Neuroepidemiology of cancer and treatment-related neurocognitive dysfunction in adult-onset cancer patients and survivors

Comparative effectiveness of interventions for cancer treatment-related cognitive impairment in adult cancer survivors: protocol for a systematic review

BACKGROUND

Cancer treatment-related cognitive impairment (CTRCI) can substantially reduce the quality of life of cancer survivors. Many treatments of CTRCI have been evaluated in randomized controlled trials (RCTs), including psychological interventions, pharmacologic interventions, and other therapies. There is a pressing need to establish the benefits and harms of previously studied CTRCI treatments. The proposed systematic review and network meta-analyses will assess the relative efficacy and safety of competing interventions for the management of CTRCI.

METHODS

In consultation with the review team, an experienced medical information specialist will draft electronic search strategies for MEDLINE®, Embase, CINAHL, PsycINFO, and the Cochrane Trials Registry. We will seek RCTs of interventions for the treatment of CTRCI in adults with any cancer, except cancers/metastases of the central nervous system. Due to the anticipated high search yields, dual independent screening of citations will be expedited by use of an artificial intelligence/machine learning tool. The co-primary outcomes of interest will be subjective and objective cognitive function. Secondary outcomes of interest will include measures of quality of life, mental and physical health symptoms, adherence to treatment, and harms (overall and treatment-related harms and harms associated with study withdrawal), where feasible, random-effects meta-analyses and network meta-analyses will be pursued. We will address the anticipated high clinical and methodological heterogeneity through meta-regressions, subgroup analyses, and/or sensitivity analyses.

DISCUSSION

The proposed systematic review will deliver a robust comparative evaluation of the efficacy and safety of existing therapies for the management of CTRCI. These findings will inform clinical decisions, identify evidence gaps, and identify promising therapies for future evaluation in RCTs.

"Why am I still suffering?": Experience of long-term fatigue and neurocognitive changes in oropharyngeal cancer survivors following (chemo)radiotherapy

Background

Late effects of cancer treatment, such as neurocognitive deficits and fatigue, can be debilitating. Other than head and neck-specific functional deficits such as impairments in swallowing and speech, little is known about survivorship after oropharyngeal cancer. This study examines the lived experience of fatigue and neurocognitive deficits in survivors of oropharyngeal squamous cell cancer and impact on their daily lives.

Methods

This work is part of the multicentre mixed method ROC-oN study (Radiotherapy for Oropharyngeal Cancer and impact on Neurocognition), evaluating fatigue and neurocognitive function in patients following radiotherapy +/- chemotherapy for oropharyngeal cancer and impact on quality of life. Semi-structured interviews were conducted in adults treated with radiotherapy (+/-chemotherapy) for oropharyngeal squamous cell carcinoma >/=24 months from completing treatment. Reflexive thematic analysis performed.

Results

21 interviews (11 men and 10 women; median age 58 years and median time post-treatment 5 years) were conducted and analysed, yielding six themes: (1) unexpected burden of fatigue, (2) noticing changes in neurocognitive function, (3) the new normal, (4) navigating changes, (5)insufficient awareness and (6)required support. Participants described fatigue that persisted beyond the acute post-treatment period and changes in neurocognitive abilities across several domains. Paid and unpaid work, emotions and mood were impacted. Participants described navigating the new normal by adopting self-management strategies and accepting external support. They reported lack of recognition of these late effects, being poorly informed and being unprepared. Follow-up services were thought to be inadequate.

Conclusions

Fatigue and neurocognitive impairment were frequently experienced by survivors of oropharyngeal cancer, at least two years after treatment. Patients felt ill-prepared for these late sequelae, highlighting opportunities for improvement of patient information and support services.

Investigation of cognitive functions in children with bone tumours and lymphoma in treatment process

BACKGROUND

Neurocognitive sequelae are among the most debilitating effects of cancer observed in children. Yet we know very little about the impact on neurocognitive functioning, especially cancer types that develop outside the central nervous system. This study aimed to assess and compare the cognitive functions (CoF) of children with bone tumours and lymphoma in the treatment process.

METHODS

The CoF of children with bone tumours (n = 44), lymphoma (n = 42) and their non-cancer peers (n = 55) were assessed with Dynamic Occupational Therapy Assessment for Children. The CoF of children with cancer were compared with their non-cancer peers. Then, children with bone tumours and lymphoma were compared in binary.

RESULTS

One-hundred forty-one children aged 6-12 years with a mean age of 9.4 (SD = 1.5) were included in this study. The orientation and visuomotor construction functions of children with bone tumours and orientation, praxis and visuomotor construction functions of children with lymphoma performed worse than their non-cancer peers (pk  < 0.001). While orientation, spatial perception, visuomotor construction and thinking operations functions of children with bone tumours and lymphoma were similar (pk  > 0.016), praxis functions of children with lymphoma were found to be worse than children with bone tumours (pk  < 0.016).

CONCLUSIONS

Our findings show that children with bone tumours and lymphoma in the process of treatment are at risk for impairment of their CoF. The findings highlight the importance of assessing CoF in children with bone tumours and lymphoma and considering specific differences between groups. It is essential to assess CoF and develop early intervention plans in these children.

Patient-reported neurocognitive function in adult survivors of childhood and adolescent osteosarcoma and Ewing sarcoma

PURPOSE

Little is known regarding long-term neurocognitive outcomes in osteosarcoma and Ewing sarcoma (EWS) survivors despite potential risk factors. We evaluated associations among treatment exposures, chronic health conditions, and patient-reported neurocognitive outcomes in adult survivors of childhood osteosarcoma and EWS.

METHODS

Five-year survivors of osteosarcoma (N = 604; median age 37.0 years) and EWS (N = 356; median age 35.0 years) diagnosed at < 21 years from 1970 to 1999, and 697 siblings completed the Childhood Cancer Survivor Study Neurocognitive Questionnaire and reported chronic health conditions, education, and employment. Prevalence of reported neurocognitive difficulties were compared between diagnostic groups and siblings. Modified Poisson regression identified factors associated with neurocognitive difficulties.

RESULTS

Osteosarcoma and EWS survivors, vs. siblings, reported higher prevalences of difficulties with task efficiency (15.4% [P = 0.03] and 14.0% [P = 0.04] vs. 9.6%, respectively) and emotional regulation (18.0% [P < 0.0001] and 15.2% [P = 0.03] vs. 11.3%, respectively), adjusted for age, sex, and ethnicity/race. Osteosarcoma survivors reported greater memory difficulties vs. siblings (23.5% vs. 16.4% [P = 0.01]). Comorbid impairment (i.e., ≥ 2 neurocognitive domains) was more prevalent in osteosarcoma (20.0% [P < 0.001]) and EWS survivors (16.3% [P = 0.02]) vs. siblings (10.9%). Neurological conditions were associated with worse task efficiency (RR = 2.17; 95% CI = 1.21-3.88) and emotional regulation (RR = 1.88; 95% CI = 1.01-3.52), and respiratory conditions were associated with worse organization (RR = 2.60; 95% CI = 1.05-6.39) for EWS. Hearing impairment was associated with emotional regulation difficulties for osteosarcoma (RR = 1.98; 95% CI = 1.22-3.20). Patient report of cognitive difficulties was associated with employment but not educational attainment.

CONCLUSIONS

Survivors of childhood osteosarcoma and EWS are at increased risk for reporting neurocognitive difficulties, which are associated with employment status and appear related to chronic health conditions that develop over time.

IMPLICATIONS FOR CANCER SURVIVORS

Early screening, prevention, and treatment of chronic health conditions may improve/prevent long-term neurocognitive outcomes.

Neuroprotective effect of herbal extracts inhibiting soluble epoxide hydrolase (sEH) and cyclooxygenase (COX) against chemotherapy-induced cognitive impairment in mice

Chemotherapy-induced cognitive impairment (CICI) is a novel clinical condition characterized by memory, learning, and motor function deficits. Oxidative stress and inflammation are potential factors contributing to chemotherapy's adverse effects on the brain. Inhibition of soluble epoxide hydrolase (sEH) has been proven effective in neuroinflammation and reversal of memory impairment. The research aims to evaluate the memory protective effect of sEH inhibitor and dual inhibitor of sEH and COX and compare its impact with herbal extracts with known nootropic activity in an animal model of CICI. In vitro sEH, the inhibitory activity of hydroalcoholic extracts of Sizygium aromaticum, Nigella sativa, and Mesua ferrea was tested on murine and human sEH enzyme as per the protocol, and IC50 was determined. Cyclophosphamide (50 mg/kg), methotrexate (5 mg/kg), and fluorouracil (5 mg/kg) combination (CMF) were administered intraperitoneally to induce CICI. The known herbal sEH inhibitor, Lepidium meyenii and the dual inhibitor of COX and sEH (PTUPB) were tested for their protective effect in the CICI model. The herbal formulation with known nootropic activity viz Bacopa monnieri and commercial formulation (Mentat) were also used to compare the efficacy in the CICI model. Behavioral parameter such as cognitive function was assessed by Morris Water Maze besides investigating oxidative stress (GSH and LPO) and inflammatory (TNFα, IL-6, BDNF and COX-2) markers in the brain. CMF-induced CICI, which was associated with increased oxidative stress and inflammation in the brain. However, treatment with PTUPB or herbal extracts inhibiting sEH preserved spatial memory via ameliorating oxidative stress and inflammation. S. aromaticum and N. sativa inhibited COX2, but M. Ferrea did not affect COX2 activity. Lepidium meyenii was the least effective, and mentat showed superior activity over Bacopa monnieri in preserving memory. Compared to untreated animals, the mice treated with PTUPB or hydroalcoholic extracts showed a discernible improvement in cognitive function in CICI.

Episodic Memory and Recollection Network Disruptions Following Chemotherapy Treatment in Breast Cancer Survivors: A Review of Neuroimaging Findings

Simple Summary

Memory disturbances are amongst the most common and disruptive symptoms of chemotherapy-related cognitive impairment. Chemotherapy treatments commonly cause neurotoxicity within the hippocampus, creating a vulnerability to memory impairment. Most clinical assessments of long-term memory in breast cancer survivors assess basic verbal and visual memory processing, and do not capture the complexities of everyday event memories, including episodic and autobiographical memory. This review focuses on structural and functional neuroimaging studies identifying disruptions in the hippocampus and recollection network, and related episodic memory impairments in chemotherapy-treated breast cancer survivors. We argue for the need to better characterize memory dysfunction following chemotherapy treatments. Given the importance of episodic and autobiographical memory to a person’s personal history and quality of life, an under-appreciation of how this memory domain is impacted by standard cancer treatments potentially diminishes the negative experiences of breast cancer survivors, and neglects cognitive problems that could benefit from intervention strategies.

Abstract

Long-term memory disturbances are amongst the most common and disruptive cognitive symptoms experienced by breast cancer survivors following chemotherapy. To date, most clinical assessments of long-term memory dysfunction in breast cancer survivors have utilized basic verbal and visual memory tasks that do not capture the complexities of everyday event memories. Complex event memories, including episodic memory and autobiographical memory, critically rely on hippocampal processing for encoding and retrieval. Systemic chemotherapy treatments used in breast cancer commonly cause neurotoxicity within the hippocampus, thereby creating a vulnerability to memory impairment. We review structural and functional neuroimaging studies that have identified disruptions in the recollection network and related episodic memory impairments in chemotherapy-treated breast cancer survivors, and argue for the need to better characterize hippocampally mediated memory dysfunction following chemotherapy treatments. Given the importance of autobiographical memory for a person’s sense of identity, ability to plan for the future, and general functioning, under-appreciation of how this type of memory is impacted by cancer treatment can lead to overlooking or minimizing the negative experiences of breast cancer survivors, and neglecting a cognitive domain that may benefit from intervention strategies.

Prevalence of self-reported memory problems in adults with type 2 diabetes mellitus and cancer in the USA

PURPOSE

To determine the prevalence of memory problems in individuals with or without a history of DM and cancer and assess possible compounding effects of these diseases on self-reported memory problems (SRMP).

METHODS

We used data from the 2009-2018 National Health and Nutrition Examination Survey. We conducted logistic regression analyses to determine the associations among DM, cancer, and SRMP, adjusting for age, sex, race/ethnicity, education, and poverty level. We examined the interaction effects of comorbid DM and cancer on SRMP. We compared participants with both DM and cancer to those with cancer only and to those with no DM or cancer.

RESULTS

We included 26,842 adults ≥ 20 years old (N = 3374 with DM, N = 23,468 without DM) and 51.87% female. There were 10,434 Whites, 5730 Blacks, 6795 Hispanics, and 3883 other races/multiracial. More individuals with DM reported memory problems than those without DM (p < 0.0001). More individuals with cancer reported memory problems than those without cancer (p < 0.0001). Of those with both DM and cancer, 14.19% reported memory problems. More individuals with DM had cancer than those without DM (p < 0.0001). Of those with both diseases, 55.75% had DM before the cancer diagnosis. DM (odds ratio[OR] = 1.87, 95%CI, 1.55-2.26) and cancer (OR = 1.81, 95%CI, 1.43-2.30) predicted SRMP. The interaction between DM and cancer was significant, and the likelihood of having both diseases compared to having neither DM nor cancer was OR = 2.09, 95%CI, 1.41 - 3.11.

CONCLUSION

Strategies to mitigate SRMP in individuals with comorbid DM and cancer history should consider the impact of both diseases.

Assessment and Management of Cognitive Function in Patients with Prostate Cancer Treated with Second-Generation Androgen Receptor Pathway Inhibitors

Preservation of cognitive function is an important outcome in oncology. Optimal patient management requires an understanding of cognitive effects of the disease and its treatment and an efficacious approach to assessment and management of cognitive dysfunction, including selection of treatments to minimize the risk of cognitive impairment. Awareness is increasing of the potentially detrimental effects of cancer-related cognitive dysfunction on functional independence and quality of life. Prostate cancer occurs most often in older men, who are more likely to develop cognitive dysfunction than younger individuals; this population may be particularly vulnerable to treatment-related cognitive disorders. Prompt identification of treatment-induced cognitive dysfunction is a crucial aspect of effective cancer management. We review the potential etiologies of cognitive decline in patients with prostate cancer, including the potential role of androgen receptor pathway inhibitors; commonly used tools for assessing cognitive function validated in metastatic castration-resistant prostate cancer and adopted in non-metastatic castration-resistant prostate cancer trials; and strategies for management of cognitive symptoms. Many methods are currently used to assess cognitive function. The prevalence and severity of cognitive dysfunction vary according to the instruments and criteria applied. Consensus on the definition of cognitive dysfunction and on the most appropriate approaches to quantify its extent and progression in patients treated for prostate cancer is lacking. Evidence-based guidance on the appropriate tools and time to assess cognitive function in patients with prostate cancer is required.

Reliability of self-report versus the capacity to consent to treatment instrument to make medical decisions in brain metastasis and other metastatic cancers

OBJECTIVE

To evaluate the ability of persons with metastatic cancer to self-assess their medical decision-making capacity (MDC). To investigate this, we compared an objective measure of MDC with self-ratings and evaluated predictors of agreement.

METHODS

Data were obtained from a cross-sectional study of metastatic cancer patients at a large academic medical center. Across all standards of MDC, sensitivity, specificity, and reliability using Gwet's AC1 statistic were calculated using the objective measure as the gold standard. Logistic regression was used to evaluate predictors of agreement between the measures across all MDC standards.

RESULTS

In those with brain metastases, high sensitivity (greater than 0.7), but low specificity was observed for all standards. Poor reliability was observed across all standards. Higher age resulted in higher odds of disagreement for Standard 3 (appreciation) (OR: 1.07, 95% CI: 1.00, 1.15) and Standard 4 (reasoning) (OR: 1.05, 95% CI: 1.00, 1.10). For Standard 3, chemotherapy use and brain metastases compared to other metastases resulted in higher odds of disagreement (Chemotherapy: OR: 5.62, 95% CI: 1.37, 23.09, Brain Metastases: OR: 5.93, 95% CI: 1.28, 27.55). For Standard 5 (understanding), no predictors were associated with disagreement.

CONCLUSIONS

For less cognitively complex standards (e.g., appreciation), self-report may be more valid and reliable than more cognitively complex standards (e.g., reasoning or understanding). However, overall, MDC self-report in the current sample is suboptimal. Thus, the need for detailed assessment of MDC, especially when patients are older or used chemotherapy, is indicated. Other studies should be conducted to assess MDC agreement longitudinally.

Neurocognitive Impairment After Hematopoietic Stem Cell Transplant for Hematologic Malignancies: Phenotype and Mechanisms

Hematopoietic stem cell transplant (HSCT) plays a central role in the treatment of hematologic cancers. With the increasing survival of patients after HSCT, survivorship issues experienced by this population have become an important outcome. Cognitive impairment is an established sequela of HSCT, with studies to date establishing its presence, associated risk factors, and clinical phenotype. There are multiple potential contributors to cognitive impairment after HSCT. Efforts are ongoing to further characterize its clinical phenotype, associated biomarkers, and biologic underpinnings. A fundamental knowledge of post-HSCT cognitive impairment is of value for all clinicians who interface with this population, and further academic efforts are needed to more fully understand the impact of this cancer treatment on brain health. IMPLICATIONS FOR PRACTICE: As survival outcomes after hematopoietic stem cell transplant (HSCT) improve, an awareness of the post-treatment challenges faced by this population has become central to its care. HSCT can have a sustained and broad impact on brain health, causing cognitive dysfunction, fatigue, disturbed mood, and sleep. In affected patients, autonomy, return to work, relationships, and quality of life may all be affected. A fundamental fluency in this area is important for clinicians interfacing with HSCT survivors, facilitating the identification and management of cognitive dysfunction and concurrent symptom clusters, and stimulating interest in these sequelae as areas for future clinical research.

Risk of Cognitive Effects in Comorbid Patients With Prostate Cancer Treated With Androgen Receptor Inhibitors

Prostate cancer (PC) is primarily a disease of older men. As the risk of neurocognitive decline increases as people age, cognitive dysfunction is a potential complication in men with PC, imposing detrimental effects on functional independence and quality of life. Importantly, risk of cognitive decline may increase with exposure to androgen deprivation therapy and other hormonal therapies. Particular consideration should be given to patients with castration-resistant PC (CRPC), many of whom require continuous, long-term androgen deprivation therapy combined with a second-generation androgen receptor inhibitor. Non-comparative evidence from interventional trials of androgen receptor inhibitors in men with non-metastatic CRPC suggests differential effects on cognitive function and central nervous system-related adverse events within this drug class. Drug-drug interactions with concomitant medications for chronic, non-malignant comorbidities differ among ARIs and thus may contribute further to cognitive impairment. Hence, establishing baseline cognitive function is a prerequisite to identifying subsequent clinical decline associated with androgen receptor-targeted therapies. Although brief, sensitive screening tools for cancer-related cognitive dysfunction are lacking, mental status can be ascertained from the initial medical history and neurocognitive examination, progressing to more in-depth evaluation when impairment is suspected. On-treatment neurocognitive monitoring should be integrated into regular clinical follow-up to preserve cognitive function and quality of life throughout disease management. This review summarizes the multiple factors that may contribute to cognitive decline in men with CRPC, awareness of which will assist clinicians to optimize individual treatment. Practical, clinic-based strategies for managing the risks for and symptoms of cognitive dysfunction are also discussed.

Patterns of Sequelae in Women with a History of Localized Breast Cancer: Results from the French VICAN Survey

Breast cancer (BC) remains complex for women both physically and psychologically. The objectives of this study were to (1) assess the evolution of the main sequelae and treatment two and five years after diagnosis in women with early-stage breast cancer, (2) explore patterns of sequelae associated with given sociodemographic, clinical, and lifestyle factors. The current analysis was based on 654 localized BC patients enrolled in the French nationwide longitudinal survey "vie après cancer" VICAN (January-June 2010). Information about study participants was collected at enrollment, two and five years after diagnosis. Changes over time of the main sequelae were analyzed and latent class analysis was performed to identify patterns of sequelae related to BC five years after diagnosis. The mean age (±SD) of study participants at inclusion was 49.7 (±10.5) years old. Six main classes of sequelae were identified two years and five years post-diagnosis (functional, pain, esthetic, fatigue, psychological, and gynecological). A significant decrease was observed for fatigue (p = 0.03) and an increase in cognitive sequelae was reported (p = 0.03). Two latent classes were identified-functional and esthetic patterns. Substantial sequelae remain up to five years after BC diagnosis. Changes in patient care pathways are needed to identify BC patients at a high risk.

Clinical correlates of the ability to consent to research participation in brain metastasis

OBJECTIVE

Impairment in the ability to provide informed consent is common in persons with brain metastasis. However, little is known about what factors contribute to this impairment in the patient group. Our objective is to determine if the associations between demographic, cognitive, and clinical variables correlate with the ability to provide informed consent in persons with brain metastasis.

METHODS

We administered a comprehensive neuropsychological battery to a group of 61 persons with brain metastasis. Demographic and clinical information was also collected. All diagnoses were made by board-certified oncologists and were verified histologically. Statistical analyses included Pearson's product-moment correlations, point biserial correlations, and linear regression.

RESULTS

Results indicated that combinations of education, verbal memory, executive function, whole brain radiation therapy, and chemotherapy affected various aspects of the ability to provide informed consent. Subsequent regression models demonstrated that these variables contributed a significant amount of shared variance to the ability to provide informed consent.

CONCLUSION

We found that the ability of persons with brain metastasis to provide informed consent is a cognitively complex ability that is also affected by education and treatment variables. This information can help clinical researchers in identifying persons with brain metastasis at risk of an impaired ability to provide informed consent and aid in the consenting process.

Capacity to consent to research participation in adults with metastatic cancer: comparisons of brain metastasis, non-CNS metastasis, and healthy controls

Background

To evaluate the ability of individuals with metastatic cancer to provide informed consent to research participation, we used a structured vignette-based interview to measure 4 consenting standards across 3 participant groups.

Methods

Participants included 61 individuals diagnosed with brain metastasis, 41 individuals diagnosed with non-CNS metastasis, and 17 cognitively intact healthy controls. All groups were evaluated using the Capacity to Consent to Research Instrument (CCRI), a performance-based measure of research consent capacity. The ability to provide informed consent to participate in research was evaluated across 4 consent standards: expressing choice, appreciation, reasoning, and understanding. Capacity performance ratings (intact, mild/moderate impairment, severe impairment) were identified based on control group performance.

Results

Results revealed that the brain metastasis group performed significantly lower than healthy controls on the consent standard of understanding, while both metastatic cancer groups performed below controls on the consent standard of reasoning. Both metastatic cancer groups performed similar to controls on the standards of appreciation and expressing choice. Approximately 60% of the brain metastasis group, 54% of the non-CNS metastasis group, and 18% of healthy controls showed impaired research consent capacity.

Conclusions

Our findings, using a performance-based assessment, are consistent with other research indicating that the research consent process may be overly cumbersome and confusing. This, in turn, may lead to research consent impairment not only in patient groups but also in some healthy adults with intact cognitive ability.

Item-level psychometrics of a brief self-reported memory problem screening measure in breast cancer survivors

Background: We previously developed and psychometrically validated a self-reported memory problem (SRMP) measure using principal component analysis. In the present study, we applied item response theory (IRT) analysis to further examined the construct validity and determine item-level psychometric properties for the SRMP.Methods: The sample included 530 female breast cancer survivors (61% non-Hispanic White, mean age = 57 years) who were recruited from community-based organizations and large health care systems. We examined the construct validity, item-level psychometric properties, and differential item functioning (DIF) of the SRMP using confirmatory factor analysis (CFA), IRT and logistic regression analysis models.Results: The CFA confirmed a one-factor structure for the SRMP (comparative fit index [CFI] = 0.996, root-mean-square-error-approximation [RMSEA] = 0.059). As expected, SRMP scores correlated significantly with pain, mood, and fatigue; but not spiritual health locus of control (SPR). DIF analysis showed no measurement differences based on race/ethnicity and age groups.Conclusion: The CFA and DIF analysis supported the construct validity of the SRMP and its use in an ethnically diverse breast cancer population. These findings provide further evidence of the generalizability for the SRMP, and support its utilization as a psychometrically valid and reliable screening measure of cancer and treatment-related memory difficulties.

Cancer cell's neuroendocrine feature can be acquired through cell-cell fusion during cancer-neural stem cell interaction

Advanced and therapy-resistant prostate tumors often display neural or neuroendocrine behavior. We assessed the consequences of prostate cancer cell interaction with neural cells, which are rich in the human prostate and resident of the prostate tumor. In 3-dimensional co-culture with neurospheres, red fluorescent human LNCaP cells formed agglomerates on the neurosphere surface. Upon induced neural differentiation, some red fluorescent cells showed morphology of fully differentiated neural cells, indicating fusion between the cancer and neural stem cells. These fusion hybrids survived for extended times in a quiescent state. A few eventually restarted cell division and propagated to form derivative hybrid progenies. Clones of the hybrid progenies were highly heterogeneous; most had lost prostatic and epithelial markers while some had acquired neural marker expression. These results indicate that cancer cells can fuse with bystander neural cells in the tumor microenvironment; and cancer cell fusion is a direct route to tumor cell heterogeneity.

Progression of Alzheimer's Disease by Self-Reported Cancer History in the Alzheimer's Disease Neuroimaging Initiative

BACKGROUND

Cross-sectional studies suggest self-reported cancer history is associated with decreased risk of Alzheimer's disease (AD). However, little is known about how self-reported cancer affects longitudinal AD progression, the primary outcome in clinical trials and observational studies.

OBJECTIVE

To determine self-reported cancer history's effect on longitudinal AD progression in an observational study.

METHODS

We utilized data from the Alzheimer's Disease Neuroimaging Initiative (ADNI) to evaluate progression to AD by self-reported all-cancer, breast, prostate, colorectal, or non-melanoma skin cancer history. Linear mixed effects models were used to examine baseline differences and rates of progression on the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) by self-reported cancer history. Age at AD onset was examined using consensus clinical diagnoses with Cox proportional hazards regression.

RESULTS

Among 1,271 participants, models revealed no significant differences in progression over time but did reveal significantly lower baseline ADAS-Cog score, indicating better cognition at a given age in those with self-reported cancer history. Cox models indicated those with self-reported cancer history had significantly later age of AD onset (HR: 0.67, 95% CI: 0.53-0.85) after adjustment for covariates.

CONCLUSION

Participants with self-reported cancer history entered ADNI with better cognition and later age of AD onset, but progressed similarly to participants without such history, indicating differences in AD between those with and without self-reported cancer history emerge early in the disease course. Such differences in longitudinal progression by self-reported cancer history could affect AD trials and observational studies, given the current focus on early disease course. Further investigation is warranted with detailed longitudinal assessment of cancer and AD.

Similar neurocognitive patterns in patients treated with lenalidomide: chemobrain effect?

Purpose: o report and describe cognitive impairments during lenalidomide treatment in three patients. Despite the relevant clinical impact of chemotherapy-related cognitive deficit (known as "chemobrain effect"), very few data are available in the literature. Methods: We present three subjects who developed cognitive impairment during treatment with lenalidomide. Their neuropsychological assessment was evaluated in order to better define the cognitive areas involved. For each patient medical history, drug therapy, physical examination and other instrumental tests (brain CT scan and/or MRI scan, FDG-PET and electroencephalography) were collected. Results: In all patients, we observed an homogeneous neuropsychological pattern characterized by long-term verbal and visuospatial memory deficits, and decline in attentional and executive functions. Conclusions: Lenalidomide treatments can determine severe cognitive impairments especially in elderly patients. Our data suggest the need for a careful evaluation of cognitive decline risk before and after drug administration. However, larger studies are required to confirm our findings.

Evaluation of the effects of chemotherapy on brain glucose metabolism in children with Hodgkin's lymphoma

OBJECTIVE

Chemobrain is a recently proposed pathological entity. ¹⁸F-FDG PET/CT can show objective abnormalities to explain brain disorders caused by chemotherapy, although no study has investigated these phenomena in children to date. The main objective of the present study was to examine quantitatively the effects of chemotherapy on brain metabolism in a homogeneous population of children treated for Hodgkin's lymphoma using 18F-FDG PET/CT.

METHODS

In this retrospective study, we included 20 children, newly diagnosed with Hodgkin's lymphoma, who underwent ¹⁸F-FDG PET/CT at initial staging and at least one PET/CT in follow-up. The SPM12 software provided t-maps to show the difference in metabolism between these PET/CTs. The statistical maps were analyzed with xjView software to identify the brain regions associated with the clusters detected.

RESULTS

Altered glucose metabolism was found in the frontal, cingular, and temporoinsular regions after two cycles of chemotherapy. Results in children were compared to a group of 35 adults. For the same statistical threshold, the extent and depth of the metabolic alterations were less in the adult group than in children.

CONCLUSIONS

¹⁸F-FDG PET/CT is useful in providing objective data to explain brain disorders caused by chemotherapy. This could lead to better care and should be compared to neuropsychological test results.

Neuropsychological Practice in the Oncology Setting

Oncology has experienced positive shifts in survival curves for many cancers largely due to the development of earlier diagnostics and better therapeutics. This has increased the visibility and need for survivorship services, including clinical neuropsychology. Patients with cancer frequently experience cognitive dysfunction related to the presence of cancer itself and treatment neurotoxicity. These cognitive difficulties can profoundly impact patient functioning and autonomy with accompanying declines in quality of life. Clinical neuropsychologists are uniquely positioned to evaluate the cognitive and affective sequelae of cancer and treatment and provide interventions and recommendations that can benefit well-being and potentially alter the disease course. Despite increasing recognition of the importance of neuropsychological issues to cancer survivorship, many neuropsychologists have limited training and guidance regarding navigating and implementing services within the oncology setting. This article provides the basic rationale for neuropsychological practice and research activities in oncology, as well as the experience of the Section of Neuropsychology at The University of Texas MD Anderson Cancer Center.

Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes

Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.

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.

Associations between Mild Cognitive Dysfunction and End-of-Life Outcomes in Patients with Advanced Cancer

BACKGROUND

Cognitive function of patients with advanced cancer is frequently compromised.

OBJECTIVE

To determine the extent that patients' cognitive screening scores was associated with their end-of-life (EoL) treatment preferences, advance care planning (ACP), and care.

DESIGN

Patients were interviewed at baseline and administered a cognitive screen. Caregivers completed a postmortem assessment.

SETTING/SUBJECTS

Patients with distant metastases and disease progression after first-line chemotherapy and their caregivers (n = 609) were recruited from outpatient clinics and completed baseline and postmortem assessments.

MEASUREMENTS

In logistic regression models adjusting for patients' age, education level, and performance status, patients' scores on the Pfeiffer Short Portable Mental Status exam at baseline predicted ACP, treatments, and treatment preferences at baseline, and location of death and caregiver perceptions of the patients' death in a postmortem assessment.

RESULTS

For each additional error, patients were less likely to consider the intensive care unit a bad place to die (adjusted odds ratio [AOR] = 0.81; confidence interval [95% CI]: 0.66-0.98; p = 0.03) and less likely to have an inpatient hospice stay (AOR = 0.63; 95% CI: 0.40-1.00; p = 0.05). After death (n = 318), caregivers were more likely to perceive that patients died at patients' preferred location (AOR = 1.38; 95% CI: 1.01-1.88; p = 0.04) and less likely to perceive that patients preferred to extend life over relieving discomfort (AOR = 0.63; 95% CI: 0.40-0.99; p = 0.05).

CONCLUSIONS

Patient cognitive screening scores were associated with EoL outcomes. Rather than avoid patients who are cognitively impaired, oncologists should consider ACP with them.