Psychometric properties and measurement equivalence of the English and Chinese versions of the functional assessment of cancer therapy-cognitive in Asian patients with breast cancer

Replication and Meta-analysis of the Association between BDNF Val66Met Polymorphism and Cognitive Impairment in Patients Receiving Chemotherapy

Cancer-related cognitive impairment (CRCI) adversely affects cancer patients. We had previously demonstrated that the BDNF Val66Met genetic polymorphism is associated with lower odds of subjective CRCI in the multitasking and verbal ability domains among breast cancer patients receiving chemotherapy. To further assess our previous findings, we evaluated the association of BDNF Val66Met polymorphism with subjective and objective CRCI in a temporally separate cohort of patients and pooled findings from both the original (n = 145) and current (n = 193) cohorts in a meta-analysis. Subjective CRCI was assessed using FACT-Cog. Objective CRCI was evaluated using computerized neuropsychological tests. Genotyping was carried out using Sanger sequencing. The association of BDNF Val66Met genotypes and CRCI was examined with logistic regression. A fixed-effect meta-analysis was conducted using the inverse variance method. In the meta-analysis (n = 338), significantly lower odds of CRCI were associated with Met allele carriers based on the global FACT-Cog score (OR = 0.52, 95% CI 0.29–0.94). Furthermore, Met allele carriers were at lower odds of developing impairment in the domains of memory (OR = 0.34, 95% CI: 0.17–0.70), multitasking (OR = 0.33, 95% CI: 0.18–0.59), and verbal ability (OR = 0.46, 95% CI: 0.24–0.88). Consistent with the previous study, lower odds of subjective CRCI among patients with the BDNF Met allele was observed after adjusting for potential confounders in the multitasking (OR = 0.30, 95% CI: 0.14–0.67) domain. In conclusion, carriers of the BDNF Met allele were protected against global subjective CRCI, particularly in the domains of memory, multitasking, and verbal ability. Our findings further contribute to the understanding of CRCI pathophysiology.

Important differences and meaningful changes for the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog)

Background

We estimated clinically important, group-level differences in self-reported cognitive function for the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) instrument. We also investigated individual level change that could be considered meaningful for cancer survivors affected by cognitive impairment following chemotherapy, and that could be used for responder analyses. We used data from a multi-site randomized controlled trial in 242 participants that evaluated a web-based intervention for improving self-reported cognitive functioning in adult cancer survivors who reported cognitive impairment and who had adjuvant chemotherapy in the previous 6–60 months. We used anchor and distribution methods to estimate a range of clinically important differences (CIDs) and investigated meaningful change thresholds (MCTs) for the FACT-Cog and the Perceived Cognitive Impairments (PCI) subscale, post-intervention and at six-month follow-up with empirical cumulative distribution functions. Our primary anchor was the patient reported cognitive function subscale of the European Organization for Research and Treatment of Cancer Quality of Life-Cognitive Functioning Scale (EORTC-CF).

Results

Most participants were female (95%) breast cancer survivors (89%). Correlation of changes in the FACT-Cog and the EORTC-CF were 0.55 post-intervention and 0.61 at follow-up. Anchor-based CID estimates for the FACT-Cog using our primary anchor were 11.3 points (post) and 8.8 (follow-up), which corresponds to a standardized effect size of 0.49 and 0.38; 8.6% and 6.6% of the total scale’s range. Anchor-based CID estimates for the FACT-Cog PCI subscale were 7.4 (post) and 4.6 points (follow-up), which corresponds to a standardized effect size of 0.50 and 0.31; 10.3% and 6.4% of the PCI range). Empirical cumulative distribution functions of change in FACT-Cog demonstrating possible MCTs showed that anchor change of none, minimally better and much better were well separated.

Conclusions

The CID and MCT estimates from this manuscript can help in the design, analysis and interpretation of self-reported cognitive function in cancer patients and survivors.

Efficacy of Acupuncture Therapy for Chemotherapy-Related Cognitive Impairment in Breast Cancer Patients

Background

Chemotherapy can cause adverse effects such as chemotherapy-related cognitive impairment (CRCI). In this prospective study, the efficacy of traditional Chinese medicine acupuncture therapy in relieving CRCI and its impact on serum brain-derived neurotrophic factor (BDNF) are evaluated.

Material/Methods

Eighty patients were randomly divided into a treatment group and a control group with 40 patients in each group. The treatment group was treated at the following acupuncture points: Baihui (DU20), Sishencong (EX-HN1), Shenting (DU24), Zusanli (ST36), Taixi (K13), Dazhong (K14), and Juegu (GB39). Cognitive function was assessed using the functional assessment of cancer treatment cognition test (FACT-COG, version 3), the auditory-verbal learning test (AVLT), the verbal fluency test (VFT), the symbol digit modality test (SDMT), the clock-drawing test (CDT), and the trail-making test part B (TMT-B). In addition, blood serum levels of BDNF were measured before and after treatment. Correlations between change in BDNF levels and cognitive function were also analyzed.

Results

CRCI was ameliorated in the acupuncture treatment group, with scores on FACT-COG, AVLT-recognition and CDT assessments all significantly increased (P<0.05 in all cases). In addition, serum BDNF levels after acupuncture treatment were significantly higher than before treatment (t=3.242, P<0.01). Moreover, the level of BDNF was positively correlated with the total score of FACT-COG, AVLT-recognition, and CDT (r=0.694, 0.628, and 0.532, respectively; all P<0.05). The control group showed no statistically significant difference in any measures over the same period.

Conclusions

Acupuncture therapy is effective in the treatment of CRCI in breast cancer patients through a mechanism that may be related to an increase of BDNF.

Impact of Adjuvant Anthracycline-Based and Taxane-Based Chemotherapy on Plasma VEGF Levels and Cognitive Function in Breast Cancer Patients: A Longitudinal Study

BACKGROUND

Vascular endothelial growth factor (VEGF) has been shown to induce neurogenesis in the brain and yield neuroprotective effects. It is hypothesized that chemotherapy reduces circulating VEGF levels and leads to cognitive decline among patients. This multicenter longitudinal study aimed to evaluate the impact of chemotherapy on VEGF levels and the association between VEGF levels and cognitive function.

PATIENTS AND METHODS

A total of 145 early-stage breast cancer patients were recruited and assessed before chemotherapy (T1), during chemotherapy (T2), and at the end of chemotherapy (T3). At each time point, plasma VEGF levels were assessed using a multiplex immunoassay. Cognitive function was assessed using both Functional Assessment of Cancer Therapy-Cognitive Function, Version 3 (FACT-Cog), and Headminder (a computerized, web-based neuropsychologic battery).

RESULTS

Generally, we observed higher-than-baseline plasma VEGF levels after the start of chemotherapy (P < .001). Among patients receiving anthracycline-based chemotherapy, the median plasma VEGF levels were significantly higher at T2 (T2: 37.3 pg/mL vs. T1: 21.3 pg/mL; P < .001) and T3 (T3: 35.5 pg/mL vs. T1: 21.3 pg/mL; P < .001) than at baseline. Plasma VEGF levels were not associated with chemotherapy-associated cognitive impairment.

CONCLUSION

Breast cancer patients experience an increasing trend in plasma VEGF levels during chemotherapy, and the regimen types may have a differential effect on circulating VEGF levels. Furthermore, changes in plasma VEGF levels during chemotherapy were not associated with cognitive impairment. VEGF may play a minor role in mediating the occurrence of chemotherapy-associated cognitive impairment.

The Structure of the FACT-Cog v3 in Cancer Patients, Students, and Older Adults

CONTEXT

The Functional Assessment of Cancer Therapy-Cognitive (FACT-Cog) version 3 questionnaire is designed to assess perceived cognitive function and impact on quality of life in cancer patients.

OBJECTIVES

We examined the factor structure of the FACT-Cog version 3 in samples of cancer patients, older adults, and students.

METHODS

Data from three populations were sourced. Cancer patient data (N = 158) came from two studies, one evaluating a web-based cognitive training program, and the other evaluating symptoms in patients receiving chemotherapy. The older adult sample (N = 477) was commercial brain training users in the general population. The student sample (N = 154) came from a study examining the relation between cognitive test performance and perceived cognitive function.

RESULTS

The patient sample conformed to the traditional four-factor structure (impairments, abilities, noticeability, and quality of life), with some support for separating the broad impairment/ability factors into specific cognitive domains. The older adult sample was best described using both impairments/abilities and specific cognitive domains. The student sample suggested two impairment/ability factors but separation of concentration/acuity and memory/verbal impairment items.

CONCLUSION

The FACT-Cog can be used in populations other than cancer patients, with modifications to the scoring system. Even when used with cancer patients, it is worth considering scoring specific cognitive domains separately.

Psychometric properties and measurement equivalence of the Multidimensional Fatigue Syndrome Inventory- Short Form (MFSI-SF) amongst breast cancer and lymphoma patients in Singapore

Background

Currently, several fatigue measurement instruments are available to evaluate and measure cancer-related fatigue. Amongst them, Multidimensional Fatigue Syndrome Inventory-Short Form (MFSI-SF) is a self-reported instrument and a multidimensional scale that aims to capture the global, somatic, affective, cognitive and behavioural symptoms of fatigue. This study examines the psychometric properties and measurement equivalence of the English and Chinese versions of MFSI-SF in breast cancer and lymphoma patients in Singapore.

Methods

Patients were recruited from National Cancer Centre Singapore. Validity, reliability and responsiveness of MFSI-SF were evaluated in this study. Convergent validity was evaluated by correlating total and subscales of MFSI-SF to known related constructs in EORTC QLQ-C30. Known group validity was assessed based on patients’ cancer stage, pain, insomnia and depression symptoms. Reliability was evaluated by Cronbach’s α. Responsiveness analyses were performed with patients who have undergone at least one cycle of chemotherapy. Multiple regression was used to compare the total and subscale scores of MSFI-SF between the two language versions.

Results

Data from 246 (160 English and 86 Chinese version) breast cancer and lymphoma patients were included in the study. Moderate to high correlations were observed between correlated MFSI-SF subscales and EORTC QLQ-C30 domains (|r| = 0.524 to 0.774) except for a poor correlation (r = 0.394) observed between MFSI-SF vigour subscale and EORTC QLQ-C30 role functioning subscale. Total MFSI-SF scores could differentiate between patients with higher depression, pain and insomnia status. Internal consistency of MFSI-SF was also high (α = 0.749 to 0.944). Moderate correlation was observed between change in total MFSI-SF score and change in fatigue symptom scale score and global QoL score on EORTC QLQ-C30 (|r| = 0.478 and 0.404 respectively). Poor correlations were observed between change in scores of hypothesised subscales (|r| = 0.202 to 0.361) except for a moderate correlation between change in MFSI-SF emotional fatigue score and change in EORTC QLQ-C30 emotional functioning domain score. Measurement equivalence was established for all subscales and total MFSI-SF score except for the emotional and vigour subscales.

Conclusions

This study supports the use of MFSI-SF as a reasonably valid scale with good internal consistency for measuring fatigue levels in the Singapore cancer population.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0846-6) contains supplementary material, which is available to authorized users.

A review of cognitive screening tools in cancer

PURPOSE OF REVIEW

Cancer-related cognitive impairment (CRCI) is highly prevalent, and assessment of cognition is crucial in providing optimal cancer care. Neuropsychological assessment (NPA) can be lengthy and expensive. Cognitive screening tools are plenty but validity has not been thoroughly studied for use in cancer patients.

RECENT FINDINGS

Our search of the recent literature revealed that the Montreal Cognitive Assessment, Mini-Mental State Examination, and Clock Draw Test were the most frequently studied objective screening tools. The Functional Assessment of Cancer Therapy-Cognitive Function and the Cognitive Symptom Checklist-Work 21 were the most commonly studied subjective measures of perceived cognitive impairment. Evidence supports using the Montreal Cognitive Assessment or the Clock Draw Test over the Mini-Mental State Examination to screen for cognitive impairment within specific patient populations. In addition, adding a subjective measure of cognitive impairment (e.g., Functional Assessment of Cancer Therapy-Cognitive Function) may increase diagnostic sensitivity.

SUMMARY

These suggest that cognitive screening tools may have a role in screening for CRCI, particularly when full NPA is not feasible. Researchers must continue to conduct high-quality studies to build an evidence to guide best practices in screening for CRCI.

Evaluation of plasma brain-derived neurotrophic factor levels and self-perceived cognitive impairment post-chemotherapy: a longitudinal study

Background

Preliminary evidence suggests that changes in plasma brain-derived neurotrophic factor (BDNF) levels may contribute to the occurrence of chemotherapy-associated cognitive impairment (CACI), and a previous study suggested that carriers of the BDNF Met homozygous genotype are protected from CACI.

Methods

This multicenter, prospective cohort study involved chemotherapy-receiving early-stage breast cancer (ESBC) patients. Self-perceived cognitive function was longitudinally assessed using the validated FACT-Cog (ver. 3) across three time points: Prior to chemotherapy (T1), during chemotherapy (T2), and at the end of chemotherapy (T3). Plasma BDNF levels were quantified using enzyme-linked immunosorbent assay. Genotyping was performed using Sanger Sequencing.

Results

A total of 51 chemotherapy-receiving ESBC patients (mean age: 52.6 ± 9.5 years) were recruited, and 11 patients (21.6%) reported subjective cognitive impairment post-chemotherapy. Overall, there was a reduction in median plasma BDNF levels over time (T1: 5423.0 pg/ml; T2: 5313.6 pg/ml; T3: 4050.3 pg/ml; p < 0.01). After adjusting for confounding factors, longitudinal analysis revealed that BDNF levels were associated with self-reported concentration deficit (p = 0.032). Carriers of Val/Val (p = 0.011) and Val/Met (p = 0.003) BDNF genotypes demonstrated a significant reduction in plasma BDNF levels over time; however, plasma BDNF levels were similar across all time points among Met homozygous carriers (p = 0.107).

Conclusion

There was a statistically significant change in BDNF levels post-chemotherapy in ESBC patients, and plasma BDNF levels were associated with self-perceived concentration deficit in patients receiving chemotherapy.

Psychometric Properties of the Functional Assessment of Cancer Therapy-Neutropenia in Asian Cancer Patients With Chemotherapy-Induced Neutropenia

CONTEXT

The Functional Assessment of Cancer Therapy-Neutropenia (FACT-N) is a neutropenia-specific questionnaire to assess patients' health-related quality of life.

OBJECTIVES

This study aimed to examine the psychometric properties of FACT-N among cancer patients with chemotherapy-induced neutropenia (CIN).

METHODS

This prospective, cross-sectional study included multiethnic Asian cancer patients. Patients completed the questionnaires within seven days after diagnosed with CIN. Eligible patients completed either the English or Chinese version of the EuroQol 5-Dimensions (EQ-5D) and the FACT-N once, according to their language preference. The reliability was evaluated by using Cronbach alpha (α). The known-group validity was assessed based on patient's Eastern Cooperative Oncology Group performance status, neutropenia grade, and experience of fever. The convergent validity was evaluated by contrasting the FACT-N subscales with the EQ-5D domains. Multiple linear regression models were performed to compare the FACT-N total scores between the two language versions.

RESULTS

A total of 276 eligible patients (200 English speaking and 76 Chinese speaking) were included in this study. Internal consistencies within the FACT-N subscales were satisfactory (Cronbach α = 0.71-0.85), except for the flu-like symptoms subscale (Cronbach α = 0.67). For known-group validity, the FACT-N total score could differentiate patients according to their Eastern Cooperative Oncology Group performance status (P < 0.001), neutropenia grade (P = 0.028), and experience of fever (P < 0.001). The correlations between the FACT-N subscales and their hypothesized constructs in EQ-5D domains were weak to moderate (|r| = 0.15-0.44). The measurement equivalence between the English and Chinese versions was established for the FACT-N total scores.

CONCLUSION

The FACT-N is a valid and reliable instrument to be used in clinical practice to evaluate the health-related quality of life among multiethnic Asian patients with CIN.

Brain-derived neurotrophic factor genetic polymorphism (rs6265) is protective against chemotherapy-associated cognitive impairment in patients with early-stage breast cancer

Background

Brain-derived neurotrophic factor (BDNF), a neurotrophin that regulates neuronal function and development, is implicated in several neurodegenerative conditions. Preliminary data suggest that a reduction of BDNF concentrations may lead to postchemotherapy cognitive impairment. We hypothesized that a single nucleotide polymorphism (rs6265) of the BDNF gene may predispose patients to cognitive impairment. This study aimed to evaluate the effect of BDNF gene polymorphism on chemotherapy-associated cognitive impairment.

Methods

Overall, 145 patients receiving chemotherapy for early-stage breast cancer (mean age: 50.8 ± 8.8 y; 82.1% Chinese) were recruited. Patients' cognitive functions were assessed longitudinally using the validated Functional Assessment of Cancer Therapy–Cognitive Function (v.3) and an objective computerized tool, Headminder. Genotyping was performed using Sanger sequencing. Logistic regression was used to evaluate the association between BDNF Val66Met polymorphism and cognition after adjusting for ethnicity and clinically important covariates.

Results

Of the 145 patients, 54 (37%) reported cognitive impairment postchemotherapy. The Met/Met genotype was associated with statistically significant lower odds of developing cognitive impairment (odds ratio [OR] = 0.26; 95% CI: 0.08–0.92; P = .036). The Met carriers were less likely to experience impairment in the domains of verbal fluency (OR = 0.34; 95% CI: 0.12–0.90; P = .031) and multitasking ability (OR = 0.37; 95% CI: 0.15–0.91; P = .030) compared with the Val/Val homozygote. No associations were observed between Headminder and the BDNF Val66Met polymorphism.

Conclusions

This is the first study to provide evidence that carriers of the BDNF Met allele are protected against chemotherapy-associated cognitive impairment. Further studies are required to validate the findings.

Assessment of mental health literacy in patients with breast cancer

INTRODUCTION

Psychosocial distress is often underdiagnosed and undertreated among breast cancer patients due to the poor recognition of the associated symptoms and inadequate knowledge of the treatments available.

OBJECTIVE

To evaluate the mental health literacy of breast cancer patients by assessing (1) their ability to recognize the symptoms of anxiety, fatigue, depression, and cognitive disturbances, and (2) their knowledge of help-seeking options and professional treatments.

METHODS

In this multi-center, cross-sectional study, early-stage breast cancer patients receiving chemotherapy underwent four assessments to measure their levels of anxiety, depression, fatigue, and cognitive disturbances. With the aid of cancer-specific vignettes, a questionnaire was administered to evaluate their mental health literacy.

RESULTS

Fifty-four patients were recruited (77.7% Chinese, aged 52.7 ± 8.5 years). Clinically significant anxiety (15.1%), fatigue (27.8%), and cognitive disturbances (25.9%) were more prevalent than depression (5.6%). Although the majority of the patients could recognize the symptoms of fatigue accurately (75.9%), less than half could identify those of anxiety (35.2%), depression (48.1%), and cognitive disturbances (48.1%). Patients were more receptive to help from their family members (score: 3.39 out of 4.00) and oncologists (score: 3.13) than from other mental health specialists, such as psychiatrists (score: 2.26) and psychologists (score: 2.19) in the management of their psychosocial distress. Approximately half of the patients indicated that embarrassment and fear were their main barriers to seeking professional treatment (55.6%).

CONCLUSIONS

Our results suggest that the mental health literacy of breast cancer patients was inadequate. Intervention and management strategies could be implemented to teach these patients about evidence-based treatments and professional help that are specific to mental disorders.

Perceived cognitive impairment in Chinese patients with breast cancer and its relationship with post-traumatic stress disorder symptoms and fatigue

OBJECTIVE

Clinical reports have shown that adjuvant chemotherapy has a negative impact on perceived cognitive impairment (PCI) of patients with breast cancer; however, evidence concerning the effects of psychological factors such as post-traumatic stress disorder (PTSD) symptoms on PCI is limited, especially in relation to Chinese patients with breast cancer. This research investigated the associations between psychological factors and PCI in Chinese women with breast cancer.

METHODS

In total, 204 women with breast cancer were assessed for PCI, PTSD symptoms, fatigue, anxiety, and depression using self-report measures. Hierarchical linear regression was conducted to investigate the associations between the variables of interest and PCI.

RESULTS

Two hundred and two women were included in the final analysis; two of those originally tested were excluded because of missing data. A univariate analysis showed that PCI was significantly related to education, PTSD symptoms (re-experience, avoidance, and hyperarousal), fatigue, depression, anxiety, and undergoing chemotherapy or radiotherapy. Hierarchical linear regression revealed that PTSD symptoms and fatigue (ΔR(2)  = 0.26, P < 0.001) independently accounted for PCI in Chinese women with breast cancer regardless of age, education level, chemotherapy and radiotherapy. Hyperarousal was the only contributing PTSD symptom to PCI (B = -1.24, SE = 0.33, β = -0.39, P < 0.001).

CONCLUSIONS

Besides chemotherapy, PTSD symptoms, especially hyperarousal, and fatigue are important risk factors for significant PCI and are therefore worthy of further investigation.

Drum-Assisted Recovery Therapy for Native Americans (DARTNA): results from a pretest and focus groups

Drum-Assisted Recovery Therapy for Native Americans (DARTNA) is a substance abuse treatment intervention for American Indians/Alaska Natives (AI/ANs). This article provides results from 1) an initial pretest of DARTNA provided to 10 AI/AN patients with histories of substance use disorders, and 2) three subsequent focus groups conducted among AI/AN DARTNA pretest participants, substance abuse treatment providers, and the DARTNA Community Advisory Board. These research activities were conducted to finalize the DARTNA treatment manual; participants also provided helpful feedback which will assist toward this goal. Results suggest that DARTNA may be beneficial for AI/ANs with substance use problems.