cancer group showed a trend toward lower performance in attention, processing speed, and executive function at follow-up. There were no significant associations between brain imaging metrics and cognition or days on hormonal therapy.

CONCLUSION

Older women with breast cancer showed brain changes in the first year of hormonal therapy. Increased brain activation during working memory processing may be a sign of functional compensation for treatment-related structural changes. This hypothesis should be tested in larger samples over longer time periods.

CLINICALTRIALS

GOV IDENTIFIER

NCT03451383.

Personalizing Adjuvant Endocrine Therapy for Early-Stage Hormone Receptor-Positive Breast Cancer

Endocrine therapy has undergone major changes in the past few years, and is no longer a "one- size- fits- all" prescription. This article discussed some of the new developments and directions.

Effects of Vigorous Versus Restorative Yoga Practice on Objective Cognition Functions in Sedentary Breast and Ovarian Cancer Survivors: A Randomized Controlled Pilot Trial

Purpose:

Many cancer survivors experience cancer-related cognitive impairment (CRCI). We conducted a randomized controlled pilot trial of 2 types of yoga practice and evaluated their effects on participants’ objective cognitive function.

Methods:

Sedentary breast or ovarian cancer survivors were randomized to practice either restorative yoga (with more meditative practice and minimal physical exertion) or vigorous yoga (with considerable physical exertion and minimal meditative practice) in 60-minute supervised sessions 3 times a week for 12 weeks, followed by 12 weeks of home practice. We used the NIH Toolbox Cognition Domain to evaluate participants at baseline, week 12, and week 24.

Results:

We enrolled 35 participants. For women in the restorative yoga group, overall cognitive function was statistically significantly improved at weeks 12 and 24 compared to baseline (P = .03 and 0.004; Cohen’s D = 0.3 and 0.5). Fluid cognitive function also significantly improved at weeks 12 and 24 (P = .02 and 0.0007; Cohen’s D = 0.3 and 0.6), whereas improvements in crystallized cognition were not significant. For women in the vigorous yoga group, significant improvement was only seen in tasks of crystallized cognition at week 24 (P = .03; Cohen’s D = 0.5). Between-group comparisons showed that at week 24, women in the restorative yoga group had significantly higher scores on fluid cognition tasks.

Conclusions:

Patients who participated in yoga practice demonstrated improvement in objective cognitive function over time. Restorative yoga may be more effective in improving fluid cognitive function at week 24 when compared to vigorous yoga. These promising findings should be confirmed in definitive studies.

Trial registration:

Clinicaltrials.gov; NCT02305498 (Date Registered: December 2, 2014)

Long-Term Cognitive Dysfunction in Cancer Survivors

Cancer-related cognitive impairment (CRCI) is a frequent side effect experienced by an increasing number of cancer survivors with a significant impact on their quality of life. Different definitions and means of evaluation have been used in available literature; hence the exact incidence of CRCI remains unknown. CRCI can be described as cognitive symptoms reported by cancer patients in self-reported questionnaires or as cognitive changes evaluated by formal neuropsychological tests. Nevertheless, association between cognitive symptoms and objectively assessed cognitive changes is relatively weak or absent. Studies have focused especially on breast cancer patients, but CRCI has been reported in multiple types of cancer, including colorectal, lung, ovarian, prostate, testicular cancer and hematological malignancies. While CRCI has been associated with various treatment modalities, including radiotherapy, chemotherapy, hormone therapy and novel systemic therapies, it has been also detected prior to cancer treatment. Therefore, the effects of cancer itself with or without the psychological distress may be involved in the pathogenesis of CRCI as a result of altered coping mechanisms after cancer diagnosis. The development of CRCI is probably multifactorial and the exact mechanisms are currently not completely understood. Possible risk factors include administered treatment, genetic predisposition, age and psychological factors such as anxiety, depression or fatigue. Multiple mechanisms are suggested to be responsible for CRCI, including direct neurotoxic injury of systemic treatment and radiation while other indirect contributing mechanisms are hypothesized. Chronic neuroinflammation mediated by active innate immune system, DNA-damage or endothelial dysfunction is hypothesized to be a central mechanism of CRCI pathogenesis. There is increasing evidence of potential plasma (e.g., damage associated molecular patterns, inflammatory components, circulating microRNAs, exosomes, short-chain fatty acids, and others), cerebrospinal fluid and radiological biomarkers of cognitive dysfunction in cancer patients. Discovery of biomarkers of cognitive impairment is crucial for early identification of cancer patients at increased risk for the development of CRCI or development of treatment strategies to lower the burden of CRCI on long-term quality of life. This review summarizes current literature on CRCI with a focus on long-term effects of different cancer treatments, possible risk factors, mechanisms and promising biomarkers.

Moderators of inflammation-related depression: a prospective study of breast cancer survivors

Inflammation has been shown to predict depression, but sensitivity to inflammation varies across individuals. Experimental studies administering potent pro-inflammatory agents have begun to characterize this sensitivity. However, risk factors for inflammation-associated depression in naturalistic contexts have not been determined. The present study examined key psychological and behavioral risk factors (state anxiety, perceived stress, negative affect, disturbed sleep, and childhood adversity) as potential moderators of the relationship between inflammation and depressive symptoms in a prospective longitudinal study of breast cancer survivors. Women with early stage breast cancer were recruited after completing primary cancer treatment (n_final = 161). Depressive symptoms, inflammatory markers (CRP, IL-6, and sTNF-RII), and key risk factors were assessed post treatment (T1), at 6 and 12-month follow-ups (T2 and T3), and during a final follow-up (TF) 3-6 years after T1; childhood adversity was measured only at T3. Inflammatory markers were combined into a single inflammatory index prior to analyses. Women who reported higher levels of state anxiety, perceived stress, negative affect, and/or sleep disturbance at T1 (post-treatment) exhibited higher depressive symptoms at times when inflammation was higher than typical (interaction βs ranged from .06 to .08; all ps < .014). Results demonstrate the relevance of these risk factors for understanding inflammation-associated depression in a clinical context and could inform targeted strategies for prevention and treatment among at-risk populations.

Focal white matter microstructural alteration after anthracycline-based systemic treatment in long-term breast cancer survivors: a structural magnetic resonance imaging study

Understanding the neural correlates of cognitive problems in patients with breast cancer (BC) after systemic treatment have been a topic of increasing investigation. The heterogeneity of the systemic treatment regimens may undermine our ability to identify brain microstructural alterations resulting from any given regimen. We investigated the detrimental effects of the anthracycline-based systemic treatment (AST) regimen (epirubicin and cyclophosphamide + docetaxel + tamoxifen) on brain gray matter (GM) and white matter (WM) microstructural alteration in long-term BC survivors. We performed a battery of neuropsychological tests and structural magnetic resonance imaging (MRI) to 31 long-term BC survivors who had received the AST regimen (AST group) and 43 healthy controls (HC group). Voxel-based morphometry evaluated the whole-brain voxel-wise GM volume, while diffusion tensor imaging technique with tract-based spatial statistics analysis evaluated whole-brain WM microstructural alteration. Partial least squares regression (PLSR) was used to evaluate the relationship between cognitive impairment and brain microstructural alteration in BC survivors. Compared with the HC group, the AST group exhibited a significantly poorer performance in attention, as well as a marginal significantly poorer performance in verbal working memory and executive function. Significantly lower fractional anisotropy (FA), higher radial diffusivity (RD), and lower axial diffusivity (AD) in multiple brain WM regions were showed in AST group compared with the HC group. Overlap of lower FA and higher RD was found in the body of corpus callosum (CC) and bilateral superior corona radiata (SCR), whereas overlap of lower FA and AD was found in the body of CC and right SCR. The PLSR results showed that the WM regions with overlap of lower FA and AD were significantly associated with executive and verbal working memory decline. No significant difference was observed in the GM volume between groups. Our results suggest that microstructural abnormalities of certain vulnerable WM regions in the AST regimen-exposed brain may provide neuroimaging evidence for the identification of brain injury and cognitive impairment induced by specific chemotherapy regimens.

Association of APOE4 genotype and treatment with cognitive outcomes in breast cancer survivors over time

This prospective longitudinal study of breast cancer survivors (n = 167) examined the association of apolipoprotein ε4 (APOE ε4) genotype with cognition and interactions with chemotherapy or endocrine therapy up to 6 years after treatment. In general, we found no effects of ε4 across timepoints and treatment exposures; post hoc analysis at 3-6 years suggested a trend towards worse cognition in the domains of attention and learning among ε4 carriers exposed to endocrine therapy. Further study is needed.

Endocrine Therapy With or Without CDK4/6 Inhibitors in Women With Hormone-receptor Positive Breast Cancer: What do we Know About the Effects on Cognition?

Adjuvant endocrine therapy (ET) is the cornerstone of treatment for hormone-receptor positive breast cancer. Recently, ET is increasingly combined with "cyclin-dependent kinases 4 and 6'' (CDK4/6) inhibitors. Given the importance of estrogens in neural processes and the role of cyclin D in hippocampal cell proliferation, it is plausible that these therapies affect cognition, but studies on these potential cognitive effects are sparse. In this review, we summarize existing knowledge on the cognitive effects of ET and CDK4/6 inhibitors in pre-, peri- and postmenopausal patients with breast cancer. We show that several clinical studies support adverse cognitive effects, especially on verbal memory, after ET-induced decrease of estrogen-levels or inactivation of estrogen-receptors. Clinical studies on the cognitive effects of CDK4/6 inhibitors are virtually non-existent and no conclusions can yet be drawn. Longitudinal studies on the cognitive effects of the combined ET-CDK4/6 inhibitors are highly needed to properly inform patients about potential short-term and long-term cognitive side effects. These studies should preferably include cognitive assessments (including a measurement prior to ET), and be designed in such a way that they can account for variables such as type and duration of ET, CDK4/6 inhibition, menopausal status, and other disease- and treatment-related symptoms that can impact cognition, such as fatigue and distress.

Longitudinal Changes in Cognitive Function in a Nationwide Cohort Study of Patients With Lymphoma Treated With Chemotherapy

BACKGROUND

Cancer-related cognitive decline (CRCD) is an important clinical problem, but limited research exists on assessment of cognitive function in patients with lymphoma.

METHODS

The overall objective of this nationwide, prospective, observational study conducted in the National Cancer Institute Community Clinical Oncology Research Program (NCORP) was to assess changes in memory, attention, and executive function in patients with lymphoma from pre- (A1) to postchemotherapy (A2) and to 6 months postchemotherapy (A3). Individuals without cancer served as noncancer controls, paired to patients by age and sex, and assessed at the same time-equivalent points. Longitudinal linear mixed models (LMM) including A1, A2, and A3 and adjusting for age, education, race, sex, cognitive reserve score, baseline anxiety, and depressive symptoms were fit. We assessed changes in patients compared with control participants without cancer and assessed differences in cognitive function in those patients with Hodgkin vs non-Hodgkin disease and by disease subtype. All statistical tests were 2-sided.

RESULTS

Patients with lymphoma (n = 248) and participants without cancer serving as controls (n = 212) were recruited from 19 NCORP sites. From pre- to postchemotherapy and from prechemotherapy to 6 months follow-up, patients reported more cognitive problems over time compared with controls (Functional Assessment of Cancer-Therapy-Cognitive Function [FACT-Cog] perceived cognitive impairment effect size (ES) = 0.83 and 0.84 for A1 to A2 and A1 to A3, respectively; P < .001; single-item cognitive symptoms ES range = 0.55 to 0.70 inclusive of A1 to A2 and A1 to A3; P < .001); the complaints were more pronounced in women with lymphoma compared with men with lymphoma (FACT-Cog Perceived Cognitive Impairment (PCI) score group-by-time-by-sex interaction, P = .007). Patients with lymphoma also performed statistically significantly less well on tests of verbal memory and delayed recall, attention and executive function, and telephone-based category fluency.

CONCLUSION

Patients with lymphoma experience worse patient-reported and objectively assessed cognitive function from prechemotherapy to 6-month follow-up compared with age- and sex-paired controls without cancer assessed at similar time intervals.

Executive Functioning and Depressive Symptoms After Cancer: The Mediating Role of Coping

OBJECTIVE

Cognitive difficulties are a common complaint among patients with breast cancer and may adversely affect psychological well-being. In particular, problems with executive functioning (EF) may interfere with coping, which is known to influence depressive symptoms. The current study was designed to examine correlations between EF, coping, and depressive symptoms in breast cancer survivors and to longitudinally test the hypothesis that coping mediates the relationship between EF and depressive symptoms.

METHODS

Participants included 171 women with early-stage breast cancer assessed at the end of primary treatment with surgery, radiation, and/or chemotherapy and at 6 months, 1 year, and 2 years after treatment follow-ups as part of the Mind-Body Study. Participants completed questionnaires to assess subjective EF, approach and avoidant coping, and depressive symptoms, and neuropsychological testing was conducted to assess objective EF. Bivariate correlations were used to examine associations between EF, coping, and depressive symptoms. Mediation analyses were conducted using a bootstrapping approach (PROCESS).

RESULTS

At 1 year after treatment, objective and subjective EFs were correlated with avoidant coping (r = -0.172 [p = .024] and r = 0.297 [p < .001], respectively). In longitudinal analyses, use of the avoidant strategy behavioral disengagement at 1 year mediated the association between objective (95% bootstrap confidence interval = -0.282 to -0.042) and subjective (95% bootstrap confidence interval = 0.020 to 0.254) EFs at 6 months and depressive symptoms at 2 years.

CONCLUSIONS

This study highlights how problems with EF during survivorship are associated with avoidant coping and depressive symptoms. Thus, these findings identify potential cognitive and affective targets for depression intervention in this population.

Perceived Cognitive Impairment in Breast Cancer Survivors and Its Relationships with Psychological Factors

Simple Summary

Cognitive complaints are common adverse effects for breast cancer survivors, with potential negative impacts on quality of life or return to work. Identifying subjects at risk could allow to reduce cognitive disorders or to set up appropriate care. In this study we explored current cognitive complaints reported by breast cancer survivors, using the Functional Assessment of Cancer Therapy-Cognition (FACT-Cog) questionnaire and examined the relationships between current cognitive complaints and current psychological symptoms (especially post-traumatic stress symptoms). This large survey showed that about half of breast cancer survivors reported cognitive complaints after cancer treatments. These complaints were mainly associated with chemotherapy, age, self-reported sleep difficulties, the frequency of psychotropic treatments and psychological factors including post-traumatic stress symptoms or. Some modifiable risk factors should be detected early to reduce persistent cognitive complaints after cancer, including sleep difficulties and post-traumatic stress symptoms.

Abstract

Cognitive complaints are common adverse effects in cancer patients. Identifying subjects at risk could make it possible to limit their impact. We aimed to explore the relationship between current cognitive complaints and demographic and psychological factors in a group of breast cancer survivors. Through an online survey, cancer survivors reported current cognitive complaints using the FACT-Cog questionnaire (Perceived Cognitive Impairment) and answered questions about their demographics, lifestyle and cancer-related characteristics. Anxiety, depression, fatigue and post-traumatic stress symptoms were also assessed. We used multivariable logistic regression models to explore the relationships between current cognitive complaints and social and psychological factors. Among the 1393 breast cancer survivors, 47.2% (n = 657) reported current cognitive complaints. Chemotherapy (OR = 2.26, 95%CI = 1.67–3.05), age (OR_{21-44 vs. >65} = 0.14, 95%CI = 0.07–0.27), sleep difficulties (OR_{never vs. often} = 2.41, 95%CI = 1.47–3.95), frequency of psychotropic treatments (OR_{never vs. >1/week} = 1.70, 95%CI = 1.23–2.36), post-traumatic stress symptoms (OR = 2.05, 95%CI = 1.57–2.69) and employment status (OR_{full-time or part-time vs. sick leave} = 1.64, 95%CI = 1.08–2.49) were strongly associated with current cognitive complaints. In this large study, about half of breast cancer survivors reported cognitive complaints, particularly after chemotherapy. Some risk factors should be detected early to reduce persistent cognitive complaints after cancer: mainly sleep difficulties, post-traumatic stress symptoms and psychotropic medications.

Aromatase Inhibitors in Postmenopausal Women with Hormone Receptor-Positive Breast Cancer: Profiles of Psychological Symptoms and Quality of Life in Different Patient Clusters

BACKGROUND

Aromatase inhibitors (AIs) as adjuvant therapy after breast cancer (BC) surgery have demonstrated to reduce the risk of disease recurrence, to lower the risk of contralateral BC, and to improve survival when compared to tamoxifen in patients with limited-stage hormone receptor-positive (HR+) BC. However, AIs are associated with adverse events that can have a significant impact on patient quality of life (QoL).

AIM

This study aimed to identify profiles of psychological symptoms and QoL in HR+ BC patients undergoing AI therapy.

METHOD

Data were collected with questionnaires administered at three time points: AI initiation (t0); 3 months after AI initiation (t1); and 6 months after AI initiation (t2). The FACT-G, FACT-B, and FACT-ES questionnaires were used to assess QoL; psychological symptoms were assessed using the SCL-90-R.

RESULTS

43 women were enrolled in the study (t0), and 37 completed the t1 evaluation and 29 the t2 evaluation. We found (1) a progressive decrease over time in FACT-G and FACT-ES scores, in particular in the Physical, Emotional, and Endocrine subscales, and an increase in the SOM (somatization) subscale of the SCL-90-R; (2) the presence of 4 clusters related to different psychological symptoms and QoL evolution over time; (3) that patients belonging to the cluster characterized by worsening symptoms and QoL during time differed from the others in the Emotional subscale of the FACT-B and in the GSI (Global Score), OCD (obsessive-compulsive), DEP (depression), ANX (anxiety), and SLP (sleep disorders) dimensions of the SCL-90-R and had significantly higher BMI levels; and (4) that 3 items from the SCL-90-R and 2 items from FACT Emotional Well-Being subscale were predictive of the "worst" cluster.

CONCLUSIONS

Although larger studies are needed to confirm these results, our data open up new ways of investigation into the effects of AIs on QoL in HR+ BC patients.

Effects of acupuncture versus cognitive behavioral therapy on cognitive function in cancer survivors with insomnia: A secondary analysis of a randomized clinical trial

BACKGROUND

Cancer-related cognitive impairment is a prevalent, disruptive condition potentially exacerbated by sleep disturbances. The current study was performed to evaluate the effects of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on objective and subjective cognitive function in cancer survivors with insomnia.

METHODS

Using data from a randomized clinical trial (160 survivors) that compared acupuncture versus CBT-I for insomnia occurring in cancer survivors, the authors analyzed cognitive outcomes and their relationship to insomnia symptoms. Analysis was limited to 99 patients who reported baseline cognitive difficulties. Interventions were delivered over 8 weeks. Objective attention, learning, and memory were evaluated using the Buschke Selective Reminding Test. Subjective cognitive function was assessed using the Brown Attention-Deficit Disorder Scales. Insomnia symptoms were assessed using the Insomnia Severity Index. All outcomes were collected at baseline, week 8, and week 20.

RESULTS

From baseline to week 8, acupuncture produced statistically significant within-group improvements in objective attention (Cohen D, 0.29), learning (Cohen D, 0.31), and memory (Cohen D, 0.33) that persisted to week 20 (all P < .05), whereas CBT-I produced a statistically significant within-group improvement in objective attention from baseline to week 20 (Cohen D, 0.50; P < .05); between-group differences were not statistically significant. Both interventions produced statistically significant within-group improvements in subjective cognitive function at weeks 8 and 20 compared with baseline (all P < .001); between-group differences were not statistically significant. In the acupuncture group, patients with clinically meaningful responses with regard to insomnia symptoms demonstrated a significantly greater improvement in subjective cognitive function compared with those without clinically meaningful insomnia responses (P = .006).

CONCLUSIONS

Among cancer survivors with insomnia, both acupuncture and CBT-I produced significant improvements in objective and subjective cognitive function. However, the effect sizes varied and only survivors in the acupuncture group demonstrated a significant relationship between cognitive and sleep outcomes. These preliminary findings warrant further investigation to guide the personalized management of patients with cancer-related cognitive impairment.

Changes in Attentional Function in Patients From Before Through 12 Months After Breast Cancer Surgery

CONTEXT

Although approximately 75% of patients with breast cancer report changes in attentional function, little is known about how demographic, clinical, symptom, and psychosocial adjustment (e.g., coping) characteristics influence changes in the trajectories of attentional function over time.

OBJECTIVES

This study evaluated interindividual variability in the trajectories of self-reported attentional function and determined which demographic, clinical, symptom, and psychosocial adjustment characteristics were associated with initial levels and with changes in attentional function from before through 12 months after breast cancer surgery.

METHODS

Before surgery, 396 women were enrolled. Attentional Function Index (AFI) was completed before and nine times within the first 12 months after surgery. Hierarchical linear modeling was used to determine which characteristics were associated with initial levels and trajectories of attentional function.

RESULTS

Given an estimated preoperative AFI score of 6.53, for each additional month, the estimated linear rate of change in AFI score was an increase of 0.054 (P < 0.001). Higher levels of comorbidity, receipt of adjuvant chemotherapy, higher levels of trait anxiety, fatigue, and sleep disturbance, and lower levels of energy and less sense of control were associated with lower levels of attentional function before surgery. Patients who had less improvements in attentional function over time were nonwhite, did not have a lymph node biopsy, had received hormonal therapy, and had less difficulty coping with their disease.

CONCLUSION

Findings can be used to identify patients with breast cancer at higher risk for impaired self-reported cognitive function and to guide the prescription of more personalized interventions.

Cognitive complaints by hematopoietic cell transplantation recipients and change in neuropsychological performance over time

PURPOSE

Hematopoietic stem cell transplant (HSCT) recipients are at risk for cognitive decline. Cross-sectional studies show patients' complaints of cognitive decline do not correlate well with concurrently measured objective neuropsychological performance, but rather with emotional variables and health-related quality of life. This longitudinal study investigated whether patient self-report of cognitive status would be concordant with objectively measured neuropsychological performance after accounting for change from their own pre-transplant objective baseline.

METHODS

Pre-HSCT and at 30 and 100 days post-HSCT, 46 patients underwent computerized neuropsychological testing (CogState) and completed surveys assessing patient-reported cognitive complaints, emotional symptoms (depression, anxiety), sleep quality, daytime sleepiness, and physical and functional well-being. Correlations were calculated between cognitive complaints and neuropsychological performance (at each time-point and across time-points), as well as all other patient-reported variables.

RESULTS

Patient-reported cognitive complaints were largely independent of concurrently assessed objective neuropsychological performance. Uniquely, our longitudinal data demonstrated significant medium to large effect size associations between subjective cognitive complaints post-HSCT with objectively measured change from pre-HSCT in attention, visual learning, and working memory (p < .05-.01). Subjective cognitive complaints post-HSCT were also associated with depression, anxiety, daytime sleepiness and physical well-being (p < .05-.001).

CONCLUSIONS

Patients appear better able to assess their cognitive functioning relative to their own baseline and changes across time rather than relative to community norms. Thus, patient complaints of cognitive compromise justify further in-depth neuropsychological, emotional, and functional assessment. Future research into relationships between cognitive complaints and neuropsychological performance should account for changes in performance over time.

Quality of life and psychological functioning in postmenopausal women undergoing aromatase inhibitor treatment for early breast cancer

INTRODUCTION

Aromatase inhibitors (AIs) dramatically increased breast cancer (BC) survival, leading to enhanced attention to their long-term consequences on psychological functioning. Conflicting data has been examined regarding the association between AIs administration and the clinical psychological features in BC survivors (BCSs).

PURPOSE

As psychological symptoms often occur in such chronic diseases, our study aimed at exploring anxious and depressive symptoms and the perceived quality of life (QoL) in BCSs assessed for osteoporosis.

METHODS

The total sample consisted of a clinical sample of 51 outpatient postmenopausal women, diagnosed with BC, and a control group composed of 51 healthy postmenopausal women. All recruited participants were evaluated through the clinical gold standard interview and completed the following self-rating scales: the Hamilton Anxiety Rating Scale, Beck Depression Inventory II edition, and 36-Item Short Form Health Survey, which were administered at baseline and after 6 months in BCSs in AIs treatment, compared with controls. Moreover, all participants were assessed for vitamin D status, bone mineral density (BMD) and subclinical vertebral fractures. Data regarding age, age at menopause, body mass index (BMI), smoking habits and alcohol consumption was collected.

RESULTS

BCSs (n = 51) showed higher anxious and depressive symptoms, and lower perceived QoL vs. controls (n = 51) (p<0.05 for all). After 6 months of treatment with AIs, BCSs showed significant reduction of anxious and depressive symptoms and a significantly higher perceived QoL for both physical and mental components, vs. controls.

CONCLUSIONS

The improvement of clinical psychological features and perceived QoL was associated with AIs treatment in women being treated with, for early breast cancer. Further studies are needed to obtain a deeper comprehension of the correlation between clinical psychological and physical features in BCSs.

The Effect of Exercise on Cancer-Related Cognitive Impairment and Applications for Physical Therapy: Systematic Review of Randomized Controlled Trials

BACKGROUND

Cancer-related cognitive impairment (CRCI), often called "chemo-brain" or "chemo-fog," is a common side effect among adults with cancer, which can persist well after treatment completion. Accumulating evidence demonstrates exercise can improve cognitive function in healthy older adults and adults with cognitive impairments, suggesting exercise may play a role in managing CRCI.

PURPOSE

The purpose was to perform a systematic review of randomized controlled trials (RCTs) to understand the effect of exercise on CRCI.

DATA SOURCES

Relevant literature was retrieved from CINAHL, Medline (Ovid), and EMBASE.

STUDY SELECTION

Eligible articles were RCTs that prescribed aerobic, resistance, combined aerobic/resistance, or mind-body (eg, yoga or Qigong) exercise during or following cancer treatment and included cognitive function outcome measures.

DATA EXTRACTION

Descriptive information and Cohen d effect sizes were directly extracted or calculated for included trials.

DATA SYNTHESIS

Twenty-nine trials were included in the final analysis. A statistically significant effect of exercise on self-reported cognitive function, both during and postadjuvant treatment, was reported in 12 trials (41%) (Cohen d range: 0.24-1.14), most commonly using the EORTC QLQ-C30. Ten trials (34%) performed neuropsychological testing to evaluate cognitive function; however, only 3 trials in women with breast cancer reported a significant effect of exercise (Cohen d range: 0.41-1.47).

LIMITATIONS

Few RCTs to date have evaluated the effect of exercise on CRCI as a primary outcome. Twenty-six trials (90%) in this review evaluated CRCI as secondary analyses.

CONCLUSIONS

Evidence supporting exercise as a strategy to address CRCI is limited. Future research evaluating CRCI as a primary outcome, including self-reported and objective measures, is needed to confirm the possible role of exercise in preventing and managing cognitive impairments in adults with cancer.

Cognitive decline in older long-term survivors from Non-Hodgkin Lymphoma: a multicenter cross-sectional study

OBJECTIVES

To compare cognition in a group of older long-term survivors from Non-Hodgkin Lymphoma (NHL) and in a corresponding group of non-cancer controls of the same age. Functional status, polypharmacy and multimorbidity were also evaluated.

METHODS

A cross-sectional study was performed in a population of 63 outpatient long-term survivors from NHL, aged 65 or more and 61 non-cancer controls. Socio-demographic, clinical and functional data were collected. Cognitive function was assessed through neuropsychological tests.

RESULTS

NHL survivors showed a slightly worse functional status than controls, they were affected by more chronic conditions (3.4 vs 2.3; p = .003) and were taking a higher number of medications (3.4 vs 2.3; p = .03). The Mini Mental State Examination (MMSE) was not significantly different between the groups. NHL survivors performed worse than controls in executive functioning (Trail Making Test B-A 47.9 vs 32.1 p = .04, OR for Stroop test time over 75th percentile in survivors: 2.66; CI 95% 1.04-6.61; OR for Multiple Features Target Cancellation time over 75th percentile in survivors: 2.84; CI 95% 1.10-7.31). A small, statistically significant difference was also observed in verbal memory scores between the two groups. .

CONCLUSIONS

The findings of this study suggest that, compared with non-cancer controls, older survivors from NHL may have a lower cognitive performance, especially in the executive functioning and attention domains, regardless of multimorbidity and polypharmacy. Further evidence from larger samples is needed to confirm such findings and better characterize cognitive decline in NHL survivors.

Cognitive Functioning and Psychological Well-being in Breast Cancer Patients on Endocrine Therapy

BACKGROUND/AIM

Anti-cancer therapies may deteriorate cognitive functioning, affective functioning and psychological well-being.

MATERIALS AND METHODS

In this prospective longitudinal pilot study, premenopausal and postmenopausal patients received adjuvant endocrine therapy (ET) (tamoxifen with or without LHRH analog or aromatase inhibitor) or were observed only (control group). At baseline testing and 6, 12 and 24 months thereafter, cognitive, depression and anxiety tests and quality of life (QOL) measurements were performed.

RESULTS

Overall, 46 cases were evaluated. None of the studied cognitive parameters differed between the subgroups or changed by time. No differences were found regarding anxiety, depression or QOL measures either. Baseline cognitive test and QOL results were in association with later anxiety and depression.

CONCLUSION

No cognitive impairment was found during the two years of ET. Baseline cognitive scores and QOL dimensions proved good predictors of later anxiety and depression.

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.

Identifying Cancer-Related Cognitive Impairment Using the FACT-Cog Perceived Cognitive Impairment

Cancer-related cognitive impairment (CRCI) is a concerning problem for many cancer survivors. Evaluating patients for CRCI has been a challenge, in part because of a lack of standardized practices. Self-report instruments are often used to assess CRCI, but there are no validated cutpoints. We present the results of receiver operating characteristic curve analysis identifying cutpoints of the Functional Assessment of Cancer Therapy-Cognition perceived cognitive impairment (PCI) in female breast cancer survivors for identifying CRCI cases. We defined presence of CRCI based on elevated complaints on the Patient's Assessment of Own Functioning Inventory compared with healthy control scores. Our results indicate that scores less than 54 in PCI scores using 18 items and scores less than 60 in PCI scores using 20 items exhibited good ability to discriminate CRCI cases from noncases (area under the receiver operating characteristic curve was 0.84 [95% CI = 0.73 to 0.94]). These preliminary results represent an important contribution toward standardizing practices across CRCI studies.

Subjective cognitive functioning and associations with psychological distress in adult brain tumour survivors

PURPOSE

The impact of brain tumour on subjective cognitive function (SCF) has received little attention despite the implications of these perceptions for quality of life. SCF consists of two related yet distinct components, perceived cognitive impairment (PCI) and perceived cognitive abilities (PCA). This study compared the SCF of adult brain tumour survivors and healthy controls and examined demographic, illness-related, and psychological factors associated with SCF.

METHOD

Sixty-five adult survivors with primary brain tumour (age, 22-75 years), and 65 age- and sex-matched controls were recruited. Participants with brain tumour completed the Brief Test of Adult Cognition by Telephone, Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog), ratings of physical symptoms, Depression Scale of the Depression Anxiety Stress Scales-21 (DASS-Depression), and Generalized Anxiety Disorder-7 (GAD-7) scale. Controls completed the FACT-Cog, DASS-Depression, and GAD-7.

RESULTS

Adult brain tumour survivors reported significantly greater PCI and lower PCA than controls, after accounting for anxiety. Higher PCI was significantly related to fatigue, pain, treatment-related side-effects, anxiety, and depression. Lower PCA was significantly associated with fatigue, pain, poorer objective cognitive function, lower education, anxiety, and depression. Anxiety uniquely accounted for 9-14% of variance in SCF.

CONCLUSIONS

Adult brain tumour survivors were found to experience poorer SCF than healthy controls after accounting for anxiety. SCF was related to multiple factors after brain tumour; however, an independent association with anxiety was identified.

IMPLICATIONS FOR CANCER SURVIVORS

These findings highlight the potential value of psychological interventions targeting anxiety and cognitive effects to improve quality of survivorship after brain tumour.

Trajectories of Cognitive Function and Associated Phenotypic and Genotypic Factors in Breast Cancer

OBJECTIVES

This study identified women with unique trajectories of executive function, concentration, and visual working memory before and during adjuvant therapy for breast cancer, and examined phenotypic and genotypic predictors associated with subgroups.

SAMPLE & SETTING

399 postmenopausal women, of whom 288 were women with early-stage breast cancer and 111 were women without breast cancer, matched on age and years of education to the women with breast cancer, and all at an urban cancer center.

METHODS & VARIABLES

A repeated-measures design was used; assessments occurred before adjuvant therapy and every six months post-therapy initiation. Group-based trajectory modeling determined subgroups. Multinomial logistic regression identified phenotypic and genotypic characteristics.

RESULTS

Three executive function and concentration trajectory subgroups were identified.

IMPLICATIONS FOR NURSING

Advancing age, greater pretherapy fatigue, and poorer pretherapy cognitive function are associated with the low subgroups. DNA repair and oxidative stress mechanisms may be involved in the cognitive changes that women experience.

The Relationship Between Insomnia and Cognitive Impairment in Breast Cancer Survivors

Background

Cancer-related cognitive impairment is an emerging public health burden. Growing research suggests that sleep disturbances contribute to poor cognition. Our study aimed to evaluate the association between insomnia and cognitive impairment in breast cancer survivors.

Methods

We analyzed cross-sectional data from a cohort study of postmenopausal women with stage 0–III hormone receptor-positive breast cancer on aromatase inhibitor therapy. The study was conducted between November 2011 and April 2015 at an academic cancer center (Philadelphia, PA). Insomnia was assessed with the Insomnia Severity Index. Perceived cognitive impairment was assessed with the cognitive subscale of the Breast Cancer Prevention Trial Symptom Checklist. We used linear regression to evaluate the association between insomnia and perceived cognitive impairment.

Results

Among 1072 patients, 556 (51.9%) reported insomnia and 847 (79.0%) were bothered by cognitive symptoms (forgetfulness, difficulty concentrating, distractibility). Greater perceived cognitive impairment was reported by patients with mild insomnia (regression coefficient [β] = 0.35, 95% confidence interval [CI] = 0.23 to 0.46, P < .001), moderate insomnia (β = 0.51, 95% CI = 0.36 to 0.65, P < .001), and severe insomnia (β = 0.94, 95% CI = 0.67 to 1.21, P < .001), compared with those without insomnia. Greater perceived cognitive impairment was also associated with patients younger than 55 years (β = 0.30, 95% CI = 0.15 to 0.45, P < .001), taxane-based chemotherapy (β = 0.11, 95% CI = 0.004 to 0.22, P = .04), anxiety (β = 0.47, 95% CI = 0.30 to 0.64, P < .001), and depression (β = 0.65, 95% CI = 0.35 to 0.94, P < .001).

Conclusions

Among postmenopausal breast cancer survivors receiving aromatase inhibitor therapy, insomnia and cognitive impairment are prevalent and characterized by a graded association, in which severity of perceived cognitive impairment increases as insomnia severity increases. Our findings warrant further research to determine whether addressing sleep is a strategy to improve management of cancer-related cognitive impairment.

Cognitive effects of adjuvant endocrine therapy in older women treated for early-stage breast cancer: a 1-year longitudinal study

PURPOSE

Evidence suggests endocrine therapy (ET) for breast cancer (BC) has adverse cognitive effects, but its specific effects on older women are unknown. This is despite the fact that older women are at increased risk of both breast cancer (BC) and cognitive decline relative to younger women. This study prospectively examined the cognitive effects of ET in a cohort of older BC patients. Our primary outcome measure was change in verbal memory, the cognitive domain most consistently affected by estrogen deprivation.

METHODS

Forty-two chemotherapy-naïve women age 60+, without dementia and recently diagnosed with hormone receptor-positive BC, completed neuropsychological tests at the time of ET initiation and after 1 year of treatment. Change in age-standardized verbal memory performance was examined using paired t tests. To assess a broader range of potential cognitive effects, we also examined changes in visual memory, processing speed, frontal executive function, and perceptual reasoning.

RESULTS

Participants exhibited significant decline from baseline to 1 year in verbal memory (p = 0.01). This decline was small to moderate in effect size (d = - 0.40). Performance on other domains did not change significantly over the year (all p > 0.05).

CONCLUSIONS

Our findings suggest potentially detrimental effects of ET on verbal memory in older women after just 1 year of treatment. Given that ET is prescribed for courses of 5 to 10 years, additional studies examining longer-term effects of treatment in older women are critical.

The cognitive effects of endocrine therapy in survivors of breast cancer: A prospective longitudinal study up to 6 years after treatment

BACKGROUND

After treatment of primary breast cancer, endocrine therapy (ET) is prescribed for patients with hormone receptor-positive cancers. Despite ET recommendations of 5 to 10 years of treatment, to the authors' knowledge there is little prospective study of its impact on cognitive function over an extended period of time. ET has known pharmacologic effects on the brain. Cognitive side effects are a concern for many women, with mixed findings reported in various studies. The current prospective longitudinal study examined the neuropsychological effects of ET over time, up to 6 years after treatment.

METHODS

A total of 189 survivors of early-stage breast cancer enrolled in the study prior to initiating ET if prescribed, and were followed at 6 months (175 patients), 12 months (173 patients), and for 3 to 6 years (102 patients) with self-report and neuropsychological assessments. Using linear mixed models, the authors examined whether neuropsychological performance or impairment rates differed over time based on whether or not ET was received.

RESULTS

The authors did not find any effect of ET on neuropsychological performance or impairment at any time point among survivors who received it compared with women who did not. However, those who participated in the 3-year to 6-year year visit demonstrated better executive function at baseline.

CONCLUSIONS

In the current observational cohort study, no detrimental effect of ET on cognitive function was identified in survivors of early-stage breast cancer receiving treatment with ET compared with those who were not.

Fatigue after breast cancer treatment: Biobehavioral predictors of fatigue trajectories

OBJECTIVE

Fatigue is a common side effect of cancer treatment, but there is considerable variability in fatigue severity and persistence among survivors. This study aimed to characterize longitudinal trajectories of fatigue after breast cancer treatment and to identify predictors of varying fatigue trajectories.

METHODS

Women (N = 191) from the Mind-Body Study completed assessments after primary treatment for early stage breast cancer and at regular follow-ups that occurred up to 6 years after treatment (M = 4.3 years). Growth mixture models were used to characterize fatigue trajectories, and demographic, medical, and biobehavioral risk factors were examined as predictors of trajectory group.

RESULTS

Five trajectories were identified, characterized as High, Recovery, Late, Low, and Very Low fatigue. The High and Recovery groups (40% of sample) evidenced elevated fatigue at posttreatment that declined in Recovery but persisted in the High group. In bivariate analyses, trajectory groups differed significantly on depressive symptoms, sleep disturbance, childhood adversity, body mass index, and the inflammatory marker soluble TNF receptor type II, which were higher in the High and/or Recovery groups. In multivariate models, depressive symptoms and childhood adversity distinguished High and Recovery from other groups. Rates of chemotherapy were higher in the Recovery than in the High or Late group, whereas rates of endocrine therapy were higher in the High than in the Recovery group.

CONCLUSIONS

There are distinct longitudinal trajectories of fatigue after breast cancer treatment. Psychological factors are strongly associated with adverse fatigue trajectories, and together with treatment exposures may increase risk for cancer-related fatigue. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Cognitive performance in survivors of breast cancer and markers of biological aging

BACKGROUND

Biological aging pathways accelerated by cancer treatments may be a mechanism for cognitive impairment in cancer survivors. The goal of the current study was to examine whether indicators of biological aging, namely elevated levels of DNA damage, reduced telomerase enzymatic activity, and shorter peripheral blood mononuclear cell (PBMC) telomere length (TL) would be related to cognitive function in a cohort of survivors of breast cancer.

METHODS

The authors evaluated a cross-sectional sample of 94 women aged 36 to 69 years who were treated for early-stage breast cancer 3 to 6 years previously. Leukocyte DNA damage, PBMC telomerase enzymatic activity, PBMC TL, and the inflammatory marker soluble tumor necrosis factor receptor II (sTNF-RII) were determined from blood samples. Cognitive function was assessed using a neuropsychological test battery and self-report. Linear regression models examined the relationship between biological aging predictors and cognitive outcomes.

RESULTS

Both higher DNA damage and lower telomerase were found to be statistically significantly related to lower executive function scores adjusting for age, body mass index, race, years from treatment, and intelligence score (standardized coefficients [B], -0.23 and 0.30; all P values <.05). In addition, lower telomerase activity was associated with worse attention and motor speed scores (B values, 0.30 and 0.24; P &lt;.05). sTNF-RII and TL were found to be unrelated to any of the neurocognitive domains.

CONCLUSIONS

The results of the current study suggest a significant association between measures of biological aging and objective measures of cognitive performance in survivors of breast cancer. Future prospective studies are needed to confirm a causal role of biological aging as a driver of declines in cognitive function after cancer treatment.

Longitudinal Trajectory and Characterization of Cancer-Related Cognitive Impairment in a Nationwide Cohort Study

PURPOSE

Cancer-related cognitive impairment (CRCI) is an important clinical problem in patients with breast cancer receiving chemotherapy. Nationwide longitudinal studies are needed to understand the trajectory and severity of CRCI in specific cognitive domains.

PATIENTS AND METHODS

The overall objective of this nationwide, prospective, observational study conducted within the National Cancer Institute Community Clinical Oncology Research Program was to assess trajectories in specific cognitive domains in patients with breast cancer (stage I-IIIC) receiving chemotherapy, from pre- (A1) to postchemotherapy (A2) and from prechemotherapy to 6 months postchemotherapy (A3); controls were assessed at the same time-equivalent points. The primary aim assessed visual memory using the Cambridge Neuropsychological Test Automated Battery Delayed Match to Sample test by longitudinal mixed models including A1, A2, and A3 and adjusting for age, education, race, cognitive reserve score, and baseline anxiety and depressive symptoms. We also assessed trajectories of CRCI in other aspects of memory as well as in attention and executive function with computerized, paper-based, and telephone-based cognitive tests.

RESULTS

In total, 580 patients with breast cancer (mean age, 53.4 years) and 363 controls (mean age, 52.6 years) were assessed. On the Delayed Match to Sample test, the longitudinal mixed model results revealed a significant group-by-time effect ( P < .005); patients declined over time from prechemotherapy (A1) to 6 months postchemotherapy (A3; P = .005), but controls did not change ( P = .426). The group difference between patients and controls was also significant, revealing declines in patients but not controls ( P = .017). Several other models of computerized, standard, and telephone tests indicated significantly worse performance by patients compared with controls from pre- to postchemotherapy and from prechemotherapy to 6 months postchemotherapy.

CONCLUSION

This nationwide study showed CRCI in patients with breast cancer affects multiple cognitive domains for at least 6 months postchemotherapy.

Exploratory Study of Associations Between DNA Repair and Oxidative Stress Gene Polymorphisms and Cognitive Problems Reported by Postmenopausal Women With and Without Breast Cancer

PURPOSE

Women with breast cancer report varying frequencies of cognitive problems during adjuvant systemic therapy. This variability suggests latent subgroups. Therefore, we identified latent subgroups of self-reported cognitive problems among postmenopausal women with and without breast cancer. We explored associations between membership in these subgroups and (a) demographic, clinical, and symptom characteristics and (b) variations in candidate gene polymorphisms.

METHODS

We evaluated frequency of cognitive problems using the Patient Assessment of Own Functioning Inventory. Growth mixture modeling identified latent subgroups over 18 months of adjuvant systemic therapy and at matched time points for women without cancer ( N = 331). We evaluated for differences among subgroups in demographic, clinical, and symptom characteristics and in 41 single nucleotide polymorphisms in 10 candidate genes involved in DNA repair and oxidative stress pathways ( n = 199). We modeled associations between genotypes and subgroup membership using multinomial logistic regression.

RESULTS

We identified three latent subgroups: more frequent, persistent, and almost never. Receipt of chemotherapy plus anastrozole, depressive symptoms, and baseline neuropathic symptoms increased the odds of belonging to the more frequent subgroup. Anxiety and depressive symptoms increased the odds of belonging to the persistent subgroup. With covariates controlled for, carrying the ERCC5 rs873601 G minor allele increased the odds of reporting more frequent cognitive problems.

CONCLUSIONS

Chemotherapy plus anastrozole, depressive symptoms, and presence of neuropathic symptoms may predict more frequent cognitive problems during systemic therapy that later resolve. Mood dysregulation before therapy may predict persistent cognitive problems during therapy. ERCC5 genotype may influence frequency of cognitive problems after controlling for these risk factors.

Cognitive sequelae of endocrine therapy in women treated for breast cancer: a meta-analysis

PURPOSE

Evidence suggests anti-estrogen endocrine therapy (ET) is associated with adverse cognitive effects; however, findings are based on small samples and vary in the cognitive abilities affected. We conducted a meta-analysis to quantitatively synthesize the evidence.

METHODS

Electronic databases were searched in November 2016. Fourteen studies totaling 911 BC patients on aromatase inhibitors (AIs) or tamoxifen (TAM) and 911 controls (i.e., non-cancer controls and BC controls not using ET) were included. Neuropsychological tests were categorized into six domains. Effect sizes were computed to compare (1) ET patients versus controls and (2) TAM patients versus AI patients.

RESULTS

In cross-sectional comparisons, ET patients performed worse than control groups on verbal learning/memory, visual learning/memory, frontal executive function, and processing speed, but did not differ on psychomotor efficiency or visuospatial function. Subgroup analyses revealed that verbal learning/memory was the only domain where ET patients performed worse than both non-cancer and BC controls. In other domains, ET patients and BC controls performed equivalently. Regarding change from pre-treatment performance, ET patients did not differ from controls on any domain. TAM and AI patients did not from one another differ overall; however, subgroup analyses indicated that TAM patients performed better than non-steroidal AI patients on several domains, but showed few performance differences relative to steroidal AI patients.

CONCLUSIONS

Verbal learning/memory was the only domain where ET patients performed worse than both non-cancer and BC controls, suggesting specific adverse effects on this domain. Additional studies assessing change from pre-treatment performance and differences between steroidal and non-steroidal AIs are warranted.

Biomarkers of aging associated with past treatments in breast cancer survivors

Radiation and chemotherapy are effective treatments for cancer, but are also toxic to healthy cells. Little is known about whether prior exposure to these treatments is related to markers of cellular aging years later in breast cancer survivors. We examined whether past exposure to chemotherapy and/or radiation treatment was associated with DNA damage, telomerase activity, and telomere length 3–6 years after completion of primary treatments in breast cancer survivors (stage 0–IIIA breast cancer at diagnosis). We also examined the relationship of these cellular aging markers with plasma levels of Interleukin (IL)-6, soluble TNF-receptor-II (sTNF-RII), and C-reactive protein (CRP). Ninety-four women (36.4–69.5 years; 80% white) were evaluated. Analyses adjusting for age, race, BMI, and years from last treatment found that women who had prior exposure to chemotherapy and/or radiation compared to women who had previously received surgery alone were more likely to have higher levels of DNA damage (P = .02) and lower telomerase activity (P = .02), but did not have differences in telomere length. More DNA damage and lower telomerase were each associated with higher levels of sTNF-RII (P’s < .05). We found that exposure to chemotherapy and/or radiation 3–6 years prior was associated with markers of cellular aging, including higher DNA damage and lower telomerase activity, in post-treatment breast cancer survivors. Furthermore, these measures were associated with elevated inflammatory activation, as indexed by sTNF-RII. Given that these differences were observed many years after the treatment, the findings suggest a long lasting effect of chemotherapy and/or radiation exposure.

Past exposure to chemotherapy and radiation is associated with signs of cellular aging among breast cancer survivors. Zorica Scuric, Judith Carroll, and colleagues from the University of California, Los Angeles, USA, tested markers of biological aging and inflammation in blood samples taken from women 3–6 years after their initial treatment for stage 0–IIIA breast cancer. They found that women who had received chemotherapy and/or radiation were more likely to have high levels of DNA damage, lower activity of telomerase—an enzyme involved in maintaining the length of chromosomes—and elevated inflammatory activation compared to women who underwent surgery alone. The findings point to an enduring biological effect of chemotherapy and radiation, and suggest that some breast cancer survivors may be vulnerable to accelerated aging because of their prior treatment.

Treatments for Breast Cancer That Affect Cognitive Function in Postmenopausal Women

About one of every eight women will develop breast cancer during her lifetime. Approximately a quarter of a million new cancer cases are expected in 2017. Of those breast cancers, 60% to 75% will have characteristics suggesting that estrogens are likely to promote growth of those tumors. Consequently, inhibiting estrogen synthesis is one of the main treatments of choice. Therefore, women must understand the potential adverse effects of those treatments on quality of life. This review discusses (a) the role of estrogens locally synthesized in the brain in laboratory animals and women, (b) the effects of estrogens and blockers of estrogen synthesis on cognitive function, and (c) the limitations in experiments on women taking inhibitors. This article aims to provide women and oncologists with information that will encourage them to consider side effects of aromatase inhibitors (AIs) treatment on the brain.

Evaluating cognitive complaints in breast cancer survivors with the FACT-Cog and quantitative electroencephalography

PURPOSE

Targeted methods for evaluating cognitive dysfunction in breast cancer survivors are needed to effectively address this important survivorship issue. To address this need, we examined the validity of a self-report instrument (The functional assessment of cancer therapy: cognitive function; FACT-Cog) regarding correspondence with neuropsychological performance versus depression and evaluated neurophysiological biomarkers of cognition and depressed mood in a sample of breast cancer survivors several years from diagnosis.

METHODS

This is a cross-sectional study sample from the prospective observational Mind Body Study. Recruited participants were breast cancer survivors at least 3 years from cancer diagnosis who were part of a longitudinal cohort, and were without current psychiatric disorder or history of a neurological or cognitive disorder at baseline (after completion of primary cancer treatment). Exploratory analysis of the FACT-Cog and quantitative electroencephalography (qEEG) were conducted, with respect to their association with neuropsychological domain scores and depressive symptoms as measured by the Beck Depression Inventory, 2nd edition (BDI-II).

RESULTS

Self-reported cognitive abilities and the impact of cognitive dysfunction on quality of life were associated with memory function in addition to depressive symptoms in our sample of breast cancer survivors. qEEG measures exhibit differential patterns of association with neuropsychological performance and mood.

CONCLUSIONS

Our findings indicate that perceived cognitive abilities and the impact of cognitive difficulties on quality of life are valid indicators of objective cognitive function, independent of depressive symptoms. Neurophysiological correlates of cognitive function and depressive symptoms represent promising biomarkers of these behavioral difficulties in survivorship.

Perceived cognitive function for breast cancer survivors: association of genetic and behaviorally related variables for inflammation

PURPOSE

We explored relationships between genetic variability and behaviorally related variables (body mass index and exercise frequency) for inflammation, and perceived cognitive function (PCF) for breast cancer survivors (BCS). Our primary aim was to explore relationships between select single-nucleotide polymorphisms (SNPs) for IL1R1, IL6, TNF genes, and PCF. Our secondary aim was to explore whether body mass index (BMI) and exercise frequency moderate these relationships.

METHODS

We conducted an exploratory candidate gene substudy. Saliva samples from participants (N = 101) in a larger, cross-sectional study were genotyped. Multiple linear regression analysis was used to explore relationships between SNPs and PCF, controlling for age, education level, fatigue, and distress. Hierarchical expansion of regression models included main effects for BMI and exercise frequency and interaction effects between BMI, exercise frequency, and each SNP.

RESULTS

The most parsimonious regression model included fatigue, exercise frequency, and IL1R1rs2287047 minor alleles (AA+GG) (R ² = 0.244, adjusted R ² = 0.220, p = 0.013). No other SNPs were significant. Higher exercise frequency (b = 7.300, p = 0.013) and IL1R1rs2287047 (AA+AG) (b = 6.512, p = 0.025) predicted better PCF. Greater fatigue predicted poorer PCF (b = -2.359, p < 0.01). No interaction was demonstrated between BMI and exercise related to PCF or between BMI, exercise, and SNPs.

CONCLUSIONS

Our results suggest a protective relationship between IL1R1rs2287047 (AA+AG) and PCF and provide further evidence supporting exercise as a potential intervention for poorer PCF. Ours is the first study to investigate genetic variability associated with inflammation, behaviorally related variables, and PCF for BCS.

Cognitive Complaints in Survivors of Breast Cancer After Chemotherapy Compared With Age-Matched Controls: An Analysis From a Nationwide, Multicenter, Prospective Longitudinal Study

Purpose Cancer-related cognitive impairment is an important problem for patients with breast cancer, yet its trajectory is not fully understood. Some previous cancer-related cognitive impairment research is limited by heterogeneous populations, small samples, lack of prechemotherapy and longitudinal assessments, use of normative data, and lack of generalizability. We addressed these limitations in a large prospective, longitudinal, nationwide study. Patients and Methods Patients with breast cancer from community oncology clinics and age-matched noncancer controls completed the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) at prechemotherapy and postchemotherapy and at a 6-month follow-up as an a priori exploratory aim. Longitudinal models compared FACT-Cog scores between patients and controls at the three assessments and adjusted for age, education, race, menopausal status, and baseline reading ability, anxiety, and depressive symptoms. A minimal clinically important difference cutoff determined percentages of impairment over time. Results Of patients, 581 patients with breast cancer (mean age, 53 years; 48% anthracycline-based regimens) and 364 controls (mean age, 53 years) were assessed. Patients reported significantly greater cognitive difficulties on the FACT-Cog total score and four subscales from prechemotherapy to postchemotherapy compared with controls as well as from prechemotherapy to 6-month follow-up (all P < .001). Increased baseline anxiety, depression, and decreased cognitive reserve were significantly associated with lower FACT-Cog total scores. Treatment regimen, hormone, or radiation therapy was not significantly associated with FACT-Cog total scores in patients from postchemotherapy to 6-month follow-up. Patients were more likely to report a clinically significant decline in self-reported cognitive function than were controls from prechemotherapy to postchemotherapy (45.2% v 10.4%) and from prechemotherapy to 6-month follow-up (36.5% v 13.6%). Conclusion Patients with breast cancer who were treated in community oncology clinics report substantially more cognitive difficulties up to 6 months after treatment with chemotherapy than do age-matched noncancer controls.

Cognitive Complaints in Survivors of Breast Cancer After Chemotherapy Compared With Age-Matched Controls: An Analysis From a Nationwide, Multicenter, Prospective Longitudinal Study

Purpose Cancer-related cognitive impairment is an important problem for patients with breast cancer, yet its trajectory is not fully understood. Some previous cancer-related cognitive impairment research is limited by heterogeneous populations, small samples, lack of prechemotherapy and longitudinal assessments, use of normative data, and lack of generalizability. We addressed these limitations in a large prospective, longitudinal, nationwide study. Patients and Methods Patients with breast cancer from community oncology clinics and age-matched noncancer controls completed the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) at prechemotherapy and postchemotherapy and at a 6-month follow-up as an a priori exploratory aim. Longitudinal models compared FACT-Cog scores between patients and controls at the three assessments and adjusted for age, education, race, menopausal status, and baseline reading ability, anxiety, and depressive symptoms. A minimal clinically important difference cutoff determined percentages of impairment over time. Results Of patients, 581 patients with breast cancer (mean age, 53 years; 48% anthracycline-based regimens) and 364 controls (mean age, 53 years) were assessed. Patients reported significantly greater cognitive difficulties on the FACT-Cog total score and four subscales from prechemotherapy to postchemotherapy compared with controls as well as from prechemotherapy to 6-month follow-up (all P < .001). Increased baseline anxiety, depression, and decreased cognitive reserve were significantly associated with lower FACT-Cog total scores. Treatment regimen, hormone, or radiation therapy was not significantly associated with FACT-Cog total scores in patients from postchemotherapy to 6-month follow-up. Patients were more likely to report a clinically significant decline in self-reported cognitive function than were controls from prechemotherapy to postchemotherapy (45.2% v 10.4%) and from prechemotherapy to 6-month follow-up (36.5% v 13.6%). Conclusion Patients with breast cancer who were treated in community oncology clinics report substantially more cognitive difficulties up to 6 months after treatment with chemotherapy than do age-matched noncancer controls.

The Impact of Endocrine Therapy on Cognitive Functions of Breast Cancer Patients: A Systematic Review

BACKGROUND AND OBJECTIVE

The purpose of the present review was to study the impact of endocrine therapy (ET) on the cognitive outcomes of breast cancer patients.

MATERIALS AND METHODS

We systematically searched the literature using the MEDLINE (1966-2015), Scopus (2004-2015), ClinicalTrials.gov (2008-2015) and Cochrane Central Register (CENTRAL) databases, as well as the references of the electronically retrieved articles.

RESULTS

Twelve studies were included in the present systematic review, which assessed the cognitive function of 2756 patients. Among these patients, 2381 received ET, whereas the remaining 375 served as controls (placebo or no therapy). The majority of patients were postmenopausal, and the minimum follow-up period was 3 months and the maximum 2 years. Treatment with ET seems to be accompanied by altered cognitive abilities, including verbal memory, verbal fluency, motor speed, attention and working memory. Tamoxifen seems to be related to decreased cognitive performances compared with treatment with an aromatase inhibitor.

CONCLUSIONS

ET among breast cancer patients seems to negatively alter the cognitive outcomes of breast cancer patients. However, the methodological heterogeneity of the included studies, as well as the relatively small follow-up period, render imperative the conduct of further studies in the field.

Over-irradiation

Decreasing the burden of radiation therapy (RT) for breast cancer includes, next to complete omission, several ways to tailor the extent of RT. Possible options for this include lowering of the total dose, such as selective omission of the boost, hypofractionated RT to shorten the duration of treatment, the selective introduction of partial breast irradiation and anatomy based target volume contouring to decrease the size of the irradiated volumes. Elective regional nodal irradiation showed in several randomised trials and meta-analyses to significantly impact on local-regional control, disease-free survival, breast cancer mortality and overall survival. The generalisability of these results remains complex in the light of the decreasing use of axillary lymph node dissection, the use of more effective adjuvant systemic therapy, the increasing use of primary systemic therapy and continuously improving RT techniques. In general, the use of RT compensates for the decreasing extent of surgery to the breast and the axillary lymph nodes, eliminating residual tumour cells while maintaining better aesthetic and functional results. In some occasions, however, the indications for the extent of RT have to be based on limited pathological staging information. Research is ongoing to individualise RT more on the basis of biological factors including gene expression profiles. When considering age, treatment decisions should rather be based on biological instead of formal age. The aim of this review article is to put current evidence into the right perspective, and to search for an appropriate appreciation of the balance between efficacy and side effects of local-regional RT.

Long-term trajectories of self-reported cognitive function in a cohort of older survivors of breast cancer: CALGB 369901 (Alliance)

BACKGROUND

The number of survivors of breast cancer aged ≥65 years (“older”) is growing, but to the authors' knowledge, little is known regarding the cognitive outcomes of these individuals.

METHODS

A cohort of cognitively intact older survivors with nonmetastatic, invasive breast cancer was recruited from 78 sites from 2004 through 2011; approximately 83.7% of the survivors (1280 survivors) completed baseline assessments. Follow‐up data were collected at 6 months and annually for up to 7 years (median, 4.1 years). Cognitive function was self‐reported using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ‐C30); scores ranged from 0 to 100, with a higher score indicating better function. Group‐based trajectory modeling determined trajectories; women were assigned to a trajectory group based on the highest predicted probability of membership. Multinomial logistic regression evaluated the association between receipt of chemotherapy (with or without hormonal treatment) and trajectory group.

RESULTS

Survivors were aged 65 to 91 years; approximately 41% received chemotherapy. There were 3 cognitive trajectories: “maintained high” (42.3% of survivors); “phase shift” (50.1% of survivors), with scores slightly below but parallel to maintained high; and “accelerated decline” (7.6% of survivors), with the lowest baseline scores and greatest decline (from 71.7 [standard deviation, 19.8] to 58.3 [standard deviation, 21.9]). The adjusted odds of being in the accelerated decline group (vs the maintained high group) were 2.1 times higher (95% confidence interval, 1.3‐3.5) for survivors who received chemotherapy (with or without hormonal therapy) versus those treated with hormonal therapy alone. Greater comorbidity and frailty also were found to be associated with accelerated decline.

CONCLUSIONS

Trajectory group analysis demonstrated that the majority of older survivors maintained good long‐term self‐reported cognitive function, and that only a small subset who were exposed to chemotherapy manifested accelerated cognitive decline. Future research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline. Cancer 2016;122:3555–3563. © 2016 American Cancer Society

Among older survivors of breast cancer who were followed for up to 7 years, approximately 42% reported maintaining high cognitive function, but receipt of chemotherapy (with or without hormonal therapy) appeared to double the odds of being in the group that reported accelerated cognitive decline (vs maintaining high function), compared with receiving hormonal treatment alone. Further research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline.