The perceptions of Australian oncologists about cognitive changes in cancer survivors

Improve the management of cancer-related cognitive impairment in clinical settings: a European Delphi study

PURPOSE

Cancer-related cognitive impairment (CRCI) is under-addressed by healthcare professionals owing to a lack of clinical management guidelines. This European Delphi study proposes recommendations to healthcare professionals for the management of CRCI in patients with non-central nervous system (non-CNS) cancers.

METHODS

Twenty-two recommendations were developed based on a literature review and authors' clinical experience, split into three categories: screening, cognitive assessment, intervention. The survey included European professionals, experts in CRCI. The Delphi method was used: experts rated the clinical relevancy of recommendations on a 9-point Likert scale in three rounds. A recommendation was accepted if all votes were between 7 and 9. Recommendations not accepted in round 1 and round 2 were deleted, or modified and rated in round 3.

RESULTS

Eighteen professionals (psychologists, physicians, researchers) voted and accepted 15 recommendations. Experts recommended the systematic screening of CRCI, followed by a short objective cognitive assessment, if complaints screened. A comprehensive evaluation is recommended if CRCI persists 6 months post-treatment. Cognitive rehabilitation, physical activity, meditative-movement therapy, and multimodal intervention should be offered. Recommendations about frequency and duration of interventions, the professional to administer cognitive rehabilitation and the use of meditation and cognitive training without psychoeducation were not accepted.

CONCLUSIONS

This survey provides 15 recommendations to assist healthcare professionals in detecting, assessing and offering interventions for CRCI.

IMPLICATIONS FOR CANCER SURVIVORS

These recommendations should be included in supportive care to help healthcare professionals to detect CRCI and propose the best available intervention for patients with cognitive complaints. Developing CRCI management in clinical settings would improve patients' quality of life.

Experiences of women with breast cancer disclosing cancer-related cognitive impairment symptoms to health professionals: a Systematic review and meta-synthesis

OBJECTIVE

Cancer-related cognitive impairment involves changes in cognitive domains among people diagnosed with cancer. This review aimed to explore and synthesize the experiences of women with breast cancer disclosing cancer-related cognitive impairment symptoms to health professionals.

METHODS

A systematic review and meta-synthesis was conducted to generate synthesized findings from existing literature. Six databases were searched from inception until mid-October 2022, with eligible studies appraised using the QualSyst Quality Assessment Checklist.

RESULTS

Three synthesized findings were generated from eight included studies. Findings highlight that women initiated conversations disclosing symptoms and frequently experienced dismissal or minimization from health professionals. Women rarely received information about cognitive impairment symptoms before treatment. Women reported that health professionals could be more involved in managing cognitive impairment symptoms.

CONCLUSION

This meta-synthesis highlights the importance of health professionals providing information before treatment and following up on cognitive impairment symptoms.

Cognitive impairment experienced by Chinese breast cancer survivors

To identify cognitive function in Chinese breast cancer survivors. Research questions were: is cognitive function was associated with breast cancer and/or chemotherapy treatment and/or psychological functioning:? and did women with breast cancer experience more cognitive and psychological issues than age-matched women without cancer? Breast cancer survivors with chemotherapy (n = 106, mean age = 50.2 ± 9.5), breast cancer survivors without chemotherapy (n = 100, mean age = 50.5 ± 10.0) and matched healthy controls (n = 96, mean age = 47.9 ± 9.1) completed a battery of cognitive and psychosocial functioning. Demographic characteristics were also collected. The Perceived Cognitive Impairment score for cancer groups was significantly higher than for the healthy group (p = 0.04), but not between the cancer groups. Processing speed was significantly slower in the cancer groups than in the healthy group (both p < 0.001), but not between the cancer groups. Age, living status and education were significantly associated with the FACT-Cog (all p < 0.05). The correlations between the FACT-Cog score and BSI score were strong (r = 0.60 p < 0.01), and between the HADS anxiety and depression scales were strong (r = 0.53 and 0.50, p < 0.01) but correlations were weaker between performance based cognitive tests and measures of psychological functioning. Breast cancer groups indicated more cognitive impairment and reduced psychological functioning compared to the healthy group. However, there was no differences between the breast cancer groups. Chinese breast cancer survivors experienced excess cognitive impairment not associated with usual ageing. Assessment and intervention to address cognitive impairment should be made available to breast cancer survivors.

Effectiveness of a Computerized Home-Based Cognitive Stimulation Program for Treating Cancer-Related Cognitive Impairment

Cancer patients assert that after chemotherapy their cognitive abilities have deteriorated. Cognitive stimulation is the clinical treatment of choice for reversing cognitive decline. The current study describes a computerized home-based cognitive stimulation program in patients who survived breast cancer. It aims to assess safety and effectiveness of cognitive stimulation in the oncology population. A series of 45-min training sessions was completed by the participants. A thorough assessment was performed both before and after the intervention. The mini-Mental Adjustment to Cancer Scale, the Cognitive Assessment for Chemo Fog Research, and the Functionality Assessment Instrument in Cancer Treatment-Cognitive Function served as the main assessment tools. The State-Trait Anxiety Inventory, Beck Depression Inventory, Brief Fatigue Inventory, and Measuring Quality of Life-The World Health Organization data were gathered as secondary outcomes. Home-based cognitive stimulation demonstrated beneficial effects in the oncology population, with no side effects being reported. Cognitive, physical, and emotional improvements were observed, along with decreased interference in daily life activities and a better overall quality of life.

CanCOG®: Cultural Adaptation of the Evidence-Based UCLA Cognitive Rehabilitation Intervention Program for Cancer Survivors in Portugal

Cognitive difficulties are highly prevalent and negatively impact cancer survivors' quality of life. The UCLA Cognitive Rehabilitation Intervention Program (in short, UCLA program) is an evidence-based intervention developed and tested in the US to address the cognitive complaints of cancer survivors. Since there are no cognitive rehabilitation programs available for Portuguese cancer-related settings, this study aimed to culturally adapt the UCLA program to Portugal. Nine steps were implemented for this cultural adaptation: needs assessment, initial contacts, translation, cultural adaptation, independent review by a panel of experts (n = 6), focus group discussions with cancer survivors (n = 11), systematization of inputs and improvement of the final materials, fidelity check, and preliminary acceptability assessment. The findings suggested that changes to the original materials were needed. A Portuguese name, "CanCOG^®-Reabilitação Cognitiva no Cancro" (in English "CanCOG^®-Cognitive Rehabilitation in Cancer"), and a logo were created to make it more memorable and appealing for the Portuguese population. The language was adjusted to ensure content accessibility and semantic and conceptual equivalence. Finally, references to several cultural aspects, such as habits, customs, and traditions, were adapted to fit the new cultural context. The UCLA program may be a promising tool to help alleviate the cognitive difficulties reported by cancer survivors in different cultural contexts. Future research is needed to confirm the feasibility, acceptability, and preliminary efficacy of its Portuguese version, "CanCOG^®-Reabilitação Cognitiva no Cancro".

Associating persistent self-reported cognitive decline with neurocognitive decline in older breast cancer survivors using machine learning: The Thinking and Living with Cancer study

INTRODUCTION

Many cancer survivors report cognitive problems following diagnosis and treatment. However, the clinical significance of patient-reported cognitive symptoms early in survivorship can be unclear. We used a machine learning approach to determine the association of persistent self-reported cognitive symptoms two years after diagnosis and neurocognitive test performance in a prospective cohort of older breast cancer survivors.

MATERIALS AND METHODS

We enrolled breast cancer survivors with non-metastatic disease (n = 435) and age- and education-matched non-cancer controls (n = 441) between August 2010 and December 2017 and followed until January 2020; we excluded women with neurological disease and all women passed a cognitive screen at enrollment. Women completed the FACT-Cog Perceived Cognitive Impairment (PCI) scale and neurocognitive tests of attention, processing speed, executive function, learning, memory and visuospatial ability, and timed activities of daily living assessments at enrollment (pre-systemic treatment) and annually to 24 months, for a total of 59 individual neurocognitive measures. We defined persistent self-reported cognitive decline as clinically meaningful decline (3.7+ points) on the PCI scale from enrollment to twelve months with persistence to 24 months. Analysis used four machine learning models based on data for change scores (baseline to twelve months) on the 59 neurocognitive measures and measures of depression, anxiety, and fatigue to determine a set of variables that distinguished the 24-month persistent cognitive decline group from non-cancer controls or from survivors without decline.

RESULTS

The sample of survivors and controls ranged in age from were ages 60-89. Thirty-three percent of survivors had self-reported cognitive decline at twelve months and two-thirds continued to have persistent decline to 24 months (n = 60). Least Absolute Shrinkage and Selection Operator (LASSO) models distinguished survivors with persistent self-reported declines from controls (AUC = 0.736) and survivors without decline (n = 147; AUC = 0.744). The variables that separated groups were predominantly neurocognitive test performance change scores, including declines in list learning, verbal fluency, and attention measures.

DISCUSSION

Machine learning may be useful to further our understanding of cancer-related cognitive decline. Our results suggest that persistent self-reported cognitive problems among older women with breast cancer are associated with a constellation of mild neurocognitive changes warranting clinical attention.

Australian oncology health professionals' knowledge, perceptions, and clinical practice related to cancer-related cognitive impairment and utility of a factsheet

PURPOSE

Cancer-related cognitive impairment (CRCI) can have debilitating effects on cancer survivors' quality of life. Despite this, patients often report a lack of information provided by health professionals (HPs) to assist with understanding and managing cognitive changes. This study aimed to explore Australian oncology HPs' understanding of and clinical practice related to CRCI including the use of a Cancer Council Australia CRCI factsheet.

METHODS

Australian oncology HPs (medical oncologists, cancer nurses, and clinical psychologists) completed a questionnaire that assessed CRCI knowledge, prior to receiving the factsheet. Semi-structured interviews were conducted to explore their perceptions of CRCI and the factsheet. Interviews were recorded, transcribed, and analyzed using framework analysis to identify key themes.

RESULTS

Questionnaires were completed by twenty-nine HPs. Most HPs had moderate to high knowledge of CRCI, yet low knowledge of the relationship between CRCI and cancer. Twenty-six (response rate 90%) HPs; medical oncologists (n = 7), cancer nurses (n = 12), and clinical psychologists (n = 7), consented to be interviewed. Three main themes were identified: (1) Is CRCI impact real or over-rated?; (2) If it is important, they will tell me: identifying and responding to CRCI in clinical practice; and (3) Using a factsheet in clinical practice.

CONCLUSION

This study's multi-disciplinary exploration of Australian oncology HPs' perceptions of CRCI highlighted that health professional perceptions drive CRCI discussions with patients. Further education to support clinicians to discuss CRCI is required. Consideration of the barriers and facilitators within healthcare settings is important for successful integration of the factsheet into routine care.

Cancer-related cognitive impairment: a mixed methods evaluation of a standard factsheet

PURPOSE

To understand the impact of cancer survivors accessing a standard factsheet regarding cancer-related cognitive impairment (CRCI), publicly available to the Australian public via Cancer Council Australia's websites.

METHODS

Twenty-three cancer survivors completed a questionnaire assessing pre-factsheet knowledge of CRCI. Semi-structured interviews were conducted to explore participants' experiences of CRCI and perceptions of the factsheet. Interviews were analysed via thematic analysis using a framework approach. Finally, participants completed another questionnaire assessing post-factsheet change in knowledge of CRCI.

RESULTS

Pre- and post-factsheet questionnaire change scores indicated increased knowledge and greater confidence about CRCI. Interview data resulted in five themes: generally positive perceptions of the factsheet's layout and wording; survivors, regardless of treatments received, experienced CRCI symptoms, with some having strong negative emotional responses to their symptoms; perceptions of the factsheet's strategies to manage CRCI ranged from relevant and useful, to impractical or unrealistic if symptoms were too severe; interactions with healthcare system influenced survivors' perceptions of help-seeking, with negative healthcare experiences a major barrier; and generally positive impacts of the factsheet, with survivors praising the factsheet's ability to validate the CRCI experience, increase CRCI knowledge, influence health beliefs, and prompt help-seeking.

CONCLUSION

The factsheet presentation and wording were acceptable to participants. Its ability to normalise and raise awareness for CRCI validated participants' symptoms. The factsheet's potential as a first-line intervention in a stepped-care approach was identified, with participants finding the suggested self-management strategies practical. The factsheet may overcome barriers to self-reporting by encouraging patients to talk with HCPs about CRCI.

Management of Cancer-Related Cognitive Impairment: A Systematic Review of Computerized Cognitive Stimulation and Computerized Physical Activity

Cancer-related cognitive impairment (CRCI) occurs frequently in patients living with cancer, with consequences on quality of life. Recently, research on the management of these difficulties has focused on computerized cognitive stimulation and computerized physical activity programs. This systematic review presents the state of knowledge about interventions based on computerized-cognitive stimulation and/or physical activity to reduce CRCI. The review followed the PRISMA guidelines. A search was conducted in PUBMED and Web of Science databases. Risk of bias analysis was conducted using the Rob2 tool and the quality of evidence was conducted following the GRADE approach. A total of 3776 articles were initially identified and 20 of them met the inclusion criteria. Among them, sixteen investigated computerized-cognitive stimulation and four computerized-physical activity. Most of the studies were randomized controlled trials and assessed the efficacy of a home-based intervention on objective cognition in adults with cancer. Overall, cognitive improvement was found in 11/16 computerized-cognitive stimulation studies and 2/4 computerized-physical activity studies. Cognitive stimulation or physical activity improved especially cognitive complaints, memory, and attention. These results suggest the efficacy of both computerized-cognitive stimulation and physical activity. However, we report a high risk of bias for the majority of studies and a low level of quality of evidence. Therefore, further investigations are needed to confirm the efficacy of these interventions and to investigate the possible added benefit on cognition of a combined computerized-cognitive/physical intervention.

Serum neurofilament light chain levels as biomarker of paclitaxel-induced cognitive impairment in patients with breast cancer: a prospective study

OBJECTIVE

To prospectively assess the utility of serum neurofilament light chain (sNfL) levels in identifying the risk to develop chemotherapy-induced cognitive impairment (CICI) in cancer patients. We also examined if sNfL can be identified as an early biomarker of CICI development.

METHODS

We longitudinally measured sNfL levels in 20 female patients with breast cancer, scheduled to receive the 12 weekly paclitaxel-based regimen. An equal number of age-matched female heathy subjects was incuded as control group. CICI was graded by means of the Montreal Cognitive Assessment scale (MOCA); peripheral neurotoxicity (PN) was graded using the neurosensory Common Criteria for Adverse Events (CTCAE)v5.0, while sNfL levels were quantified using a high-sensitive technique (Quanterix, Simoa) before the administration of chemotherapy (T0), after 3 courses (T1), and at the end of chemotherapy (T2).

RESULTS

Pre-treatment sNfL levels were comparable in patients and controls (p = 0.103). At T2, 5/20 patients (mean age 61.4 ± 5.0 years) developed CICI. These 5 patients also had clinically-significant PN. Patients with and without CICI had comparable sNfL values at T2 (p = 0.1). In addition, at T2, sNfL levels did not correlate significantly with MOCA score in CICI patients (p = 0.604). The difference of sNfL levels between T1 and T0 failed to predict independently the occurrence of CICI at T2.

CONCLUSION

Our findings do not support the utility of measuring sNfL levels as a biomarker of CICI. Grade 2-3 PN most strongly confounded our outcomes. Considering the small sample size, which might have prevented the results from being extrapolated, further testing in larger studies is warranted.

Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer

Background

Patients suffering from cancers are increasingly numerous in general practice consultations. The General Practitioner (GP) should be at the heart of the management of patients. Several studies have examined the perceptions of GPs confronted with the patient suffering from cancer and the relationships of GPs with oncologists, but few studies have focused on the patients’ perspective. We studied the three-way relationship between the oncologist, the GP, and the patient, from the patient’s point of view.

Methods

A questionnaire validated by a group consisting of GPs, oncologists, nurses, an epidemiologist and quality analyst, was administered over a three-week period to patients suffering from cancer receiving chemotherapy in a day hospital.

Results

The analysis was based on 403 questionnaires. Patients had confidence in the GP’s knowledge of oncology in 88% of cases; 49% consulted their GP for pain, 15% for cancer-related advice, and 44% in emergencies. Perceived good GP/oncologist communication led patients to turn increasingly to their GP for cancer-related consultations (RR = 1.14; p = 0.01) and gave patients confidence in the GP’s ability to manage cancer-related problems (RR = 1.30; p < 0.01). Mention by the oncologist of the GP’s role increased the consultations for complications (RR = 1.82; p < 0.01) as well as recourse to the GP in an emergency (RR = 1.35; p < 0.01).

Conclusion

Patients suffering from cancer considered that the GP was competent, but did not often consult their GP for cancer-related problems. There is a discrepancy between patients’ beliefs and their behaviour. When the oncologist spoke to patients of the GP’s role, patients had recourse to their GP more often. Systematically integrating a GP consultation to conclude cancer diagnosis disclosure, could improve management and care coordination.

Long-Term Fatigue and Cognitive Disorders in Breast Cancer Survivors

Survivors of early-stage breast cancer may report treatment-related side effects that persist for several years after the end of primary treatment. Among these, fatigue and cognitive disorders are frequent complaints and can negatively impact quality of life. Cancer-related fatigue is a very prevalent and distressing long-term side effect among breast cancer survivors that typically improves after completion of treatment, although many patients report severe fatigue several years post-treatment. Cognitive disorders are also common among survivors of breast cancer, especially if treated with chemotherapy. These symptoms are usually mild-to-moderate and often transient. Cognitive recovery is frequently observed within months or a few years after completion of chemotherapy or endocrine therapy. However, some breast cancer survivors may have persistent cognitive difficulties. Several types of interventions have proved to be beneficial in reducing cancer-related fatigue and cognitive difficulties. Most of these interventions for cancer-related fatigue are thought to be effective by reducing inflammation or disrupting pro-inflammatory circuits. Further studies are needed on cognitive management that has showed promising results. This narrative review summarizes the state of the art regarding long-term fatigue and cognitive disorders in patients with early breast cancer, describing prevalence, impact, pathophysiology, and risk factors, and focusing on available interventions.

Cognitive complaints in cancer survivors and expectations for support: Results from a web-based survey

Background

Cognitive complaints are common in cancer survivors. We aimed to assess cognitive complaints in cancer survivors and the associated factors using a large web–based survey.

Methods

This online survey was proposed to cancer survivors. Participants completed several questions on cognitive complaints experience, expectations for support of cognitive difficulties, preexisting knowledge about chemotherapy–associated cognitive problems and demographic and medical variables. We used multivariable logistic regression models to estimate Odds Ratios and 95% confidence intervals to estimate associations.

Results

Among 1610 eligible participants (median age 52 [21‐84]), >85% (n = 1393) were breast cancer survivors. Median postcancer treatment time (excluding hormone therapy) was 2.83 years [0.8‐33]. Seventy five percent of the participants (n = 1214) reported cognitive complaints related to cancer treatments. Cognitive difficulties had an impact on work resumption for 76% of the participants (n = 754/982). Most cancer survivors would like to receive support (75%, n = 909) and especially cognitive training (72%, n = 658). Chemotherapy was strongly associated with cognitive complaints (multivariable OR = 3.67, 95% CI: 2.80‐4.82). Self–reported sleep difficulties (OR_{often vs. never} = 2.84, 95% CI: 1.80‐4.47), preexisting knowledge about chemotherapy–associated cognitive problems (OR_{No vs. Yes} = 1.69, 95% CI: 1‐29‐2.22) and age (OR_{21‐64 vs. ≥65} = 0.37, 95% CI: 0.23‐0.58) were also associated with cancer–related cognitive complaints.

Conclusions

According to this large web–based survey including mainly breast cancer survivors, cognitive complaints were reported by three quarters of participants, which reinforces that cognitive difficulties are a major issue in cancer survivors. Chemotherapy, self–reported sleep difficulties and preexisting knowledge about chemotherapy–associated cognitive problems were strongly associated with cancer–related cognitive complaints. Most cancer survivors wished to receive support and especially cognitive training.

Preventing adverse information effects on health outcomes: A self-affirmation intervention reduced information-induced cognitive decline in gastrointestinal cancer patients

RATIONALE

Nocebo studies show that informing patients about treatment side effects can adversely impact expectancies and symptom reporting.

OBJECTIVE

The current study examined how to inform patients fully about treatment side effects without increasing their occurrence. Extending theoretical assumptions about self-affirmation from the social-psychological to the medical domain, we tested whether allowing cancer patients to self-affirm prior to informing them about potential cognitive decline reduced the occurrence of Adverse Information Effects (AIE) on cognitive problem reporting (CPR) and verbal memory performance.

METHOD

Participants were 90 Dutch and Belgian gastrointestinal cancer patients with and without chemotherapy experience. Patients were randomized across three experimental conditions (information about chemotherapy-related cognitive problems with or without self-affirmation; no-information control) before completing an online questionnaire. Data were collected from May until August 2015. Main dependent variables were CPR and verbal memory performance. Stigma consciousness was included as a moderator.

RESULTS

Informing patients about chemotherapy-related cognitive problems increased CPR and decreased scores on two out of three memory measures. Self-affirmation reduced these AIE. Stigma conscious patients reported more problems in the information than the self-affirmation group.

CONCLUSIONS

Nocebo effects may be reduced by allowing patients the opportunity to restore their self-integrity at the implicit level. Self-affirmation has the potential to reduce AIE in patient populations without withholding relevant information about potential treatment side effects.

How to Identify and Manage Cognitive Dysfunction After Breast Cancer Treatment

Attention and memory dysfunction is a common complaint among patients with breast cancer that can be reported during and up to several years after treatment. It can negatively affect patients' quality of life and their ability to work. This phenomenon has mainly been studied in patients with breast cancer who are treated with adjuvant chemotherapy. Women describe concentration problems and difficulties with word finding, multitasking, or remembering new information, as well as more effort and time needed to accomplish these tasks. Such cognitive dysfunction is subtle or moderate and occurs in 15% to 25% of patients. Older patients seem more likely to experience cognitive decline with chemotherapy than do young women with breast cancer. Patients who report that cognitive dysfunction has affected their daily lives for 6 to 12 months after the end of chemotherapy or during hormone therapy may need referral to a neuropsychologist. During the cognitive assessment, the etiology of their cognitive complaints is sought and neuropsychological tests are administered to assess objective cognitive functioning. Psychological factors-fatigue and pain-should be assessed systematically with cognitive complaints to identify precisely the cause of the problems. A nonpharmacologic approach-mainly cognitive rehabilitation-seems to be the most promising for the management of these difficulties, but these preliminary results require confirmation. In the future, early detection of cognitive impairment and cognitive rehabilitation should be included in the portfolio of oncology supportive care to facilitate the return to work of young women and to avoid potential repercussions on adherence to oral treatments and on autonomy in older patients.