Chemotherapy-related cognitive impairment: does integrating complementary medicine have something to add? Review of the literature

Electroacupuncture for Cancer-Related Cognitive Impairment: A Clinical Feasibility Study

BACKGROUND

Cancer-related cognitive impairment (CRCI) is a significant problem for cancer patients, as the number of cancer survivors experiencing cognitive impairments is increasing in the absence of standard treatment. There have been attempts to improve the cognitive function of patients with cancer using acupuncture; however, no studies have been conducted using electroacupuncture. Thus, we designed a preliminary study to investigate the feasibility of a clinical trial using electroacupuncture in CRCI patients.

METHODS

We conducted a single-arm, pilot, clinical trial to investigate the feasibility of a study protocol for further large-scale clinical trials of electroacupuncture in CRCI patients. All participants were treated with electroacupuncture twice a week for 30 minutes at a time, for 8 weeks on acupoints GV20, GV24, EX-HN1, and GB20, HT7, PC6, and KI3. Both subjective and objective outcomes of cognitive function, quality of life (QoL), and psychological factors were measured in all participants at baseline, week 4, 8, and 12. For safety assessment, vital signs, laboratory examinations, and adverse events (AEs) were observed throughout the trial.

RESULTS

A total of 12 participants were enrolled at Daejeon and Dunsan Korean Medicine Hospital of Daejeon University from 21 April 2017 to 31 January 2018. After 8 weeks of treatment, electroacupuncture significantly improved both subjective and objective cognitive outcomes, including the perceived cognitive impairments scale of the Functional Assessment of Cancer Therapy-Cognitive Function, QoL scale of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire-C30, Korean version of Montreal Cognitive Assessment, Boston Naming Test, Seoul Verbal Learning Test, and Rey Complex Figure Test. During the entire trial period, 19 AEs were observed, with no serious AEs. Additionally, it was found that all feasibility outcomes, including recruitment, completion, and adherence rates, achieved successful results as the ratio exceeded 0.8.

CONCLUSION

Our study results revealed that electroacupuncture improved cognitive complaints in cancer patients, and we expect electroacupuncture to be a safe and effective management therapy for CRCI patients. These feasibility trial results will be used as preliminary data for future randomized controlled clinical trials.

TRIAL REGISTRATION NUMBER

Korean Clinical Trial Registry (KCT0002168).

Electroacupuncture trigeminal nerve stimulation plus body acupuncture for chemotherapy-induced cognitive impairment in breast cancer patients: An assessor-participant blinded, randomized controlled trial

Chemotherapy causes various side effects, including cognitive impairment, known as 'chemobrain'. In this study, we determined whether a novel acupuncture mode called electroacupuncture trigeminal nerve stimulation plus body acupuncture (EA/TNS + BA) could produce better outcomes than minimum acupuncture stimulation (MAS) as controls in treating chemobrain and other symptoms in breast cancer patients. In this assessor- and participant-blinded, randomized controlled trial, 93 breast cancer patients under or post chemotherapy were randomly assigned to EA/TNS + BA (n = 46) and MAS (n = 47) for 2 sessions per week over 8 weeks. The Montreal Cognitive Assessment (MoCA) served as the primary outcome. Digit span test was the secondary outcomes for attentional function and working memory. The quality of life and multiple functional assessments were also evaluated. EA/TNS + BA treated group had much better performance than MAS-treated group on reverse digit span test at Week 2 and Week 8, with medium effect sizes of 0.53 and 0.48, respectively, although no significant differences were observed in MoCA score and prevalence of chemobrain between the two groups. EA/TNS + BA also markedly reduced incidences of diarrhoea, poor appetite, headache, anxiety, and irritation, and improved social/family and emotional wellbeing compared to MAS. These results suggest that EA/TNS + BA may have particular benefits in reducing chemotherapy-induced working memory impairment and the incidence of certain digestive, neurological, and distress-related symptoms. It could serve as an effective intervention for breast cancer patients under and post chemotherapy (trial registration: https://www.clinicaltrials.gov: NCT02457039).

Gene prioritization, communality analysis, networking and metabolic integrated pathway to better understand breast cancer pathogenesis

Consensus strategy was proved to be highly efficient in the recognition of gene-disease association. Therefore, the main objective of this study was to apply theoretical approaches to explore genes and communities directly involved in breast cancer (BC) pathogenesis. We evaluated the consensus between 8 prioritization strategies for the early recognition of pathogenic genes. A communality analysis in the protein-protein interaction (PPi) network of previously selected genes was enriched with gene ontology, metabolic pathways, as well as oncogenomics validation with the OncoPPi and DRIVE projects. The consensus genes were rationally filtered to 1842 genes. The communality analysis showed an enrichment of 14 communities specially connected with ERBB, PI3K-AKT, mTOR, FOXO, p53, HIF-1, VEGF, MAPK and prolactin signaling pathways. Genes with highest ranking were TP53, ESR1, BRCA2, BRCA1 and ERBB2. Genes with highest connectivity degree were TP53, AKT1, SRC, CREBBP and EP300. The connectivity degree allowed to establish a significant correlation between the OncoPPi network and our BC integrated network conformed by 51 genes and 62 PPi. In addition, CCND1, RAD51, CDC42, YAP1 and RPA1 were functional genes with significant sensitivity score in BC cell lines. In conclusion, the consensus strategy identifies both well-known pathogenic genes and prioritized genes that need to be further explored.

Effects of Acupuncture on Cancer-Related Cognitive Impairment in Chinese Gynecological Cancer Patients: A Pilot Cohort Study

Background: Among women in China, gynecological cancers are the second most common cancers after breast cancer. Cancer-related cognitive impairment (CRCI) has emerged as a significant problem affecting gynecological cancer survivors. While acupuncture has been used in different aspects of cancer care, the possible positive effects of acupuncture on cognitive impairment have received little attention. This study hypothesized that patients would demonstrate lower neurocognitive performance and lower structural connectivity compared to healthy controls. This pilot study also hypothesized that acupuncture may potentially be effective in treating CRCI of cancer patients by increasing brain structural connectivity and integrity. Methods: This prospective cohort study consisted of 3 stages: the first stage included a group of gynecological cancer patients and a group of age-matched healthy controls. This baseline stage used a core set of neurocognitive tests to screen patients with cognitive impairment and used a multimodal approach of brain magnetic resonance imaging (MRI) to explore the possible neurobiological mechanism of cognitive impairment in cancer patients, comparing the results with a group of noncancer controls. The second stage involved assigning CRCI patients into the acupuncture intervention group, while patients without CRCI were assigned into the cancer control group. The third stage was a postintervention assessment of neurocognitive function by the same set of neurocognitive tests at baseline. To explore the possible neurobiological basis of acupuncture for treating CRCI, this study also used a multimodal MRI approach to assess changes in brain structural connectivity, and neurochemical properties in patients at pre- and postacupuncture intervention. Results: This study found that the prevalence of cognitive impairment in Chinese gynecological cancer patients at diagnosis was 26.67%. When investigating the microstructural white matter in the brain, diffusion tensor imaging data in this study indicated that premorbid cognitive functioning (before clinical manifestations become evident) has already existed, as the global and local connectome properties in the entire patient group were lower than in the healthy control group. Using magnetic resonance spectroscopy, this study indicated there was a significant reduction of relative concentration of NAA (N-acetyl aspartate) in the left hippocampus, comparing these results with healthy controls. Regarding the effects of acupuncture on reducing CRCI, patients in the acupuncture group reported better neurocognitive test performance after matching for age, menopausal status, cancer stage, and chemotherapy regimen dosage. On a microstructural level, acupuncture’s ability to reduce CRCI may be attributed to a reduction in demyelination and an enhancement of the neuronal viability of white matter in the hippocampus. Conclusion: This pilot study indicates that acupuncture is a promising intervention in treating CRCI in gynecological cancer patients undergoing chemotherapy; however, it requires evaluation in larger randomized controlled studies to definitively assess its benefit. By using a multimodal imaging approach, this pilot study also provides novel insights into the neurobiological basis of cognitive impairment on the human brain that has been induced by cancer and/or its treatment.

THE CREATIVE PSYCHOSOCIAL GENOMIC HEALING EXPERIENCE (CPGHE) AND GENE EXPRESSION IN BREAST CANCER PATIENTS: A FEASIBILITY STUDY

BACKGROUND

Biomarkers associated with inflammation and immune function are increasingly being used to examine mechanisms of the effects of mind-body therapies. Less researched are biomarkers associated with cognitive and executive functioning in the study of mind-body therapy mechanisms and effects. This study explored the feasibility of recruiting breast cancer patients (BCPs) and implementation fidelity of participation in a research project utilizing the 4-stage Creative Psychosocial Genomic Healing Experience (CPGHE), a mind-body protocol that is theorized to create epigenetic effects via targeted psychological change in emotional triggers in coping with cancer.

METHODS

Eight BCPs were identified as eligible (stages I, II, III, early phases of treatment) and five consented to one of two intervention groups (allocated to a single session or two sessions of CPGHE). Blood draws were examined pre- and post- intervention for a stress/inflammation gene expression marker, Nuclear Factor kappa-B (NF-kB), and three markers associated with synaptic plasticity undergirding cognitive and executive functioning: Early Growth Response 1 (EGR1), activity-regulated cytoskeleton-associated protein (Arc), and brain-derived neurotrophic factor (BDNF).

RESULTS

One consented BCP dropped out due to illness. The remaining four adhered to the 4-stage CPGHE protocol and found the CPGHE experience beneficial. Blood samples for the gene expression results were collected and processed according to planned protocol without incident.

CONCLUSION

Implementing the CPGHE and achieving good adherence among a sample of BCPs is feasible. Processing of blood samples collected from BCPs for gene expression data is also feasible.

Predicting ligand-dependent tumors from multi-dimensional signaling features

Targeted therapies have shown significant patient benefit in about 5-10% of solid tumors that are addicted to a single oncogene. Here, we explore the idea of ligand addiction as a driver of tumor growth. High ligand levels in tumors have been shown to be associated with impaired patient survival, but targeted therapies have not yet shown great benefit in unselected patient populations. Using an approach of applying Bagged Decision Trees (BDT) to high-dimensional signaling features derived from a computational model, we can predict ligand dependent proliferation across a set of 58 cell lines. This mechanistic, multi-pathway model that features receptor heterodimerization, was trained on seven cancer cell lines and can predict signaling across two independent cell lines by adjusting only the receptor expression levels for each cell line. Interestingly, for patient samples the predicted tumor growth response correlates with high growth factor expression in the tumor microenvironment, which argues for a co-evolution of both factors in vivo.

Complementary medicine for treatment of agitation and delirium in older persons: a systematic review and narrative synthesis

BACKGROUND

Agitation and delirium frequently occur in cognitively impaired older people. We conducted a systematic review with narrative synthesis of the literature aiming to assess effectiveness of complementary and alternative medicine (CAM) modalities to address these conditions.

METHODS

Following preliminary search, we included 40 original researches on CAM treatment of delirium and agitation in older persons. Then, the quality of these studies was assessed using the Downs and Black Checklist and Quality Assessment Tool for Studies with Diverse Designs, and the effect sizes were calculated. We subsequently conducted a narrative synthesis of the main findings, including theory development, preliminary synthesis, exploration of relationships within and between studies, and assessment of synthesis robustness.

RESULTS

Forty articles that met the inclusion criteria were analyzed. Sixteen of these were randomized controlled trials. One article specifically addressed CAM treatment of delirium in patients without dementia, and the remaining 39 articles described treatments of agitated older persons with dementia. Thirty-five of the 40 included studies suggested that the investigated CAM therapies may ameliorate the severity of agitation and delirium. The physiological surrogates of agitation assessed in these studies included cortisol level, chromogranin A level, and heart rate variability. Very few of the studies systematically assessed safety issues, although no major adverse effects were reported.

CONCLUSION

Overall, the systematic review of the literature suggests that several CAM modalities are potentially beneficial in the treatment of agitation and delirium among older persons. We suggest that promising CAM modalities should be further explored through large-scale randomized controlled trials in different clinical settings. Copyright © 2017 John Wiley & Sons, Ltd.

Review complementary and integrative interventions for cancer-related cognitive changes

Cognitive sequelae from a diagnosis of cancer and the subsequent treatment impact survivors’ quality of life and can interfere with both social relationships and employment. The search for evidence-based prevention and intervention strategies continues for both central nervous system (CNS) and non-CNS cancer-related cognitive changes. Complementary therapies in conjunction with conventional medicine are being included in integrative programs designed to maximize symptom management in cancer treatment centers providing survivorship care. The purpose of this article is to review the existing evidence for the use of complementary and integrative interventions to prevent or treat cancer-related cognitive changes and to discuss the rationale for current and future research. Search terminology included: Complementary, alternative, and integrative medicine, cognition, cognitive function, and cancer, and yielded 20 studies that met criteria for inclusion. Preliminary results published to date indicate that some complementary therapies may be beneficial to cancer survivors experiencing cognitive concerns. A number of gaps in the literature remain primarily due to preliminary study designs, small sample sizes, lack of objective cognitive testing, and cognitive function not being a primary endpoint for much of the published work.

Long-term cognitive function change among breast cancer survivors

Cognitive decline is a common health problem among breast cancer patients and understanding trajectories of cognitive change following among breast cancer survivors is an important public health goal. We conducted a longitudinal study to investigate the cognitive function changes from 18 month to 3 years after breast cancer diagnosis among participants of the Shanghai Breast cancer survivor study, a population-based cohort study of breast cancer survivors. In our study, we completed cognitive function evaluation for 1,300 breast cancer survivors at the 18th month's survey and 1,059 at 36th month's survey, respectively, using a battery of cognitive function measurements. We found the scores in attention and executive function, immediate memory and delayed memory significantly improved from 18 to 36 months after breast cancer diagnosis. The improvements appeared in breast cancer survivors receiving treatments (i.e., surgery, radiotherapy, tamoxifen, or chemotherapy combined with or without tamoxifen), but not in those who received neither chemotherapy nor tamoxifen treatment. The results indicate that cognitive functions, particularly immediate verbal episodic memory, and delayed memory significantly improved among breast cancer survivors from 18 to 36 months after cancer diagnosis. In general, comorbidity was inversely associated with the improvements.

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

OBJECTIVE

This study was designed to examine the psychometric properties and measurement equivalence of the English and Chinese versions of the Functional Assessment of Cancer Therapy-Cognitive Function (Version 3) (FACT-Cog) in multiethnic Asian patients with breast cancer.

METHODS

This prospective study involved patients with breast cancer from the National Cancer Centre Singapore. The concurrent validity of the FACT-Cog was assessed according to its strength of correlation with the validated European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 cognitive functioning scale, and its association with fatigue, global health status, and anxiety. The known-group validity was assessed on the basis of receipt of chemotherapy. Factor analysis was conducted to ascertain the one-factor structure of each cognitive domain. The reliability was evaluated by using Cronbach's alpha and intraclass correlation coefficient within the cognitive domains. Multiple regression analyses were performed to compare the total scores between the two language versions, adjusting for covariates.

RESULTS

A total of 185 English-speaking and 143 Chinese-speaking patients were recruited. Both the English and Chinese FACT-Cog total scores correlated strongly with the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 cognitive functioning scale scores (r = 0.725 and 0.646), whereas correlations with fatigue, anxiety, and global health status were weak to moderate (|r| = 0.376-0.589). Regarding the known-group validity, more severe perceived cognitive disturbance was observed among patients receiving chemotherapy than among those who were not for both versions (P = .010 and .008, respectively). Internal consistencies within the cognitive domains were high (Cronbach's α 0.707-0.929), and test-retest reliability was satisfactory for both versions (intraclass correlation coefficient 0.762 and 0.697). The measurement equivalence between the English and Chinese versions was established for all domains except the multitasking domain.

CONCLUSION

The English and Chinese versions of the FACT-Cog are valid, reliable, and equivalent for clinical and research use.