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

Randomized Controlled Trial of Virtually Delivered Cognitive Behavioral Therapy for Insomnia to Address Perceived Cancer-Related Cognitive Impairment in Cancer Survivors

PURPOSE

Comorbid insomnia and cancer-related cognitive impairment (CRCI) are experienced by up to 26% of individuals diagnosed with cancer. This study examined the efficacy and durability of cognitive behavioral therapy for insomnia (CBT-I) on perceived CRCI in cancer survivors.

METHODS

Atlantic Canadian cancer survivors with insomnia and CRCI were randomly assigned to receive seven weekly virtual CBT-I sessions (n = 63) or placed in a waitlist control group (n = 69) to receive treatment after the waiting period. Participants completed assessments at baseline, 1 month (mid-treatment), and 2 months (post-treatment). Age- and education-adjusted mixed-effects models using intention-to-treat principles assessed change at post-treatment. Data from both groups were then pooled to assess the durability of effects at 3 and 6 months. A mediation analysis examined whether change in insomnia symptoms mediated the effect of CBT-I on cognitive outcomes.

RESULTS

The mean age of the sample was 60 years, 77% were women, and breast cancer was the most common diagnosis (41%). The treatment group reported an 11.35-point reduction in insomnia severity, compared with a 2.67-point reduction in the waitlist control group (P < .001). The treatment group had a greater overall improvement than the waitlist control on perceived cognitive impairment (P < .001; d = 0.75), cognitive abilities (P < .001; d = 0.92), and impact on quality of life (P < .001; d = 1.01). These improvements were maintained at follow-up. Change in insomnia symptoms fully mediated the effect of CBT-I on subjective cognitive outcomes.

CONCLUSION

Treating insomnia with CBT-I produces clinically meaningful and durable improvements in CRCI. There is an urgent need increase access to evidence-based treatment for insomnia in cancer centers and the community.

Personal Resources and Total Pain: Exploring the Multiple Mediation of Fear of Recurrence, Meaning-Making, and Coping in Posttreatment Cancer Patients

BACKGROUND

People with cancer who have completed treatment still experience negative effects, such as an increased risk of experiencing cancer-related pain. Psychological factors tend to influence cancer patients' ability to cope with pain in various dimensions. Although personal resources are an important factor in buffering total pain, still little is known about the intervening variables and underlying mechanisms.

PURPOSE

The current study examined the relationship between psychological flexibility, self-esteem, and total pain, while considering fear of recurrence, meaning-making, and coping as potential mediating factors.

METHODS

Adults (N = 304) who completed medical treatment (radiotherapy, chemotherapy, and combined therapy) participated in this study. They completed questionnaires measuring the aforementioned variables. Structural equation models were used to examine mediation effects.

RESULTS

Psychological flexibility, and partly self-esteem, were negatively related to the dimensions of total pain. However, to a large extent, these relationships were serially and parallelly mediated by fear of recurrence, meaning-making, and emotion-oriented coping.

CONCLUSIONS

Consistent with the meaning-making model, cognitive (meaning-making), and affective (fear of recurrence and emotional coping) factors may be potential mechanisms underlying the association between psychological flexibility, self-esteem, and total pain in posttreatment cancer patients. In this study, they tended to interact in the area of physiological and psychosocial experiences of cancer-related pain.

The Mediating Effect of Coping Style in the Relationship Between Sleep Quality and Perceived Cognitive Impairment Among Breast Cancer Patients: A Cross-sectional Study

BACKGROUND

Perceived cognitive impairment is a significant symptom experienced by breast cancer patients and may be affected by sleep quality. Coping styles have potential relevancies with both sleep quality and perceived cognitive impairment. However, the empirical evidence supporting their association among breast cancer patients is limited.

OBJECTIVE

This study explored the associations between sleep quality, coping styles, and perceived cognitive impairment and tested the mediating role of coping styles in breast cancer patients.

METHODS

A total of 294 breast cancer patients were included in this cross-sectional study. Patients were assessed using the Pittsburgh Sleep Index Scale, the Simplified Coping Styles Questionnaire, and the Functional Assessment of Cancer Therapy-Cognitive Functioning (Version 3) Scale. The data were analyzed using SPSS and Process macros.

RESULTS

The direct effect of sleep quality on reported cognitive impairment was significant (β = -0.245, P < .001). Furthermore, sleep quality was found to have a significant indirect effect on perceived cognitive impairment through positive coping style (β = -0.026, P < .05) and negative coping style (β = -0.131, P < .05).

CONCLUSIONS

Our research suggests that sleep quality has both a direct effect on perceived cognitive impairment and an indirect effect through positive and negative coping styles in breast cancer patients. Moreover, negative coping style had a more pronounced mediating effect than positive coping style.

IMPLICATIONS FOR PRACTICE

Clinical medical staff could reduce the perceived cognitive impairment of breast cancer patients by improving their sleep quality and encouraging them to adopt a more positive coping style.

Neuropsychological test performance and self-reported cognitive functioning associated with work-related outcomes in occupationally active cancer survivors with cognitive complaints

PURPOSE

To assess cognitive functioning in occupationally active non-central nervous system cancer survivors with cognitive complaints using neuropsychological tests, and to investigate the association between (1) formally assessed cognitive functioning and self-reported work-related outcomes and (2) self-reported cognitive functioning at work and self-reported work-related outcomes.

METHODS

Baseline data of a multicenter, randomized controlled trial (n = 279) were used. Associations between neuropsychological test performance (Amsterdam Cognition Scan) and self-reported cognitive functioning (Cognitive Symptom Checklist-work) with work ability (Work Ability Index) and work functioning (Work Role Functioning Questionnaire) were examined using multivariate linear regression.

RESULTS

Thirty percent of cancer survivors had lower than expected performance on neuropsychological tests. Higher overall neuropsychological test performance was associated with better work ability (Cohen's f2 = 0.014) and physical functioning at work (Cohen's f2 = 0.13). Furthermore, higher motor performance was associated with better work ability (Cohen's f2 = 0.018). In addition, self-reported work-related cognitive complaints were associated with self-reported work-related outcomes (Cohen's f2 = 0.13-0.35).

CONCLUSIONS

The percentage of cancer survivors with lower than expected performance on neuropsychological tests exceeded the percentage expected in a normal population. This neuropsychological test performance was weakly associated with various aspects of work ability and work functioning. Stronger associations were found between self-reported cognitive functioning at work with self-reported work-related outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

A cognitive rehabilitation approach that specifically aims at reducing cognitive symptoms at work could be a valuable part of interventions that aim to improve work-related outcomes. Trial registration The study is registered at ClinicalTrials.gov (NCT03900806) at 03 April 2019 (current status: ongoing), https://clinicaltrials.gov/ct2/show/NCT03900806?term=NCT03900806&draw=2&rank=1.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CANCER SURVIVORS

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

Prediction of cognitive decline in older breast cancer survivors: the Thinking and Living with Cancer study

PURPOSE

Cancer survivors commonly report cognitive declines after cancer therapy. Due to the complex etiology of cancer-related cognitive decline (CRCD), predicting who will be at risk of CRCD remains a clinical challenge. We developed a model to predict breast cancer survivors who would experience CRCD after systematic treatment.

METHODS

We used the Thinking and Living with Cancer study, a large ongoing multisite prospective study of older breast cancer survivors with complete assessments pre-systemic therapy, 12 months and 24 months after initiation of systemic therapy. Cognition was measured using neuropsychological testing of attention, processing speed, and executive function (APE). CRCD was defined as a 0.25 SD (of observed changes from baseline to 12 months in matched controls) decline or greater in APE score from baseline to 12 months (transient) or persistent as a decline 0.25 SD or greater sustained to 24 months. We used machine learning approaches to predict CRCD using baseline demographics, tumor characteristics and treatment, genotypes, comorbidity, and self-reported physical, psychosocial, and cognitive function.

RESULTS

Thirty-two percent of survivors had transient cognitive decline, and 41% of these women experienced persistent decline. Prediction of CRCD was good: yielding an area under the curve of 0.75 and 0.79 for transient and persistent decline, respectively. Variables most informative in predicting CRCD included apolipoprotein E4 positivity, tumor HER2 positivity, obesity, cardiovascular comorbidities, more prescription medications, and higher baseline APE score.

CONCLUSIONS

Our proof-of-concept tool demonstrates our prediction models are potentially useful to predict risk of CRCD. Future research is needed to validate this approach for predicting CRCD in routine practice settings.

Quality of working life can protect against cognitive and emotional vulnerability in women living with metastatic breast cancer: a cross-sectional study

PURPOSE

Research focusing on the cognitive and emotional health of women with metastatic breast cancer (MBC) is limited. The focal aim of the current study was to explore how quality of working life was related to global health, perceived cognitive function, anxiety and depression. To this end, women's experience of employers after MBC diagnosis and its relationship to quality of working life was also explored.

METHODS

Women living with MBC (N = 88) completed online questionnaires assessing their global health status, perceived cognitive and emotional vulnerability and their experience of employers following diagnosis. Women working at the time of the study also reported on their quality of working life.

RESULTS

Women's experience of employers after MBC diagnosis was positively related to their quality of working life. Importantly, greater quality of working life met with better perceived cognitive function and global health, as well as lower levels of depression in working women.

CONCLUSIONS

Our study is the first to establish the role of quality of working life in protecting against levels of cognitive vulnerability and emotional vulnerability to depression in women with MBC. We also highlight the importance of having a positive experience with employers. Our findings suggest that educational programmes can be provided to employers to enhance their understanding and awareness of the needs of women with MBC.

IMPLICATIONS FOR CANCER SURVIVORS

Women with MBC may benefit from employers accessing educational (or support) programmes that can increase their awareness of the treatment-related sequelae and needs of women with MBC in the workplace.

Caregivers' perception of patients' interpersonal and psychiatric alterations: What is the impact on their health?

PURPOSE

Previous research conducted among caregivers of patients with cancer revealed a poor Quality of Life (QoL) and high levels of distress. In addition to the influence of patients' clinical state, caregivers' appraisals of patients' difficulties should be considered as another predictor of poor caregiver health. This study aims to test the association between caregivers' health (i.e., QoL, depression and anxiety) and their perception of patients' difficulties.

METHODS

199 caregivers of patients with cancer completed an online survey based on questionnaires measuring their QoL, depression and anxiety, as well as their perception of patients' cognitive, emotional, functional, psychiatric and interpersonal difficulties.

RESULTS

It was found that the appraisal of patients' impairments in all domains was mainly correlated with poor caregivers' QoL (Pearson correlations ranged from 0.14 to 0.45; p ≤ .05). Furthermore, linear regression analyses showed that, after controlling for age, sex education level, professional activity and living with or without the patient, the appraisal of patients' interpersonal abilities (β = 0.25, p ≤ .05), psychiatric difficulties (β = -0.25, p ≤ .01) and living with the patient were the main predictors of caregivers' QoL.

CONCLUSION

This study highlights the importance of better understanding the role of patients' social and psychiatric difficulties when examining caregivers' health. This indicates the importance of providing support and offering information to caregivers to alert them to the role of patients' social and psychiatric difficulties on their own health. Future studies should better understand how these difficulties are associated with caregivers' perception of identity/sociability alterations in patients and how caregivers cope with these changes.

Depression, Inflammation, and Intestinal Permeability: Associations with Subjective and Objective Cognitive Functioning throughout Breast Cancer Survivorship

About one-in-three breast cancer survivors have lingering cognitive complaints and objective cognitive impairment. Chronic inflammation and intestinal permeability (i.e., leaky gut), two risk factors for cognitive decline, can also fuel depression-another vulnerability for cognitive decline. The current study tested whether depression accompanied by high levels of inflammation or intestinal permeability predicted lower subjective and objective cognitive function in breast cancer survivors. We combined data from four breast cancer survivor studies (n = 613); some had repeated measurements for a total of 1015 study visits. All participants had a blood draw to obtain baseline measures of lipopolysaccharide binding protein-a measure of intestinal permeability, as well as three inflammatory markers that were incorporated into an inflammatory index: C-reactive protein, interleukin-6, and tumor necrosis factor-α. They reported depressive symptoms on the Center for Epidemiological Studies depression scale (CES-D), and a binary variable indicated clinically significant depressive symptoms (CES-D ≥ 16). The Kohli (749 observations) and the Breast Cancer Prevention Trial (591 observations) scales assessed subjective cognitive function. Objective cognitive function tests included the trail-making test, Hopkins verbal learning test, Conners continuous performance test, n-back test, FAS test, and animal-naming test (239-246 observations). Adjusting for education, age, BMI, cancer treatment type, time since treatment, study visit, and fatigue, women who had clinically elevated depressive symptoms accompanied by heightened inflammation or intestinal permeability reported poorer focus and marginally poorer memory. However, poorer performance across objective cognitive measures was not specific to inflammation-associated depression. Rather, there was some evidence of lower verbal fluency; poorer attention, verbal learning and memory, and working memory; and difficulties with visuospatial search among depressed survivors, regardless of inflammation. By themselves, inflammation and intestinal permeability less consistently predicted subjective or objective cognitive function. Breast cancer survivors with clinically significant depressive symptoms accompanied by either elevated inflammation or intestinal permeability may perceive greater cognitive difficulty, even though depression-related objective cognitive deficits may not be specific to inflammation- or leaky-gut-associated depression.

Neuroimaging based biotypes for precision diagnosis and prognosis in cancer-related cognitive impairment

Cancer related cognitive impairment (CRCI) is commonly associated with cancer and its treatments, yet the present binary diagnostic approach fails to capture the full spectrum of this syndrome. Cognitive function is highly complex and exists on a continuum that is poorly characterized by dichotomous categories. Advanced statistical methodologies applied to symptom assessments have demonstrated that there are multiple subclasses of CRCI. However, studies suggest that relying on symptom assessments alone may fail to account for significant differences in the neural mechanisms that underlie a specific cognitive phenotype. Treatment plans that address the specific physiologic mechanisms involved in an individual patient's condition is the heart of precision medicine. In this narrative review, we discuss how biotyping, a precision medicine framework being utilized in other mental disorders, could be applied to CRCI. Specifically, we discuss how neuroimaging can be used to determine biotypes of CRCI, which allow for increased precision in prediction and diagnosis of CRCI via biologic mechanistic data. Biotypes may also provide more precise clinical endpoints for intervention trials. Biotyping could be made more feasible with proxy imaging technologies or liquid biomarkers. Large cross-sectional phenotyping studies are needed in addition to evaluation of longitudinal trajectories, and data sharing/pooling is highly feasible with currently available digital infrastructures.

The Effect of a Home-Based Tele-Exercise Training Program on the Quality of Life and Physical Performance in Breast Cancer Survivors

The number of breast cancer (BCa) survivors has been steadily increasing due to advances in anti-cancer treatments, though these individuals suffer from various cancer- and treatment-related long-term side effects. The present study aimed at investigating the effects of a home-based tele-exercise training intervention on physical- and mental health-associated parameters in BCa survivors. A total of 13 female BCa survivors (age: 58.31 ± 3.13 years, BMI: 25.68 ± 0.62 kg/m², waist circumference: 96.54 ± 1.84 cm) participated in a two-month group tele-exercise program twice per week which included aerobic, resistance and flexibility exercises. The results of the study revealed that the tele-exercise intervention improved participants' body mass index (BMI) (p < 0.001), waist circumference (p < 0.001), cardiorespiratory fitness (6 min walk test) (p < 0.001) and muscle function (sit to stand (p < 0.01), sit ups (p < 0.001) and push-ups (p < 0.001)). Beneficial effects were also observed on perceived anxiety (Zung Self-Rating Anxiety Scale) (p < 0.001), post-traumatic stress disorder (PTSD) symptoms (PCL-C) (p < 0.01), self-reported fatigue (p < 0.001), quality of life (QoL) (p < 0.05) and physical (p < 0.05), cognitive (p < 0.01) and emotional (p < 0.05) functioning (EORTQ-QLQ-C30). Our findings suggest that common cancer- and treatment-related adverse effects on physical performance, mental health and the overall QoL can be ameliorated through tele-exercise training programs in BCa survivors.

Anxiety, depression, and concentration in cancer survivors: National Health and Nutrition Examination Survey results

PURPOSE

We report on prevalence of anxiety, depression, and concentration difficulties and their associations in survivors of cancer in a nationally representative sample up to 25 years after diagnosis.

METHODS

Using the National Health and Nutrition Examination Survey (NHANES) data from 2015 to 2018, participants between the ages of 18 and 79 self-reported on cancer history, symptoms of anxiety, depression, and difficulties with concentration.

RESULTS

Of 10,337 participants, 691 (6.7%) reported a previous diagnosis of cancer; the median time since diagnosis was 8 years. Prevalence was similar between those with and without cancer for anxiety (45.8% versus 46.9%) and depression (19.7% versus 20.0%). Concentration difficulties were more common (11.3% versus 9.0%) for those with a history of cancer compared to those without (adjusted OR = 1.38, 95% CI: 1.00-1.90). Prevalence of mental health symptoms was not related to time since diagnosis. Anxiety and depression were highly correlated (r = 0.81, 95% CI: 0.74-0.86) and moderately correlated with difficulty with concentration (r = 0.52, 95%CI: 0.40-0.64 and r = 0.64, 95% CI: 0.53-0.74 respectively).

CONCLUSIONS

Difficulty with concentration was more commonly reported by participants with than without a cancer history. Report of anxiety and depression was no different between participants with and without a history of cancer. Anxiety, depression, and difficulties with concentration were strongly related. Further research is needed to explore if there is a causal association, and if so, the direction of these correlations, so that interventions may be appropriately targeted.

The Efficacy of Reminiscence Therapy in Cancer-Related Symptom Management: A Systematic Review and Meta-Analysis

BACKGROUND

At present, simple reminiscence has been widely used in the field of neurocognitive disorders, life review/life review therapy has been widely used in the field of cancer, and both simple reminiscence and life review/life review therapy are suitable for psychological disorders such as depression and anxiety. However, the efficacy of reminiscence in treating cancer-related symptom has not been fully assessed.

OBJECTIVES

To evaluate the effect of reminiscence therapy (RT) on relieving cancer-related symptoms such as anxiety and depression in cancer survivals.

METHODS

China National Knowledge Infrastructure (CNKI), VIP database, Wanfang Data Knowledge Service Platform, China Biomedical Database, PubMed, Cochrane Library, Embase, EBSCO, Scopus, and Ovid databases were searched. To collect clinical randomized controlled trials (RCT) on RT and cancer-related studies published from the establishment of the database to October 05, 2021. Two researchers independently evaluated the articles that met the inclusion criteria, meta-analysis was performed using RevMan5.4 software.

RESULTS

A total of 20 RCTs published in 2010 to 2021 were included, with a total of 1853 cancer patients. Meta-analysis results showed that the anxiety scale (HADS-A and HAMA and SAS) and depression scale (HADS-D and HAMD and SDS) scores of the RT group were significantly lower than those of the control group (HADS-A: P = .0002; HAMA: P < .00001; SAS: P = .0010; HADS-D: P = .01; HAMD: P < .00001; SDS: P = .0001). Meta-analysis results showed that RT can improve overall quality of life of cancer patients of RT group to a certain extent hope (P < .00001). Meta-analysis results showed that the scores on the hope and dignity were significantly increased, and the difference were statistically significant (P < .001).

CONCLUSION

This review indicates that RT has significant efficacy on cancer-related symptoms such as anxiety and depression. RT for cancer survivals can effectively improve quality of life, self-hope, and self-esteem. The findings of this meta-analysis can provide direction for future symptom management research.

The Relationship Between Self-reported Cognitive Abilities and Psychological Symptoms in Breast Cancer Survivors

BACKGROUND

Many breast cancer survivors (BCSs) report numerous symptoms following cancer treatment, including cognitive concerns and psychological symptoms (anxiety and depression). However, the association among these symptoms is not well understood.

OBJECTIVES

The objectives were to, primarily, examine the relationship between self-reported cognitive ability and psychological symptoms (anxiety and depressive symptoms) controlling for potential confounders of age, education, and time posttreatment and, secondarily, examine the relationship between self-reported cognitive domains (attention, language, visuoperception, visual memory, and verbal memory) and psychological symptoms.

METHODS

This secondary data analysis pooled data from 2 theoretically and conceptually congruent, institutional review board-approved studies of BCSs. Breast cancer survivors completed the Multiple Ability Self-report Questionnaire (cognitive ability), Spielberger State Trait Anxiety Inventory-State (anxiety), and Center for Epidemiological Studies-Depression Scale (depressive symptoms). Data were analyzed using descriptive statistics, Pearson correlations, and separate linear regression.

RESULTS

One hundred fifty-five BCSs who were on average 54.8 (SD, 8.9) years of age, approximately 5 years (mean, 5.2 [SD, 3.8] years) posttreatment, and well-educated (mean, 15.2 [SD, 2.2] years) completed questionnaires. In bivariate correlations, higher anxiety and depressive symptoms were significantly related to cognitive abilities in all domains ( P = <.01). In the regression model, increased anxiety was associated with poorer cognitive abilities in all domains ( P < .01).

CONCLUSIONS

Anxiety and depressive symptoms were associated with decrements in self-reported cognitive abilities among BCSs.

IMPLICATIONS FOR PRACTICE

With increasing numbers of BCSs, more research is needed to address psychological symptoms, which correlate with cognitive function. Findings from this analysis can inform clinical BCS survivorship care planning and future interventional research, focused on comprehensive symptom management.

Assessing cancer-related cognitive function in the context of everyday life using ecological mobile cognitive testing: A protocol for a prospective quantitative study

Objective

Millions of cancer survivors are at risk for cancer-related cognitive impairment (CRCI), yet accurate and accessible assessments of cognitive functioning remain limited. Ecological mobile cognitive testing (EMCT) could offer a solution. This paper presents the protocol for a study that aims to (1) establish the reliability and validity of EMCT to assess CRCI in breast cancer survivors, and (2) prospectively evaluate within-person processes (and interactions) among context, mood, and behavior that explain cognitive variability, everyday functioning, and quality of life of cancer survivors.

Methods

Participants will include breast cancer survivors (>21 years old) who are within 5 years of completing chemotherapy treatment. Participants will complete two virtual visits (baseline, follow-up) 2 months apart to assess self-reported cognitive symptoms and cognitive performance, sociodemographic characteristics, clinical history, everyday functioning, and quality of life. Between virtual visits, EMCT will be used to sample cognitive functioning every other day (28 times total). We will use linear mixed-effect regressions and single-level multiple regression models to analyze the data.

Results

We anticipate a minimum of 124 breast cancer survivors enrolling and completing data collection. Study results will be published in peer-reviewed scientific journals.

Conclusions

Our findings will have broad implications for assessing CRCI in an ecologically valid and person-centered way using EMCT. We aim to provide this protocol to aid researchers who would like to apply this approach to their studies.

Effects of physical exercise on cognitive function of breast cancer survivors receiving chemotherapy: A systematic review of randomized controlled trials

Background

Cognitive impairment has a great negative impact on quality of life for breast cancer survivors. Emerging evidence suggested that physical exercise can improve cognitive function in order adults with Alzheimer's disease. However, less is known about the effects of physical exercise on cognitive function for breast cancer survivors. The purpose of this meta-analysis was to evaluate the effect of physical exercise on cognitive function in breast cancer survivors.

Methods

EMBASE, the Cochrane Library, Web of Science and PubMed were searched from the establishment of the databases to June 2021. Randomized controlled trials were included. All analysis were conducted using the Revman 5.3.

Results

12 studies (936 participants) indicated that exercise improved self-reported cognitive function (MD 10.12, 95% CI [5.49,14.76], p < 0.0001), cognitive fatigue (MD -5.41, 95% CI [-10.31,-0.51], p = 0.03) and executive function (MD -13.63, 95% CI [-21.86,-5.39], p = 0.0001).

Conclusion

Physical exercise can improve cognitive function for breast cancer survivors, particularly in self-reported cognitive function, and executive function. Future studies need to explore the effect of exercise on cognitive function from the frequency and duration of exercise.

•

Physical exercise can improve cognitive function among breast cancer survivors.

•

Aerobic exercise and combined exercise intervention were more effective than other exercise.

•

Physical exercise can improve self-reported cognitive function, cognitive fatigue and executive function in breast cancer patients.

Cognitive adverse effects of chemotherapy and immunotherapy: are interventions within reach?

One in three people will be diagnosed with cancer during their lifetime. The community of cancer patients is growing, and several common cancers are becoming increasingly chronic; thus, cancer survivorship is an important part of health care. A large body of research indicates that cancer and cancer therapies are associated with cognitive impairment. This research has mainly concentrated on chemotherapy-associated cognitive impairment but, with the arrival of immunotherapies, the focus is expected to widen and the number of studies investigating the potential cognitive effects of these new therapies is rising. Meanwhile, patients with cognitive impairment and their healthcare providers are eagerly awaiting effective approaches to intervene against the cognitive effects of cancer treatment. In this Review, we take stock of the progress that has been made and discuss the steps that need to be taken to accelerate research into the biology underlying cognitive decline following chemotherapy and immunotherapy and to develop restorative and preventive interventions. We also provide recommendations to clinicians on how to best help patients who are currently experiencing cognitive impairment.

Prevalence of cognitive impairment following chemotherapy treatment for breast cancer: a systematic review and meta-analysis

Breast cancer survival rates have markedly improved. Consequently, survivorship issues have received increased attention. One common sequel of treatment is chemotherapy-induced cognitive impairment (CICI). CICI causes a range of impairments that can have a significant negative impact on quality of life. Knowledge of the prevalence of this condition is required to inform survivorship plans, and ensure adequate resource allocation and support is available for sufferers, hence a systematic review of prevalence data was performed. Medline, Scopus, CINAHL and PSYCHInfo were searched for eligible studies which included prevalence data on CICI, as ascertained though the use of self-report, or neuropsychological tests. Methodological quality of included studies was assessed. Findings were synthesised narratively, with meta-analyses being used to calculate pooled prevalence when impairment was assessed by neuropsychological tests. The review included 52 studies. Time-points considered ranged from the chemotherapy treatment period to greater than 10 years after treatment cessation. Summary prevalence figures (across time-points) using self-report, short cognitive screening tools and neuropsychological test batteries were 44%, 16% and 21–34% respectively (very low GRADE evidence). Synthesised findings demonstrate that 1 in 3 breast cancer survivors may have clinically significant cognitive impairment. Prevalence is higher when self-report based on patient experience is considered. This review highlights a number of study design issues that may have contributed to the low certainty rating of the evidence. Future studies should take a more consistent approach to the criteria used to assess impairment. Larger studies are urgently needed.

Late Effects of Cancer Treatment, Job Resources, and Burnout Complaints Among Employees With a Breast Cancer Diagnosis 2–10 Years Ago: A Longitudinal Study

Purpose

The aim of this study was to investigate the effect of possible late effects of cancer treatment (physical complaints, fatigue, and cognitive complaints) and of two job resources (autonomy and supportive leadership style) on future burnout complaints, among employees living 2–10 years beyond breast cancer diagnosis.

Methods

Data at T1 (baseline questionnaire) and at T2 (9 months later) were collected in 2018 and 2019 (N = 287). These data were part of a longitudinal study among Dutch speaking workers with a cancer diagnosis 2–10 years ago. All complaints and job resources were self-reported. Longitudinal multivariate regression analyses were executed, controlling for years since diagnosis, living with cancer (recurrence or metastasis), and other chronic or severe diseases. Mediation by baseline burnout complaints was considered.

Results

A higher level of fatigue and cognitive complaints at baseline (T1) resulted in higher future burnout complaints (at T2), with partial mediation by baseline burnout complaints. No effect of physical complaints at T1 was observed. Higher levels of autonomy or a supportive leadership style resulted in lower burnout complaints, with full mediation by baseline burnout complaints. Buffering was observed by autonomy in the relationship of cognitive complaints with future burnout complaints. No moderation was observed by supportive leadership.

Conclusion

The level of burnout complaints among employees 2–10 years beyond breast cancer diagnosis may be an effect of fatigue or cognitive complaints, and awareness of this effect is necessary. Interventions to stimulate supportive leadership and autonomy are advisable, the latter especially in the case of cognitive complaints.

Prospective Rates, Longitudinal Associations, and Factors Associated With Comorbid Insomnia Symptoms and Perceived Cognitive Impairment

Background

Insomnia and cognitive impairment are both common conditions experienced by people diagnosed with cancer. Individually, these conditions have negative impacts on functioning, but the combined burden has yet to be evaluated. The purpose of this research was to estimate rates of comorbid insomnia and perceived cognitive impairments, examine the longitudinal associations between these two conditions, and identify demographic and clinical factors associated with reporting both insomnia and perceived cognitive impairment.

Methods

In this secondary analysis, a heterogeneous sample of 962 patients completed the Insomnia Severity Index (ISI) and the Cognitive Failures Questionnaire (CFQ) at the time of their cancer surgery (baseline; T1) and then again at 2 (T2), 6 (T3), 10 (T4), 14 (T5), and 18 (T6) months. Correlations and partial correlations, controlling for age and education level, were computed at each time point to assess the relationship between ISI and CFQ scores. Cross-lagged correlations assessed associations between ISI and CFQ scores over time. Proportions of patients with comorbid insomnia and cognitive impairments were calculated and logistic regressions investigated changes over time in these proportions. ANOVAs, logistic regressions, ordinal regressions, and multinomial regressions were used to identify risk factors of having comorbid insomnia and cognitive difficulties.

Results

Significant and bidirectional correlations between ISI and CFQ scores were observed at each time point and over time. The proportion of patients having both clinical levels of insomnia and perceived cognitive difficulties ranged from 18.73 to 25.84% across time points and this proportion was significantly greater at T1 and T2 than T4, T5, and T6. Participants who reported comorbid insomnia and cognitive impairment were more likely to be younger, female, not currently working, currently receiving chemotherapy, with clinical levels depression and anxiety, and using antidepressants or anxiolytics.

Conclusion

Comorbid insomnia and perceived cognitive impairment affects around one in five patients and is more frequent at the beginning of the cancer care trajectory. The relationship between insomnia and cognitive impairment appears to be bidirectional. Insomnia may represent an important patient level vulnerability that when identified and treated can improve perception of cognitive function.

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.

Cognitive Impairment in Older Cancer Patients Treated with First-Line Chemotherapy

Simple Summary

Chemotherapy-related cognitive impairment is frequently reported by patients and can have a negative impact on their quality of life. Elderly patients appear to be particularly at risk for cognitive decline but they are rarely included in studies. Our study investigated cognitive impairment during chemotherapy and its predictive factors among a large elderly population (≥70 years) treated with first-line chemotherapy. The aim was to identify risk factors before starting chemotherapy in order to manage and help elderly patients with decision making.

Abstract

Older cancer patients are vulnerable to chemotherapy-related cognitive impairment. We prospectively evaluated cognitive impairment and its predictive factors during first-line chemotherapy in elderly cancer patients (≥70 years). Cognitive function was evaluated by the Mini-Mental State Examination (MMSE) with adjusted scores for age and sociocultural level. Multidimensional geriatric assessment was performed at baseline and during chemotherapy including the MMSE, Instrumental Activities in Daily Living (IADL), Mini-Nutritional Assessment (MNA), and the Geriatric Depression Scale (GDS15). Quality of life (QoL) was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire (QLQ-C30). Of 364 patients included, 310 had two MMSE evaluations including one at baseline and were assessed. Among these patients, 86 (27.7%) had abnormal MMSE, 195 (62.9%) abnormal MNA, 223 (71.9%) abnormal IADL, and 137 (43.1%) had depressive symptoms at baseline. MMSE impairment during chemotherapy was observed in 58 (18.7%) patients. Abnormal baseline MNA (odds ratio (OR) = 1.87, p = 0.021) and MMSE (OR = 2.58, p = 0.022) were independent predictive factors of MMSE impairment. These results suggest that pre-existing cognitive impairment and malnutrition are predictive factors for cognitive decline during chemotherapy in elderly cancer patients. Detection and management of these risk factors should be systematically considered in this population before starting chemotherapy.

Investigating how cancer-related symptoms influence work outcomes among cancer survivors: a systematic review

Purpose

The purpose of this study is to investigate how different cancer-related symptoms influence work outcomes among cancer survivors.

Methods

A literature search was performed in PubMed, EMBASE, CINAHL, PsycINFO, and Scopus to identify studies published between 1st January 1999 and 30th October 2020 that investigated the impact of specific cancer-related symptoms on work outcomes among cancer survivors who have completed primary antineoplastic treatment. Study findings were extracted and grouped by symptoms and work outcomes, allowing comparison of associations between these outcomes.

Results

Seventy-three articles representing 68 studies were eligible for inclusion. From these studies, 27 cancer-related symptoms, 9 work outcomes, and 68 unique associations between specific symptoms and work outcomes were identified. Work status (return to work and employment rates) was most commonly studied, and symptom burden was mainly measured from the patient’s perspective. Higher symptom burden was generally associated with trends of poorer work outcomes. Significant associations were reported in most studies evaluating body image issues and work status, oral dysfunction and work status, fatigue and work ability, and depression and work ability.

Conclusion

Several cancer-related symptoms were consistently associated with inferior work outcomes among cancer survivors. Body image issues and oral dysfunction were shown to be associated with poorer employment rates, while fatigue and depression were linked to lower levels of work performance.

Implications for Cancer Survivors

Failure to return to work and decreased productivity post-cancer treatment can have negative consequences for cancer survivors and society at large. Findings from this review will guide the development of work rehabilitation programs for cancer survivors.

Protocol registration

PROSPERO identifier CRD42020187754

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01097-5.

Are Sleep Complaints Related to Cognitive Functioning in Non-Central Nervous System Cancer? A Systematic Review

Patients with non-central nervous system (CNS) cancer frequently report cognitive complaints, that are recurrent and affect their quality of life. In order to improve supportive care of these cognitive difficulties, it is important to identify associated factors. Sleep disturbance is a good candidate to study, as patients with non-CNS cancer frequently report sleep disorders, and sleep plays a key role in cognitive functioning. The objective of the present systematic review was to summarize the results of studies evaluating the relationship between cognition and sleep in non-CNS cancer, and to highlight the need for further studies. PubMed [Medline] and Scopus databases were screened from April to November 2020 for studies published in English evaluating the association between cognition and sleep in adults with non-CNS cancer. The characteristics and risk of bias for each of the 30 included studies have been reported. Greater cognitive complaints in patients with non-CNS cancer were related to poorer self-reported sleep quality in almost all studies (n = 22/24). By contrast, around half of the studies reported a significant association between poorer neuropsychological performances and sleep complaints (n = 5/11). The studies were found to have several limitations, such as the lack of a control group, which would have shed the light on the period of occurrence of this association (e.g. after cancer diagnosis or after cancer treatments). Our review also identified factors that may influence the relationship between cognition and sleep. Recommendations are given for improving the methodology of future studies and extending the impact of their results.

Cognitive function and emotional vulnerability in metastatic breast cancer: Moderating effects of age and social support

OBJECTIVE

Previous literature has established a relationship between cognitive function and symptoms of anxiety, depression, and post-traumatic stress in primary breast cancer, but not in metastatic breast cancer (MBC). The current study examined the relationship between cognitive function and symptoms of anxiety, depression, and post-traumatic stress as well as the moderating effects of age, time since MBC diagnosis, and social support.

METHODS

Subjective and objective measures of cognitive function as well as self-reports of emotional vulnerability were completed by 59 women diagnosed with MBC who were recruited through social media and support groups.

RESULTS

Emotional vulnerability scores were associated with perceived measures of cognitive function. Additionally, low levels of perceived cognitive function were met with increased levels of depression with social support moderating this relationship buffering against depression. Age was found to moderate the relationship between cognitive function and post-traumatic stress with younger women at a greater risk of vulnerability. Out of all the emotional vulnerability measures, only anxiety negatively correlated with objective task performance.

CONCLUSIONS

This study established a relationship between cognitive function and emotional vulnerability in MBC patients. It emphasised how vulnerable younger MBC women are to post-traumatic stress, and the importance of the combined effects of cognitive function and social support in buffering against depression. Our results have important implications for developing new interventions and treatment plans that consider the roles of these factors in ensuring a better quality of life in MBC.

Trajectories of Cognitive Symptoms in Sick-Listed Cancer Survivors

Simple Summary

The effects of cognitive symptoms on the ability to work are of major concern for cancer survivors. The aim of our study was to explore trajectories of cognitive functioning in sick-listed cancer survivors with work capacity. We found that cognitive functioning improved between two and four years after first day of sick leave, although cognitive symptoms remained of clinical concern in cancer survivors who are non-durable work-disabled (partly or fully). This underlines the importance to provide partly and fully, non-durable work disabled cancer survivors with evidence-based treatment options for their self-perceived cognitive symptoms.

Abstract

Many non-central nervous system (CNS) cancer survivors experience cognitive symptoms, which may affect their self-perceived work ability. Little is known about trajectories of self-perceived cognitive functioning in cancer survivors in the period after work disability assessment. Therefore, we evaluated: (1) trajectories of self-reported cognitive functioning, in cancer survivors with work capacity, (2) differences in trajectories of self-reported cognitive functioning between three work disability groups, and (3) explanatory factors of trajectories of self-reported cognitive functioning. Participants (n = 206) were assessed on self-reported cognitive functioning at three time points between two and four years after first day of sick leave. A statistically significant improvement in cognitive functioning was found in the total group (β = 4.62, SE = 0.91, p < 0.001). When comparing cancer survivors in different work disability groups, similar trajectories of cognitive functioning were observed. Fatigue was the only factor found to be associated with the reported trajectory (β = −0.23, SE = 0.086, p = 0.08). Self-perceived cognitive functioning scores remained considerably lower than the mean score of the general Dutch population, indicating that cognitive symptoms are a persistent problem in sick-listed cancer survivors and that evidence-based treatment options are warranted.

Self-perceived cognitive functioning and quality of life among cancer survivors: results from the PROFILES registry

PURPOSE

The aim was to investigate the level of self-perceived cognitive functioning and its associated factors among a large population-based cohort of cancer survivors and their matched controls.

METHODS

Data were obtained from population-based PROFILES registry cohorts, including colon, rectum, prostate or thyroid cancer, Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL), chronic lymphocytic leukemia, multiple myeloma (MM), melanoma, or basal cell carcinoma (BCC)/squamous cell carcinoma (SCC). All patients completed the EORTC QLQ-C30 from which self-perceived cognitive functioning, fatigue, functioning, and global health status/quality of life (GHS/QoL) were used. The PROFILES registry data were linked with the Netherlands Cancer Registry to obtain sociodemographic and clinical data.

RESULTS

Six thousand seven hundred eighty-six survivors were included (response rate=76%). Survivors, except for melanoma and BCC/SCC, reported on average lower self-perceived cognitive functioning scores compared to their matched controls (all p's<0.01). Largest differences with the norm were observed in thyroid cancer, HL, NHL and MM, and younger survivors (<50 years). Survivors with lower emotional functioning and more fatigue were more likely to report impaired self-perceived cognitive functioning.

CONCLUSION

Self-perceived impaired cognitive functioning is prevalent among a wide range of cancer survivors, especially among survivors <50 years. Approaches targeting cognitive problems including attention for co-occurring symptoms such as fatigue and emotional impairments are needed to improve care for these patients.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors and clinicians should be aware that impaired self-perceived cognitive functioning is a frequently reported consequence of cancer and its treatment among survivors of various cancer types. Clinicians can redirect survivors to a relevant healthcare provider or program to target cognitive problems.