Preliminary assessment of cognitive function in breast cancer patients treated with tamoxifen

The cognitive effects of adjuvant chemotherapy in early stage breast cancer: a prospective study

PURPOSE

The primary purpose of this study was to evaluate the cognitive effects of adjuvant chemotherapy in post-menopausal breast cancer patients.

PATIENTS AND METHODS

Breast cancer patients scheduled to receive adjuvant chemotherapy (n = 61) completed comprehensive cognitive testing before and after treatment. A control group of women receiving adjuvant hormonal therapy (n = 51) was tested at comparable intervals.

RESULTS

Mean scores for both patient groups were within the normal range relative to published norms on all cognitive tests at both time points, and generally inclined or stayed the same from baseline to retest in both groups. However, in an analysis of individual change scores, the chemotherapy patients were 3.3 times more likely than the hormonal patients to show reliable cognitive decline (31 and 12%, respectively). Chemotherapy subjects showing decline were less educated and had higher baseline depression scores than their counterparts who did not decline. Working memory was the cognitive domain most vulnerable to the effects of chemotherapy.

CONCLUSION

These data support previous findings of a subtle negative influence of chemotherapy on cognitive function in a subgroup of breast cancer patients. The results are discussed in terms of the importance of study design.

Cognitive function after chemotherapy in adults with solid tumours

BACKGROUND

Evidence is emerging that some cancer survivors suffer cognitive impairment after chemotherapy; the cause is unknown.

METHODS

Here we review studies evaluating cognitive impairment in adult cancer survivors and discuss methodological challenges associated with this research. We evaluate evidence for cognitive impairment in cancer patients, the incidence of self-reported impairment, and identify potential mechanisms and confounders.

RESULTS

Most studies of cognitive function are cross-sectional and report impairment in 15-45% of subjects. Longitudinal studies suggest that some impairment is present prior to receiving chemotherapy, and that this worsens in some patients. The aetiology is unknown. A larger number of subjects self-report changes in cognitive function after chemotherapy; this does not correlate with objective testing.

CONCLUSIONS

Cognitive impairment occurs in a subset of cancer survivors and is generally subtle. Most evidence suggests an association with chemotherapy although other factors associated with the diagnosis and treatment of cancer may contribute.

Safety of aromatase inhibitors in the adjuvant setting

The third-generation aromatase inhibitors (AIs) letrozole, anastrozole, and exemestane are replacing tamoxifen as adjuvant therapy in most postmenopausal women with early breast cancer. Although AIs have demonstrated superior efficacy and better overall safety compared with tamoxifen in randomized controlled trials, they may not provide the cardioprotective effects of tamoxifen, and bone loss may be a concern with their long-term adjuvant use. Patients require regular bone mineral density monitoring, and prophylactic bisphosphonates are being evaluated to determine whether they may protect long-term bone health. AIs decrease the risks of thromboembolic and cerebrovascular events compared with tamoxifen, and the overall rate of cardiovascular events in patients treated with AIs is within the range seen in age-matched, non-breast-cancer populations. AIs are also associated with a lower incidence of endometrial cancer and fewer vaginal bleeding/discharge events than tamoxifen. Compared with tamoxifen, the incidence of hot flashes is lower with anastrozole and letrozole but may be higher with exemestane. Generally, adverse events with AIs are predictable and manageable, whereas tamoxifen may be associated with life-threatening events in a minority of patients. Overall, the benefits of AIs over tamoxifen are achieved without compromising overall quality of life.

Chemotherapy-Related Change in Cognitive Function: A Conceptual Model

PURPOSE/OBJECTIVES

To develop a conceptual model of chemotherapy-related changes in cognitive function.

DATA SOURCES

MEDLINE, CINAHL, HealthStar, and PsycINFO databases.

DATA SYNTHESIS

Patients undergoing chemotherapy often complain of forgetfulness, absentmindedness, and an inability to focus when performing a variety of daily tasks. Changes in cognitive function have been referred to by the colloquial term "chemo-brain." The authors conducted an examination of the literature to investigate relationships among concepts and to synthesize current knowledge.

CONCLUSIONS

Cognitive function, defined as higher-order mental processes, may be altered along two distinct and interacting pathways: (a) the cancer diagnosis, which can lead to anxiety, stress, distress, and depression; and (b) the direct physiologic effects of cancer treatment. The Chemotherapy-Related Change in Cognitive Function conceptual model is informed by a review of literature that illustrates antecedents, moderators, mediators, and consequences that may be relevant to this issue.

IMPLICATIONS FOR NURSING

When a patient presents with cognitive complaints, the problems can be evaluated for intervention when an overall understanding exists of chemotherapy-related cognitive changes based on a conceptual model that continues to be informed through well-conceptualized and well-designed research.

Clinical management of adverse events in adjuvant therapy for hormone-responsive early breast cancer

Systemic adjuvant therapy has proven highly effective at reducing recurrences and deaths in patients who have received primary therapy for early breast cancer. However, as with all treatments, adjuvant therapy can cause unwanted side effects, and effective management of these events is essential to ensure that patients comply with, and continue, treatment. Adjuvant endocrine therapy is not associated with the more severe, acute toxicities of chemotherapy, and can therefore be taken for many years. At present, the standard duration of postoperative adjuvant endocrine therapy is 5 years. Prevention and treatment of adverse events associated with long-term endocrine therapy is particularly important in the adjuvant setting, where patients are clinically cancer free. In this situation, the efficacy benefits are not, therefore, obvious to the patient, but side effects may have a negative impact on daily life. Tamoxifen has been the gold standard endocrine therapy for hormone-receptor-positive early breast cancer for many years, and the long-term side effects of this agent are well documented. In recent years, the aromatase inhibitors (AIs) have begun to displace tamoxifen as the adjuvant therapy of choice, owing to greater efficacy and good tolerability. Predictably, the AIs and tamoxifen have partially overlapping side-effect profiles. Both therapies are associated with typical symptoms of estrogen deprivation; however, tamoxifen also has estrogenic activity in some tissues, which can cause either detrimental (genital tract) or beneficial (bone, cardiovascular system, lipids) effects that are not associated with AI use. To reduce treatment discontinuations, it is important that patients are made aware of the possible side effects of adjuvant therapy and the management strategies available to them, prior to starting therapy. The role of physical, alternative and pharmaceutical therapies in the management of adverse events associated with endocrine therapy has been investigated, and strategies are now available to alleviate symptoms and enable patients to benefit from adjuvant endocrine therapy without a significant adverse impact on quality of life.

The social and emotional toll of chemotherapy - patients' perspectives

The aim of this paper is to briefly describe the unique methodology employed by nine nurse researchers who conducted research into the social and emotional effects of chemotherapy from the patient's perspective, and to present four dominant themes. The research developed from discussions at a local UK Nurses Oncology Forum, during which nurses voiced their concern about the social and emotional implications for people receiving chemotherapy. It was anticipated that understanding the issues from the patient's perspective would assist nurses to reconsider and reshape the care provided, particularly in the chemotherapy clinic. Using principles of phenomenology, the nurse researchers collected data from participants using conversational-style interviews. Some participants kept diaries of chemotherapy experiences. These data were subsequently analysed using a modified phenomenological analysis framework. Nineteen people were recruited to the study, resulting in 98 interviews and seven diaries. Eight major themes emerged from the data: striving for normality, the role of significant others, feeling up - feeling down, flagging, being sociable, anxiety, the chemotherapy process, and participating in the research. Relationship dynamics, the perceived role of significant others and the frustrations associated with lack of concentration and memory loss are important findings that should influence nursing care and management.

Cognitive impairment associated with adjuvant therapy in breast cancer

The purpose of this study was to determine whether cognitive function changes over time in women with breast cancer who received adjuvant therapy as compared to women with breast cancer who received no adjuvant therapy. Three groups of women (n = 46) were studied; groups 1 and 2 consisted of women with stage I or II breast cancer. Group 1 received chemotherapy and group 2 received chemotherapy plus tamoxifen. Group 3 consisted of women with ductal carcinoma in situ who received no chemotherapy or tamoxifen. Cognitive function was evaluated at three timepoints. Time 1 occurred after surgery and before chemotherapy initiation in groups 1 and 2. Time 1 for group 3 occurred post-surgery. Time 2 occurred within 1 week after the conclusion of chemotherapy for groups 1 and 2 and at a comparable time for group 3. Time 3 occurred 1 year after Time 2. Women who received chemotherapy plus tamoxifen exhibited deterioration on measures of visual memory and verbal working memory and reported more memory complaints. Women who received chemotherapy alone also exhibited deteriorations in verbal working memory. Conversely, cognitive function scores improved in women who received no therapy, indicating practice effects. In conclusion, adjuvant chemotherapy in women with breast cancer can be associated with deteriorations in memory and this may persist over time. The addition of tamoxifen may lead to more widespread memory deficits.

Complex actions of sex steroids in adipose tissue, the cardiovascular system, and brain: Insights from basic science and clinical studies

Recent publications describing the results of the Women's Health Initiative (WHI) and other studies reporting the impact of hormone therapy on aging women have spurred reexamination of the broad use of estrogens and progestins during the postmenopausal years. Here, we review the complex pharmacology of these hormones, the diverse and sometimes opposite effects that result from the use of different estrogenic and progestinic compounds, given via different delivery routes in different concentrations and treatment sequence, and to women of different ages and health status. We examine our new and growing appreciation of the role of estrogens in the immune system and the inflammatory response, and we pose the concept that estrogen's interface with this system may be at the core of some of the effects on multiple physiological systems, such as the adipose/metabolic system, the cardiovascular system, and the central nervous system. We compare and contrast clinical and basic science studies as we focus on the actions of estrogens in these systems because the untoward effects of hormone therapy reported in the WHI were not expected. The broad interpretation and publicity of the results of the WHI have resulted in a general condemnation of all hormone replacement in postmenopausal women. In fact, careful review of the extensive literature suggests that data resulting from the WHI and other recent studies should be interpreted within the narrow context of the study design. We argue that these results should encourage us to perform new studies that take advantage of a dialogue between basic scientists and clinician scientists to ensure appropriate design, incorporation of current knowledge, and proper interpretation of results. Only then will we have a better understanding of what hormonal compounds should be used in which populations of women and at what stages of menopausal/postmenopausal life.

Altered frontocortical, cerebellar, and basal ganglia activity in adjuvant-treated breast cancer survivors 5-10 years after chemotherapy

PURPOSE

To explore the relationship of regional cerebral blood flow and metabolism with cognitive function and past exposure to chemotherapy for breast cancer.

PATIENTS AND METHODS

Subjects treated for breast cancer with adjuvant chemotherapy remotely (5-10 years previously) were studied with neuropsychologic testing and positron emission tomography (PET), and were compared with control subjects who had never received chemotherapy. [O-15] water PET scans was acquired during performance of control and memory-related tasks to evaluate cognition-related cerebral blood flow, and [F-18] fluorodeoxyglucose (FDG) PET scans were acquired to evaluate resting cerebral metabolism. PET scans were analyzed by statistical parametric mapping and region of interest methods of analysis.

RESULTS

During performance of a short-term recall task, modulation of cerebral blood flow in specific regions of frontal cortex and cerebellum was significantly altered in chemotherapy-treated subjects. Cerebral activation in chemotherapy-treated subjects differed most significantly from untreated subjects in inferior frontal gyrus, and resting metabolism in this area correlated with performance on a short-term memory task previously found to be particularly impaired in chemotherapy-treated subjects. In examining drug-class specific effects, metabolism of the basal ganglia was significantly decreased in tamoxifen + chemotherapy-treated patients compared with chemotherapy-only breast cancer subjects or with subjects who had not received chemotherapy, while chemotherapy alone was not associated with decreased basal ganglia activity relative to untreated subjects.

CONCLUSION

Specific alterations in activity of frontal cortex, cerebellum, and basal ganglia in breast cancer survivors were documented by functional neuroimaging 5-10 years after completion of chemotherapy.

Self-reported cognitive problems in women receiving adjuvant therapy for breast cancer

Self-reported cognitive problems are common among women receiving adjuvant therapy for breast cancer but are unrelated to actual cognitive impairment. To date, no studies have objectively measured impairment and asked patients to speak about the type and extent of problems they encounter. We report interview data from 142 breast cancer patients receiving adjuvant therapy. We aimed to identify the types of problems and the extent to which they interfered with everyday life. We investigated the relationship between self-reported and objective cognitive impairment, quality of life and psychological distress. The majority of participants reported problems with their memory (71% overall at 6 months, 60% at 18 months) and concentration (64% and 42%, respectively). This was unrelated to objective cognitive decline; rather, it was associated with psychological distress and quality of life. For the vast majority, the problems reported were everyday slips and lapses. The neuropsychological measures routinely used may lack the sensitivity to detect these subtle changes experienced by this group. In addition, the effects of mood on cognition may be more important in everyday life than in the highly structured neuropsychological test situation. Future research should focus on developing cognitive assessments that tap everyday functioning.

Effects of high-dose and conventional-dose adjuvant chemotherapy on long-term cognitive sequelae in patients with breast cancer: an electrophysiologic study

BACKGROUND

The mechanisms underlying cognitive deficits found in a number of patients with breast cancer treated with adjuvant chemotherapy are still unclear. In the current study, we used a combination of measures of brain electric activity and cognitive performance during information processing to elucidate the origin of these cognitive deficits.

PATIENTS AND METHODS

Twenty-nine patients at high risk with breast cancer treated with adjuvant conventional-dose cyclophosphamide/epirubicin/5-fluorouracil or adjuvant high-dose cyclophosphamide/thiotepa/carboplatin were compared with 23 patients with stage I breast cancer not treated with chemotherapy approximately 4 years after completion of treatment. We studied reaction times and the amplitudes and latencies of the P3, an electrophysiologic index of information processing, in a task with different conditions related to input, central, and output processing of information.

RESULTS

The amplitude of the P3 component was significantly reduced in patients with breast cancer treated with high-dose cyclophosphamide/thiotepa/carboplatin compared with patients with breast cancer not treated with chemotherapy. We observed no significant differences in reaction times and P3 latency between the treatment groups.

CONCLUSION

Our data show electrophysiologic alterations in patients with breast cancer treated with high-dose chemotherapy 4 years after completion of treatment. The observed P3 reduction might be a result of suboptimal phasic cortical arousal and problems with the allocation of processing resources in these patients.

A 3-year prospective study of the effects of adjuvant treatments on cognition in women with early stage breast cancer

The neuropsychological performance of 85 women with early stage breast cancer scheduled for chemotherapy, 43 women scheduled for endocrine therapy and/or radiotherapy and 49 healthy control subjects was assessed at baseline (T1), postchemotherapy (or 6 months) (T2) and at 18 months (T3). Repeated measures analysis found no significant interactions or main effect of group after controlling for age and intelligence. Using a calculation to examine performance at an individual level, reliable decline on multiple tasks was seen in 20% of chemotherapy patients, 26% of nonchemotherapy patients and 18% of controls at T2 (18%, 14 and 11%, respectively, at T3). Patients who had experienced a treatment-induced menopause were more likely to show reliable decline on multiple measures at T2 (OR=2.6, 95% confidence interval (CI) 0.823–8.266 P=0.086). Psychological distress, quality of life measures and self-reported cognitive failures did not impact on objective tests of cognitive function, but were significantly associated with each other. The results show that a few women experienced objective measurable change in their concentration and memory following standard adjuvant therapy, but the majority were either unaffected or even improve over time.

A meta-analysis of the neuropsychological effects of adjuvant chemotherapy treatment in women treated for breast cancer

Given the improvement in mortality rates associated with breast cancer, the importance of understanding the long-term neuropsychological consequences of chemotherapy is becoming increasingly vital. This study applies meta-analytic techniques to the scant literature on the relationship between contemporary adjuvant chemotherapy treatment for breast cancer and cognitive dysfunction as examined through neuropsychological indices. Seven studies (involving more than 300 participants) were selected from over 200 potential articles, based on three inclusion criteria: presence of breast cancer, administration of chemotherapy treatment, and use of neuropsychological tests. From these, nine treatment-control comparisons were used to generate 129 Hedge's d effect sizes across the cognitive domains of simple attention, working memory short- and long-term memory, speed of processing, language, spatial abilities, and motor function. Small to medium cumulative effect sizes, showing diminished cognitive function for chemotherapy treatment groups compared to control groups, were obtained for each of the eight cognitive domains. Overall, these results suggest that women who undergo adjuvant chemotherapy as treatment for breast cancer may experience subtle yet consequential cognitive decline.

Psychosocial determinants and outcomes of chemotherapy in older women with breast cancer: what do we know? What do we need to know?

With the aging of the U.S. population and rising breast cancer incidence with advancing age, the absolute number of women aged 65 years and older diagnosed with and surviving breast cancer will dramatically increase over the coming decades. Despite this demographic imperative, we know little about the impact of adjuvant therapies in this age group. We synthesized data to describe key findings and gaps in knowledge about the outcomes of adjuvant breast cancer treatment in women aged 65 years and and older ("older women"). We reviewed research published between 1995 and June 2005 on breast cancer outcomes among older women treated with adjuvant therapy for breast cancer. Outcomes included communication, emotional distress, satisfaction, and multiple quality-of-life domains. Only 16 articles focused exclusively on older women and chemotherapy; and only one included a large sample of older women (N = 1755). Most common domains included comorbidities, symptoms, and survival. Of the 13 clinical trials and three observational studies we reviewed, only one clinical trial measured quality of life and psychological factors such as coping. None of the studies examined patient preferences or patient-physician communication (processes of care) in older women. Few studies have been designed to specifically evaluate adjuvant therapy processes and outcomes among older women, especially interactions between treatment and comorbidity, and the impact of the processes of care on outcomes. In addition, only narrow segments of the older population with breast cancer (e.g., well-educated, nonminority women) have been included in trials to date. Thus, at present we do not have sufficient data to assist physicians and their older patients in developing adjuvant treatment decisions and plans tailored to older women's needs, preferences, and concerns.

The phenomenon of chemo brain

During and following chemotherapy, some patients experience difficulties with memory, attention, and other aspects of cognitive function. This constellation of deficits commonly is referred to as chemo brain. Although the phenomenon is not understood completely, it is assuming greater significance as cancer survival improves. Return to prediagnosis levels of domestic, employment, and academic activity is expected in most survivors. Advances in basic, imaging, and clinical sciences are beginning to unravel pathophysiologic mechanisms and develop neuroprotective strategies. Pharmacologic options are borrowed from diverse diseases, including attention-deficit/hyperactivity disorder and neurodegenerative diseases. Conventional therapies soon may find new applications; for example, recent preclinical data suggest that erythropoietin may have some neuroprotective abilities, which may positively affect patients experiencing chemo brain. A collaborative model is bringing together international specialists interested in unraveling the mysteries of the phenomenon and developing management strategies to attenuate its effects. This article will review the clinical features of chemo brain as well as a working hypothesis regarding pathophysiology. The potential and emerging interventions that can be used by oncology nurses to assist patients and their families to cope with this enigmatic dysfunction will be discussed.

Mild cognitive impairment after adjuvant chemotherapy in breast cancer patients--evaluation of appropriate research design and methodology to measure symptoms

The development of new chemotherapeutic agents and regimens has contributed to reduced risk of cancer recurrence and prolonged patient survival. However, mild cognitive impairment (MCI), also known as ''chemofog'' or ''chemobrain'' following adjuvant chemotherapy for breast cancer has been reported since the late 1980s. Unfortunately, little is known about it's mechanism, type, severity, and episode length. This article reviewed related studies on the subject, and found that chemotherapy-induced MCI appears to occur in 10-40% of patients, and memory loss and lack of concentration are the most frequent symptoms. The symptoms are apparently transient, but take at least several years to disappear. Reviewed studies show a lack of clear understanding of what causes MCI directly. There is also a lack of consistency in symptom measurement. We point to the need to conduct well-designed studies which begin with a proper hypothesis. Future research needs to be randomized and longitudinal with a base measurement point before the chemotherapy cycle starts. Future studies must adopt an effective and sensitive method to measure MCI. The latest imaging technique, positron emission tomography (PET) may be a powerful tool. Also, all confounding factors, such as age, education, intelligence quotient (IQ), fatigue and depression, hormonal therapy and other treatments should be controlled within the study design. It is hoped that the results of such future studies will allow medical professionals to contemplate effective prevention, treatment and rehabilitation for MCI.

Electrophysiological correlates of information processing in breast-cancer patients treated with adjuvant chemotherapy

Cognitive deficits are found in a number of breast-cancer patients who have undergone adjuvant (Cyclophosphamide, Methotrexate, and 5-Fluorouracil (CMF)) chemotherapy, but the underlying mechanisms are still unclear. The objective of this study is to investigate information processing in these patients with concurrent registration of brain activity. Twenty-six breast-cancer patients treated with adjuvant CMF chemotherapy and a control group of 23 stage I breast-cancer patients not treated with chemotherapy were examined. Mean time since treatment for the CMF patients was 5.1 years after the last CMF course, and for the control patients 3.6 years after termination of radiotherapy. An information processing task was administered with concurrent EEG registration. Reaction times and the amplitudes and latencies of an Event Related Potential component (P3) in different task conditions related to input, central, and output processing of information were studied. Significant differences in latency and amplitude of the P3 component were found between the treatment groups with an earlier and reduced P3 in the chemotherapy group. Patients treated with chemotherapy had longer reaction times (although not significantly different) than the control group on all task conditions. Our data provide further evidence for long-term neurocognitive problems in breast-cancer patients treated with adjuvant (CMF) chemotherapy and offer new information regarding abnormalities in brain functioning in these patients.

Neurocognitive performance in breast cancer survivors exposed to adjuvant chemotherapy and tamoxifen

The primary aim of the current study was to examine whether neurocognitive functioning among breast cancer survivors (BCS) exposed to systemic adjuvant chemotherapy differs from that seen among BCS who did not receive chemotherapy. The performance of each of these BCS groups was compared to a demographically matched comparison group without history of breast cancer, a group not included in the majority of previous cognitive functioning studies. We also sought to explore whether usage of the anti-estrogen drug tamoxifen, a common component of breast cancer treatment, was related to neurocognitive functioning. Finally, we wished to examine the relationship between subjective report of cognitive functioning and objective performance on neurocognitive measures among BCS. Fifty-three survivors of breast cancer (all between 2-5 years after diagnosis and initial surgical removal of cancerous tissue) and 19 healthy non-BCS comparison subjects were administered a comprehensive neurocognitive battery, and measures of mood, energy level, and self-reported cognitive functioning. Those BCS who received adjuvant chemotherapy performed significantly worse in the domains of verbal learning, visuospatial functioning, and visual memory than BCS treated with surgery only. Those who received both chemotherapy and tamoxifen showed the greatest compromise. Although patients who received chemotherapy (with and without tamoxifen) performed worse than those treated with surgery only on several domains, neither group was significantly different from demographically matched comparison subjects without a history of breast cancer. Finally, we found no relationship between subjective cognitive complaints and objective performance, although cognitive complaints were associated with measures of psychological distress and fatigue. We highlight ways in which these data converge with other recent studies to suggest that systemic chemotherapy, especially in combination with tamoxifen, can have adverse yet subtle effects on cognitive functioning.

Selective estrogen receptor modulators (SERMs) for the brain: current status and remaining challenges for developing NeuroSERMs

Multiple issues regarding the efficacy of estrogen action in the brain remain unresolved. These include the timing, formulation and duration of the therapy intervention. Moreover, issues of thrombotic and neoplastic risks must be factored into the design of estrogen alternatives developed to prevent age-associated neurodegenerative disorders, as well as other climacteric symptoms such as hot flush and sleep dysfunction. One strategy to address these issues is to develop molecules that selectively target and activate estrogen mechanisms of action in the brain while avoiding activation of estrogen receptors peripheral to the brain, particularly in reproductive organs. An overview of recent advances in our understanding of the molecular mechanisms of estrogen action is discussed in the context of designing an efficacious NeuroSERM that will activate cellular, biochemical and genomic events required for the promotion of memory function and neuronal survival. Pharmacological analyses of estrogen receptor subtypes and the case for a membrane-associated estrogen receptor splice variant in mediating these mechanisms are provided along with a summary of the activation profiles of existing clinically relevant estrogen alternatives or SERMs in neurons. Results of these endeavors have yielded insights into strategies for developing novel molecules with NeuroSERM potential in order to prevent brain related climacteric symptoms and neurodegenerative diseases.

Does hormone therapy for the treatment of breast cancer have a detrimental effect on memory and cognition? A pilot study

This pilot study examines whether hormone therapy for breast cancer affects cognition. Patients participating in a randomised trial of anastrozole, tamoxifen alone or combined (ATAC) (n=94) and a group of women without breast cancer (n=35) completed a battery of neuropsychological measures. Compared with the control group, the patients were impaired on a processing speed task (p=0.032) and on a measure of immediate verbal memory (p=0.026) after controlling for the use of hormone replacement therapy in both groups. Patient group performance was not significantly related to length of treatment or measures of psychological morbidity. The results showed specific impairments in processing speed and verbal memory in women receiving hormonal therapy for the treatment of breast cancer. Verbal memory may be especially sensitive to changes in oestrogen levels, a finding commonly reported in studies of hormone replacement therapy in healthy women. In view of the increased use of hormone therapies in an adjuvant and preventative setting their impact on cognitive functioning should be investigated more thoroughly.

Impact of the selective estrogen receptor modulator, tamoxifen, on neuronal outgrowth and survival following toxic insults associated with aging and Alzheimer's disease

We investigated the estrogen agonist/antagonist properties of the selective estrogen receptor modulators (SERMs), tamoxifen (TMX) and 4-hydroxy-tamoxifen (OHT), using an in vitro neuron model system to determine the impact of the neuroprotective and neurotrophic properties of these SERMs. Low concentrations of TMX or OHT were without effect on a marker of neuronal viability, basal release of lactate dehydrogenase (LDH), whereas high concentrations of both SERMs (2500 ng/ml) induced a significant increase in LDH, indicating the potential toxicity of both SERMs at high concentrations. Subsequent experiments revealed that subtoxic concentrations of both TMX and OHT induced significant neuroprotection against beta-amyloid(25-35)-induced toxicity; 15-20% and 10-15% (P < 0.05), respectively and also against glutamate-induced toxicity; 25-30% and 20-40% (P < 0.05 and P < 0.01), respectively. Additional in vitro experiments included analysis of neuron survival to determine whether the SERM, OHT, acted competitively or synergistically with the endogenous estrogen, 17 beta-estradiol (E2). These revealed that neuron survival following exposure to the neurotoxins beta-amyloid and excitotoxic glutamate was significantly increased in cultures treated with OHT (50 ng/ml) (10%, P < 0.01) and that the magnitude of survival was equivalent to E2 (10 ng/ml). The combined presence of OHT and E2 significantly protected against both beta-amyloid(25-35) and excitotoxic glutamate-induced neuron death (10%, P < 0.01) but was not significantly different from either OHT or E2 alone. To assess neurotrophic effects of these same SERMs, cultured neurons from brain regions involved in memory function and Alzheimer's disease were evaluated by morphological analysis of individual neurons. Results of these analyses demonstrated that TMX treatment did not significantly increase the process outgrowth or morphological complexity of cortical, hippocampal, or basal forebrain neurons. Similar analyses showed that OHT also failed to significantly increase the neuronal outgrowth of either cortical or hippocampal neurons. Results of these studies predict that TMX and OHT could exert a neuroprotective function but would not promote estrogen-dependent memory function.

Familial juvenile hypertrophy of the breast

OBJECTIVE

Juvenile (virginal) hypertrophy of the breast (JHB) is a relatively rare condition leading to gigantomastia in peripubertal females. The pathology is limited usually to the breast, with otherwise normal growth and development and without any other deformities. The rapid growth of the breast (bilateral or unilateral) in adolescent girls leads to significant physical and psychological difficulties. This gigantomastia is treated surgically by breast reduction or mastectomy and its modification. Familial JHB was described only once in the literature, and its etiology is unknown.

RESULTS

We report here on a familial pattern of juvenile hypertrophy of the breast accompanied by congenital anonychia. To the best of our knowledge, this is the first report of such a presentation. Our study dealt with four members of the same family, related through their fathers, enduring congenital anonychia of hands and feet with no functional limitation and who showed rapid uncontrolled breast enlargement in prepubertal age. This was severe enough to cause the curtailment of their social activity and cessation of schooling. The mothers of all four patients had normal breasts and nails, whereas their fathers had anonychia. The genetic basis for the association between the two clinical findings is yet to be determined.

CONCLUSION

The four girls underwent breast reduction surgery.

Neuropsychological dysfunction associated with cancer and cancer therapies: a conceptual review of an emerging target

Neuropsychological dysfunction associated with cancer and cancer treatment is a growing concern. Methodological limitations permeate the corpus of research in this area and have limited our understanding of the multifactorial nature of this process. The following review provides a summary of the current state of knowledge and highlights future directions.

What is the effect of systemic anticancer treatment on cognitive function?

Treatment regimens for solid tumours have been extensively investigated for their physical toxic effects, but far less is known about the potential impairment of cognitive function by anticancer treatment regimens. Here, we review published studies that examined cognitive function in adult patients receiving systemic therapy for solid tumours. Our review suggests that patients can experience cognitive changes related to their treatment. However, several studies had methodological limitations, such as use of a limited sample size, lack of baseline assessment, and lack of control for potential confounding factors. Better designed clinical trials are required so that the difficulties patients face in terms of reduced cognitive function as a result of anticancer treatment can be fully elucidated. These trials should have sufficient statistical power and, importantly, should also be prospective.

Estrogen- and tamoxifen-associated effects on brain structure and function

We evaluated the effects of estrogen and tamoxifen, a selective estrogen receptor modulator, on positron emission tomography (PET) measures of brain glucose metabolism and magnetic resonance imaging (MRI) measures of hippocampal atrophy. Three groups of postmenopausal women were studied, women taking estrogen (ERT+), women with breast cancer taking tamoxifen (TAM), and women not taking estrogen or tamoxifen (ERT-). All subjects received a PET scan, an MRI scan, and cognitive testing. The TAM group showed widespread areas of hypometabolism in the inferior and dorsal lateral frontal lobes relative to the other two groups. The ERT- group showed lower metabolism in the inferior frontal cortex and temporal cortex with respect to the ERT+ group. The TAM group also showed significantly lower semantic memory scores than the other two groups. Finally, the TAM group had smaller right hippocampal volumes than the ERT+ group, an effect that was of borderline significance. Both right and left hippocampal volumes were significantly smaller than the ERT+ group when a single outlier was removed. The ERT- group had hippocampal volumes that were intermediate to the other two groups. These findings provide physiological and anatomical evidence for neuroprotective effects of estrogen.

Regulation of aromatase expression by the nuclear receptor LRH-1 in adipose tissue

Aromatase is the enzyme responsible for estrogen production, and is the product of the CYP19 gene. This gene is under the control of many tissue-specific promoters, each of which is regulated by different cohorts of factors. In normal breast adipose tissue, relatively low levels of aromatase are expressed via the action of the adipose specific promoter I.4. Breast tumor-derived factors such as prostaglandin E(2) (PGE(2)) strongly stimulate aromatase expression via an alternative promoter, promoter II, leading to increased estrogenic drive and tumor growth. Understanding the mechanisms that regulate promoter II activity in tumorous breast may therefore identify new targets for breast cancer drug discovery. The current study describes the role of the orphan nuclear receptor LRH-1 and its co-regulators in modulating aromatase expression in breast adipose tissue.

First-line endocrine treatment of breast cancer: aromatase inhibitor or antioestrogen?

Until recently, endocrine therapy for breast cancer was relatively simple. If the tumour expressed hormone receptors, regardless of stage and age, tamoxifen was indicated. While this largely remains the case for premenopausal women, clinical trials in postmenopausal women have broadened our choice to include one of three selective aromatase inhibitors (AIs), the nonsteroidal agents anastrozole or letrozole and the steroidal agent exemestane. Comparative data concerning the efficacy, toxicity, tolerability and cost of AI vs tamoxifen continues to evolve with over 40 000 women slated to be involved in clinical trials. Currently, tamoxifen remains an appropriate choice for adjuvant treatment, and will remain so unless a clear survival advantage emerges for adjuvant AI therapy. However, anastrozole is widely seen as a useful alternative, with particular merit for patients prone to the development of serious tamoxifen side effects. For endocrine therapy naïve advanced disease, several trials have provided evidence that a nonsteroidal AI has replaced tamoxifen as optimal treatment. In the neoadjuvant setting, letrozole was also more effective than tamoxifen, both in terms of response rates and the incidence of breast-conserving surgery, and so AI therefore also dominates this evolving indication. The ongoing adjuvant clinical trials ask all the relevant questions regarding tamoxifen and AI in combination, sequence and duration, except for 5 years of an AI vs a longer period. For both the advanced and early-stage disease, resistance remains the key obstacle to overcome, and trials that combine endocrine agents with signal transduction inhibitors such as HER1 and HER2 kinase inhibitors, farnesyl transferase inhibitors, mTOR inhibitors as well as COX2 inhibitors are being developed in a concerted attempt to address this problem.

CNS: sex steroids and SERMs

The central nervous system (CNS) is one of the main target tissues for sex steroid hormones, which act both through genomic mechanisms, modulating synthesis, release, and metabolism of many neuropeptides and neurotransmitters, and through nongenomic mechanisms, influencing electrical excitability, synaptic function, and morphological features. The identification of the brain as a de novo source of neurosteroids modulating cerebral function, suggests that the modifications in mood and cognitive performances occurring in postmenopausal women could also be related to a modification in the levels of neurosteroids, particularly allopregnanolone and DHEA, GABA-A agonist, and antagonist, respectively. The selective estrogen receptor modulators (SERMs) are compounds that activate the estrogen receptors with different estrogenic and antiestrogenic tissue-specific effects. In addition to the effects of the classic steroid hormones on the CNS, the study of selective estrogen receptor modulators impact on the neuroendocrine system has recently provided encouraging results, indicating that raloxifene analog LY 117018 and the new generation SERM EM-652 have an estrogen-like action on beta-endorphin and on allopregnanolone in ovariectomized rats, while they exert an anti-estrogenic effect in fertile rats and in ovariectomized rats treated with estrogens. In addition, raloxifene administration in postmenopausal women plays an estrogen-like effect on circulating beta-EP and allopregnanolone levels, and it restores the response of beta-EP and allopregnanolone to neuroendocrine tests. In conclusion, the positive effects of HRT on mood and cognition in postmenopausal women occur via the modulation of neuroendocrine pathways and probably also of neurosteroidogenesis. The effects of raloxifene on mood and cognition encourage the efforts in the research of an ideal estrogen replacement therapy, showing all the positive effects of estrogens and fewer side effects.

Neuropsychological functioning following systemic treatment in women treated for breast cancer: a review

The aim of this review was to evaluate the effect of treatment and illness-related factors on neuropsychological functioning in women treated for breast cancer. Eight studies were identified examining neuropsychological test performance following systemic treatment. Six of the eight studies suggest that neuropsychological functioning may be impaired following treatment. However, there are a number of important methodological issues which limit interpretation of these results. Therefore, it is unclear whether neuropsychological outcome differs according to a range of treatment, biomedical and psychological factors. Larger samples with longitudinal follow-up are required in order to examine the treatment-related factors that best predict cognitive deficits.

The impact of adjuvant therapy for breast cancer on cognitive function: current evidence and directions for research

Available evidence supports the hypothesis that adjuvant chemotherapy for breast cancer can produce cognitive deficits, and that these deficits may have a significant impact on patients' quality of life. Studies have generally compared the results of a variety of cognitive measures performed following treatment to standardized population-based norms or to cancer patients who received local therapy, rather than to the individual's baseline level of functioning. Several longitudinal studies are in progress or in the planning stages to better quantify and understand the incidence and impact of cognitive effects of adjuvant chemotherapy, and to identify possible susceptibility factors in subgroups. Although the neurocognitive changes appear to be subtle, there may be enough data to consider discussing the possibility of cognitive dysfunction as an adverse effect when assessing the risks and benefits of adjuvant chemotherapy. Likewise, as the aromatase inhibitors are increasingly given to larger numbers of women in the adjuvant setting, it will be important to understand the cognitive impact of estrogen deprivation. Finally, there is interest in examining supportive pharmacologic or behavioral measures that might prevent or decrease cognitive effects in this setting. Herein, the data on cognitive changes associated with chemotherapy for breast cancer, current and future research directions, as well as possible treatments are reviewed.

The clock-drawing test in elderly Italian community dwellers: associations with sociodemographic status and risk factors for vascular cognitive impairment

To evaluate whether performance in the clock-drawing test (CDT) is associated with sociodemographic status and risk factors for cognitive impairment, we examined 744 Italian community dwellers aged > or =65 (73 +/- 6) years scoring > or =24 on the MMSE. CDT was scored by two different methods, the Sunderland and the Wolf-Klein methods. Sociodemographic, lifestyle, clinical and biochemical variables were also recorded. For both scoring methods, lower CDT scores were associated with age, poor education, increased serum C-reactive protein and history of cancer. Associations of lower CDT scores with increased serum glucose and history of cerebrovascular disease were also found for the method with the highest sensitivity to cognitive impairment. This study shows that in elderly community dwellers, CDT may be not totally free from sociodemographic biases, and that it is associated with risk factors for cognitive impairment and frailty.

Neuropsychological effects of treatments for adults with cancer: a meta-analysis and review of the literature

A meta-analysis was conducted to evaluate possible neuropsychological effects of treatments for cancer in adults. A search revealed 30 studies, encompassing 29 eligible samples, and leading to inclusion of a total of 838 patients and control participants. A total of 173 effect sizes (Cohen's d) were extracted across 7 cognitive domains and as assessed in the literature via 3 methods of comparison (post-treatment compared with normative data, controls, or baseline performance). Statistically significant negative effect sizes were found consistently across both normative and control methods of comparison for executive function, verbal memory, and motor function. The largest effects were for executive function and verbal memory normative comparisons (-.93 and -.91, respectively). When limiting the sample of studies in the analyses to only those with relatively "less severe" diagnoses and treatments, the effects remained. While these results point toward some specific cognitive effects of systemic cancer therapies in general, no clear clinical implications can yet be drawn from these results. More research is needed to clarify which treatments may produce cognitive decrements, the size of those effects, and their duration, while ruling out a wide variety of possible mediating or moderating variables.

Outcomes and quality of life following breast cancer treatment in older women: when, why, how much, and what do women want?

BACKGROUND

There are few comprehensive reviews of breast cancer outcomes in older women. We synthesize data to describe key findings and gaps in knowledge about the outcomes of breast cancer in this population.

METHODS

We reviewed research published between 1995 and June 2003 on breast cancer quality of life and outcomes among women aged 65 and older treated for breast cancer. Outcomes included communication, satisfaction, and multiple quality of life domains.

RESULTS

Few randomized trials or cohort studies that measured quality of life after treatment focused exclusively on older women. Studies from older women generally noted that, with the exception of axillary dissection, type of surgical treatment generally had no effect on long-term outcomes. In contrast, the processes of care, such as choosing therapy, good patient-physician communication, receiving treatment concordant with preferences about body image, and low perceptions of bias, were associated with better quality of life and satisfaction.

CONCLUSIONS

With the exception of axillary dissection, the processes of care, and not the therapy itself, seem to be the most important determinants of long-term quality of life in older women.

Psychiatric aspects of women with breast cancer

Women with breast cancer face not only cancer-related taboos but also issues related to changes in sexuality, femininity, and fertility. Although increased emphasis on the woman's participation in the medical decision-making process has afforded her more treatment options, it also gives her more responsibility in determining her course of treatment through the continuum of cancer care. Patients must deal with a variety of issues related to social reintegration, long-term effects of cancer treatment, employment, disability, sexuality, family, and social networks. Screening for distress related to psychological, spiritual/religious, or social concerns can provide guidance for service delivery to those in need.

The effects of hormone therapy on cognition in breast cancer

The use of hormonal therapies for the treatment of breast cancer is common, yet few studies have examined the possible cognitive effects. Several regions of the brain, important in memory and cognition, are rich in oestrogen receptors. As a result, the long-term use of anti-oestrogens may have potential consequences for cognition. This project aims to establish whether significant cognitive deficit exists in women receiving hormone therapy for breast cancer and to develop a cognitive package that is sensitive to the potential effects of oestrogen deficiency on cognition. Cognitive assessments measured a range of memory and attention functions in patient and control groups to identify whether cognitive impairment, if apparent, occurs at a widespread or function specific level. Ninety-four patients from the anastrozole, tamoxifen and combined (ATAC) trial and 35 non-cancer controls were assessed. Groups did not differ significantly in age or estimated full-scale intelligence. The patient group did not differ from controls on measures of working memory, attention and visual memory but was significantly impaired compared to the control group on measures of verbal memory (P=0.026) and processing speed (P=0.032). Cognitive performance in the patient group was not significantly related to length of time on trial or measures of psychological morbidity. As more and more hormonal agents are used in clinical trials of both adjuvant and preventive settings it is of vital importance that any potentially deleterious effects on cognitive function are measured adequately. Preliminary results from this study suggest that anti-oestrogen therapy may cause a specific deficit in verbal memory that corroborates the links between oestrogen levels and verbal memory often reported in studies of the cognitive benefits of hormone replacement therapy.

Estrogen and selective estrogen receptor modulators: neuroprotection in the Women's Health Initiative era

Estrogen has been comprehensively studied as a neuroprotective agent in women, animals, and a variety of in vitro models of neural injury and degeneration. Most data suggest that estrogen can benefit the ischemic brain and reduce cell death. However, recent data from the Women's Health Initiative have raised concerns about the utility and safety of chronic estrogen use in women. While estrogen is a potent and reproducible neuroprotectant in animals and in vitro, its current administration in women has had unanticipated and paradoxical effects. Nonetheless, estrogen's diverse actions make it an ideal prototype for developing new neuroprotectants such as selective estrogen receptor modulators (SERMs). SERMs represent a class of drugs with mixed estrogen agonistic and antagonistic activity. Experimental and clinical data suggest a neuroprotective role for SERMs in normal and injured brain. The discrepancy among observational studies, preclinical data, and clinical trials emphasizes the need for further study of the mechanisms leading to the increased incidence of stroke observed in postmenopausal women. Research is still needed to optimize combined or estrogen alone hormone replacement therapy options as well as the prevention/management of cerebrovascular/ central nervous system disorders. This review critiques estrogen and SERMs' neuroprotective potential in experimental and clinical studies of stroke and cerebrovascular disease.

Cognitive dysfunction following adjuvant chemotherapy for breast cancer: two case studies

PURPOSE/OBJECTIVES

To describe the cognitive dysfunction experienced by two women after they received adjuvant chemotherapy for breast cancer and to discuss the potential role of changes in reproductive status and depression in the development of cognitive dysfunction.

DATA SOURCES

Journal articles, research data, and clinical experience.

DATA SYNTHESIS

Following chemotherapy, 17%-50% of women with breast cancer experience cognitive dysfunction that may include decrements in memory, attention, and psychomotor efficiency. One mechanism that may contribute to cognitive dysfunction involves changes in reproductive status resulting from chemotherapy. Additionally, the presence of depression may confound the experience of cognitive dysfunction.

CONCLUSIONS

A comprehensive description of cognitive dysfunction and improved understanding of the interrelationships among cognitive dysfunction, reproductive hormone levels, and depression in women with breast cancer receiving adjuvant chemotherapy may hasten the development of interventions for the management of cognitive dysfunction.

IMPLICATIONS FOR NURSING

Nurses should teach women with breast cancer and their families about the potential for cognitive dysfunction after chemotherapy so the problem can be recognized and interventions can be implemented to help women compensate for the dysfunction.

Adjuvant breast cancer treatment and cognitive function: current knowledge and research directions

Evidence is mounting that potentially curative systemic adjuvant therapy for early-stage breast cancer may result in cognitive impairment. Five published studies have investigated cognitive function in this setting, and the consistent results of all five studies suggest an adverse effect of adjuvant chemotherapy. These studies are reviewed with particular attention to their methodologic limitations. For example, all five studies used cross-sectional designs, none controlled for possible confounding hormonal factors, and three examined patients who had not received a uniform chemotherapy regimen. The potential roles of chemotherapy-induced menopause and of adjuvant hormonal therapy in cognitive impairment are also discussed. Priorities for future research include confirmation of an effect of adjuvant chemotherapy in a study with a longitudinal design, closer examination of the potential contribution of hormonal factors, and similar studies on the effect of adjuvant therapy on cognitive function in other cancer types. If an effect of systemic adjuvant therapy on cognitive function is confirmed, such an effect will have implications for informed consent. It may also result in incorporation of objective measures of cognition in clinical trials of adjuvant therapy and in the investigation of preventive interventions that might minimize the impact of cognitive dysfunction after cancer treatment.

Cognitive dysfunction and chemotherapy: neuropsychological findings in perspective

Currently, the interest in cognitive functioning following chemotherapy is rapidly expanding as is reflected in a growing number of published studies on this topic. Although most studies are indicative of cognitive deficits after chemotherapy, definite conclusions on the role of chemotherapy on cognitive function can often not be drawn due to methodological problems. On the basis of the studies on cognitive functioning after chemotherapy that are conducted in The Netherlands Cancer Institute, the current article describes a number of such methodological topics that obscure straightforward interpretation of neuropsychological findings in toxicity research. Measurement issues that diverge from usual assessment issues encountered in psychosocial oncology will be described, and factors that might play a role in the cause of cognitive impairment will be evaluated. Also, future developments necessary to gain more insight into the prevalence, the pattern, and the impact of cognitive problems following chemotherapy are discussed

Breast cancer chemotherapy-related cognitive dysfunction

Cognitive side effects of systemic chemotherapy have become an increasing concern among breast cancer survivors, their families, and health care professionals. A growing body of research supports the hypothesis that chemotherapy can produce long-term cognitive changes in at least a subgroup of cancer survivors. We review evidence implicating systemic chemotherapy as the cause of cognitive changes; describe the limitations due to lack of longitudinal studies and gaps in knowledge (ie, no clear mechanism by which chemotherapy can produce cognitive changes has been proposed); discuss possible factors like age, intelligence quotient/education, and psychological, genetic, and hormonal factors that might increase risk for chemotherapy-induced cognitive changes; and outline future directions for research. Such future research includes large-scale, longitudinal studies of pretreatment neuropsychological assessments, use of imaging techniques and the development of animal models to study the mechanisms of chemotherapy-induced changes in cognitive functioning, and the development of interventions to prevent or reduce the negative cognitive effects of chemotherapy

Estrogen and cognitive aging in women

The steady increase in female life expectancy has attracted attention to the importance of preventing cognitive aging and Alzheimer's disease (AD) in women. Evidence from randomized, controlled trials and from cross-sectional and longitudinal studies shows that estrogen-replacement therapy preferentially protects against a decline in verbal memory in healthy postmenopausal women and decreases the risk of AD. Although results are not consistent across studies, they indicate that treatment with estrogen during the postmenopausal years might protect against cognitive aging in women during the latter part of their life.

Late effects of adjuvant chemotherapy on cognitive function: a follow-up study in breast cancer patients

BACKGROUND

Neuropsychological examinations have shown an elevated risk for cognitive impairment 2 years after therapy in breast cancer patients randomized to receive adjuvant high-dose cyclophosphamide, thiotepa, carboplatin (CTC) chemotherapy compared with a non-treated control group of stage I breast cancer patients. Patients randomized to receive standard-dose fluorouracil, epirubicin, cyclophosphamide (FEC) chemotherapy showed no elevated risk compared with controls. However, breast cancer patients treated with conventional cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy showed a higher risk of cognitive impairment. The present study was designed to obtain a greater insight into these long-term neuropsychological sequelae following chemotherapy and their course in time.

PATIENTS AND METHODS

At 4 years post-therapy, 22 of the original 34 CTC patients, 23 of 36 FEC patients, 31 of 39 CMF patients and 27 of 34 control patients were re-examined with neuropsychological tests.

RESULTS

Improvement in performance was observed in all chemotherapy groups, whereas in the control group there was a slight deterioration in test results. A differential attrition was observed among the groups, with a relatively high percentage of initially cognitively impaired patients from the CTC group dropping out due to factors related to disease progression.

CONCLUSIONS

The results suggest that cognitive dysfunction following adjuvant chemotherapy in breast cancer patients may be transient. Additional studies are needed to investigate the differential attrition of patients with cognitive impairment.