Cancer- and cancer treatment-associated cognitive change: an update on the state of the science

Association of geriatric measures and global frailty with cognitive decline after allogeneic hematopoietic cell transplantation in older adults

INTRODUCTION

Allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, and its potential impact on cognition in this population is understudied. This work aims to evaluate the ability of cancer-specific geriatric assessments (cGA) and a global frailty index based on accumulation of deficits identified in the cGA to predict the risk of cognitive decline after alloHCT in older adults.

MATERIALS AND METHODS

AlloHCT recipients aged 50 years or older completed a cGA, including a cognitive evaluation by the Blessed Orientation Memory Concentration (BOMC) test, at baseline prior to alloHCT and then at 3, 6, and 12 months after transplant. Baseline frailty was assessed using a deficit accumulation frailty index (DAFI) calculated from the cGA. A multinomial logit model was used to examine the association between predictors (individual cGA measures, DAFI) and the following three outcomes: alive with stable or improved cognition, alive with cognitive decline, and deceased. In post-hoc analyses, analysis of variance was used to compare BOMC scores at baseline, 3, 6, and 12 months across frailty categories.

RESULTS

In total, 148 participants were included, with a median age of 62 (range 50-76). At baseline, 12% had cognitive impairment; at one year, 29% of survivors had improved BOMC scores, 33% had stable BOMC, and 37% had worse BOMC. Prior to transplant, 25% were pre-frail and 11% were frail. Individual baseline cGA measures were not associated with cognitive change at one year as assessed by BOMC. Adjusting for age, sex, and education, those who were frail at baseline were 7.4 times as likely to develop cognitive decline at one year than those who were non-frail, although this finding did not reach statistical significance (95% confidence interval [CI] 0.74-73.8, p = 0.09). The probability of being alive with stable/improved cognition at 12 months for the non-frail, pre-frail, and frail groups was 43%, 34%, and 8%, respectively.

DISCUSSION

Baseline geriatric measures and frailty were not significantly associated with cognitive change as assessed by BOMC in adults aged 50 or older after alloHCT. However, the study was underpowered to detect clinically meaningful differences, and future work to elucidate potential associations between frailty and cognitive outcomes is warranted.

Should We Use COMM (Current Opioid Misuse Measure) to Screen for Opioid Abuse in Patients With Cancer Pain?

BACKGROUND

Growing concerns about opioid use disorder (OUD) and the resulting decrease in opioid availability for patients with cancer pain highlight the need for reliable screening tools to identify the subset of patients at increased risk for aberrant opioid use. Our study examines the utility of Current Opioid Misuse Measure (COMM) recommended by the NCCN Clinical Practice Guidelines in Oncology for Adult Cancer Pain.

PATIENTS AND METHODS

We analyzed prospectively collected patient-reported outcomes of 444 consecutive patients with cancer seen in pain clinics of a cancer center at 2 time points within 100 days. The relationship of COMM to other OUD screening tools, pain, opioid doses, patient demographics, and mortality was examined using univariate and multivariable logistic regression. We also examined individual items of COMM for face validity.

RESULTS

Among 444 patients who completed pain surveys at 2 time points, 157 (35.4%) did not complete COMM surveys. Using a COMM cutoff of ≥13, a total of 84 patients (29.3%; 84/287) scored positive for aberrant drug use. As patients remained on opioids for 49 to 100 days, the likelihood of improving COMM score (turning from positive to negative) was 6.1 times greater than the reverse. The number of patients with COMM ≥13 was 3.8 times higher than the number of patients with CPT diagnostic codes for OUD, 5.3 times higher than those with a positive urine drug screening, and 21 times higher than those with a positive CAGE (Cut Down, Annoyed, Guilty, Eye-Opener Questionnaire) score. COMM ≥13 was not associated with pain relief response (worst pain intensity score ≥2 points on the Brief Pain Inventory), opioid doses, gender, or age. Contrary to the intended use of COMM to identify aberrant opioid use, COMM ≥13 predicted mortality: patients with COMM ≥13 were 1.9 times more likely to die within 12 months.

CONCLUSIONS

Our study found that using COMM in a cancer population may significantly overestimate the risk of opioid misuse. Using COMM without modifications can create an additional barrier to cancer pain management, such as limiting appropriate opioid use.

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.

Pretreatment Cancer-Related Cognitive Impairment in Hodgkin Lymphoma Patients

BACKGROUND

Cancer-related cognitive impairment (CRCI) is one of the most serious side effects of cancer that negatively impacts the quality of life of cancer patients and survivors. There is evidence of CRCI in Hodgkin lymphoma patients (HL); however, there is a lack of studies examining the presence of cognitive deficits before starting any treatment in HL patients.

METHODS

Forty adult patients (N = 40) newly diagnosed with HL (with no previous cancer diagnoses) and 40 healthy controls (N = 40) matched for age, sex, education, and premorbid intellect completed the neuropsychological battery and subjective and objective measures of affective distress and quality of life.

RESULTS

The results showed impairment in three out of six cognitive domains: verbal memory and learning, speed of processing/psychomotor speed, and abstraction/executive functions in the HL patients before the initiation of any treatment. The speed of processing/psychomotor speed domain is negatively correlated with depression.

CONCLUSION

Cognitive deterioration in verbal memory and learning and abstraction/executive functions domains in HL patients seems to occur before the initiation of treatment independently of anxiety, depression, or physical symptoms. This suggests that HL itself may cause cognitive deficits in these cognitive domains. However, the underlying causes of CRCI still remain unclear.

Effects of vortioxetine on hippocampal-related cognitive impairment induced in rats by androgen deprivation as a model of prostate cancer treatment

Advances in prostate cancer treatment have significantly improved survival, but quality of life for survivors remains an under-studied area of research. Androgen deprivation therapy (ADT) is a foundational treatment for advanced prostate cancer and is used as an adjuvant for prolonged periods in many high-risk, localized tumors. More than half of patients treated with ADT experience debilitating cognitive impairments in domains such as spatial learning and working memory. In this study, we investigated the effects of androgen deprivation on hippocampal-mediated cognition in rats. Vortioxetine, a multimodal antidepressant, has been shown to improve cognition in depressed patients. Thus, we also tested the potential efficacy of vortioxetine in restoring impaired cognition after ADT. We further investigated mechanisms that might contribute to these effects, measuring changes in the circuitry and gene expression within the dorsal hippocampus. ADT via surgical castration induced impairments in visuospatial cognition on the novel object location test and attenuated afferent-evoked local field potentials recorded in the CA1 region of the dorsal hippocampus. Chronic dietary administration of vortioxetine effectively reversed these deficits. Castration significantly altered gene expression in the hippocampus, whereas vortioxetine had little effect. Pathway analysis revealed that androgen depletion altered pathways related to synaptic plasticity. These results suggest that the hippocampus may be vulnerable to ADT, contributing to cognitive impairment in prostate cancer patients. Further, vortioxetine may be a candidate to improve cognition in patients who experience cognitive decline after androgen deprivation therapy for prostate cancer and may do so by restoring molecular and circuit-level plasticity-related mechanisms compromised by ADT.

Functional aging trajectories of older cancer survivors: a latent growth analysis of the US Health and Retirement Study

PURPOSE

We aimed to identify prototypical functional aging trajectories of US cancer survivors aged 50 and older, overall and stratified by sociodemographic and health-related characteristics.

METHODS

Data were from 2986 survivors of a first incident cancer diagnosis (except non-melanoma skin cancer) after age 50 in the population representative U.S. Health and Retirement Study from 1998-2016. Cancer diagnoses, episodic memory function, and activity of daily living (ADL) limitations were assessed at biennial study interviews. Using time of cancer diagnosis as the baseline, we used group-based trajectory modeling to identify trajectories of memory function and ADL limitations following diagnosis.

RESULTS

We identified five memory loss trajectories (high: 8.4%; medium-high: 18.3%; medium-low: 21.5%; low: 25.5%; and, very low: 26.2%), and four ADL limitation trajectories (high/increasing limitations: 18.7%; medium limitations: 18.7%; low limitations: 8.14%; no limitations: 60.0). The high memory loss and high/increasing ADL limitation trajectories were both characterized by older age, being female (52% for memory, 58.9% for ADL), having lower pre-cancer memory scores, and a higher prevalence of pre-cancer comorbidities including stroke (30.9% for memory and 29.7% for ADL), hypertension (64.7% for memory and 69.8 for ADL), and depressive symptoms. In joint analyses, we found that generally those with higher memory were more likely to have fewer ADL limitations and vice versa.

CONCLUSION

Older cancer survivors experience heterogeneous trajectories of functional aging that are largely characterized by comorbidities prior to diagnosis.

IMPLICATION FOR CANCER SURVIVORS

Results can help identify older cancer survivors at increased risk for accelerated functional decline.

Feasibility and Acceptability of a Virtual "Coping with Brain Fog" Intervention for Improving Cognitive Functioning in Young Adults with Cancer

Purpose: Cancer-related cognitive deficits (CRCDs) are common among young adults (YAs) (ages: 18-39) with cancer and can be debilitating. We aimed to determine the feasibility and acceptability of a virtual Coping with Brain Fog intervention among YAs with cancer. Our secondary aims were to explore the intervention's effect on cognitive functioning and psychological distress. Methods: This prospective feasibility study involved eight weekly, 90-minute virtual group sessions. Sessions focused on psychoeducation on CRCD, memory skills, task management, and psychological well-being. The primary outcomes were feasibility and acceptability of the intervention evaluated through attendance (>60% not missing >2 consecutive sessions) and satisfaction (Client Satisfaction Questionnaire [CSQ] score >20). Secondary outcomes included the following: cognitive functioning (Functional Assessment of Cancer Therapy-Cognitive Function [FACT-Cog] Scale) and symptoms of distress (Patient-Reported Outcomes Measurement Information System [PROMIS] Short Form-Anxiety/Depression/Fatigue) and participants' experiences using semistructured interviews. Paired t-tests and summative content analysis were used for quantitative and qualitative data analyses. Results: Twelve participants (five male, mean age = 33 years) were enrolled. All but one participant met feasibility criteria of not missing >2 consecutive sessions (11/12 = 92%). The mean CSQ score was 28.1 (standard deviation 2.5). Significant improvement in cognitive function as measured by FACT-Cog Scale was observed postintervention (p < 0.05). Ten participants adopted strategies from the program to combat CRCD, and eight reported CRCD symptom improvement. Conclusion: A virtual Coping with Brain Fog intervention is feasible and acceptable for the symptoms of CRCD among YAs with cancer. The exploratory data indicate subjective improvement in cognitive function, and will inform the design and implementation of a future clinical trial. ClinicalTrials.gov Registration: NCT05115422.

Brain gray matter reduction and premature brain aging after breast cancer chemotherapy: a longitudinal multicenter data pooling analysis

Brain gray matter (GM) reductions have been reported after breast cancer chemotherapy, typically in small and/or cross-sectional cohorts, most commonly using voxel-based morphometry (VBM). There has been little examination of approaches such as deformation-based morphometry (DBM), machine-learning-based brain aging metrics, or the relationship of clinical and demographic risk factors to GM reduction. This international data pooling study begins to address these questions. Participants included breast cancer patients treated with (CT+, n = 183) and without (CT-, n = 155) chemotherapy and noncancer controls (NC, n = 145), scanned pre- and post-chemotherapy or comparable intervals. VBM and DBM examined GM volume. Estimated brain aging was compared to chronological aging. Correlation analyses examined associations between VBM, DBM, and brain age, and between neuroimaging outcomes, baseline age, and time since chemotherapy completion. CT+ showed longitudinal GM volume reductions, primarily in frontal regions, with a broader spatial extent on DBM than VBM. CT- showed smaller clusters of GM reduction using both methods. Predicted brain aging was significantly greater in CT+ than NC, and older baseline age correlated with greater brain aging. Time since chemotherapy negatively correlated with brain aging and annual GM loss. This large-scale data pooling analysis confirmed findings of frontal lobe GM reduction after breast cancer chemotherapy. Milder changes were evident in patients not receiving chemotherapy. CT+ also demonstrated premature brain aging relative to NC, particularly at older age, but showed evidence for at least partial GM recovery over time. When validated in future studies, such knowledge could assist in weighing the risks and benefits of treatment strategies.

Abnormal brain glucose metabolism patterns in patients with advanced non-small-cell lung cancer after chemotherapy：A retrospective PET study

PURPOSE

This study was designed to investigate the acute or chronic post-chemotherapy effect and different chemotherapy cycles effect on brain glucose metabolism.

METHODS

A total of seventy-three patients who received chemotherapy after being diagnosed with advanced non-small-cell lung cancer (NSCLC) and underwent 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan at Nuclear Medicine Department of the Fifth Hospital of Sun Yat-sen University between September 2017 and August 2022 were included. Seventy-two healthy control patients who underwent whole-body 18F-FDG PET/CT scans at our department, without any evidence of malignancy and confirmed by follow-up visits, were included. Advanced NSCLC patients were classified into six arms: short-to-long course (chemotherapy cycles under 4, between 5 and 8 and more than 8) in acute chemotherapy effect (AC) group (scanned 18F-FDG PET/CT within 6 months post-chemotherapy) or chronic chemotherapy effect (CC) group (the interval between scanning and the last chemotherapy session more than six months). Statistical Parametric Mapping (SPM) analysis between patients' groups and healthy controls' brain 18F-FDG PET was performed (uncorrected p ˂ 0.001 with cluster size above 20 contiguous voxels).

RESULTS

There were no significant differences between patients' groups and healthy controls in age, gender and body mass index (BMI). SPM PET analyses revealed anomalous brain metabolic activity in different groups (p ˂ 0.001). Short-course + AC group exhibited hypermetabolism in the cerebellum and widespread hypometabolism in bilateral frontal lobe predominantly. Only hypometabolic brain regions were observed in middle-course + AC patients. Long-course + AC group displayed a greater number of abnormalities. Notably, these metabolic abnormalities tended to decrease in CC groups versus AC groups across all courses.

CONCLUSION

Our study revealed that patients with advanced NSCLC who underwent chemotherapy exhibited persistent abnormal brain metabolism patterns during continuous chemotherapy and these abnormalities tended to recover after completion of chemotherapy over time, but without correlation to an increasing number of chemotherapy cycles. 18F-FDG PET/CT may serve as a possible modality for evaluating brain function and guiding appropriate treatment timing.

Prospective evaluation of return to work, health-related quality of life and psychosocial distress after radical cystectomy: 1-year follow-up in 230 employed German bladder cancer patients

PURPOSE

To evaluate return to work (RTW), health-related quality of life (HRQoL) and psychosocial distress (PD) after radical cystectomy (RC) and creation of an ileal conduit (IC) or an orthotopic ileal neobladder (NB) for bladder cancer.

METHODS

The study relied on prospectively collected data for 842 patients, who underwent 3 weeks of inpatient rehabilitation (IR) after surgery between April 2018 and December 2019. HRQoL (EORTC QLQ-C30) and PD (Questionnaire on Stress in Cancer Patients [QSC-R10]) were evaluated at the beginning (T1) and end (T2) of IR as well as both 6 (T3) and 12 months after surgery (T4). Regression analyses were performed to identify predictors of HRQoL and RTW, respectively.

RESULTS

Two hundred thirty patients (IC n = 51, NB n = 179) were employed before surgery (27.3%). HRQoL improved steadily, while high PD was present in 51.0% of patients at T4. RTW rate was 86.8 and 80.6% at T3 and T4, respectively. Linear regression analysis identified RTW as the only predictor for better HRQoL at T4 (OR [odds ratio] 12.823, 95% CI [confidence interval] 2.927-22.720, p = 0.012). Multivariate regression analysis identified age ≤ 59 years (OR 7.842; 95% CI 2.495-24.645; p < 0.001) as an independent positive predictor and lymph node metastasis (OR 0.220; 95% CI 0.054-0.893; p = 0.034) as an independent negative predictor of RTW at T4.

CONCLUSION

Global HRQoL improved steadily during the follow-up and RTW rates are high. However, patients often reported high PD, reflecting a need for additional psychosocial support within aftercare.

Targeting ryanodine receptor type 2 to mitigate chemotherapy-induced neurocognitive impairments in mice

Chemotherapy-induced cognitive dysfunction (chemobrain) is an important adverse sequela of chemotherapy. Chemobrain has been identified by the National Cancer Institute as a poorly understood problem for which current management or treatment strategies are limited or ineffective. Here, we show that chemotherapy treatment with doxorubicin (DOX) in a breast cancer mouse model induced protein kinase A (PKA) phosphorylation of the neuronal ryanodine receptor/calcium (Ca2+) channel type 2 (RyR2), RyR2 oxidation, RyR2 nitrosylation, RyR2 calstabin2 depletion, and subsequent RyR2 Ca2+ leakiness. Chemotherapy was furthermore associated with abnormalities in brain glucose metabolism and neurocognitive dysfunction in breast cancer mice. RyR2 leakiness and cognitive dysfunction could be ameliorated by treatment with a small molecule Rycal drug (S107). Chemobrain was also found in noncancer mice treated with DOX or methotrexate and 5-fluorouracil and could be prevented by treatment with S107. Genetic ablation of the RyR2 PKA phosphorylation site (RyR2-S2808A) also prevented the development of chemobrain. Chemotherapy increased brain concentrations of the tumor necrosis factor-α and transforming growth factor-β signaling, suggesting that increased inflammatory signaling might contribute to oxidation-driven biochemical remodeling of RyR2. Proteomics and Gene Ontology analysis indicated that the signaling downstream of chemotherapy-induced leaky RyR2 was linked to the dysregulation of synaptic structure-associated proteins that are involved in neurotransmission. Together, our study points to neuronal Ca2+ dyshomeostasis via leaky RyR2 channels as a potential mechanism contributing to chemobrain, warranting further translational studies.

Comparative evaluation of doxorubicin, cyclophosphamide, 5-fluorouracil, and cisplatin on cognitive dysfunction in rats: Delineating the role of inflammation of hippocampal neurons and hypothyroidism

Chemotherapeutic agents such as doxorubicin, cyclophosphamide, fluorouracil, and cisplatin are commonly used to treat a variety of cancers and often result in chemobrain, which manifests as difficulties in learning and memory processes that can persist in the years following treatment. The current study aims to evaluate the cognitive function following treatment with these agents and the underlying mechanisms using a rat model of neuroinflammation and possible implication of thyroid toxicity in chemotherapy induced cognitive dysfunction. Wistar female rats were treated with a single dose of doxorubicin (DOX, 25 mg/kg), 5-fluorouracil (5-FU, 100 mg/kg), cisplatin (8 mg/kg), and cyclophosphamide (CYP, 200 mg/kg) by intraperitoneal injection. The cognitive performance of rats was then evaluated in spatial memory tasks using the Y-maze, novel object recognition (NOR), and elevated plus maze (EPM) tests. Serum levels of thyroid hormones (T3, T4, FT3, and FT4) and thyroid stimulating hormone (TSH) were measured, followed by estimation of TNFα, IL-6, and IL-1β in the hippocampal tissue. Results revealed that all the chemotherapeutic agents produced impairment of cognitive function, and significant increase of pro-inflammatory cytokines such as TNFα, IL-6 and IL-1β in the hippocampal tissues. There was a significant reduction in thyroid hormones (T3, FT3, and T4) and an increase in thyroid stimulating hormone (TSH) in serum, which may also have contributed to the decline in cognitive function. In conclusion, DOX, 5-FU, CYP, and cisplatin produces impairment of spatial memory possibly by inflammation of hippocampal neurons and endocrine disruption (hypothyroidism) in rats.

Epigenetic aging in older breast cancer survivors and noncancer controls: preliminary findings from the Thinking and Living with Cancer Study

BACKGROUND

Cancer and its treatments may accelerate aging in survivors; however, research has not examined epigenetic markers of aging in longer term breast cancer survivors. This study examined whether older breast cancer survivors showed greater epigenetic aging than noncancer controls and whether epigenetic aging related to functional outcomes.

METHODS

Nonmetastatic breast cancer survivors (n = 89) enrolled prior to systemic therapy and frequency-matched controls (n = 101) ages 62 to 84 years provided two blood samples to derive epigenetic aging measures (Horvath, Extrinsic Epigenetic Age [EEA], PhenoAge, GrimAge, Dunedin Pace of Aging) and completed cognitive (Functional Assessment of Cancer Therapy-Cognitive Function) and physical (Medical Outcomes Study Short Form-12) function assessments at approximately 24 to 36 and 60 months after enrollment. Mixed-effects models tested survivor-control differences in epigenetic aging, adjusting for age and comorbidities; models for functional outcomes also adjusted for racial group, site, and cognitive reserve.

RESULTS

Survivors were 1.04 to 2.22 years biologically older than controls on Horvath, EEA, GrimAge, and DunedinPACE measures (p = .001-.04) at approximately 24 to 36 months after enrollment. Survivors exposed to chemotherapy were 1.97 to 2.71 years older (p = .001-.04), and among this group, an older EEA related to worse self-reported cognition (p = .047) relative to controls. An older epigenetic age related to worse physical function in all women (p < .001-.01). Survivors and controls showed similar epigenetic aging over time, but Black survivors showed accelerated aging over time relative to non-Hispanic White survivors.

CONCLUSION

Older breast cancer survivors, particularly those exposed to chemotherapy, showed greater epigenetic aging than controls that may relate to worse outcomes. If replicated, measurement of biological aging could complement geriatric assessments to guide cancer care for older women.

Effectiveness of Nonpharmacologic Interventions for Chemotherapy-Related Cognitive Impairment in Breast Cancer Patients: A Systematic Review and Network Meta-analysis

BACKGROUND

Neurotoxicity is a major adverse effect of chemotherapy in breast cancer (BC) patients. A number of nonpharmacologic interventions are used to alleviate chemotherapy-related cognitive impairment (CRCI), but no studies have compared their effectiveness.

OBJECTIVES

The aim of this study was to identify and compare the effectiveness of different nonpharmacologic interventions for CRCI in BC patients.

METHODS

A systematic review and network meta-analysis was conducted following the Cochrane guidelines. All randomized controlled trials were searched in the Cochrane Library, PubMed, MEDLINE (via OVID), Web of Science, EMBASE, and CINAHL databases from inception to September 2021. Studies using nonpharmacologic interventions to manage CRCI symptoms were included. A network meta-analysis and a comparative effects ranking were completed by STATA v14.0.

RESULTS

Twelve studies with 8 nonpharmacologic interventions were included. For subjective outcomes on CRCI, there was no significant difference between nonpharmacologic interventions. For objective outcomes, qigong and exercise were more effective than the psychotherapy. Qigong and exercise were also more effective than music therapy. The top 3 interventions were psychotherapy (83.4%), music therapy (60.8%), and electroacupuncture (52.5%) for subjective outcomes and qigong (87.7%), exercise (82.1%), and electroacupuncture (70.3%) for objective outcomes.

CONCLUSION

In the subjective evaluation, it was difficult to judge which interventions are best, but psychotherapy had the greatest probability. For objective evaluation, qigong and exercise may be the best nonpharmacologic interventions.

IMPLICATIONS FOR PRACTICE

This study provides evidence for the effectiveness of nonpharmacologic interventions for CRCI in BC patients and facilitates support for future clinical trials and work.

"Chemobrain" in childhood cancer survivors-the impact on social, academic, and daily living skills: a qualitative systematic review

PURPOSE

To examine children's experiences of chemotherapy-induced cognitive impairment--colloquially "chemobrain"--and the impact on children's social, academic, and daily living skills via a qualitative systematic review. Experiencing chemotherapy as a child, when the brain is still developing, may cause lifelong detriment to survivors' lives. There is a significant gap in understanding their lived experience, including the self-identified barriers that children face following treatment. Such a gap can only be fully bridged by listening to the child's own voice and/or parent proxy report through an exploration of the qualitative research literature.

METHODS

A search of MEDLINE, Embase, PsycINFO, and CINAHL databases was conducted. Inclusion criteria were qualitative studies with a focus on children (0-18 years) during and/or following chemotherapy treatment and explored children's experiences of chemobrain.

RESULTS

Two synthesized findings were identified from six studies. (1) Chemobrain has an academic and psychosocial impact, which may not be understood by education providers. (2) Children and their parents have concerns about their reintegration and adaptation to school, social lives, and their future selves as independent members of society. Children's experiences primarily related to changes in their academic and social functioning.

CONCLUSION

This review highlights two important considerations: (1) the lived experiences of pediatric childhood cancer survivors guiding where future interventions should be targeted, and (2) a need to perform more qualitative research studies in this area, as well as to improve the quality of reporting among the existing literature, given that this is a current gap in the field.

[Risk factors for cancer-related cognitive impairment in breast and colorectal cancer patients who undergo chemotherapy]

BACKGROUND

Our study aims to evaluate the impact of different factors on cancer-related cognitive impairment in patients who undergo chemotherapy.

METHODOLOGY

Prospective longitudinal single-centre study that included patients with breast and colon carcinoma who underwent chemotherapy as part of their treatment. Clinical and genetic characteristics of the patients (single nucleotide polymorphisms, SNPs) were collected. Patients' neurocognitive status was assessed using eleven validated tests at three time points: before chemotherapy (M0 - baseline), between one and four weeks after completing chemotherapy (M1), and between 24-30 weeks after completing chemotherapy (M2).

RESULTS

Sixty-two patients were included in this study; 82% were female, median age was 56 years (range 30-74), and 64.5% had been diagnosed with breast cancer. Overall, better cognitive results at M0 were associated with age < 55 years, higher educational level, absence of comorbidities, and the CC variant rs471692 (TOP2A). Significant decline was found between M0 to M1 in the Rey Auditory Verbal Learning Test and the Letter and Number test, with evidence of recovery in M2 compared to M0 regarding the following test: Visual Memory, Functioning Assessment Short Test (FAST), Digit Symbol Substitution and Cube. In the multivariate analysis, being =55 years of age, adjuvant chemotherapy, presence of comorbidities, tobacco and alcohol use, and GT variant rs1800795 were associated with cognitive decline between M0 and M1.

CONCLUSION

Being =55 years of age, female, presence of comorbidities and basic education level are related to a higher risk of cognitive impairment after chemotherapy.

Cardiorespiratory fitness is associated with hippocampal resting state connectivity in women newly diagnosed with breast cancer

Background

Breast cancer and its treatment are associated with aberrant patterns of resting state functional connectivity (rsFC) between the hippocampus and several areas of the brain, which may account for poorer cognitive outcomes in patients. Higher cardiorespiratory fitness (CRF) has been associated with enhanced rsFC and cognitive performance; however, these associations have not been well studied in breast cancer. We examined the relationship between CRF, rsFC of the hippocampus, and cognitive performance among women newly diagnosed with breast cancer.

Methods

Thirty-four postmenopausal women newly diagnosed with Stage 0-IIIa breast cancer (Mage = 63.59 ± 5.73) were enrolled in a 6-month randomized controlled trial of aerobic exercise vs. usual care. During baseline assessments, participants completed functional brain imaging, a submaximal CRF test, and cognitive testing. Whole-brain, seed-based analyses were used to examine the relationship between CRF and hippocampal rsFC, with age, years of education, and framewise displacement included as covariates. Cognition was measured with a battery of validated neurocognitive measures, reduced to seven composite factors.

Results

Higher CRF was positively associated with greater rsFC of the hippocampus to a cluster within the dorsomedial and dorsolateral frontal cortex (z-max = 4.37, p = 0.003, cluster extent = 1,020 voxels). Connectivity within cluster peaks was not significantly related to cognitive factors (all ps > 0.05).

Discussion

CRF was positively associated with hippocampal rsFC to frontal cortex structures, comprising a network of regions commonly suppressed in breast cancer. Future longitudinal research is needed to explore whether baseline rsFC predicts long-term cognitive resilience in breast cancer.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Tumor-mediated microbiota alteration impairs synaptic tagging/capture in the hippocampal CA1 area via IL-1β production

Cancer patients often experience impairments in cognitive function. However, the evidence for tumor-mediated neurological impairment and detailed mechanisms are still lacking. Gut microbiota has been demonstrated to be involved in the immune system homeostasis and brain functions. Here we find that hepatocellular carcinoma (HCC) growth alters the gut microbiota and impedes the cognitive functions. The synaptic tagging and capture (STC), an associative cellular mechanism for the formation of associative memory, is impaired in the tumor-bearing mice. STC expression is rescued after microbiota sterilization. Transplantation of microbiota from HCC tumor-bearing mice induces similar STC impairment in wide type mice. Mechanistic study reveals that HCC growth significantly elevates the serum and hippocampus IL-1β levels. IL-1β depletion in the HCC tumor-bearing mice restores the STC. Taken together, these results demonstrate that gut microbiota plays a crucial role in mediating the tumor-induced impairment of the cognitive function via upregulating IL-1β production.

Nose to brain delivery of naringin-loaded chitosan nanoparticles for potential use in oxaliplatin-induced chemobrain in rats: impact on oxidative stress, cGAS/STING and HMGB1/RAGE/TLR2/MYD88 inflammatory axes

OBJECTIVES

Oxaliplatin induces chemobrain in cancer patients/survivors. Nutraceutical naringin has antioxidant and anti-inflammatory properties with low oral bioavailability. Our aim was to formulate naringin in chitosan nanoparticles for nose to brain delivery and assess its neuroprotective effect against oxaliplatin-induced chemobrain in rats.

METHODS

Naringin chitosan nanoparticles were prepared by ionic gelation. Rats were administered oral naringin (80 mg/kg), intranasal naringin (0.3 mg/kg) or intranasal naringin-loaded chitosan nanoparticles (0.3 mg/kg). Naringin's neuroprotective efficacy was assessed based on behavioral tests, histopathology, and measuring oxidative stress and inflammatory markers.

RESULTS

Selected nanoparticles formulation showed drug loading of 5%, size of 150 nm and were cationic. Intranasal naringin administration enhanced memory function, inhibited hippocampal acetylcholinesterase activity, and corrected oxaliplatin-induced histological changes. Moreover, it reduced malondialdehyde and elevated reduced glutathione hippocampal levels. Furthermore, it decreased levels of inflammatory markers: NF-kB and TNF-α by 1.25-fold. Upstream to this inflammatory status, intranasal naringin downregulated the hippocampal protein levels of two pathways: cGAS/STING and HMGB1/RAGE/TLR2/MYD88.

CONCLUSION

Intranasal naringin-loaded chitosan nanoparticles showed superior amelioration of oxaliplatin-induced chemobrain in rats at a dose 267-fold lower to that administered orally. The potential involvement of cGAS/STING and HMGB1/RAGE/TLR2/MYD88 pathways in the mechanistic process of either oxaliplatin-induced chemobrain or naringin-mediated neuroprotection was evidenced.

Cognitive Aging in Older Breast Cancer Survivors

BACKGROUND

Cancer and cancer treatments may affect aging processes, altering the trajectory of cognitive aging, but the extant studies are limited in their intervals of assessment (two-five years). We studied the cognitive performance of a cohort of survivors and controls aged from 60 to 89 years utilizing cross-sectional cognitive performance data as an indicator of potential aging trajectories and contrasted these trends with longitudinal data collected over two years.

METHODS

Female breast cancer survivors who had been diagnosed and treated at age 60 or older and were 5- to 15-year survivors (N = 328) and non-cancer controls (N = 158) were assessed at enrollment and at 8, 16, and 24 months with standard neuropsychological tests and comprehensive geriatric assessment.

RESULTS

A cross-sectional baseline analysis found the expected inverse association of age with cognition in both groups, with survivors performing lower overall than controls in learning and memory (LM). Younger survivors, i.e., those under 75 years of age, exhibited lower performance in both LM and attention, and processing speed and executive function (APE), compared to controls, with no differences being observed between older survivors and controls, which tracked with deficit accumulation trends.

CONCLUSION

Cognitive differences between the survivors and controls for the LM and APE domains were prominent in younger survivors, as was deficit accumulation, suggesting a mediating effect on cognition. Deficit accumulation may represent a modifiable risk factor in cancer survivorship that may be targeted for prevention and intervention.

Intolerance of Uncertainty and Cognition in Breast Cancer Survivors: The Mediating Role of Anxiety

Cancer-related cognitive impairment (CRCI) is one of the most prevalent symptoms that breast cancer survivors experience. While cancer treatments are established contributors to CRCI, inter-individual differences in CRCI are not well understood. Individual differences in sensitivity to uncertainty are potential contributors to CRCI; however, no prior studies have attempted to examine this link in the context of breast cancer. To address the gap, we used preliminary findings from an ongoing cross-sectional study. A total of 38 women with stage I-III breast cancer (1-4 years post-treatment) were included in this study. Intolerance of uncertainty (IU) was assessed using the Intolerance of Uncertainty Scale. Self-reported cognitive function was assessed with the Neuro-QoL questionnaire. Anxiety was assessed using the Patient-Reported Outcomes Measurement System Bank. From this study, we found that anxiety mediates the association between IU and cognitive function of survivors. In other words, among post-menopausal breast cancer survivors, those with higher IU showed higher anxiety and consequently had lower cognitive function. This finding suggests that assessing IU may help predict the risk of CRCI. This study expands the current knowledge that addresses the importance of IU as a factor associated with cognitive health.

Chemical characterization of the polyphenolic rich fraction of Thunbergia erecta and its therapeutic potential against doxorubicin and cyclophosphamide-induced cognitive impairment in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Thunbergia erecta (Benth.) was traditionally used as anxiolytic, sedative and antidepressant.

AIM OF THE STUDY

The study aimed to characterize T. erecta leaf ethyl acetate fraction of alcohol extract (TEAF) and evaluate its neuroprotective effect on doxorubicin and cyclophosphamide-induced chemobrain.

MATERIALS AND METHODS

Chemical profiling of TEAF was done using (Liquid chromatography coupled with mass (LC-ESI-MS/MS). In vivo chemobrain model was performed by cognitive impairment induced by doxorubicin and cyclophosphamide. Behavioral assessments included moris water maze, y maze, novel object recognition task and passive avoidance tests. Histological examination and oxidative stress markers were investigated. Protein expression of HMDGB1/RAGE/pNF-κB pathway markers was done using western blotting. All results were applied to hippocampus and prefrontal cortex of rats. Molecular docking was done within the active sites of Human Receptor for Advanced Glycation Endproducts (RAGE) using Discovery studio software.

RESULTS

Twenty-one phytoconstituents, mostly polyphenolics, were characterized in TEAF of which eleven compounds were tentatively identified for the first time from T. erecta leaves where rosmarinic acid (11) represents the most prevailing compound. TEAF resulted in a marked dose-dependent amelioration of the histopathological changes evidenced by normal histological structure demonstrated in the hypocampal gesture of rats. TEAF demonstrated an enhanced memory and learning functioning in the different behavioral tests assessed especially at 200 mg/kg. It showed significant long-term spatial memory enhancement manifested by 50.32% increase in probe trial relative to chemobrain-induced group. It showed pronounced antioxidant activity evidenced by the significant elevation of prefrontal cortical and hippocampal reduced glutathione levels by 2.45 and 2.65 folds, respectively relative to the chemobrain-induced group. The pronounced reduction in hydrogen peroxide (1.24-1.93 folds) and malondialdehyde levels (1.42-2.60 folds) with significant elevation of catalase activity (12.65-31.47%) induced by TEAF supported its potent antioxidant activity. TEAF reversed the inflammatory cytokines release induced by chemotherapy via its interference with HMGB1/RAGE pathway suppressing the expression of HMBG1, RAGE, p65 (NF-kB), and IL-1β. In silico studies showed that rosmarinic acid displayed the best fitting at the active site of RAGE (ΔG = -40.39 kcal/mol).

CONCLUSIONS

Thunbergia erecta can act as a promising remedy for chemobrain that further consolidates its traditional importance.

Neuropsychological monitoring of cognitive function and ICF–based mental components in patients with malignant brain tumours

Background

Cognitive deficits are one of the important clinical features of patients with brain tumours, which can affect up to 30–90% of patients before treatment. The consequence is a significant and rapid degradation of the patient’s intellectual functioning, seizures, paralysis and other symptoms that prevent independent functioning. This results in a reduced quality of life and a psychological crisis not only for the patient but also for their relatives. Maintaining the patient’s function at the highest level for as long as possible is particularly important, given that long-term remission or a cure is unlikely or accompanied by significant disability.

Purpose

This paper aims to provide a narrative review to the neuropsychological procedure for monitoring cognitive function in patients with brain tumours, which may be helpful in developing adequate clinical practice and appropriate management procedures.

Methods

A narrative review was applied to search broadly across disciplines, retrieving literature from several databases (PubMed, Web of Science, and EBSCOhost).

Results

(1) discussing the methodological aspects of neuropsychological tools for monitoring cognitive function in brain tumour patients, (2) identifying the most commonly used tools and (3) their practical applicability according to the cognitive function components of the International Classification of Functioning, Disability and Health (ICF).

Conclusion

This article points to the need to systematise research tools or develop new ones, adapted to diagnostic needs with high psychometric characteristics, with particular attention to memory processes and learning effect. Rehabilitation of patients is also an important issue, which requires the use of adequate tools to assess functional disability. The International Classification of Functioning, Disability and Health (ICF) seems to be useful in this respect. The ICF has the advantage of targeting actions to improve the condition of the individual and to keep them as long as possible in a state of well-being that allows them to function effectively in society or to return to work. This is particularly important in view of the ageing population and the increasing number of diagnoses related to brain tumours.

Non-Classical Intercellular Communications: Basic Mechanisms and Roles in Biology and Medicine

In multicellular organisms, interactions between cells and intercellular communications form the very basis of the organism’s survival, the functioning of its systems, the maintenance of homeostasis and adequate response to the environment. The accumulated experimental data point to the particular importance of intercellular communications in determining the fate of cells, as well as their differentiation and plasticity. For a long time, it was believed that the properties and behavior of cells were primarily governed by the interactions of secreted or membrane-bound ligands with corresponding receptors, as well as direct intercellular adhesion contacts. In this review, we describe various types of other, non-classical intercellular interactions and communications that have recently come into the limelight—in particular, the broad repertoire of extracellular vesicles and membrane protrusions. These communications are mediated by large macromolecular structural and functional ensembles, and we explore here the mechanisms underlying their formation and present current data that reveal their roles in multiple biological processes. The effects mediated by these new types of intercellular communications in normal and pathological states, as well as therapeutic applications, are also discussed. The in-depth study of novel intercellular interaction mechanisms is required for the establishment of effective approaches for the control and modification of cell properties both for basic research and the development of radically new therapeutic strategies.

The Role of Cognitive Dysfunction and Health Literacy on the Quality of Life in Cancer Survivors

Background: Cancer disease is considered one of the basic health problems in the world, which threatens the health of human life. It causes numerous personal, family and social damages in physical, psychological, and social dimensions. Objectives: The present study aimed at investigating health literacy and cognitive dysfunction on the quality of life of cancer survivors to make better decisions for the daily functioning, quality of life, and work capacity of cancer survivors so that their lives can be spent with more peace and less stress. Methods: With a descriptive correlational design, 350 cancer survivors of the Cancer Research Center of Shahid Beheshti University of Medical Sciences (Shohaday Tajrish Hospital) from September to November 2021, who had been treated for at least one year, volunteered online and in person. Cognitive failure (Broadbent et al., 1982), cancer health literacy test (Dumenci et al., 2014), and quality of life of adults surviving cancer (Avis et al, 2005). Results: Pearson correlation showed a negative relationship between cognitive dysfunction and quality of life; so, path analysis showed that 25% of the quality of life is explained by cognitive dysfunction, but cancer health literacy was not correlated with the quality of life of cancer survivors. Conclusions: According to the findings, the optimization of cognitive functions after treatment was emphasized to increase the quality of life of cancer survivors.

First-Line Immunotherapy with Check-Point Inhibitors: Prospective Assessment of Cognitive Function

Approximately 40% of patients with cancer are eligible for check-point inhibitor (CPI) therapy. Little research has examined the potential cognitive impact of CPIs. First-line CPI therapy offers a unique research opportunity without chemotherapy-related confounders. The purpose of this prospective, observational pilot was to (1) demonstrate the feasibility of prospective recruitment, retention, and neurocognitive assessment for older adults receiving first-line CPI(s) and (2) provide preliminary evidence of changes in cognitive function associated with CPI(s). Patients receiving first-line CPI(s) (CPI Group) were assessed at baseline (n = 20) and 6 months (n = 13) for self-report of cognitive function and neurocognitive test performance. Results were compared to age-matched controls without cognitive impairment assessed annually by the Alzheimer's Disease Research Center (ADRC). Plasma biomarkers were measured at baseline and 6 months for the CPI Group. Estimated differences for CPI Group scores prior to initiating CPIs (baseline) trended to lower performance on the Montreal Cognitive Assessment-Blind (MOCA-Blind) test compared to the ADRC controls (p = 0.066). Controlling for age, the CPI Group's 6-months MOCA-Blind performance was lower than the ADRC control group's 12-months performance (p = 0.011). No significant differences in biomarkers were detected between baseline and 6 months, although significant correlations were noted for biomarker change and cognitive performance at 6 months. IFNγ, IL-1β, IL-2, FGF2, and VEGF were inversely associated with Craft Story Recall performance (p < 0.05), e.g., higher levels correlated with poorer memory performance. Higher IGF-1 and VEGF correlated with better letter-number sequencing and digit-span backwards performance, respectively. Unexpected inverse correlation was noted between IL-1α and Oral Trail-Making Test B completion time. CPI(s) may have a negative impact on some neurocognitive domains and warrant further investigation. A multi-site study design may be crucial to fully powering prospective investigation of the cognitive impact of CPIs. Establishment of a multi-site observational registry from collaborating cancer centers and ADRCs is recommended.

Pre-Treatment Breast Cancer Patients Show Neural Differences in Frontal Alpha Asymmetry

Cognitive impairment has been observed consistently in a subset of breast cancer survivors. Yet, still unknown is whether neural and behavioral effects of cancer exist prior to treatment, which may contribute to later cognitive decline. The current study investigated pre-treatment differences in attention performance and frontal alpha asymmetry (FAA), an established neural index of inhibitory control, in non-metastatic breast cancer patients (n = 42) compared with healthy controls (n = 28). We additionally investigated whether differences between groups appear in specific cuing conditions and across different stages of information processing. Participants underwent EEG while completing the Attention Network Task (ANT), a cognitive measure of alerting, orienting, and inhibitory control of attention. Results revealed no behavioral differences between patients and controls but significantly greater right-hemisphere alpha activity (reduced inhibitory control) in patients, particularly to uninformative (no cue, double cue) versus informative (valid cue) cues and in later stages of information processing (400-800 ms post-stimulus). Results suggest neural differences between groups to uncertain stimulus environments that have yet to manifest behaviorally. FAA may thus serve as a unique neural correlate that could potentially be used to predict later cognitive decline.

Association Between Cardiovascular Disease and Cognitive Dysfunction in Breast Cancer Survivors

BACKGROUND

Breast cancer survivors (BCSs) may have a greater risk for cardiovascular disease (congestive heart failure and hypertension), which in turn, can affect cognitive dysfunction, a frequent, bothersome, and potentially debilitating symptom.

OBJECTIVE

The purpose of this study was to examine the relationship of cardiovascular disease on cognitive function in BCSs.

METHODS

Baseline data from a double-blind randomized controlled trial for cognitive training of BCSs were examined. Early-stage BCS (stages I-IIIA) who were 21 years or older, completed adjuvant therapy (≥6 months), and reported cognitive concerns completed questionnaires and a brief neuropsychological assessment, including tests of memory, attention and working memory, speed of processing, and verbal fluency. Descriptive statistics, Pearson correlation coefficient, and separate linear regression models for each cognitive domain were conducted.

RESULTS

Forty-seven BCSs, who were on average 57.3 (SD, 8.1) years old, were 58% White, and had some college education (75%), completed the study. Furthermore, 44.7% of the BCS had cardiovascular disease (congestive heart failure or hypertension). In linear regression models, cardiovascular disease was significantly related to immediate and delayed memory and attention and working memory ( P < .01-.05).

CONCLUSION

Breast cancer survivors who have cardiovascular disease may also be at a greater risk for cognitive dysfunction post treatment. Results from this study inform both clinical practice and future research, specifically by examining the intersection between cancer, cardiovascular disease (cardiotoxicity), and cognition.

IMPLICATIONS FOR PRACTICE

Nurses should be aware that BCSs with co-occurring cardiovascular disease are at a higher risk for cognitive dysfunction and work within the multidisciplinary team to optimize BCS health and function.

Construction of a predictive model for cognitive impairment risk in patients with advanced cancer

AIMS

The purpose of this study was to identify risk factors for cognitive impairment in advanced cancer patients and to develop predictive models based on these risk factors.

BACKGROUND

Cancer-related cognitive impairment seriously affects the quality of life of advanced cancer patients. However, neural network models of cognitive impairment in patients with advanced cancer have not yet been identified.

DESIGN

A cross-sectional design was used.

METHODS

This study collected 494 questionnaires between January and June 2022. Statistically significant clinical indicators were selected by univariate analysis, and the artificial neural network model and logistic regression model were used for multivariate analysis. The predicted value of the model was estimated using the area under the subject's working characteristic curve.

RESULT

The artificial neural network and the logistic regression models suggested that cancer course, anxiety and age were the major risk factors for cognitive impairment in advanced cancer patients. All the indexes of artificial neural network model constructed in this study are better than those of the logistic model.

CONCLUSION

The artificial neural network model can better predict the risk factors of cognitive impairment in patients with advanced cancer. Better prediction will enable nurses and other healthcare professionals to provide better targeted and timely support.

Microglia are implicated in the development of paclitaxel chemotherapy-associated cognitive impairment in female mice

Chemotherapy remains a mainstay in the treatment of many types of cancer even though it is associated with debilitating behavioral side effects referred to as "chemobrain," including difficulty concentrating and memory impairment. The predominant hypothesis in the field is that systemic inflammation drives these cognitive impairments, although the brain mechanisms by which this occurs remain poorly understood. Here, we hypothesized that microglia are activated by chemotherapy and drive chemotherapy-associated cognitive impairments. To test this hypothesis, we treated female C57BL/6 mice with a clinically-relevant regimen of a common chemotherapeutic, paclitaxel (6 i.p. doses at 30 mg/kg), which impairs memory of an aversive stimulus as assessed via a contextual fear conditioning (CFC) paradigm. Paclitaxel increased the percent area of IBA1 staining in the dentate gyrus of the hippocampus. Moreover, using a machine learning random forest classifier we identified immunohistochemical features of reactive microglia in multiple hippocampal subregions that were distinct between vehicle- and paclitaxel-treated mice. Paclitaxel treatment also increased gene expression of inflammatory cytokines in a microglia-enriched population of cells from mice. Lastly, a selective inhibitor of colony stimulating factor 1 receptor, PLX5622, was employed to deplete microglia and then assess CFC performance following paclitaxel treatment. PLX5622 significantly reduced hippocampal gene expression of paclitaxel-induced proinflammatory cytokines and restored memory, suggesting that microglia play a critical role in the development of chemotherapy-associated neuroinflammation and cognitive impairments. This work provides critical evidence that microglia drive paclitaxel-associated cognitive impairments, a key mechanistic detail for determining preventative and intervention strategies for these burdensome side effects.

Cortical thinning in chemotherapy-treated older long-term breast cancer survivors

Cognitive decline is an increasing issue for cancer survivors, especially for older adults, as chemotherapy affects brain structure and function. The purpose of this single center study was to evaluate alterations in cortical thickness and cognition in older long-term survivors of breast cancer who had been treated with chemotherapy years ago. In this prospective cohort study, we enrolled 3 groups of women aged ≥ 65 years with a history of stage I-III breast cancer who had received adjuvant chemotherapy 5 to 15 years ago (chemotherapy group, C +), age-matched women with breast cancer but no chemotherapy (no-chemotherapy group, C-) and healthy controls (HC). All participants underwent brain magnetic resonance imaging and neuropsychological testing with the NIH Toolbox Cognition Battery at time point 1 (TP1) and again at 2 years after enrollment (time point 2 (TP2)). At TP1, there were no significant differences in cortical thickness among the 3 groups. Longitudinally, the C + group showed cortical thinning in the fusiform gyrus (p = 0.006, effect size (d) = -0.60 [ -1.86, -0.66]), pars triangularis (p = 0.026, effect size (d) = -0.43 [-1.68, -0.82]), and inferior temporal lobe (p = 0.026, effect size (d) = -0.38 [-1.62, -0.31]) of the left hemisphere. The C + group also showed decreases in neuropsychological scores such as the total composite score (p = 0.01, effect size (d) = -3.9726 [-0.9656, -6.9796], fluid composite score (p = 0.03, effect size (d) = -4.438 [-0.406, -8.47], and picture vocabulary score (p = 0.04, effect size (d) = -3.7499 [-0.0617, -7.438]. Our results showed that cortical thickness could be a candidate neuroimaging biomarker for cancer-related cognitive impairment and accelerated aging in older long-term cancer survivors.

Prevalence and health outcomes in community-dwelling older adults with comorbid cancer and dementia: a longitudinal analysis

OBJECTIVES

To examine health outcomes in community-dwelling older adults with: dementia only, cancer only, and comorbid cancer and dementia.

METHODS

Longitudinal analysis was conducted using data from 2010 to 2016 waves of the Health and Retirement Study. Health outcomes included mortality, limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL), nursing home utilization, hospital stay, homecare use, self-rated health, and out-of-pocket medical expenditure. Panel regression was used for statistical analysis.

RESULTS

The prevalence of comorbid cancer and dementia ranged from 2.56% to 2.97%. Individuals with comorbid cancer and dementia demonstrated a higher likelihood of nursing home utilization and poorer self-rated health but a lower likelihood of hospital stay, homecare use, and out-of-pocket expenditures, compared to the cancer only or dementia only groups. The differences in mortality and ADL and IADL limitations were not statistically significant.

CONCLUSION

Comorbid cancer and dementia predicted longer nursing home utilization and poorer self-rated health. The results help guide care planning for individuals with comorbid cancer and dementia.

The Relationship between Cancer and Dementia: An Updated Review

The risk of cancer and dementia increases with age, raising complex questions about whether it is appropriate to continue cancer treatment in older patients. There is emerging research suggesting the association between cancer and dementia. However, the mechanistic underpinnings are still under investigation. Progress has already been made toward understanding the cognitive effects associated with cancer therapy. Such associations raise awareness about the need to establish better prevention methods and early screening in clinical practice. Additionally, recent studies have suggested possible therapeutic strategies for better preserving cognitive function and reducing the risk for dementia before patients start cancer treatment. We review the current literature and summarize the incidence and mechanisms of cognitive impairment in patients with lung cancer, breast cancer, head and neck cancer, gastric cancer, prostate cancer, colorectal cancer, and brain tumor/brain metastasis following different kinds of therapies. Possible risk factors are suggested to identify the early onset of cognitive changes in cancer patients and provide more insight into the pathophysiological process of dementia.

Elevated C-Reactive Protein and Subsequent Patient-Reported Cognitive Problems in Older Breast Cancer Survivors: The Thinking and Living With Cancer Study

PURPOSE

To examine longitudinal relationships between levels of C-reactive protein (CRP) and cognition in older breast cancer survivors and noncancer controls.

METHODS

English-speaking women age ≥ 60 years, newly diagnosed with primary breast cancer (stage 0-III), and frequency-matched controls were enrolled from September 2010 to March 2020; women with dementia, neurologic disorders, and other cancers were excluded. Assessments occurred presystemic therapy/enrollment and at annual visits up to 60 months. Cognition was measured using the Functional Assessment of Cancer Therapy-Cognitive Function and neuropsychological testing. Mixed linear effect models tested for survivor-control differences in natural log (ln)-transformed CRP at each visit. Random effect-lagged fluctuation models tested directional effects of ln-CRP on subsequent cognition. All models controlled for age, race, study site, cognitive reserve, obesity, and comorbidities; secondary analyses evaluated if depression or anxiety affected results.

RESULTS

There were 400 survivors and 329 controls with CRP specimens and follow-up data (average age of 67.7 years; range, 60-90 years). The majority of survivors had stage I (60.9%), estrogen receptor-positive (87.6%) tumors. Survivors had significantly higher adjusted mean ln-CRP than controls at baseline and 12-, 24-, and 60-month visits (all P < .05). Higher adjusted ln-CRP predicted lower participant-reported cognition on subsequent visits among survivors, but not controls (P interaction = .008); effects were unchanged by depression or anxiety. Overall, survivors had adjusted Functional Assessment of Cancer Therapy-Cognitive Function scores that were 9.5 and 14.2 points lower than controls at CRP levels of 3.0 and 10.0 mg/L. Survivors had poorer neuropsychological test performance (v controls), with significant interactions with CRP only for the Trails B test.

CONCLUSION

Longitudinal relationships between CRP and cognition in older breast cancer survivors suggest that chronic inflammation may play a role in development of cognitive problems. CRP testing could be clinically useful in survivorship care.

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.

Diet quality indices and changes in cognition during chemotherapy

PURPOSE

No evidence-based prevention strategies currently exist for cancer-related cognitive decline (CRCD). Although patients are often advised to engage in healthy lifestyle activities (e.g., nutritious diet), little is known about the impact of diet on preventing CRCD. This secondary analysis evaluated the association of pre-treatment diet quality indices on change in self-reported cognition during chemotherapy.

METHODS

Study participants (n = 96) completed the Block Brief Food Frequency Questionnaire (FFQ) before receiving their first infusion and the PROMIS cognitive function and cognitive abilities questionnaires before infusion and again 5 days later (i.e., when symptoms were expected to be their worst). Diet quality indices included the Dietary Approaches to Stop Hypertension (DASH), Alternate Mediterranean Diet (aMED), and a low carbohydrate diet index and their components. Descriptive statistics were generated for demographic and clinical variables and diet indices. Residualized change models were computed to examine whether diet was associated with change in cognitive function and cognitive abilities, controlling for age, sex, cancer type, treatment type, depression, and fatigue.

RESULTS

Study participants had a mean age of 59 ± 10.8 years and 69% were female. Although total diet index scores did not predict change in cognitive function or cognitive abilities, higher pre-treatment ratio of aMED monounsaturated/saturated fat was associated with less decline in cognitive function and cognitive abilities at 5-day post-infusion (P ≤ .001).

CONCLUSIONS

Higher pre-treatment ratio of monounsaturated/saturated fat intake was associated with less CRCD early in chemotherapy. Results suggest greater monounsaturated fat and less saturated fat intake could be protective against CRCD during chemotherapy.

Diagnostic Accuracy of Machine-Learning Models on Predicting Chemo-Brain in Breast Cancer Survivors Previously Treated with Chemotherapy: A Meta-Analysis

We performed a meta-analysis of chemo-brain diagnostic, pooling sensitivities, and specificities in order to assess the accuracy of a machine-learning (ML) algorithm in breast cancer survivors previously treated with chemotherapy. We searched PubMed, Web of Science, and Scopus for eligible articles before 30 September 2022. We identified three eligible studies from which we extracted seven ML algorithms. For our data, the χ² tests demonstrated the homogeneity of the sensitivity's models (χ² = 7.6987, df = 6, p-value = 0.261) and the specificities of the ML models (χ² = 3.0151, df = 6, p-value = 0.807). The pooled area under the curve (AUC) for the overall ML models in this study was 0.914 (95%CI: 0.891-0.939) and partial AUC (restricted to observed false positive rates and normalized) was 0.844 (95%CI: 0.80-0.889). Additionally, the pooled sensitivity and pooled specificity values were 0.81 (95% CI: 0.75-0.86) and 0.82 (95% CI: 0.76-0.86), respectively. From all included ML models, support vector machine demonstrated the best test performance. ML models represent a promising, reliable modality for chemo-brain prediction in breast cancer survivors previously treated with chemotherapy, demonstrating high accuracy.

The impact of breast cancer on social cognition in female Colombian patients

BACKGROUND

The high prevalence of female breast cancer is a global health concern. Breast cancer and its treatments have been associated with impairments in general cognition, as well as structural and functional brain changes. Considering the social challenges that some of these patients face, it is important to understand the socio-emotional effects of breast cancer as well. Nevertheless, the impact of breast cancer on social cognition has remained underexplored. The objective of this study was to assess social cognition domains and other relevant cognitive and emotional variables (executive functions, anxiety, or depression) in females with breast cancer.

METHODS

The participants were 29 female patients diagnosed with breast cancer and 29 female healthy controls. We assessed emotion recognition, theory of mind, empathy, and moral emotions. We also included measures of general cognitive functioning, quality of life, anxiety, and depression. Linear multiple regressions were performed to assess whether the group (patients or controls), GAD-7 scores, emotional and social subscales of EORTC QLQ-C30, and IFS scores predicted the social cognition variables (EET, RMET, MSAT).

RESULTS

Patients with breast cancer showed impairments in emotion recognition and in affective theory of mind. In addition, patients had lower scores in some executive functions. Only theory of mind between group differences remained significant after Bonferroni correction. Emotion recognition was associated with executive functioning, but anxiety levels were not a significant predictor of the changes in social cognition.

CONCLUSIONS

Social cognition impairments, especially in theory of mind, may be present in breast cancer, which can be relevant to understanding the social challenges that these patients encounter. This could indicate the need for therapeutic interventions to preserve social cognition skills in patients with breast cancer.

The association of health behaviors prior to cancer diagnosis and functional aging trajectories after diagnosis: Longitudinal cohort study of middle-aged and older US cancer survivors

We aimed to determine the influence of modifiable health behaviors prior to a cancer diagnosis on functional aging trajectories after diagnosis among middle-aged and older cancer survivors in the United States. Data were from biennial interviews with 2,717 survivors of a first incident cancer diagnosis after age 50 in the population-based US Health and Retirement Study from 1998 to 2016. Smoking status, alcohol use, and vigorous physical activity frequency were assessed at the interview prior to cancer diagnosis. Confounder-adjusted multinomial logistic regression was used to determine the associations between each pre-diagnosis health behavior and post-diagnosis trajectories of memory function and limitations to activities of daily living (ADLs), which were identified using group-based trajectory modeling. Overall, 20.7 % of cancer survivors were current smokers, 30.6 % drank alcohol, and 27.1 % engaged in vigorous physical activity >=once a week prior to their diagnosis. In the years following diagnosis, those who had engaged in vigorous physical activity > once a week were less likely to have a medium-high (OR: 0.5; 95 % CI: 0.2-0.9) or medium-low memory loss trajectories (OR: 0.6; 95 % CI: 0.3-1.0) versus very low memory loss trajectory, and were less likely to have a high, increasing ADL limitation trajectory (OR: 0.3; 95 % CI: 0.2, 0.6) versus no ADL limitation trajectory. Vigorous physical activity, but not smoking or alcohol use, was associated with better post-diagnosis functional aging trajectories after a first incident cancer diagnosis in mid-to-later life in this population-based study. Identification of modifiable risk factors can inform targeted interventions to promote healthy aging among cancer survivors.

Perioperative considerations in patients with chemotherapy-induced cognitive impairment: a narrative review

Patients with cancer may suffer from a decline in their cognitive function after various cancer therapies, including surgery, radiation, and chemotherapy, and in some cases, this decline in cognitive function persists even years after completion of treatment. Chemobrain or chemotherapy-induced cognitive impairment, a well-established clinical syndrome, has become an increasing concern as the number of successfully treated cancer patients has increased significantly. Chemotherapy-induced cognitive impairment can originate from direct neurotoxicity, neuroinflammation, and oxidative stress, resulting in alterations in grey matter volume, white matter integrity, and brain connectivity. Surgery has been associated with exacerbating the inflammatory response associated with chemotherapy and predisposes patients to develop postoperative cognitive dysfunction. As the proportion of patients living longer after these therapies increases, the magnitude of impact and growing concern of post-treatment cognitive dysfunction in these patients has also come to the fore. We review the clinical presentation, potential mechanisms, predisposing factors, diagnostic methods, neuropsychological testing, and imaging findings of chemotherapy-induced cognitive impairment and its intersection with postoperative cognitive dysfunction.

Chemotherapy promotes astrocytic response to Aβ deposition, but not Aβ levels, in a mouse model of amyloid and APOE

Many cancer survivors experience cancer-related cognitive impairment (CRCI), which is characterized by problems of attention, working memory, and executive function following chemotherapy and/or hormonal treatment. APOE4, the strongest genetic risk factor for Alzheimer's Disease (AD), is also a risk factor for CRCI, especially among survivors exposed to chemotherapy. We explored whether the effects of APOE genotype to chemotherapy were associated with an increase in AD pathological processes, using a mouse model of amyloid (5XFAD) along with the E3 or E4 alleles of human APOE (E3FAD and E4FAD). Six-month-old female E3FAD mice (control n = 5, treated n = 5) and E4FAD (control n = 6, treated n = 6) were treated with two doses of doxorubicin (total 10 mg/kg) or DMSO vehicle. After six weeks, mice were euthanized and brains were analyzed by immunohistochemistry and biochemical assays. Doxorubicin-treated mice had the same level of Aβ in the brain as control mice, as measured by 6E10 immunohistochemistry, Aβ40 and Aβ42 ELISAs, and plaque morphologies. Doxorubicin significantly increased the level of the astrocytic response to Aβ deposits, which was independent of APOE genotype; no effects of doxorubicin were observed on the microglial responses. These data are consistent with a model in which the effects of doxorubicin on risk of CRCI are unrelated amyloid accumulation, but possibly related to glial responses to damage.

Association of fall rate and functional status by APOE genotype in cancer survivors after exercise intervention

PURPOSE/OBJECTIVES

Cancer treatment survivors often report impaired functioning and increased falls. Not all survivors experience the same symptom burden, suggesting individual susceptibilities. APOE genotype is a potential genetic risk factor for cancer treatment related side effects. Lifestyle factors such as physical activity can mitigate the effect of APOE genotype on measures of clinical interest in individuals without a history of cancer. We tested the hypothesis that APOE genotype influences cancer treatment related side effects and symptoms as well as response to exercise intervention.

MATERIALS AND METHODS

Data from a subsample of a study of fall prevention exercise in post-treatment female cancer survivors aged 50-75 years old (https://clinicaltrials.gov NCT01635413) were used to conduct a secondary data analysis. ApoE genotype was determined by serum sampling. Physical functioning, frequency of falls, and symptom burden were assessed using survey instruments.

RESULTS

Data from 126 female cancer survivors a median of 49 months out from cancer diagnosis were analyzed. ApoE4 carriers trended toward a higher fall rate at baseline (p = 0.059), but after exercise intervention had a fall rate lower than E4 non-carriers both immediately after structured intervention (p = 0.013) and after 6 months of follow up (p = 0.002). E2 carriers did not show improved measures of depressive symptoms and self-report disability after exercise intervention. E3 homozygotes showed increased self report physical activity after the 6 month exercise intervention, but E4 and E2 carriers did not.

CONCLUSIONS

APOE genotype may modulate cancer treatment related side effects and symptoms and response to exercise intervention.

Impact of psychosocial, behavioral and lifestyle factors on subjective cognitive complaints and perceived quality of life in a large cohort of Italian breast cancer patients

The impact of psychosocial and behavioral factors on Cancer Related Cognitive Impairment manifestations is still under debate. Study's purpose is to determine the prevalence rate of cancer related cognitive impairment in a cohort of Italian breast cancer patients and to evaluate the implication of specific behavioral factors. For these purposes, a total of 233 women (106 breast cancer patients and 127 age-matched controls without oncological diagnosis) completed a questionnaire investigating cognitive functionality (FACT-Cog v3.0), sociodemographic characteristics, clinical information, psychosocial and behavioral factors (cognitive reserve, sleep quality, dietary habits, physical activity). The results indicated a higher prevalence rate of subjective cognitive complaints in breast cancer patients (37%) compared to a representative sample of women in the same age group without an oncological diagnosis (p < 0.001). Moreover, breast cancer patients showed significantly lower levels of cognitive reserve (p < 0.05) and worse sleep quality (p < 0.01) compared to age-matched controls. Further analysis revealed that breast cancer patients reporting subjective cognitive complaints differed significantly from breast cancer patients without subjective cognitive complaints on measures of perceived cognitive abilities (p < 0.001) and on the impact of cognitive difficulties on perceived quality of life (p < 0.01). Future studies are needed to examine behavioral directed interventions to prevent subjective cognitive deficits in breast cancer patients.

What microglia depletion approaches tell us about the role of microglia on synaptic function and behavior

Microglia are dynamic cells, constantly surveying their surroundings and interacting with neurons and synapses. Indeed, a wealth of knowledge has revealed a critical role of microglia in modulating synaptic transmission and plasticity in the developing brain. In the past decade, novel pharmacological and genetic strategies have allowed the acute removal of microglia, opening the possibility to explore and understand the role of microglia also in the adult brain. In this review, we summarized and discussed the contribution of microglia depletion strategies to the current understanding of the role of microglia on synaptic function, learning and memory, and behavior both in physiological and pathological conditions. We first described the available microglia depletion methods highlighting their main strengths and weaknesses. We then reviewed the impact of microglia depletion on structural and functional synaptic plasticity. Next, we focused our analysis on the effects of microglia depletion on behavior, including general locomotor activity, sensory perception, motor function, sociability, learning and memory both in healthy animals and animal models of disease. Finally, we integrated the findings from the reviewed studies and discussed the emerging roles of microglia on the maintenance of synaptic function, learning, memory strength and forgetfulness, and the implications of microglia depletion in models of brain disease.

Distinct sleep disturbance and cognitive dysfunction profiles in oncology outpatients receiving chemotherapy

PURPOSE

Sleep disturbance and cancer-related cognitive impairment (CRCI) are two of the most common symptoms reported by patients undergoing chemotherapy. Less is known about how these symptoms co-occur and their associated risk factors. Study purposes were to identify subgroups of patients with distinct sleep disturbance and CRCI profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, symptom severity scores, and QOL outcomes.

METHODS

A total of 1,333 oncology outpatients receiving chemotherapy completed self-report questionnaires on sleep disturbance and cognitive dysfunction six times over two cycles of chemotherapy. Latent profile analysis was used to identify distinct sleep disturbance AND cognitive dysfunction profiles. Parametric and non-parametric tests were used to evaluate for differences among the classes.

RESULTS

Two distinct profiles were identified (i.e., Low = low levels of both sleep disturbance and cognitive dysfunction (53.5%); High = high levels of both sleep disturbance and cognitive dysfunction (45.5%)). Patients in the High class were younger, more likely to be female, had a lower functional status and a higher level of comorbidity. In addition, these patients had a higher symptom burden and a lower quality of life.

CONCLUSION

Almost half of the patients undergoing chemotherapy experienced clinically meaningful levels of both symptoms. Of note, sleep disturbance is frequently overlooked by both clinicians and patients. Clinicians need to recommend cognitive rehabilitation and physical activity programs to decrease patients' symptom burden.

Cognitive function is well preserved in a cohort of breast cancer survivors: Roles of cognitive reserve, resilience, and general health

Many patients return to cognitively demanding work after breast cancer treatments. This makes treatment-related cognitive decline an important research topic. Psychological resilience, cognitive reserve and better perceived general health may work as protective factors against cognitive decline. The aim of this study was to analyse whether these factors are associated with cognitive function among such women.

Data from 384 breast cancer survivors who underwent neuropsychological examination at follow-up 4–9 years after surgery were used. The neurocognitive domain variable Learning and Memory was computed from Wechsler Memory Scale-III subtests Learning and Delayed Recall. Another variable, Attention, Processing speed and Executive function, was computed from semantic and verbal fluency tests, Trail Making Test A and B, and Wechsler Adult Intelligence Test-IV subtest Coding. Psychological resilience was measured with Resilience Scale-14, and perceived general health with RAND-36 subitem General Health.

Results

showed that levels of cognitive performance and general health were statistically higher than population average. Resilience and general health in separate models were associated with Attention, Processing speed and Executive function (β = 0.14, p = 0.01; β = 0.13, p = 0.03, respectively). When added simultaneously in the same model, resilience was significant (β = 0.13, p = 0.04), but general health was not. These associations were nonsignificant after controlling for confounding factors. Learning and Memory was not associated with resilience or general health.

Future research should focus on longitudinal studies identifying patients at a high risk of developing cognitive decline after breast cancer treatments and on preventive and therapeutic approaches.

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401 women were neuropsychologically examined 4–9 years after breast cancer surgery.

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Their cognitive performance was on average well preserved.

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Psychological Resilience associated with better cognitive performance in one domain.

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The association between General Health and cognition was less prominent.

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High education level might protect against cognitive decline after breast cancer.