Chemotherapy-related cognitive dysfunction

Neuropsychological Evaluation for Oncology

Cognitive dysfunction is common in cancers and their treatments. Factors that can contribute to cognitive dysfunction include direct and indirect effects of cancer, surgery, radiation, systemic therapy, as well as comorbidities, fatigue, and mood disturbance. Using objective, validated measures, a neuropsychological evaluation can provide information regarding patterns of cognitive function. Emphasis of cognitive domains assessed may vary depending on disease and treatment history. Cognitive interventions can minimize the effects of cancer-related cognitive dysfunction on daily life.

Nicotinic and Muscarinic Acetylcholine Receptor Agonists Counteract Cognitive Impairment in a Rat Model of Doxorubicin-Induced Chemobrain via Attenuation of Multiple Programmed Cell Death Pathways

Chemotherapy causes undesirable long-term neurological sequelae, chemotherapy-induced cognitive impairment (CICI), or chemobrain in cancer survivors. Activation of programmed cell death (PCD) has been proposed to implicate in the development and progression of chemobrain. Neuronal apoptosis has been extensively recognized in experimental models of chemobrain, but little is known about alternative forms of PCD in response to chemotherapy. Activation of acetylcholine receptors (AChRs) is emerging as a promising target in attenuating a wide variety of the neuronal death associated with neurodegeneration. Thus, this study aimed to investigate the therapeutic capacity of AChR agonists on cognitive function and molecular hallmarks of multiple PCD against chemotherapy neurotoxicity. To establish the chemobrain model, male Wistar rats were assigned to receive six doses of doxorubicin (DOX: 3 mg/kg) via intraperitoneal injection. The DOX-treated rats received either an a7nAChR agonist (PNU-282987: 3 mg/kg/day), mAChR agonists (bethanechol: 12 mg/kg/day), or the two as a combined treatment. DOX administration led to impaired cognitive function via neuroinflammation, glial activation, reduced synaptic/blood-brain barrier integrity, defective mitochondrial ROS-detoxifying capacity, and dynamic imbalance. DOX insult also mediated hyperphosphorylation of Tau and simultaneously induced various PCD, including apoptosis, necroptosis, and pyroptosis in the hippocampus. Concomitant treatment with either PNU-282987, bethanechol, or a combination of the two potently attenuated neuroinflammation, mitochondrial dyshomeostasis, and Tau hyperphosphorylation, thereby suppressing excessive apoptosis, necroptosis, and pyroptosis and improving cognitive function in DOX-treated rats. Our findings suggest that activation of AChRs using their agonists effectively protected against DOX-induced neuronal death and chemobrain.

Self-perceived cognitive impairment in the first year after breast cancer and the identification of at-risk patients

PURPOSE

This study investigated self-reported clinically relevant cognitive impairment of breast cancer patients in routine clinical care and assessed factors associated with new-onset clinically relevant cognitive impairment.

METHODS

Cognitive functioning was assessed before start of any treatment (T0) and at 6 (T6) and 12 (T12) months after diagnosis. Cognitive functioning (CF) was measured on a scale of 0-100 with the EORTC QLQ-C30 questionnaire, and the EORTC pre-defined threshold for clinical importance. Multivariable logistic regression analyses was used to identify factors associated with new-onset clinically relevant cognitive impairment at T6 ((CF > 75 at T0 and CF < 75 at T6 and T12) or (CF > 75 at T0 and T6 and <75 at T12)).

RESULTS

Pre-treatment, 21% of patients reported clinically relevant cognitive impairment. At T12, percentage was 32%; 20% of patients reported new-onset clinically relevant cognitive impairment at T6 and/or T12. New-onset clinically relevant cognitive impairment was associated with chemo(immuno)therapy and impairment in role and emotional functioning. Younger patients and patients receiving chemo(immuno)therapy were more likely to report new-onset clinically relevant cognitive impairment post treatment.

CONCLUSION

One in five breast cancer patients reported clinically relevant cognitive problems before start of treatment. This percentage further increased within the first year, particularly among patients treated with chemo(immuno)therapy. One in five patients reported new-onset clinically relevant cognitive impairment. Ultimately, these patients may benefit from systematic monitoring and potential referral to interventions.

Individualized trajectories in postradiotherapy neurocognitive functioning of patients with brain metastases

Background

The increasing incidence of brain metastases (BMs) and improved survival rates underscore the necessity to investigate the effects of treatments on individuals. The aim of this study was to evaluate the individual trajectories of subjective and objective cognitive performance after radiotherapy in patients with BMs.

Methods

The study population consisted of adult patients with BMs referred for radiotherapy. A semi-structured interview and comprehensive neurocognitive assessment (NCA) were used to assess both subjective and objective cognitive performance before, 3 months and ≥ 11 months after radiotherapy. Reliable change indices were used to identify individual, clinically meaningful changes.

Results

Thirty-six patients completed the 3-month follow-up, and 14 patients completed the ≥ 11-months follow-up. Depending on the domain, subjective cognitive decline was reported by 11-22% of patients. In total, 50% of patients reported subjective decline in at least one cognitive domain. Intracranial progression 3 months postradiotherapy was a risk-factor for self-reported deterioration (P = .031). Objective changes were observed across all domains, with a particular vulnerability for decline in memory at 3 months postradiotherapy. The majority of patients (81%) experienced both a deterioration as well as improvement (eg, mixed response) in objective cognitive functioning. Results were similar for the long-term follow-up (3 to ≥11 months). No risk factors for objective cognitive change 3 months postradiotherapy were identified.

Conclusions

Our study revealed that the majority of patients with BMs will show a mixed cognitive response following radiotherapy, reflecting the complex impact. This underscores the importance of patient-tailored NCAs 3 months postradiotherapy to guide optimal rehabilitation strategies.

In-vitro and in-vivo studies of two-drug cocktail therapy targeting chemobrain via the Nrf2/NF-κB signaling pathway

Today, we critically need alternative therapeutic options for chemotherapy-induced cognitive impairment (CICI), often known as chemo brain. Mitochondrial dysfunction and oxidative stress are two of the primary processes that contribute to the development of chemobrain. Therefore, the purpose of this study was to investigate how CoQ10 and berberine shield neurons from chemotherapy-induced damage in in-vitro studies and memory loss in vivo studies. For the in-vitro investigation, we employed SH-SY5Y cell lines, and for the in-vivo study, we used female Swiss albino mice divided into seven different groups. Data from in-vitro studies revealed that treatment with coenzyme Q10 (CoQ10) and berberine improved chemotherapy-induced toxicity by reducing mitochondrial and total cellular ROS, as well as apoptosis-elicited markers (caspase 3 and 9). CoQ10 and berberine therapy inhibited the nuclear translocation of NF-κB and, consequently, the subsequent expressions of NLRP3 and IL-1β, implying the prevention of inflammasome formation. Furthermore, CoQ10 and berberine therapy boosted Nrf2 levels. This is a regulator for cellular resistance to oxidants. The in vivo results showed that treatment with CoQ10 (40 mg/kg) and berberine (200 mg/kg) improved the behavioral alterations induced by CAF (40/4/25 mg/kg) in both the Morris Water Maze (MWM) and Novel Object Recognition (NOR) tests. Furthermore, biochemical and molecular evidence revealed the antioxidant, mitochondrial restorative, and anti-inflammatory potential of CoQ10 (40 mg/kg) and berberine (200 mg/kg) against CAF (40/4/25 mg/kg) subjected mice. In addition, the histological analysis using H&E staining and transmission electron microscopy (for mitochondrial morphology) showed that mice treated with the cocktails had an increased number of healthy neurons with intact mitochondria and a reduced presence of autophagic vacuoles in the hippocampal region of the brain. These findings back up our theory about this novel cocktail method for CAF-induced cognitive impairment.

Return to work improves quality of life and reduces psychosocial distress after radical cystectomy: data from a contemporary series of 230 German patients

PURPOSE

This study aims to evaluate health-related quality of life (HRQoL), psychosocial distress, and return to work (RTW) 2 years after radical cystectomy (RC) and inpatient rehabilitation (IR).

MATERIAL AND METHODS

The study relied on prospectively collected data for 842 patients, who underwent 3 weeks of IR after RC and creation of an ileal conduit (IC) or ileal neobladder (INB). Validated questionnaires surveyed patients on HRQoL and psychosocial distress (EORTC QLQ-C30, QSC-R10). Furthermore, employment status was evaluated. Regression was performed to identify predictors for HRQol, psychosocial distress, and RTW.

RESULTS

Two-hundred and thirty patients were employed pre-surgery (77.8% INB, 22.2% IC). Patients with an IC suffered significantly more often from locally advanced disease (≥ pT3: 43.1% vs 22.9%; p = 0.004). Two years after surgery, 16.1% of patients had died (median days of survival 302 (IQR 204-482). Global HRQoL improved steadily, while high psychosocial distress was present in 46.5% of patients 2 years after surgery. Employment was reported by 68.2% of patients, of which 90.3% worked full-time. Retirement was reported by 18.5%. Multivariate logistic regression analysis identified age ≤ 59 years as the only positive predictor for RTW 2 years after surgery (OR 7.730; 95% CI 3.369-17.736; p < 0.001). Gender, surgical technique, tumor stage, and socioeconomic status did not influence RTW in this model. In multivariate linear regression analysis, RTW was identified as an independent predictor of better global HRQoL (p = 0.018) and lower psychosocial distress (p < 0.001), whereas younger patient age was identified as an independent predictor for higher psychosocial distress (p = 0.002).

CONCLUSION

Global HRQoL and RTW are high among patients two years after RC. However, role and emotional, cognitive, and social functioning were significantly impaired, while high psychosocial distress persists in a material number of patients.

IMPLICATIONS FOR CANCER SURVIVORS

Our study highlights how a successful RTW decreases psychosocial distress and increases QoL in patients after RC for urothelial cancer. Nonetheless, additional efforts by employers and healthcare providers are needed in aftercare after creation of an INB or IC.

You can't spell distress without stress: Expanding our perspective of the intersection between mental and physical health in cancer survivors

Although many breast cancer survivors adjust to cancer treatment and survivorship, a sizable subgroup of women do not do so, resulting in psychological distress. Over time, this psychological distress can contribute to immune dysfunction and accompanying worsened physical symptoms as women navigate survivorship. Dr. Kiecolt-Glaser's work and mentorship has been integral to our understanding of breast cancer survivors' immune risks, and how behavioral factors may enhance these risks. As a postdoctoral fellow in the Stress and Health Lab, under Dr. Kiecolt-Glaser's mentorship, my research focused on understanding how distress is associated with immune functioning and physical health in breast cancer survivors. In this paper, we highlight Dr. Kiecolt-Glaser's influence on our careers as a strong female research and mentor, the work completed under her mentorship, and how the field of psychoneuroimmunology can continue to expand her research to better understand how distress in the cancer context confers long-term health risks.

Structural plasticity of pyramidal cell neurons measured after FLASH and conventional dose-rate irradiation

Evidence shows that ultra-high dose-rate FLASH-radiotherapy (FLASH-RT) protects against normal tissue complications and functional decrements in the irradiated brain. Past work has shown that radiation-induced cognitive impairment, neuroinflammation and reduced structural complexity of granule cell neurons were not observed to the same extent after FLASH-RT (> MGy/s) compared to conventional dose-rate (CONV, 0.1 Gy/s) delivery. To explore the sensitivity of different neuronal populations to cranial irradiation and dose-rate modulation, hippocampal CA1 and medial prefrontal cortex (PFC) pyramidal neurons were analyzed by electron and confocal microscopy. Neuron ultrastructural analyses by electron microscopy after 10 Gy FLASH- or CONV-RT exposures indicated that irradiation had little impact on dendritic complexity and synapse density in the CA1, but did increase length and head diameter of smaller non-perforated synapses. Similarly, irradiation caused no change in PFC prelimbic/infralimbic axospinous synapse density, but reductions in non-perforated synapse diameters. While irradiation resulted in thinner myelin sheaths compared to controls, none of these metrics were dose-rate sensitive. Analysis of fluorescently labeled CA1 neurons revealed no radiation-induced or dose-rate-dependent changes in overall dendritic complexity or spine density, in contrast to our past analysis of granule cell neurons. Super-resolution confocal microscopy following a clinical dosing paradigm (3×10Gy) showed significant reductions in excitatory vesicular glutamate transporter 1 and inhibitory vesicular GABA transporter puncta density within the CA1 that were largely dose-rate independent. Collectively, these data reveal that, compared to granule cell neurons, CA1 and mPFC neurons are more radioresistant irrespective of radiation dose-rate.

Systemic and targeted activation of Nrf2 reverses doxorubicin-induced cognitive impairments and sensorimotor deficits in mice

While cancer survivorship has increased due to advances in treatments, chemotherapy often carries long-lived neurotoxic side effects which reduce quality of life. Commonly affected domains include memory, executive function, attention, processing speed and sensorimotor function, colloquially known as chemotherapy-induced cognitive impairment (CICI) or "chemobrain". Oxidative stress and neuroimmune signaling in the brain have been mechanistically linked to the deleterious effects of chemotherapy on cognition and sensorimotor function. With this in mind, we tested if activation of the master regulator of antioxidant response nuclear factor E2-related factor 2 (Nrf2) alleviates cognitive and sensorimotor impairments induced by doxorubicin. The FDA-approved systemic Nrf2 activator, diroximel fumarate (DRF) was used, along with our recently developed prodrug 1c which has the advantage of specifically releasing monomethyl fumarate at sites of oxidative stress. DRF and 1c both reversed doxorubicin-induced deficits in executive function, spatial and working memory, as well as decrements in fine motor coordination and grip strength, across both male and female mice. Both treatments reversed doxorubicin-induced loss of synaptic proteins and microglia phenotypic transition in the hippocampus. Doxorubicin-induced myelin damage in the corpus callosum was reversed by both Nrf2 activators. These results demonstrate the therapeutic potential of Nrf2 activators to reverse doxorubicin-induced cognitive impairments, motor incoordination, and associated structural and phenotypic changes in the brain. The localized release of monomethyl fumarate by 1c has the potential to diminish unwanted effects of fumarates while retaining efficacy.

A systematic review of rehabilitation programs for cognitive impairment related to breast cancer: Different programs at different times?

BACKGROUND

"Cancer Related Cognitive Impairment" (CRCI) defines cognitive disorders related to cancer and its treatments. Many people with breast cancer experience signs of CRCI (incidence between 20 and 30 %) and, although several intervention options exist, there is no established standard of care. Our main objective was to provide a detailed description of the methods and results of randomized controlled trials of interventions for CRCI in breast cancer survivors, paying particular attention to the timing of the interventions within the care pathway.

METHODS

We conducted a systematic literature review following the PRISMA guidelines from 01 to 01-2019 to 16-07-2023 and included randomized controlled trials of interventions for CRCI after breast cancer with at least one objective cognitive assessment as a primary or secondary outcome.

RESULTS

Among 228 identified studies, 35 (including 2821 participants) were retained for inclusion. The interventions were classified into 4 categories: cognitive rehabilitation, physical activity, complementary therapy and pharmacological treatment. Our analysis revealed that pharmacological interventions have no effect, whereas physical activity interventions proposed in the months following the initial cancer treatment improve Quality of Life and Speed of Information Processing while interventions proposed later improve Memory and Attention (Cognitive Rehabilitation) and Perceived Cognitive Function and Depression/Anxiety/Mood (Complementary Therapies).

CONCLUSION

CRCI is multifactorial and affected individuals frequently experience high levels of fatigue, pain, anxiety and depression and are most likely to benefit from holistic approaches that include cognition, physical activity, relaxation, psychoeducation, group support and/or psychological counselling. Thus, rehabilitation programs should be designed on multi-modal approaches, using innovative, cost-effective delivery methods that increase access to treatment, and intervention outcomes should be evaluated using measures of participation.

DATABASE REGISTRATION

The review was recorded on Prospero (01-03-2020), with the registration number 135,627.

School performance and educational achievement in children exposed to maternal cancer in utero

BACKGROUND

In utero exposure to maternal cancer and cancer treatment might influence the child's cognitive development. This study investigated if exposure to maternal cancer during fetal life impacted school performance and educational achievement as adults.

METHODS

This nationwide retrospective cohort study identified all live-born children in Denmark between January 1978 and December 2013. Exposure was defined as maternal cancer diagnosis during pregnancy. Four partly overlapping birth cohorts were constructed depending on the outcome of interest: (1) receiving special educational support for birth years 2001-2013; (2) grade point average (GPA) at the final exams after 10th grade for 1986-2003; (3) educational achievement at 20 years for 1978-1998; and (4) education at 30 years for 1978-1988. Logistic and linear models were adjusted for birth year, maternal age, maternal education and maternal death.

RESULTS

The estimated probability of receiving special educational support was similar in the exposed group and the reference (adjusted OR 0.96; 95% CI 0.46 to 1.77, non-significant). The GPA did not statistically differ (0.13 grade points; 95% CI -0.18 to 0.45, non-significant). The achieved educational levels were similar for the exposed group and the reference at 20 years, with an adjusted OR of 1.07 (95% CI 0.82 to 1.40) for low versus medium educational level, and at 30 years with an adjusted OR of 0.73 (95% CI 0.35 to 1.50) for low versus high educational level and of 1.07 (95% CI 0.66 to 1.72) for medium versus high educational level.

CONCLUSION

Our findings did not indicate poorer performance in compulsory school nor impairment of adult educational achievement after exposure to maternal cancer in utero.

Comparative effect of Tai Chi and aerobic exercise on cognitive function in advanced lung cancer survivors with perceived cognitive impairment: a three-arm randomized controlled trial with mediation analysis

PURPOSE

Cancer-related cognitive impairment is prevalent in metastatic lung cancer survivors. This study aimed to compare the effectiveness of aerobic exercise and Tai Chi on perceived cognitive function and the mediating role of psychoneurological symptoms with perceived cognitive impairment.

METHODS

In a subgroup of a parent randomized clinical trial, participants who reported cognitive impairment underwent a 16-week aerobic exercise (n = 49), Tai Chi (n = 48), and control (n = 54) groups. Measures included perceived cognitive function and psychoneurological symptoms (sleep disturbance, fatigue, anxiety, and depression) assessed at baseline (T0), 16-week (T1), and 1 year (T2).

RESULTS

Participants in Tai Chi showed significant improvements compared to aerobic exercise and control groups in perceived cognitive function at T1 (AE: between-group difference, 6.52; P < 0.001; CG: 8.34; P < 0.001) and T2 (AE: between-group difference, 3.55; P = 0.05; CG: 5.94; P < 0.001). Sleep disturbance, fatigue, anxiety, and depression at month 12 explained 24%, 31%, 32%, and 24% of the effect of the intervention on cognitive function at month 12, respectively. Only anxiety at month 4 explained 23% of the intervention effect at month 12.

CONCLUSIONS

Tai Chi demonstrated beneficial effects on cognitive function in advanced lung cancer survivors with perceived cognitive impairment. Improvement in cognitive function was mediated by reducing sleep disturbance, fatigue, anxiety, and depression, highlighting the importance of addressing these symptoms in future interventions to improve cognitive function, with anxiety playing a significant role at an earlier stage.

IMPLICATIONS FOR CANCER SURVIVORS

Tai Chi is a potentially safe complementary therapeutic option for managing cognitive impairment in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04119778; retrospectively registered on 8 October 2019.

Frontal and anterior temporal hypometabolism post chemoradiation in head and neck cancer: A real-world PET study

BACKGROUND AND PURPOSE

Adverse neurological effects after cancer therapy are common, but biomarkers to diagnose, monitor, or risk stratify patients are still not validated or used clinically. An accessible imaging method, such as fluorodeoxyglucose positron emission tomography (FDG PET) of the brain, could meet this gap and serve as a biomarker for functional brain changes. We utilized FDG PET to evaluate which brain regions are most susceptible to altered glucose metabolism after chemoradiation in patients with head and neck cancer (HNCa).

METHODS

Real-world FDG PET images were acquired as standard of care before and after chemoradiation for HNCa in 68 patients. Linear mixed-effects voxelwise models assessed changes after chemoradiation in cerebral glucose metabolism quantified with standardized uptake value ratio (SUVR), covarying for follow-up time and patient demographics.

RESULTS

Voxelwise analysis revealed two large clusters of decreased glucose metabolism in the medial frontal and polar temporal cortices following chemoradiation, with decreases of approximately 5% SUVR after therapy.

CONCLUSIONS

These findings provide evidence that standard chemoradiation for HNCa can lead to decreased neuronal glucose metabolism, contributing to literature emphasizing the vulnerability of the frontal and anterior temporal lobes, especially in HNCa, where these areas may be particularly vulnerable to indirect radiation-induced injury. FDG PET shows promise as a sensitive biomarker for assessing these changes.

Synthesis and Study of the Structure-Activity Relationship of Antiproliferative N-Substituted Isosteviol-Based 1,3-Aminoalcohols

Starting from isosteviol, a series of diterpenoid 1,3-aminoalcohol derivatives were prepared via stereoselective transformations. The acid-catalysed hydrolysis and rearrangement of natural stevioside produced isosteviol, which was transformed into the key intermediate methyl ester. In the next step, an 1,3-aminoalcohol library was prepared by the reductive amination of the intermediate 3-hydroxyaldehyde obtained from isosteviol in a two-step synthesis. To study the effect of the carboxylate ester function at position 4, the free carboxylic acid, benzyl ester and acryloyl ester analogues were prepared as elongated derivatives in comparison with our earlier results in this field. The antiproliferative activity of compounds against human tumour cell lines (A2780, HeLa, MCF-7 and MDA-MB-231) was investigated. In our preliminary study, the 1,3-aminoalcohol function with N-benzyl or (1H-imidazol-1-yl)-propyl substitution and benzyl ester moiety seemed essential for the reliable antiproliferative activity. The results obtained could be a good starting point to further functionalisation towards more efficient antiproliferative diterpenes.

Measurement of Cognitive Function in Exercise Oncology Studies in Patients Treated With Chemotherapy: A Scoping Review

Cancer-associated cognitive deficits following chemotherapy have received increased attention in clinical research. Exercise has been shown to preserve cognitive function in cancer patients, though the overall effect is mixed. Here we present a scoping review of the published literature summarizing methods used to assess cognitive function in exercise oncology trials. Methods: PubMed, PsycINFO and CINAHL databases were searched using keywords "cognition," "cancer" OR "neoplasm" OR "tumor," "chemotherapy" and "exercise" OR "physical activity." Studies eligible for inclusion include prospective studies that were published in English in peer-reviewed journals that include a method of assessing cognitive function in adult cancer patients, in which an exercise modality or method of quantifying exercise habits was evident. Studies were excluded if they included a pediatric population, patients that were not diagnosed with cancer, or were systematic/narrative/scoping reviews, protocol papers or dissertation/theses. Results: A total of 29 studies met the inclusion criteria. In total, 29 unique assessments were used to evaluate cognitive function, including patient-reported outcomes (PROs; n = 8) and objective (n = 21) methods. More than half (n = 17) of included studies relied on PROs while 12 studies utilized objective measures of cognitive function Cognitive domains of the PROs were limited in scope, focusing on memory and attention/concentration while the objective measures were broader and inclusive of multiple domains. Conclusion: The results of this review indicate that mixed approaches to evaluating cognitive function in cancer patients pose a major limitation to understanding the role of exercise as an integrative approach. The evidence demonstrates a need for more uniform assessment of cognitive function in exercise oncology trials.

Long-term changes of cognitive impairment among older breast cancer survivors

PURPOSE

Cancer-related cognitive impairment is common during cancer treatment; however, it is unclear whether the impairment persists over time. Our study aimed to examine long-term cognitive impairment among older breast cancer survivors.

METHODS

Participants included 2420 community-dwelling women aged 65 years or older at enrollment (1986-1988) (404 breast cancer cases and 1:5 matched cancer-free controls) from the Study of Osteoporotic Fractures. Participants were followed for 20 years with measured cognitive function repeated up to 6 times. Cognitive impairment was defined by the Modified Mini-Mental State Examination and Trail Making Test B. Generalized linear models were used to model risk of cognitive impairment in relation to breast cancer status and time from breast cancer diagnosis.

RESULTS

Compared with controls, cognitive impairment in women with breast cancer significantly accelerated after cancer diagnosis. We also observed a more pronounced cognitive impairment after cancer diagnosis for women diagnosed with breast cancer at age ≥ 80 years or at advanced stage for both measures.

CONCLUSION

Our study with more than 20 years of follow-up data found that breast cancer survivors had accelerated cognitive impairment after cancer diagnosis, especially among women diagnosed at older age or at advanced stage, relative to women without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivors may be encouraged to engage in both physical activity and cognitive training.

Can more be done? - A qualitative study of breast cancer survivors' perspectives on regular walking exercise to improve post-chemotherapy neurotoxicity impairments

PURPOSE

Chemotherapy-induced neurotoxicity in breast cancer survivors requires attention as their population are increasing. Limited qualitative study is known about breast cancer survivors' perspectives on regular walking exercise to improve post-chemotherapy neurotoxicity impairments in their free-living setting. This study explored regular walking exercise to improve post-chemotherapy neurotoxicity impairments from breast cancer survivors' perspectives.

METHODS

A qualitative descriptive study was conducted. A purposive sample of 15 participants experiencing neurotoxicity impairments was invited to semi-structured interviews. Textual interview data were managed in NVivo. Content analysis was performed.

RESULTS

Participants were aged 39-68 and had received 4-8 cycles of chemotherapy. Most (86.7%, n = 13) reported engaging in regular walking exercise. Four main categories emerged from the data: (1) perceived effects of regular exercise on neurotoxicity impairments, (2) unmet information needs, (3) regular walking habit being self-sustained, and (4) enablers and constraints of regular walking exercise.

CONCLUSIONS

Walking exercise, as commonly employed by participants in their free-living setting, was the essence in the management of chemotherapy-induced neurotoxic conditions during survivorship. Participants undertaking walking exercise lacked informed and individualized information about the regular walking exercise regime, and vigilance to evaluate post-exercise neurotoxic conditions. These might be the unmet needs of this research area and in clinical practice. Assessing and addressing individualized endeavors in a walking exercise regime will continue to be a vital component of cancer supportive care to fill the unmet information needs in survivorship.

Effects of exercise on cancer-related cognitive impairment in breast cancer survivors: a scoping review

BACKGROUND

Cancer-related cognitive impairment (CRCI) is one of the major long-term concerns reported by breast cancer survivors after overcoming the disease. The present study undertakes a scoping review of relevant research publications to explore the effect of increasing physical activity (PA) levels or the use of exercise (EX)-based programs on CRCI in female breast cancer survivors; who have completed neo/adjuvant chemotherapy treatment and are awaiting or receiving hormonal therapy.

METHODS

An electronic search of Pubmed, Embase, Scopus, WOS, and Cochrane databases has been conducted to identify published literature from January 2000 to December 2021.

RESULTS

Of 1129 articles, twenty met the inclusion criteria. The majority of the included observational studies (90%) reported cross-sectional design; meanwhile, 72% of experimental research reported randomized controlled trials (RCTs) or randomized crossover trials. 15 neuropsychological batteries and tests, and 5 self-reported validated questionnaires were employed. Only 27% of the included articles used a combination of the previously mentioned methods. The recorder of moderate-vigorous PA (MVPA), defined as more than 3 METs, or represented as average daily minutes spent (≥ 1952 counts/min) was the most analyzed variable in cross-sectional studies, and EX programs based on aerobic training (AT) were the most proposed by RCTs.

CONCLUSIONS

The exploratory approach of this review demonstrates modest but increasingly promising evidence regarding exercise's potential to improve brain health among breast cancer survivors although these findings highlight the importance of addressing methodological heterogeneity in the same direction with the view of using exercise within the clinic area.

Neurorehabilitation in brain tumours: evidences and suggestions for spreading of knowledge and research implementation

PURPOSE OF REVIEW

The last few decades have seen an increase in life expectancy in brain tumour patients; however, many patients report sensory-motor and cognitive disabilities due to the tumour itself, but also to the effect of anticancer treatments (surgery, radiotherapy, chemotherapy), supportive treatments, as well as individual patient factors. This review outlines the principles on which to base neurorehabilitation treatments, with the aim of stimulating an early rehabilitative management, in order to reduce disability and functional limitation and improve the quality of life of the persons affected by brain tumour.

RECENT FINDINGS

Although not definitive, evidences suggest that an early neurorehabilitative evaluation, performed with a multidisciplinary approach, may identify the different functional impairments that can affect people with brain tumour. Furthermore, identifying and classifying the person's level of functioning is useful for designing achievable recovery goals, through the implementation of tailored multidisciplinary rehabilitation programs. The involvement of different professional figures allows to treat all the components (physical, cognitive, psychological and participation) of the person, and to redesign one's life project, lastly improving the quality of life.

SUMMARY

Overall, the evidences suggest a critical need for the development of this clinical area by spreading the concept of rehabilitation among neuro-oncologists and producing high quality research.

Cognitive impairments associated with chemotherapy in women with breast cancer: a meta-analysis and meta-regression

Chemotherapy is one of the most widely used treatments for breast cancer (BC). However, there is evidence of side effects like cognitive changes related to the chemotherapy treatment. The aim of the study was not only to summarize the existing evidence on the relationship between chemotherapy and cognitive performance in women with BC but also to identify additional consequences and aspects associated with these impairments. We conducted a systematic review with meta-analysis and meta-regression to present updated information on the matter. We retrieved data from the databases PubMed, Web of Science, PsycINFO, CINAHL, and Scopus. Twenty studies comprising over 2,500 women were examined and the results indicated that chemotherapy can compromise cognition in women with BC (-1.10 OR [95%CI: -1.81 to -0.74], P<0.01), with working memory (-0.49 OR [95%CI: -0.85 to -0.13], P=0.03) being the most affected among the domains. Furthermore, additional data indicated that cognitive impairment is most likely amid women with BC having a lower education level (Q=4.85, P=0.02). Our results suggested that chemotherapy affects cognitive functions in women with BC, and certain characteristics can worsen the deterioration. A comprehensive study of women with breast cancer and existing predictors contributes to optimized personal journeys, elevated life prospects, and advanced care that can also aid prognosis and therapeutic approaches.

Deleterious and protective effects of epothilone-D alone and in the context of amyloid β- and tau-induced alterations

Amyloid-β (Aβ) and hyperphosphorylated tau (P-tau) are Alzheimer's disease (AD) biomarkers that interact in a complex manner to induce most of the cognitive and brain alterations observed in this disease. Since the neuronal cytoskeleton is a common downstream pathological target of tau and Aβ, which mostly lead to augmented microtubule instability, the administration of microtubule stabilizing agents (MSAs) can protect against their pathological actions. However, the effectiveness of MSAs is still uncertain due to their state-dependent negative effects; thus, evaluating their specific actions in different pathological or physiological conditions is required. We evaluated whether epothilone-D (Epo-D), a clinically used MSA, rescues from the functional and behavioral alterations produced by intracerebroventricular injection of Aβ, the presence of P-tau, or their combination in rTg4510 mice. We also explored the side effects of Epo-D. To do so, we evaluated hippocampal-dependent spatial memory with the Hebb-Williams maze, hippocampal CA1 integrity and the intrinsic and synaptic properties of CA1 pyramidal neurons with the patch-clamp technique. Aβ and P-tau mildly impaired memory retrieval, but produced contrasting effects on intrinsic excitability. When Aβ and P-tau were combined, the alterations in excitability and spatial reversal learning (i.e., cognitive flexibility) were exacerbated. Interestingly, Epo-D prevented most of the impairments induced Aβ and P-tau alone and combined. However, Epo-D also exhibited some side effects depending on the prevailing pathological or physiological condition, which should be considered in future preclinical and translational studies. Although we did not perform extensive histopathological evaluations or measured microtubule stability, our findings show that MSAs can rescue the consequences of AD-like conditions but otherwise be harmful if administered at a prodromal stage of the disease.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transcranial Magnetic Stimulation for the Treatment of Chemo Brain

This pilot feasibility study aimed to evaluate the effects of transcranial magnetic stimulation (TMS) on chemotherapy-related cognitive impairment (CRCI), and we report here on the first patient.

BACKGROUND

Deleterious cognitive changes due to chemotherapy or CRCI are commonly referred to as "chemo brain". With the increasing survival of cancer patients, this poorly understood and inadequately treated condition will likewise have an increasing toll on individuals and society. Since there is no approved treatment for chemo brain, we have initiated a therapeutic trial using transcranial magnetic stimulation (TMS), a non-invasive brain stimulation technique approved in many countries for the treatment of neurologic and psychiatric conditions like migraine and depression.

CASE PRESENTATION

A 58-year-old woman, diagnosed 7 years prior with left breast cancer, underwent partial mastectomy with sentinel lymph node biopsy. She then received four cycles of adjuvant chemotherapy followed by radiation therapy. Afterwards, she was on tamoxifen for 4 years and then switched to aromatase inhibitors. The patient's CRCI started during chemotherapy and severely impaired her quality of life for an additional two years. In the third year after chemotherapy, the CRCI partially cleared to stabilize to the level at the time of presentation for this trial. The patient continues to have memory difficulties and decreased concentration, which makes multi-tasking very difficult to impossible. She is reliant on memory aids at work and at home. The participant underwent 10 consecutive sessions of TMS during weekdays for 2 weeks. Stimulation was directed to the left dorsolateral prefrontal cortex. After TMS, the participant significantly improved in memory function on neuropsychological testing. While she reported no subjective differences in concentration or memory, she did report an improvement in her sleep. Functional magnetic resonance imaging of the brain before and after TMS showed increased resting-state functional connectivity between the stimulation site and several brain regions. Remarkably, after 6 years of chemo brain and remaining in the same position at work due to her inability to concentrate and multi-task, she applied for and received a promotion 5-6 months after her TMS treatments.

CONCLUSIONS

This first patient in the phase 1 clinical trial testing of TMS for the treatment of "chemo brain" provided important lessons for feasibility and insights into mechanisms of potential benefit.

Metformin beyond an anti-diabetic agent: A comprehensive and mechanistic review on its effects against natural and chemical toxins

In addition to the anti-diabetic effect of metformin, a growing number of studies have shown that metformin has some exciting properties, such as anti-oxidative capabilities, anticancer, genomic stability, anti-inflammation, and anti-fibrosis, which have potent, that can treat other disorders other than diabetes mellitus. We aimed to describe and review the protective and antidotal efficacy of metformin against biologicals, chemicals, natural, medications, pesticides, and radiation-induced toxicities. A comprehensive search has been performed from Scopus, Web of Science, PubMed, and Google Scholar databases from inception to March 8, 2023. All in vitro, in vivo, and clinical studies were considered. Many studies suggest that metformin affects diseases other than diabetes. It is a radioprotective and chemoprotective drug that also affects viral and bacterial diseases. It can be used against inflammation-related and apoptosis-related abnormalities and against toxins to lower their effects. Besides lowering blood sugar, metformin can attenuate the effects of toxins on body weight, inflammation, apoptosis, necrosis, caspase-3 activation, cell viability and survival rate, reactive oxygen species (ROS), NF-κB, TNF-α, many interleukins, lipid profile, and many enzymes activity such as catalase and superoxide dismutase. It also can reduce the histopathological damages induced by many toxins on the kidneys, liver, and colon. However, clinical trials and human studies are needed before using metformin as a therapeutic agent against other diseases.

Chemobrain: An accelerated aging process linking adenosine A2A receptor signaling in cancer survivors

Chemotherapy has a significant positive impact in cancer treatment outcomes, reducing recurrence and mortality. However, many cancer surviving children and adults suffer from aberrant chemotherapy neurotoxic effects on learning, memory, attention, executive functioning, and processing speed. This chemotherapy-induced cognitive impairment (CICI) is referred to as "chemobrain" or "chemofog". While the underlying mechanisms mediating CICI are still unclear, there is strong evidence that chemotherapy accelerates the biological aging process, manifesting as effects which include telomere shortening, epigenetic dysregulation, oxidative stress, mitochondrial defects, impaired neurogenesis, and neuroinflammation, all of which are known to contribute to increased anxiety and neurocognitive decline. Despite the increased prevalence of CICI, there exists a lack of mechanistic understanding by which chemotherapy detrimentally affects cognition in cancer survivors. Moreover, there are no approved therapeutic interventions for this condition. To address this gap in knowledge, this review attempts to identify how adenosine signaling, particularly through the adenosine A2A receptor, can be an essential tool to attenuate accelerated aging phenotypes. Importantly, the adenosine A2A receptor uniquely stands at the crossroads of cancer treatment and improved cognition, given that it is widely known to control tumor induced immunosuppression in the tumor microenvironment, while also posited to be an essential regulator of cognition in neurodegenerative disease. Consequently, we propose that the adenosine A2A receptor may provide a multifaceted therapeutic strategy to enhance anticancer activity, while combating chemotherapy induced cognitive deficits, both which are essential to provide novel therapeutic interventions against accelerated aging in cancer survivors.

Detecting microstructural alterations of cerebral white matter associated with breast cancer and chemotherapy revealed by generalized q-sampling MRI

Objective

Previous studies have discussed the impact of chemotherapy on the brain microstructure. There is no evidence of the impact regarding cancer-related psychiatric comorbidity on cancer survivors. We aimed to evaluate the impact of both chemotherapy and mental health problem on brain microstructural alterations and consequent cognitive dysfunction in breast cancer survivors.

Methods

In this cross-sectional study conducted in a tertiary center, data from 125 female breast cancer survivors who had not received chemotherapy (BB = 65; 49.86 ± 8.23 years) and had received chemotherapy (BA = 60; 49.82 ± 7.89 years) as well as from 71 age-matched healthy controls (47.18 ± 8.08 years) was collected. Chemotherapeutic agents used were docetaxel and epirubicin. We used neuropsychological testing and questionnaire to evaluate psychiatric comorbidity, cognitive dysfunction as well as generalized sampling imaging (GQI) and graph theoretical analysis (GTA) to detect microstructural alterations in the brain.

Findings

Cross-comparison between groups revealed that neurotoxicity caused by chemotherapy and cancer-related psychiatric comorbidity may affect the corpus callosum and middle frontal gyrus. In addition, GQI indices were correlated with the testing scores of cognitive function, quality of life, anxiety, and depression. Furthermore, weaker connections between brain regions and lower segregated ability were found in the post-treatment group.

Conclusion

This study suggests that chemotherapy and cancer-related mental health problem both play an important role in the development of white matter alterations and cognitive dysfunction.

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

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

Cognitive impairment associated with Hodgkin's lymphoma and chemotherapy

Chemotherapy-related cognitive impairment (CRCI) is a well-documented side effect of cancer treatment in various types of tumors including Hodgkin's lymphoma (HL). However, a longitudinal study evaluating the cognitive performance of HL patients has been completely lacking. The aim of the study was to determine the presence of CRCI in HL patients before, promptly after, and 6 months after treatment. Thirty-six patients newly diagnosed with HL and 45 healthy controls (HC) completed the neuropsychological battery and psychological measures of affective distress and quality of life. The results indicate that HL patients have impaired performance compared to HC which cannot be explained by emotional factors. Cognitive impairments prior to treatment were found in 3 of 6 cognitive domains, i.e., verbal memory and learning, speed of processing/psychomotor speed, and abstraction/executive function. Promptly after the chemotherapy, deficits were found in the domains of memory and learning, verbal memory, speed of processing/psychomotor speed, and abstraction/executive function. Weaker cognitive performance persist even 6 months after the end of chemotherapy, specifically in domains of verbal memory and learning, and abstraction/executive function. Our results indicate the presence of cognitive impairment in HL patients already prior to treatment and increased damages caused by chemotherapy, while some of them may last for up to 6 months after the treatment.

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

AIMS

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

BACKGROUND

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

DESIGN

A cross-sectional design was used.

METHODS

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

RESULT

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

CONCLUSION

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

Neurological post-acute sequelae of SARS-CoV-2 infection

The novel coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can have two phases: acute (generally 4 weeks after onset) and chronic (>4 weeks after onset). Both phases include a wide variety of signs and symptoms including neurological and psychiatric symptoms. The signs and symptoms that are considered sequelae of COVID-19 are termed post-COVID condition, long COVID-19, and post-acute sequelae of SARS-CoV-2 infection (PASC). PASC symptoms include fatigue, dyspnea, palpitation, dysosmia, subfever, hypertension, alopecia, sleep problems, loss of concentration, amnesia, numbness, pain, gastrointestinal symptoms, depression, and anxiety. Because the specific pathophysiology of PASC has not yet been clarified, there are no definite criteria of the condition, hence the World Health Organization's definition is quite broad. Consequently, it is difficult to correctly diagnose PASC. Approximately 50% of patients may show at least one PASC symptom up to 12 months after COVID-19 infection; however, the exact prevalence of PASC has not been determined. Despite extensive research in progress worldwide, there are currently no clear diagnostic methodologies or treatments for PASC. In this review, we discuss the currently available information on PASC and highlight the neurological sequelae of COVID-19 infection. Furthermore, we provide clinical suggestions for diagnosing and caring for patients with PASC based on our outpatient clinic experience.

Therapeutic and Supportive Effects of Cannabinoids in Patients with Brain Tumors (CBD Oil and Cannabis)

OPINION STATEMENT

The potential medicinal properties of Cannabis continue to garner attention, especially in the brain tumor domain. This attention is centered on quality of life and symptom management; however, it is amplified by a significant lack of therapeutic choices for this specific patient population. While the literature on this matter is young, published and anecdotal evidence imply that cannabis could be useful in treating chemotherapy-induced nausea and vomiting, stimulating appetite, reducing pain, and managing seizures. It may also decrease inflammation and cancer cell proliferation and survival, resulting in a benefit in overall patient survival. Current literature poses the challenge that it does not provide standardized guidance on dosing for the above potential indications and cannabis use is dominated by recreational purposes. Furthermore, integrated and longitudinal studies are needed but these are a challenge due to arcane laws surrounding the legality of such substances. The increasing need for evidence-based arguments about potential harms and benefits of cannabis, not only in cancer patients but for other medical use and recreational purposes, is desperately needed.

Long-Term Effects of Breast Cancer Therapy and Care: Calm after the Storm?

Breast cancer is still a lethal disease and the leading cause of death in women, undermining patients' survival and quality of life. Modern techniques of surgery and radiotherapy allow for the obtaining of good results in terms of survival, however they cause long-term side effects that persist over time, such as lymphedema and neuropathy. Similarly, the advent of new therapies such as endocrine therapy revolutionized breast cancer outcomes, but side effects are still present even in years of follow-up after cure. Besides the side effects of medical and surgical therapy, breast cancer is a real disruption in patients' lives considering quality of life-related aspects such as the distortion of body image, the psychological consequences of the diagnosis, and the impact on family dynamics. Therefore, the doctor-patient relationship is central to providing the best support both during treatment and afterwards. The aim of this review is to summarize the consequences of medical and surgical treatment on breast cancer patients and to emphasize the importance of early prevention of side effects to improve patients' quality of life.

Combined Exercise and Game-Based Cognitive Training Intervention: Correlative Pilot Study of Neurotrophic and Inflammatory Biomarkers for Women With Breast Cancer

BACKGROUND

Interventions that increase neuroprotective factors and/or decrease inflammatory biomarkers may be effective in improving cognitive function for cancer survivors. Concurrent investigation of potential mechanism(s) to fully understand and refine effective interventions is needed.

OBJECTIVE

This correlative prospective substudy was conducted to investigate biomarkers related to potential mechanism(s) for a combined exercise and game-based brain training intervention designed to improve cognitive function in breast cancer survivors.

INTERVENTIONS/METHODS

Fingerstick bloodspot samples were collected at 3 time points during the randomized, wait-list controlled interventional parent study. Samples were analyzed for neuroprotective factors and inflammatory biomarker levels.

RESULTS

Insulinlike growth factor 1 (IGF-1) levels significantly increased (P < .01) for the intervention group from baseline to 4 and 16 weeks postintervention. Insulinlike growth factor 1 levels correlated with neurocognitive test performace improvement for Trail Making Test B (r = 0.31, P = .02). This association was not significant in the mixed model. No significant correlation was seen between IGF-1 levels and changes in self-report of cognitive function, activity level, or intervention dose.

CONCLUSIONS

Further investigation of IGF-1 levels is warranted as related to potential mechanisms for the Combined Exercise and Game-based Cognitive Training intervention. Future investigations should involve a larger sample cohort and incorporate objective measures of physical activity and prescribed sampling time in relationship to the most recent performance of the intervention.

IMPLICATIONS FOR PRACTICE

Fingerstick bloodspot sample collection is feasible, acceptable, and effective for conducting biomarker research. This methodology minimizes participant burden and discomfort; increases clinical trial access for home, off-site, or rural settings; and facilitates research efforts during times of pandemic restrictions.

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

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

Roasted cashew (Anacardium occidentale L.) nut-enhanced diet forestalls cisplatin-initiated brain harm in rats

The incessant dose constraining symptom of the chemotherapeutic agent, cisplatin is neurotoxicity. This examination tried to explore the neuroprotective impact of roasted cashew nut-enhanced diet against brain deficits related with treatment with cisplatin. Rats were separated in to six groups: Control, CIS (cisplatin [7 mg/kg body weight, i.p]), CIS +10% CN (cisplatin plus 10% roasted cashew nut), CIS +20% CN (cisplatin plus 20% roasted cashew nut), 10% CN (10% roasted cashew nut) and 20% CN (20% roasted cashew nut) for 28 days. Key enzymes associated with brain function, including cholinesterases (AChE and BChE), monoaminergic enzyme (MAO), arginase, and adenosine deaminase (ADA), were investigated after the treatment. The following oxidative stress indicators were also measured in the rat brain: glutathione-S-transferase (GST), glutathione peroxidase (GPx), total antioxidant capacity (TAC), total thiol (T-SH), non-protein thiol (NPSH), thiobarbituric acid reactive substances (TBARS), reactive oxygen species (ROS), nitric oxide (NO), superoxide dismutase (SOD). Our outcomes demonstrated that roasted cashew nut enhanced diet showed inhibitory impact on activities of AChE, BChE, ADA, MAO and arginase in cisplatin-induced rats. The roasted cashew nut supplemented diet also boosted redox equilibrium and displayed protection against cispaltin-induced oxidative damage to rats' brains by an increase in SOD, CAT, GST and GPx activities, TAC, T-SH, NPSH and NO levels as well as a considerable drop in ROS and RBARS levels. Roasted cashew nut enhanced diet additionally forestalled neuronal degeneration in rat brain. Thus, roasted cashew nuts could be used as a nutraceutical or functional food to treat cisplatin-induced neurotoxicity.

Practical applications

The results show that increasing roasted cashew nut consumption can significantly improve antioxidant status, reduce lipid peroxidation, and suppress cholinesterase, adenosine deaminase, monoamine oxidase, and arginase activities in the brain under cisplatin-induced circumstances.

Ranolazine alleviated cardiac/brain dysfunction in doxorubicin-treated rats

Doxorubicin (Dox), a powerful chemotherapeutic agent, has been shown to cause cardiotoxicity and neurotoxicity. Ranolazine, a drug that is commonly used to treat patients with chronic angina, has been shown to reduce toxicity from Dox therapy. Therefore, the present study aims to investigate the mechanisms behind the protective effects of ranolazine on the heart and brain in Dox-treatment. Twenty-four male Wistar rats received 6 doses of either 0.9% normal saline (0.9% NSS, i.p., n = 8) or Dox (3 mg/kg, i.p., n = 16). All Dox-treated rats were assigned into 2 groups to receive vehicle (0.9% NSS, orally; n = 8) or ranolazine (305 mg/kg/day, orally; n = 8) for 30 consecutive days. Following the treatments, left ventricular (LV) function and cognition were determined. Animals were euthanized, then the heart and brain were collected for further analysis. Dox induced systemic oxidative stress/inflammation, and cardiac injury evidenced by mitochondrial dysfunction, mitochondrial dynamic imbalance, and apoptosis, resulting in LV dysfunction. Ranolazine significantly improved LV function via attenuating cardiac injury. Dox also caused brain pathologies as indicated by increased brain inflammation, impaired blood-brain barrier integrity, brain mitochondrial dysfunction, microglial dysmorphology, hippocampal dysplasticity, and increased apoptosis, resulting in cognitive decline. Ranolazine exerted neuroprotective effects by suppressing brain pathologies and restoring cognitive function. These findings suggest that ranolazine has a potential role in cardio- and neuro-protection against chemotherapy.

Glioblastoma Multiforme Selective Nanomedicines for Improved Anti-Cancer Treatments

Glioblastoma Multiforme (GBM) is a devastating disease with a low survival rate and few efficacious treatment options. The fast growth, late diagnostics, and off-target toxicity of currently used drugs represent major barriers that need to be overcome to provide a viable cure. Nanomedicines (NMeds) offer a way to overcome these pitfalls by protecting and loading drugs, increasing blood half-life, and being targetable with specific ligands on their surface. In this study, the FDA-approved polymer poly (lactic-co-glycolic) acid was used to optimise NMeds that were surface modified with a series of potential GBM-specific ligands. The NMeds were fully characterised for their physical and chemical properties, and then in vitro testing was performed to evaluate cell uptake and GBM cell specificity. While all targeted NMeds showed improved uptake, only those decorated with the-cell surface vimentin antibody M08 showed specificity for GBM over healthy cells. Finally, the most promising targeted NMed candidate was loaded with the well-known chemotherapeutic, paclitaxel, to confirm targeting and therapeutic effects in C6 GBM cells. These results demonstrate the importance of using well-optimised NMeds targeted with novel ligands to advance delivery and pharmaceutical effects against diseased cells while minimising the risk for nearby healthy cells.

Sex Differences in Taxane Toxicities

Simple Summary

Clinically observed sex differences in acute and long-term taxane chemotherapy-induced normal tissue toxicity are routinely documented but remain poorly understood despite the significant impact such toxicities have on treatment tolerance and quality of life outcomes in cancer survivors. This review draws from pre-clinical and clinical literature to highlight sex-specific mechanisms of action in taxane drug toxicity and proposes hypotheses for sex-specific clinical discrepancies in taxane-induced acute and long-term toxicities. To our knowledge, this is the first review exploring how sex as a biological variable impacts taxane-mediated mechanisms of action and clinical outcomes. In doing so, we have provided a novel framework to investigate and understand common sex differences observed in clinical and pre-clinical research.

Abstract

The taxane family of microtubule poisons and chemotherapeutics have been studied for over 50 years and are among the most frequently used antineoplastic agents today. Still, limited research exists characterizing taxane-induced sex-specific mechanisms of action and toxicities in cancer and non-cancerous tissue. Such research is important to advance cancer treatment outcomes as well as to address clinically observed sex-differences in short- and long-term taxane-induced toxicities that have disproportionate effects on female and male cancer patients. To gain more insight into these underlying differences between the sexes, the following review draws from pre-clinical and clinical paclitaxel and taxane oncology literature, examines sex-discrepancies, and highlights uncharacterized sex-dependent mechanisms of action and clinical outcomes. To our knowledge, this is the first literature review to provide a current overview of the basic and clinical sex dimorphisms of taxane-induced effects. Most importantly, we hope to provide a starting point for improving and advancing sex-specific personalized chemotherapy and cancer treatment strategies as well as to present a novel approach to review sex as a biological variable in basic and clinical biology.

Transdisciplinary Preliminary Evaluation of Goal Maintenance in Cancer-Related Cognitive Impairment

Women treated for breast cancer often experience decreases in executive functioning, including goal maintenance, which interferes with daily living. The objective of this study was to conduct a preliminary comparison of cognitive neuroscience assessment performance with neuropsychological, self-report, and performance-based assessments of goal maintenance in women with breast cancer. Women treated for breast cancer in the preceding 3 years completed a battery of cognitive assessments. Relationships between assessment methods were evaluated using Spearman rho correlations. Consistent with prior literature, the AY condition of the Dot Pattern Expectancy (DPX) assessment had the highest error rate. No consistent relationships between the DPX and other methods of assessment were identified; however, some moderate correlations were identified between assessments. Women treated for breast cancer present with DPX performance patterns similar to that of healthy controls in past literature. A larger study is required to confirm relationships between measures of goal maintenance across disciplines.

Potential role of tryptophan catabolism in cancer-related cognitive impairment

Oncology may be the most rapidly expanding field in medicine, with several innovative diagnostic and therapeutic procedures appearing daily. Advances in oncology have improved the survival rate for patients with cancer and promoting quality of life is now one of the goals in the care of these patients. Patients face a variety of disease- and treatment-related side effects, including anorexia, nausea, vomiting, recurring infections, and sleep difficulties. Cancer-related cognitive impairment (CRCI) is an overlooked clinical condition found in oncologic practice, particularly in patients with breast cancer. Although several potential mechanisms for CRCI have been hypothesized, to our knowledge, the exact mechanism is still unknown. Alterations in the tryptophan kynurenine pathway have been shown to impair cognitive skills in several mental illnesses. However, its possible function in CRCI has yet to be investigated. The aim of this was to examine the possible interactions between tryptophan catabolism and CRCI.

Chemobrain in Breast Cancer: Mechanisms, Clinical Manifestations, and Potential Interventions

Among the potential adverse effects of breast cancer treatment, chemotherapy-related cognitive impairment (CRCI) has gained increased attention in the past years. In this review, we provide an overview of the literature regarding CRCI in breast cancer, focusing on three main aspects. The first aspect relates to the molecular mechanisms linking individual drugs commonly used to treat breast cancer and CRCI, which include oxidative stress and inflammation, reduced neurogenesis, reduced levels of specific neurotransmitters, alterations in neuronal dendrites and spines, and impairment in myelin production. The second aspect is related to the clinical characteristics of CRCI in patients with breast cancer treated with different drug combinations. Data suggest the incidence rates of CRCI in breast cancer vary considerably, and may affect more than 50% of treated patients. Both chemotherapy regimens with or without anthracyclines have been associated with CRCI manifestations. While cross-sectional studies suggest the presence of symptoms up to 20 years after treatment, longitudinal studies confirm cognitive impairments lasting for at most 4 years after the end of chemotherapy. The third and final aspect is related to possible therapeutic interventions. Although there is still no standard of care to treat CRCI, several pharmacological and non-pharmacological approaches have shown interesting results. In summary, even if cognitive impairments derived from chemotherapy resolve with time, awareness of CRCI is crucial to provide patients with a better understanding of the syndrome and to offer them the best care directed at improving quality of life.

Prevention of anticancer therapy-induced neurotoxicity: putting DNA damage in perspective

Chemotherapy-induced peripheral neuropathy (CIPN) is a severe side effect of conventional cancer therapeutics (cAT) that significantly impacts the quality of life of tumor patients. The molecular mechanisms of CIPN are incompletely understood and there are no effective preventive or therapeutic measures available to date. Here, we present a brief overview of the current knowledge about mechanisms underlying CIPN and discuss DNA damage-related stress responses as feasible targets for the prevention of CIPN. In addition, we discuss that the nematode Caenorhabditis elegans is a useful 3R-conform model organism to further elucidate molecular mechanisms of CIPN and to identify novel lead compounds protecting from cAT-triggered neuropathy.

Mechanisms of Chemotherapy-Induced Neurotoxicity

Since the first clinical trials conducted after World War II, chemotherapeutic drugs have been extensively used in the clinic as the main cancer treatment either alone or as an adjuvant therapy before and after surgery. Although the use of chemotherapeutic drugs improved the survival of cancer patients, these drugs are notorious for causing many severe side effects that significantly reduce the efficacy of anti-cancer treatment and patients’ quality of life. Many widely used chemotherapy drugs including platinum-based agents, taxanes, vinca alkaloids, proteasome inhibitors, and thalidomide analogs may cause direct and indirect neurotoxicity. In this review we discuss the main effects of chemotherapy on the peripheral and central nervous systems, including neuropathic pain, chemobrain, enteric neuropathy, as well as nausea and emesis. Understanding mechanisms involved in chemotherapy-induced neurotoxicity is crucial for the development of drugs that can protect the nervous system, reduce symptoms experienced by millions of patients, and improve the outcome of the treatment and patients’ quality of life.

Protocol for the Exercise, Cancer and Cognition - The ECCO-Study: A Randomized Controlled Trial of Simultaneous Exercise During Neo-/Adjuvant Chemotherapy in Breast Cancer Patients and Its Effects on Neurocognition

Introduction

Epidemiological studies show that increased physical activity is linked to a lower risk of breast cancer and mortality. As a result, physical activity can significantly improve patients' quality of life (QOL) both during and after therapy.Many breast cancer patients demonstrate a decrease in cognitive capacity, referred to as the symptom-complex cancer related cognitive impairment (CRCI). Most frequently reported impairments are mild to moderate deficits in processing speed, attention, memory, and executive functions. Cognitive symptoms persist for months or even years, following medical treatment in roughly 35% of afflicted people, impairing everyday functioning, limiting the ability to return to work, and lowering the overall QOL. Recent studies point toward a key role of inflammatory pathways in the CRCI genesis. Attention to physical activity as a potential supportive care option is therefore increasing. However, evidence for the positive effects of exercise on preventing CRCI is still lacking.

Patients and Methods

Against this background, the prospective, two-arm, 1:1 randomized, controlled trial investigates the influence of first line chemotherapy accompanied by exercise training on preventing CRCI in 126 patients with breast cancer at the local University Hospital. The study will evaluate biomarkers and secondary assessments suspected to be involved in the pathogenesis of CRCI in addition to objective (primary outcome) and subjective cognitive function. CRCI is believed to be connected to either functional and/or morphological hippocampal damage due to chemotherapy. Thus, cerebral magnetic resonance imaging (MRI) and hippocampal volume measurements are performed. Furthermore, a specific neuropsychological test battery for breast cancer patients has been developed to detect early signs of cognitive impairments in patients and to be integrated into practice.

Discussion

This study will explore how a long-term supervised exercise intervention program might prevent CRCI, enables optimization of supportive care and objectifies limits of psychological and physical resilience in breast cancer patients during and after chemotherapy treatment.

Trial Registration

ClinicalTrials.gov: Identifier: NCT04789187. Registered on 09 March 2021.

Comorbidity of osteoporosis and Alzheimer's disease: Is `AKT `-ing on cellular glucose uptake the missing link?

Osteoporosis and Alzheimer's disease (AD) are both degenerative diseases. Osteoporosis often proceeds cognitive deficits, and multiple studies have revealed common triggers that lead to energy deficits in brain and bone. Risk factors for osteoporosis and AD, such as obesity, type 2 diabetes, aging, chemotherapy, vitamin deficiency, alcohol abuse, and apolipoprotein Eε4 and/or Il-6 gene variants, reduce cellular glucose uptake, and protective factors, such as estrogen, insulin, exercise, mammalian target of rapamycin inhibitors, hydrogen sulfide, and most phytochemicals, increase uptake. Glucose uptake is a fine-tuned process that depends on an abundance of glucose transporters (Gluts) on the cell surface. Gluts are stored in vesicles under the plasma membrane, and protective factors cause these vesicles to fuse with the membrane, resulting in presentation of Gluts on the cell surface. This translocation depends mainly on AKT kinase signaling and can be affected by a range of factors. Reduced AKT kinase signaling results in intracellular glucose deprivation, which causes endoplasmic reticulum stress and iron depletion, leading to activation of HIF-1α, the transcription factor necessary for higher Glut expression. The link between diseases and aging is a topic of growing interest. Here, we show that diseases that affect the same biochemical pathways tend to co-occur, which may explain why osteoporosis and/or diabetes are often associated with AD.

Cannabinoid drugs against chemotherapy-induced adverse effects: focus on nausea/vomiting, peripheral neuropathy and chemofog in animal models

Although new drugs are being developed for cancer treatment, classical chemotherapeutic agents are still front-line therapies, despite their frequent association with severe side effects that can hamper their use. Cannabinoids may prevent or palliate some of these side effects. The aim of the present study is to review the basic research which has been conducted evaluating the effects of cannabinoid drugs in the treatment of three important side effects induced by classical chemotherapeutic agents: nausea and vomiting, neuropathic pain and cognitive impairment. Several published studies have demonstrated that cannabinoids are useful in preventing and reducing the nausea, vomits and neuropathy induced by different chemotherapy regimens, though other side effects can occur, such as a reduction of gastrointestinal motility, along with psychotropic effects when using centrally-acting cannabinoids. Thus, peripherally-acting cannabinoids and new pharmacological options are being investigated, such as allosteric or biased agonists. Additionally, due to the increase in the survival of cancer patients, there are emerging data that demonstrate an important cognitive deterioration due to chemotherapy, and because the cannabinoid drugs have a neuroprotective effect, they could be useful in preventing chemotherapy-induced cognitive impairment (as demonstrated through studies in other neurological disorders), but this has not yet been tested. Thus, although cannabinoids seem a promising therapeutic approach in the treatment of different side effects induced by chemotherapeutic agents, future research will be necessary to find pharmacological options with a safer profile. Moreover, a new line of research awaits to be opened to elucidate their possible usefulness in preventing cognitive impairment.

Microtubules as Regulators of Neural Network Shape and Function: Focus on Excitability, Plasticity and Memory

Neuronal microtubules (MTs) are complex cytoskeletal protein arrays that undergo activity-dependent changes in their structure and function as a response to physiological demands throughout the lifespan of neurons. Many factors shape the allostatic dynamics of MTs and tubulin dimers in the cytosolic microenvironment, such as protein–protein interactions and activity-dependent shifts in these interactions that are responsible for their plastic capabilities. Recently, several findings have reinforced the role of MTs in behavioral and cognitive processes in normal and pathological conditions. In this review, we summarize the bidirectional relationships between MTs dynamics, neuronal processes, and brain and behavioral states. The outcomes of manipulating the dynamicity of MTs by genetic or pharmacological approaches on neuronal morphology, intrinsic and synaptic excitability, the state of the network, and behaviors are heterogeneous. We discuss the critical position of MTs as responders and adaptative elements of basic neuronal function whose impact on brain function is not fully understood, and we highlight the dilemma of artificially modulating MT dynamics for therapeutic purposes.

Cognitive adverse effects of chemotherapy and immunotherapy: are interventions within reach?

One in three people will be diagnosed with cancer during their lifetime. The community of cancer patients is growing, and several common cancers are becoming increasingly chronic; thus, cancer survivorship is an important part of health care. A large body of research indicates that cancer and cancer therapies are associated with cognitive impairment. This research has mainly concentrated on chemotherapy-associated cognitive impairment but, with the arrival of immunotherapies, the focus is expected to widen and the number of studies investigating the potential cognitive effects of these new therapies is rising. Meanwhile, patients with cognitive impairment and their healthcare providers are eagerly awaiting effective approaches to intervene against the cognitive effects of cancer treatment. In this Review, we take stock of the progress that has been made and discuss the steps that need to be taken to accelerate research into the biology underlying cognitive decline following chemotherapy and immunotherapy and to develop restorative and preventive interventions. We also provide recommendations to clinicians on how to best help patients who are currently experiencing cognitive impairment.

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.