Cognitive impairment and chemotherapy: a brief overview

Early region-specific impact of adjuvant radiation therapy on cognition and quality of life in adult patients with primary brain tumors

PURPOSE

While treatments for primary brain tumors increase survival, they have cognitive sequelae. Neurocognition's anatomical distribution makes it susceptible to brain damage. This study aims to evaluate the contribution of radiotherapy on short-term cognitive impairment.

METHODS/PATIENTS

Using a prospective database of cognitive rehabilitation in adults operated on for primary brain tumors, a retrospective sub-analysis of the contribution of radiotherapy was performed. Thirty-four subdivisions of 12 neurocognitive regions were delineated in 48 irradiated patients and 30 non-irradiated patients. In the first group, the correlation between radiation dose and deterioration was evaluated. In all patients, the impact of tumor and surgical changes on dysfunction was calculated and compared with dose-dependent response.

RESULTS

The correlation between cognitive status and radiation dose is especially strong and significant in the left hemisphere and in specific subdivisions such as the posterior hippocampus or the dorsolateral prefrontal cortex, with the left prevailing over posterior dominance. Memory is the most affected domain 1 month after radiotherapy, as attention is three months later. The hippocampus is involved in various cognitive domains in addition to memory. The prefrontal subregions and the genu of the corpus callosum are more affected by the relationship with disease and surgical changes than by radiation exposure. Patients ongoing a course of radiotherapy do not benefit from concurrent cognitive rehabilitation.

CONCLUSIONS

There is a correlation between the dose of radiation received by several encephalic regions and degree of short-term domain-specific cognition decline, considering other factors of risk and cognitive rehabilitation.

Melatonin mitigates cisplatin-induced cognitive impairment in rats and improves hippocampal dendritic spine density

Cisplatin-induced cognitive impairment (chemobrain) affects a considerable percentage of cancer patients and has no established pharmacological treatment. Chemobrain can be associated with neuroinflammation and oxidative stress. Melatonin, a pineal hormone, is known to have antioxidant, anti-inflammatory and neuroprotective potential. In this study, we investigated cisplatin-induced cognitive impairment in rats and whether melatonin can improve or reverse this impairment. Behavioral testing involved measuring working memory using the novel location recognition test (NLRT) under conditions of cisplatin or cisplatin + melatonin treatment, followed by the collection of rats' brains. The brains were subsequently stained with Golgi-Cox stain and then the hippocampus area CA3 of each one was examined, and dendritic spine density was calculated. Treatment with cisplatin resulted in deficits in the rats' performance in the NLRT (P < 0.05). These deficits were prevented by the coadministration of melatonin (P < 0.05). Cisplatin also reduced the density of dendritic spines in the hippocampus (P < 0.0001), specifically CA3 area, while the coadministration of melatonin significantly reversed this reduction (P < 0.001). This study showed that melatonin can ameliorate cisplatin-induced spatial memory deficits and dendritic spines density abnormalities in rats. Given that melatonin is a safe and wildly used supplement, it is feasible to explore its use as a palliative intervention in cancer treatment.

Treadmill exercise ameliorates chemotherapy-induced memory impairment through Wnt/β-catenin signaling pathway

Doxorubicin (DOX) is a widely used chemotherapy drug for various cancers and it is known to induce cognitive impairment. The aim of this study was to investigate the effect of treadmill exercise on chemotherapy-induced memory impairment. We assessed whether DOX affects inflammation, mitochondrial Ca2+ retention capacity, and Wnt/β-catenin signaling. Male Sprague-Dawley rats were divided into control group, exercise group, DOX-injection group, and DOX-injection and exercise group. To create a DOX-induced memory impairment model, animals were injected intraperitoneally with DOX (2 mg/kg) dissolved in saline solution once a week for 4 weeks. Treadmill exercise was performed once a day, 5 days a week, for 8 consecutive weeks. Short-term memory was determined using the step-down avoidance test. Western blot was performed for the proinflammatory cytokines, Wnt/β-catenin signaling, brain-derived neurotrophic factor (BDNF), tropomyosin receptor kinase B (TrkB) in the hippocampus. Mitochondrial Ca2+ retention capacity in the hippocampus was also measured. DOX-injection rats showed deterioration of short-term memory along with decreased expression of BDNF and TrkB in the hippocampus. Levels of the proinflammatory cytokines, tumor necrosis factor-α and interleukin-6, were increased in the DOX-injection rats. Wnt/β-catenin signaling was activated and mitochondrial Ca2+ retention capacity was decreased in the DOX-injection rats. However, treadmill exercise alleviated short-term memory impairment, decreased proinflammatory cytokines, increased BDNF and TrkB expression, and enhanced mitochondrial Ca2+ retention capacity. Treadmill exercise restorated Wnt/β-catenin signaling pathway. This study demonstrated that treadmill exercise can be used for patients undergoing chemotherapy with DOX.

Neurologic Complications of Cancer Treatment

OBJECTIVE

Advances in cancer treatment have led to extended survival and increased risk of neurologic complications in an aging population. This review summarizes potential neurologic complications in patients who have undergone treatment for neurologic and systemic malignancies.

LATEST DEVELOPMENTS

Radiation and cytotoxic chemotherapy along with other targeted therapies continue to be the mainstay of cancer treatment. These advances in cancer care have led to improved outcomes and increased the need to understand the spectrum of neurologic complications that may arise from treatment. While radiation and older therapies including cytotoxic chemotherapies have side effect profiles that are widely known and well understood, this article serves as a review of the more commonly associated neurologic complications of both traditional and newer treatments being offered to this patient population.

ESSENTIAL POINTS

Neurotoxicity is a common complication of cancer-directed treatment. In general, neurologic complications of radiation therapy are more common in central nervous system malignancies, and neurologic complications of chemotherapy are more common in non-neurologic malignancies. Attempts at prevention, early detection, and intervention remain paramount in the reduction of neurologic morbidity.

First-Line Immunotherapy with Check-Point Inhibitors: Prospective Assessment of Cognitive Function

Approximately 40% of patients with cancer are eligible for check-point inhibitor (CPI) therapy. Little research has examined the potential cognitive impact of CPIs. First-line CPI therapy offers a unique research opportunity without chemotherapy-related confounders. The purpose of this prospective, observational pilot was to (1) demonstrate the feasibility of prospective recruitment, retention, and neurocognitive assessment for older adults receiving first-line CPI(s) and (2) provide preliminary evidence of changes in cognitive function associated with CPI(s). Patients receiving first-line CPI(s) (CPI Group) were assessed at baseline (n = 20) and 6 months (n = 13) for self-report of cognitive function and neurocognitive test performance. Results were compared to age-matched controls without cognitive impairment assessed annually by the Alzheimer's Disease Research Center (ADRC). Plasma biomarkers were measured at baseline and 6 months for the CPI Group. Estimated differences for CPI Group scores prior to initiating CPIs (baseline) trended to lower performance on the Montreal Cognitive Assessment-Blind (MOCA-Blind) test compared to the ADRC controls (p = 0.066). Controlling for age, the CPI Group's 6-months MOCA-Blind performance was lower than the ADRC control group's 12-months performance (p = 0.011). No significant differences in biomarkers were detected between baseline and 6 months, although significant correlations were noted for biomarker change and cognitive performance at 6 months. IFNγ, IL-1β, IL-2, FGF2, and VEGF were inversely associated with Craft Story Recall performance (p < 0.05), e.g., higher levels correlated with poorer memory performance. Higher IGF-1 and VEGF correlated with better letter-number sequencing and digit-span backwards performance, respectively. Unexpected inverse correlation was noted between IL-1α and Oral Trail-Making Test B completion time. CPI(s) may have a negative impact on some neurocognitive domains and warrant further investigation. A multi-site study design may be crucial to fully powering prospective investigation of the cognitive impact of CPIs. Establishment of a multi-site observational registry from collaborating cancer centers and ADRCs is recommended.

Endothelial TFEB signaling-mediated autophagic disturbance initiates microglial activation and cognitive dysfunction

Cognitive impairment caused by systemic chemotherapy is a critical question that perplexes the effective implementation of clinical treatment, but related molecular events are poorly understood. Herein, we show that bortezomib exposure leads to microglia activation and cognitive impairment, this occurs along with decreased nuclear translocation of TFEB (transcription factor EB), which is linked to macroautophagy/autophagy disorder, STAT3 (signal transducer and activator of transcription 3) phosphorylation and IL23A (interleukin 23 subunit alpha) expression. Pharmacological enhancement of TFEB nuclear translocation by digoxin restores lysosomal function and reduces STAT3-dependent endothelial IL23A secretion. As a consequence, we found that brain endothelial-specific ablation of Il23a ameliorated both microglia activation and cognitive dysfunction. Thus, the endothelial TFEB-STAT3-IL23A axis in the brain represents a critical cellular event for initiating bortezomib-mediated aberrant microglial activation and synapse engulfment. Our results suggest the reversal of TFEB nuclear translocation may provide a novel therapeutic approach to prevent symptoms of cognitive dysfunction during clinical use of bortezomib.Abbreviations: AAV: adeno-associated virus; BBB: blood-brain barrier; BTZ: bortezomib; DG: digoxin; DGs: dentate gyrus; DLG4/PSD95: discs large MAGUK scaffold protein 4; HBMECs: human brain microvascular endothelial cells; HP: hippocampus; IL23A: interleukin 23 subunit alpha; MBVECs: mouse brain vascular endothelial cells; mPFC: medial prefrontal cortex; NORT: novel object recognition test; OLT: object location test; PLX5622: 6-fluoro-N-([5-fluoro-2-methoxypyridin-3-yl]methyl)-5-(5-methyl-1H-pyrrolo[2,3-b]pyridin-3- yl)methyl; PPP3/calcineurin: protein phosphatase 3; SBEs: STAT3 binding elements; shRNA: small hairpin RNA; SLC17A7/VGLUT1: solute carrier family 17 member 7; SLC32A1/VGAT: solute carrier family 32 member 1; STAT3: signal transducer and activator of transcription 3, TFEB: transcription factor EB; Ub: ubiquitin.

Changes in Degree Centrality and Functional Connectivity after the First Cycle of Neoadjuvant Chemotherapy in Newly Diagnosed Breast Cancer: A Longitudinal Study

Purpose

To evaluate the longitudinal changes of brain degree centrality (DC) and functional connectivity (FC) in breast cancer patients after the first cycle of neoadjuvant chemotherapy (NAC).

Methods

Thirty-five breast cancer patients were included in the NAC group. Resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological test were performed at baseline before NAC (time point 0, TP0) and after the first cycle of NAC (time point 1, TP1). The healthy controls (HC) included 30 healthy subjects and received the same rs-fMRI scan and neuropsychological test as the above-mentioned NAC group at one time point. DC and FC analyses were conducted to assess brain connectivity of all participants. Receiver operating characteristic (ROC) curve was used to assess the ability of DC and FC in distinguishing patients before and after chemotherapy.

Results

In the NAC group, the Self-Rating Anxiety Scale scores decreased significantly over time. At TP0 and TP1, the Digital Span Test forward score of the NAC group was significantly lower than that of the HC group. In the NAC group, DC in the right middle frontal gyrus and left precentral gyrus/middle frontal gyrus decreased significantly at TP1, and FC between the left precentral gyrus/middle frontal gyrus and bilateral precuneus was significantly reduced at TP1. Through ROC analysis, we found that the area under the curve (AUC) of DC, FC, and the combined model in distinguishing patients in TP0 or TP1 was 0.7886, 0.7665, and 0.8278, respectively.

Conclusions

Brain connectivity, involving executive and motor function related brain areas, changes in the short term after NAC treatment in breast cancer patients.

Distinct sleep disturbance and cognitive dysfunction profiles in oncology outpatients receiving chemotherapy

PURPOSE

Sleep disturbance and cancer-related cognitive impairment (CRCI) are two of the most common symptoms reported by patients undergoing chemotherapy. Less is known about how these symptoms co-occur and their associated risk factors. Study purposes were to identify subgroups of patients with distinct sleep disturbance and CRCI profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, symptom severity scores, and QOL outcomes.

METHODS

A total of 1,333 oncology outpatients receiving chemotherapy completed self-report questionnaires on sleep disturbance and cognitive dysfunction six times over two cycles of chemotherapy. Latent profile analysis was used to identify distinct sleep disturbance AND cognitive dysfunction profiles. Parametric and non-parametric tests were used to evaluate for differences among the classes.

RESULTS

Two distinct profiles were identified (i.e., Low = low levels of both sleep disturbance and cognitive dysfunction (53.5%); High = high levels of both sleep disturbance and cognitive dysfunction (45.5%)). Patients in the High class were younger, more likely to be female, had a lower functional status and a higher level of comorbidity. In addition, these patients had a higher symptom burden and a lower quality of life.

CONCLUSION

Almost half of the patients undergoing chemotherapy experienced clinically meaningful levels of both symptoms. Of note, sleep disturbance is frequently overlooked by both clinicians and patients. Clinicians need to recommend cognitive rehabilitation and physical activity programs to decrease patients' symptom burden.

Impact of integrated yoga therapy on cognitive impairment and cardiac dysfunction in relation to quality of life in breast cancer patients undergoing chemotherapy: Study protocol for a two-arm randomized controlled trial

Background

Chemotherapy-related cognitive impairment (CRCI) and cardiac dysfunction (CRCD) are common adverse effects seen in breast cancer patients undergoing chemotherapy. Even though these effects significantly influence daily functioning and overall quality of life, effective strategies to avoid and/or mitigate these adverse effects remain elusive. Yoga as a Mind-body intervention has been used increasingly by cancer patients and has undergone empirical investigations as a potential intervention for patients with cancer. Furthermore, yoga is associated with improved cognition and cardiac functioning in healthy older adults and subjects with cognitive and cardiac impairments. Accordingly, in the current study, yoga holds promise as an intervention to prevent/manage CRCI and CRCD with improved overall QOL in women receiving chemotherapy for breast cancer.

Methods

The study is a two-arm, randomized controlled trial. Women diagnosed with stage I-III breast cancer and awaiting neo-adjuvant or adjuvant chemotherapy will be recruited from a tertiary care center in Bangalore, India. Following recruitment, subjects are randomized to the intervention group (integrated yoga therapy intervention during chemotherapy) or the control group (standard care during chemotherapy). The study’s primary outcome is to measure the quality of life (cognitive domain) using European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The other primary objectives will include cognitive functioning using neuropsychological test battery and cardiac autonomic function testing using heart rate variability. Secondary outcomes are Brain-derived neurotrophic factor (BDNF), brain function (functional MRI), Echocardiography, serum cortisol, Functional assessment of cancer therapy-cognition (FACT-Cog V3), perceived stress scale and Ryff Scales of Psychological Well-Being. Assessments take place before, during and after chemotherapy; 16-weeks post chemotherapy and 1-year post-baseline.

Discussion

Yoga is a promising intervention for preventing and/or managing chemotherapy-related adverse effects (CRAE) and enhancing the quality of life among breast cancer patients. The findings from this study may also help understand the inner mechanisms involved in the protective and restorative effects of yoga on CRAE and support the use of yoga prophylactically for breast cancer patients. In addition, the results of this study could help chemotherapy-exposed individuals with other solid cancer types who have cognitive and cardiac issues.

Ethics and Dissemination

The study is approved by the ethics committee of the HealthCare Global Enterprises Ltd. Hospital (EC/434/19/01) and National Institute of Mental Health and Neurosciences (NIMH/DO/ETHICS SUB-COMMITTEE (BS&amp;NS) 9th MEETING/2018).

Clinical Trial Registration

http://ctri.nic.in/Clinicaltrials/advancesearchmain.php, identifier CTRI/2020/10/028446.

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.

Extracellular Vesicles and Cancer Therapy: Insights into the Role of Oxidative Stress

Oxidative stress plays a significant role in cancer development and cancer therapy, and is a major contributor to normal tissue injury. The unique characteristics of extracellular vesicles (EVs) have made them potentially useful as a diagnostic tool in that their molecular content indicates their cell of origin and their lipid membrane protects the content from enzymatic degradation. In addition to their possible use as a diagnostic tool, their role in how normal and diseased cells communicate is of high research interest. The most exciting area is the association of EVs, oxidative stress, and pathogenesis of numerous diseases. However, the relationship between oxidative stress and oxidative modifications of EVs is still unclear, which limits full understanding of the clinical potential of EVs. Here, we discuss how EVs, oxidative stress, and cancer therapy relate to one another; how oxidative stress can contribute to the generation of EVs; and how EVs’ contents reveal the presence of oxidative stress. We also point out the potential promise and limitations of using oxidatively modified EVs as biomarkers of cancer and tissue injury with a focus on pediatric oncology patients.

Clair DK. Extracellular vesicles released after cranial radiation: An insight into an early mechanism of brain injury

Cranial radiation is important for treating both primary brain tumors and brain metastases. A potential delayed side effect of cranial radiation is neurocognitive function decline. Early detection of CNS injury might prevent further neuronal damage. Extracellular vesicles (EVs) have emerged as a potential diagnostic tool because of their unique membranous characteristics and cargos. We investigated whether EVs can be an early indicator of CNS injury by giving C57BJ/6 mice 10 Gy cranial IR. EVs were isolated from sera to quantify: 1) number of EVs using nanoparticle tracking analysis (NTA); 2) Glial fibrillary acidic protein (GFAP), an astrocyte marker; and 3) protein-bound 4-hydroxy-2-nonenal (HNE) adducts, an oxidative damage marker. Brain tissues were prepared for immunohistochemistry staining and protein immunoblotting. The results demonstrate: 1) increased GFAP levels (p < 0.05) in EVs, but not brain tissue, in the IR group; and 2) increased HNE-bound protein adduction levels (p < 0.05). The results support using EVs as an early indicator of cancer therapy-induced neuronal injury.

Clemastine Rescues Chemotherapy-Induced Cognitive Impairment by Improving White Matter Integrity

With the improvement of cancer treatment techniques, increasing attention has been given to chemotherapy-induced cognitive impairment through white matter injury. Clemastine fumarate has been shown to enhance white matter integrity in cuprizone- or hypoxia-induced demyelination mouse models. However, whether clemastine can be beneficial for reversing chemotherapy-induced cognitive impairment remains unexplored. In this study, the mice received oral administration of clemastine after chemotherapy. The open-field test and Morris water maze test were used to evaluate their anxiety, locomotor activity and cognitive function. Luxol Fast Blue staining and transmission electron microscopy were used to detect the morphological damage to the myelin. Demyelination and damage to the mature oligodendrocytes and axons were observed by immunofluorescence and western blotting. Clemastine significantly improved their cognitive function and ameliorated white matter injury in the chemotherapy-treated mice. Clemastine enhanced myelination, promoted oligodendrocyte precursor cell differentiation and increased the neurofilament 200 protein levels in the corpus callosum and hippocampus. We concluded that clemastine rescues cognitive function damage caused by chemotherapy through improving white matter integrity. Remyelination, oligodendrocyte differentiation and the increase of neurofilament protein promoted by clemastine are potential strategies for reversing the cognitive dysfunction caused by chemotherapy.

The Antagonism of the Prokineticin System Counteracts Bortezomib Induced Side Effects: Focus on Mood Alterations

The development of neuropathy and of mood alterations is frequent after chemotherapy. These complications, independent from the antitumoral mechanism, are interconnected due to an overlapping in their processing pathways and a common neuroinflammatory condition. This study aims to verify whether in mice the treatment with the proteasome inhibitor bortezomib (BTZ), at a protocol capable of inducing painful neuropathy, is associated with anxiety, depression and supraspinal neuroinflammation. We also verify if the therapeutic treatment with the antagonist of the prokineticin (PK) system PC1, which is known to contrast pain and neuroinflammation, can prevent mood alterations. Mice were treated with BTZ (0.4 mg/kg three times/week for 4 weeks); mechanical allodynia and locomotor activity were evaluated over time while anxiety (dark light and marble burying test), depression (sucrose preference and swimming test) and supraspinal neuroinflammation were checked at the end of the protocol. BTZ treated neuropathic mice develop anxiety and depression. The presence of mood alterations is related to the presence of neuroinflammation and PK system activation in prefrontal cortex, hippocampus and hypothalamus with high levels of PK2 and PKR2 receptor, IL-6 and TNF-α, TLR4 and an upregulation of glial markers. PC1 treatment, counteracting pain, prevented the development of supraspinal inflammation and depression-like behavior in BTZ mice.

Oxidative Stress and Cognitive Alterations Induced by Cancer Chemotherapy Drugs: A Scoping Review

Cognitive impairment is one of the most deleterious effects of chemotherapy treatment in cancer patients, and this problem sometimes remains even after chemotherapy ends. Common classes of chemotherapy-based regimens such as anthracyclines, taxanes, and platinum derivatives can induce both oxidative stress in the blood and in the brain, and these effects can be reproduced in neuronal and glia cell cultures. In rodent models, both the acute and repeated administration of doxorubicin or adriamycin (anthracyclines) or cisplatin impairs cognitive functions, as shown by their diminished performance in different learning and memory behavioural tasks. Administration of compounds with strong antioxidant effects such as N-acetylcysteine, gamma-glutamyl cysteine ethyl ester, polydatin, caffeic acid phenethyl ester, and 2-mercaptoethane sulfonate sodium (MESNA) counteract both oxidative stress and cognitive alterations induced by chemotherapeutic drugs. These antioxidant molecules provide the scientific basis to design clinical trials in patients with the aim of reducing the oxidative stress and cognitive alterations, among other probable central nervous system changes, elicited by chemotherapy in cancer patients. In particular, N-acetylcysteine and MESNA are currently used in clinical settings and are therefore attracting scientific attention.

Effects of brief acceptance and commitment therapy (ACT) on subjective cognitive impairment in breast cancer patients undergoing chemotherapy

PURPOSE

This study examined the efficacy of a brief acceptance and commitment therapy (ACT) on subjective cognitive impairment in breast cancer patients undergoing chemotherapy.

METHODS

Data collection was carried out in 3-time points: baseline (T1), screening (T2), and post-treatment (T3). Respondents who had significant subjective cognitive impairment were randomly divided into two groups: intervention (n = 30) and waitlist (n = 30). Respondents in the intervention group received 4 sessions of 1 hour of ACT therapy.

FINDINGS

Respondents in the intervention group showed significant improvement in subjective cognitive impairment, depression, anxiety, and psychological inflexibility after the ACT intervention (p < 0.05). After controlling the covariates, group differences in all variables were significant except for fatigue and psychological inflexibility has the highest effect size (d = 4.69).

CONCLUSION

ACT could be considered as an effective intervention to ameliorate subjective cognitive impairment, anxiety, depression, and psychological inflexibility in breast cancer patients undergoing chemotherapy.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

This study highlights the importance of screening for subjective cognitive impairment in breast cancer patients undergoing chemotherapy and heightens their opportunity to receive proper management as earlier as possible.

Abnormal topological characteristics of brain white matter network relate to cognitive and emotional deficits of non-small cell lung cancer (NSCLC) patients prior to chemotherapy

INTRODUCTION

Cancer and chemotherapy are correlated with brain functional and structural changes in cancer patients, which may lead to cognitive dysfunction. However, little is known about the structural abnormalities of brain in patients with non-small cell lung cancer (NSCLC). The aim of this study was to explore the topological properties within the brain white matter network of NSCLC patients prior to chemotherapy.

METHODS

To explore the neurobiological biomarkers of NSCLC, brain magnetic resonance imaging (MRI) data were acquired in 24 non-nervous system metastatic NSCLC patients and 25 matched healthy controls. The topological properties of the brain structural networks of NSCLC were measured by the parameters of local and global efficiency.

RESULTS

Treatment-naïve NSCLC patients showed cognitive and emotional deficits. In addition, NSCLC patients also exhibited decreased global efficacy in the left inferior frontal gyrus (triangular part), left inferior frontal gyrus (orbital part), right rolandic operculum, right gyrus rectus, right lenticular nucleus (putamen), left superior temporal gyrus and right inferior temporal gyrus. Decreased local efficacy were found in the left middle frontal gyrus (orbital part) and left superior temporal gyrus in NSCLC patients. Moreover, the aberrant brain regions were associated with the impaired cognitiion and emotion of NSCLC patients.

CONCLUSION

Overall our results suggested that altered local and global efficiency of brain white matter network were associated with cancer-induced cognitive and emotional deficits of NSCLC patients. These findings demonstrated that disrupted topological characteristics of the brain network might underlie the impaired cognition and emotion in NSCLC.

Chemotherapy-induced cognitive impairment from the forensic medicine perspective: A review of the updated literature

Chemotherapy treatments in some neoplastic patients can cause unwanted side-effects that can be accompanied by a physical weakening due to changes in executive functioning, processing speed and reaction times with a consequent inability to carry out daily life activities (ADL) or a working disability due to the loss of working memory and the inability to organize fundamental skills, influencing the quality of everyday life. Although chemotherapy-induced cognitive impairment (CICI), also known as post-chemotherapy cognitive impairment (PCCI), chemo-brain or chemo-fog, has been described in the literature since the late 1980s, the neurobiological factors behind this pathology to date are not yet fully understood. According to the finding of most studies conducted on patients affected by different forms of neoplastic diseases, there are strong enough evidence of a prominent role of some drug such as doxorubicin, cyclophosphamide, cytarabine, methotrexate, 5-fluorouracil and cisplatin in causing chemo-fog related neurological impairment. The physical incapacity that affects the patients seems, therefore, to be related to the cytotoxic effects that the chemotherapy drugs exert on the central nervous system, causing a short or long-term neurological decline. Cognitive dysfunctions could influence individual self-determination by configuring a state of transient or habitual mental infirmity capable of altering the preservation of the person's voluntary faculties, with potential consequences on the legal validity of any deeds signed by the person. The growing interest in this pathological condition by the forensic medicine community is due precisely to the non-negligible medico-legal implications that derive from it affecting aspects of private law. In this article, a review of the literature on chemotherapy-induced cognitive impairment and related issues that may arise in forensic medicine and private law was conducted.

Catechol-O-Methyltransferase Gene Polymorphisms and the Risk of Chemotherapy-Induced Prospective Memory Impairment in Breast Cancer Patients with Varying Tumor Hormonal Receptor Expression

Background

Existing research evidence indicates that breast cancer patients have different degrees of cognitive dysfunction after chemotherapy, and polymorphisms in 3 genes (catechol-O-methyltransferase, COMT; apolipoprotein E, APOE; and brain-derived neurotrophic factor, BDNF) have been associated with cognitive impairment. However, the role of these 3 gene polymorphisms in modulating cognitive impairment in breast cancer survivors with varying hormonal receptor expression is not clear at present.

To explore the effects of genetic polymorphisms in BDNF, APOE, and COMT on the regulation of prospective memory impairments induced by chemotherapy in breast cancer patients with various expression levels of estrogen receptor (ER) and progesterone receptor (PR).

Material/Methods

A total of 232 patients with breast cancer (113 with ER−/PR− and 119 with ER+/PR+) were evaluated before and after chemotherapy for cognitive function, including prospective memory. Following previously published sequencing procedures, we assessed 6 single-nucleotide polymorphisms (SNPs), including BDNF (rs6265), APOE (rs429358, rs7412), and COMT (rs165599, rs4680, rs737865).

Results

The patients showed poorer prospective memory scores after chemotherapy than before chemotherapy. Furthermore, the ER−/PR− group showed poorer event-based prospective memory (EBPM) scores than the ER+/PR+ group (z=−7.831, p<0.01) after chemotherapy. The patients with the COMT rs737865G/G genotype, compared with those with the A/A and A/G genotypes, showed a linear EBPM performance (β=1.499, 95% confidence interval (CI)=1.017~2.211) and were less likely to have memory impairment. In contrast, APOE and BDNF polymorphisms did not influence cognitive performance.

Conclusions

The patterns of hormonal receptor expression may be related to prospective memory impairments induced by chemotherapy in breast cancer patients. Furthermore, the COMT polymorphism (rs737865) was linearly related to the extent of deficits in EBPM and may represent a potential genetic marker of risk for cognitive deficits triggered by chemotherapy in patients with breast cancer.

Study protocol of the Aerobic exercise and CogniTIVe functioning in women with breAsT cancEr (ACTIVATE) trial: a two-arm, two-centre randomized controlled trial

BACKGROUND

Up to 75% of women diagnosed with breast cancer report chemotherapy-related cognitive changes (CRCC) during treatment, including decreased memory, attention, and processing speed. Though CRCC negatively impacts everyday functioning and reduces overall quality of life in women diagnosed with breast cancer, effective interventions to prevent and/or manage CRCC are elusive. Consequently, women seldom receive advice on how to prevent or manage CRCC. Aerobic exercise is associated with improved cognitive functioning in healthy older adults and adults with cognitive impairments. Accordingly, it holds promise as an intervention to prevent and/or manage CRCC. However, evidence from randomized controlled trials (RCTs) supporting a beneficial effect of aerobic exercise on CRCC is limited. The primary aim of the ACTIVATE trial is to evaluate the impact of supervised aerobic exercise on CRCC in women receiving chemotherapy for breast cancer.

METHODS

The ACTIVATE trial is a two-arm, two-centre RCT. Women diagnosed with stage I-III breast cancer and awaiting neo-adjuvant or adjuvant chemotherapy are recruited from hospitals in Ottawa (Ontario) and Vancouver (British Columbia), Canada. Recruits are randomized to the intervention group (aerobic exercise during chemotherapy) or the wait-list control group (usual care during chemotherapy and aerobic exercise post-chemotherapy). The primary outcome is cognitive functioning as measured by a composite cognitive summary score (COGSUM) of several neuropsychological tests. Secondary outcomes are self-reported cognitive functioning, quality of life, and brain structure and functioning (measured by magnetic resonance imaging (MRI)/functional MRI and electroencephalography). Assessments take place pre-chemotherapy (pre-intervention), mid-way through chemotherapy (mid-intervention/mid-wait period), end of chemotherapy (post-intervention/post-wait period; primary endpoint), 16-weeks post-chemotherapy, and at 1-year post-baseline.

DISCUSSION

Aerobic exercise is a promising intervention for preventing and/or managing CRCC and enhancing quality of life among women diagnosed with breast cancer. The ACTIVATE trial tests several novel hypotheses, including that aerobic exercise can prevent and/or mitigate CRCC and that this effect is mediated by the timing of intervention delivery (i.e., during versus post-chemotherapy). Findings may support prescribing exercise during (or post-) chemotherapy for breast cancer and elucidate the potential role of aerobic exercise as a management strategy for CRCC in women with early-stage breast cancer.

TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov database ( NCT03277898 ) on September 11, 2017.

Correlates of cognitive impairment in adult cancer survivors who have received chemotherapy and report cognitive problems

OBJECTIVE

Cognitive impairment negatively affects some cancer survivors who have completed chemotherapy; however, factors underlying this cognitive impairment remain poorly understood. We aimed to investigate (1) the relative importance of demographics, medical, and psychological characteristics associated with cognitive impairment and (2) the specific variables associated with cognitive impairment in adult cancer survivors who completed adjuvant chemotherapy.

METHODS

We performed post hoc analyses of baseline data from early-stage cancer survivors with cognitive complaints who received adjuvant chemotherapy 0.5-5 years earlier and volunteered for a trial designed to improve cognition. The primary outcome of self-reported cognitive impairment was measured using a questionnaire; secondary outcome of objective cognitive impairment was measured using a computerized neuropsychological test battery. Hierarchical linear regression determined the relative importance of demographics, medical, and psychological characteristics in associations with both self-reported and objective cognitive impairment.

RESULTS

The sample was 95% female and 89% breast cancer patients. The final model accounted for 33% of variation in self-reported cognitive impairment (n = 212, demographics 5%, medical 3%, and psychological 25%), with fatigue and stress as significant individual correlates (p values ≤ 0.0001). For the secondary analysis, the final model accounted for 19% of variation in objective cognitive impairment (n = 206, demographics 10%, medical 5%, and psychological 4%), with age, smoking history, and number of chemotherapy cycles as significant individual correlates.

CONCLUSION

We found that psychological characteristics are more important than demographic and medical characteristics in self-reported cognitive impairment, whereas other characteristics are more important in objective cognitive impairment. This suggests clinicians should investigate possible psychological problems in cancer survivors who self-report cognitive impairment.

Doxorubicin chemotherapy-induced "chemo-brain": Meta-analysis

Doxorubicin is a leading chemotherapeutic halting cellular replication and inducing p53-dependent apoptosis in cancerous tissue. Like many chemotherapies, doxorubicin damages healthy tissue throughout the body through cellular mechanisms independent of its chemotherapeutic action. Although cognitive impairment is commonly recorded in patients after chemotherapy, the occurrence of doxorubicin-induced "chemo-brain" is debated, as doxorubicin cannot cross the blood-brain barrier. However, the potential of indirect doxorubicin neurotoxicity remains, providing a foundation for doxorubicin-mediated chemo-brain. We present the first meta-analysis of defined cognitive performance of doxorubicin-treated patients. A search of PubMed and MedLine collected 494 studies, 14 of which met analysis criteria. Performance of 511 doxorubicin-treated women with breast cancer was compared to that of 306 healthy controls across measures of defined cognitive modalities. Treated patients experience significant impairment in global cognition compared to controls (g₌ -0.41, P < 0.001), with select impairment in executive function (g = -0.25, P < 0.0001), language (g = -0.30, P < 0.0001), memory (g = -0.12, P < 0.01) and processing speed (g = -0.28, P < 0.01). Within memory, short-term verbal memory is most significantly affected (g = -0.21, P < 0.01). Impairment in select cognitive modalities (executive function, language, memory, short-term verbal memory, processing speed) is prevalent in doxorubicin-treated patients, with some cognitive functions remaining intact (attention, motor function, visuospatial abilities). This information can guide the development of future interventions to improve quality-of-life (QOL) and doxorubicin-derived therapies that target cytotoxicity to cancerous tissue, avoiding healthy tissue damage, which is mediated by seemingly independent mechanisms.

Patient-Reported Neuropsychiatric Outcomes of Long-Term Survivors after Chimeric Antigen Receptor T Cell Therapy

CD19-targeted chimeric antigen receptor (CAR) modified T cell immunotherapy is a novel treatment with promising results in patients with relapsed/refractory lymphoid malignancies. CAR T cell therapy has known early toxicities of cytokine release syndrome and neurotoxicity, but little is known about long-term neuropsychiatric adverse effects. We have used patient-reported outcomes, including Patient-Reported Outcomes Measurement Information System (PROMIS) measures, to assess neuropsychiatric and other patient-reported outcomes of 40 patients with relapse/refractory chronic lymphocytic leukemia, non-Hodgkin lymphoma, and acute lymphoblastic leukemia 1 to 5 years after treatment with CD19-targeted CAR T cells. Mean T scores of PROMIS domains of global mental health, global physical health, social function, anxiety, depression, fatigue, pain, and sleep disturbance were not clinically meaningfully different from the mean in the general US population. However, 19 patients (47.5%) reported at least 1 cognitive difficulty and/or clinically meaningful depression and/or anxiety, and 7 patients (17.5%) scored ≤40 in global mental health, indicating at least 1 standard deviation worse than the general population mean. Younger age was associated with worse long-term global mental health (P = .02), anxiety (P = .001), and depression (P= .01). Anxiety before CAR T cell therapy was associated with increased likelihood of anxiety after CAR T cell therapy (P = .001). Fifteen patients (37.5%) reported cognitive difficulties after CAR T cell therapy. Depression before CAR T cell therapy was statistically significantly associated with higher likelihood of self-reported post-CAR T cognitive difficulties (P = .02), and there was a trend for an association between acute neurotoxicity and self-reported post-CAR T cognitive difficulties (P = .08). Having more post-CAR T cognitive difficulties was associated with worse global mental health and global physical health. Our study demonstrates overall good neuropsychiatric outcomes in 40 long-term survivors after CAR T cell therapy. However, nearly 50% of patients in the cohort reported at least 1 clinically meaningful negative neuropsychiatric outcome (anxiety, depression, or cognitive difficulty), indicating that a significant number of patients would likely benefit from mental health services following CAR T cell therapy. Younger age, pre-CAR T anxiety or depression, and acute neurotoxicity may be risk factors for long-term neuropsychiatric problems in this patient population. Larger studies are needed to confirm these findings.

Functioning of autobiographical memory specificity and self-defining memories in people with cancer diagnosis

OBJECTIVES

Cognitive and emotional disturbances have been associated with the diagnosis and treatment of cancer. Autobiographical memory is one of the specific cognitive processes affected during this disease. The current study had two main aims: (1) to compare the functioning of autobiographical memory specificity and its related variables (executive functioning, depression and perceived stress) in a group of persons with cancer and a control group; and (2) to analyze whether the experience of cancer evolved into a self-defining memory in the sample of participants diagnosed with this disease.

METHOD

The study sample comprised 62 participants, 31 in the group with a cancer diagnosis and 31 in the control group. Autobiographical memory specificity, executive functions, depression, stress and self-defining memory were evaluated in the current study.

RESULTS

Depressive symptomatology and reduced executive functioning, but not perceived stress levels, are related and are predictors of autobiographical memory specificity. In addition, the identified characteristics of the self-defining memories were associated with the cancer experience as a threat to physical integrity and an awareness of the meaning of life.

CONCLUSION

This emerging research line is especially important in view of its possible impacts on patients' well-being, due to the importance of psychological processes in cancer disease.

Cognitive Dysfunction and Its Predictors in Adult Patients With Cancer Receiving Chemotherapy: A Cross-Sectional Correlational Study

BACKGROUND

Chemotherapy-related cognitive dysfunction, one of the most frequently reported symptoms in patients with cancer, has a negative impact on the daily lives of patients. No research has examined cognitive dysfunction and its potential predictors in adult patients with cancer receiving chemotherapy in Saudi Arabia.

PURPOSE

The purpose of this study was to examine the sociodemographic, clinical, and psychological factors associated with cognitive dysfunction in adult patients with cancer receiving chemotherapy.

METHODS

A cross-sectional correlational study was carried out with a convenience sample of 100 adult patients with cancer receiving chemotherapy at a university teaching hospital in Saudi Arabia. The Montreal Cognitive Assessment, the Hospital Anxiety and Depression Scale, and sociodemographic and clinical surveys were completed by participants. Descriptive statistics and linear regression were used to analyze the data.

RESULTS

The data showed that the participants experienced moderate-to-severe cognitive dysfunction. Participants performed poorly in the divided attention and memory cognitive domains. Age, educational level, and depression factors were found to be significant predictors of cognitive dysfunction.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Cognitive dysfunction is commonly seen in patients with cancer receiving chemotherapy. Chemotherapy, age, and psychological factors increase susceptibility to cognitive dysfunction in adult patients with cancer. Oncology nurses should be aware that patients with cancer may be extremely vulnerable to cognitive dysfunction. Furthermore, age and psychological factors must be considered when developing symptom management and supportive care intervention programs to reduce the incidence of negative cognitive outcomes in this population.

Age-dependent brain volume and neuropsychological changes after chemotherapy in breast cancer patients

This study investigated volumetric brain changes and cognitive performance in premenopausal and postmenopausal patients treated for early-stage breast cancer. Participants underwent elaborate neurocognitive assessments (neuropsychological testing, cognitive failure questionnaire, and high-resolution T1-weighted structural MRI) before and after chemotherapy. Volumetric brain changes were estimated, using longitudinal deformation-based morphometry, and correlated with cognitive changes. In total, 180 women participated in this study, of whom 72 patients with breast cancer had received adjuvant chemotherapy (C+), 49 patients did not receive chemotherapy (C-), and 59 healthy controls (HC). The population was categorized into two age groups: A young group who were premenopausal and younger than 52 years at baseline (n = 55C+/32C-/41HC), and an older group who were postmenopausal and older than 60 years (n = 17C+/17C-/18HC). Cognitive impairment occurred after chemotherapy in both young and older patients, although older patients showed more decline in processing speed (Trail making test b). White matter volume expansion was observed after chemotherapy, only significantly present in the younger subgroup of patients. In patients not treated with chemotherapy, diffuse gray and white matter volume reduction was observed. Less white matter expansion concurred with more cognitive decline (r > .349, p < .05). In conclusion, we found age-dependent cognitive decline and white matter volume changes in patients with breast cancer after chemotherapy, which could possibly be linked to neuroinflammatory processes. White matter expansion after chemotherapy, more pronounced in premenopausal patients, correlated with less cognitive decline. This suggests such expansion to be age-dependent, possibly caused by a protective response in the younger brain to chemotherapy-induced neurotoxicity.

Impact of Lung Cancer Treatment on Cognitive Functioning

The impact of oncologic treatment for (non)-small-cell lung cancer (NSCLC and SCLC, respectively) on cognition is relevant when deciding which treatment is the most preferable option, especially when curation is not possible. A systematic search of Medline and EMBASE for studies on the effect of treatment on cognition in patients with lung cancer was performed. A total of 39 longitudinal articles were included. Study populations were heterogeneous with regards to stage and treatment type. In the 7 studies concerning SCLC, the median age of patients was between 59 and 68 years. Eighty-six percent of these studies had a loss to follow-up > 10%. Six studies used objective tests to assess cognition. Objective measurements showed a negative effect on attention, memory, and fluency after treatment. Thirty-three studies concerning NSCLC were included. The mean age of patients was between 53 and 77 years. Seventy percent of these studies included patients with stage III and IV NSCLC. Over one-half of the studies had a high rate of loss to follow-up. Eighty-eight percent used objective scales to assess cognitive functioning. Subjective decline of cognitive functioning up to 11.1% was experienced, with recovery at 4 to 6 months. Objective measurement of attention showed improvement over the course of chemotherapy. In SCLC, there is a significant negative effect on attention, memory, and fluency. In NSCLC, the longer term impact of treatment on both subjective and objective cognitive functioning appears limited. Thus, there is no evidence directing treatment choice for NSCLC based on longer term cognitive deficits. Further research is needed to precisely assess the impact of lung cancer treatment on cognition.

Plausible biochemical mechanisms of chemotherapy-induced cognitive impairment ("chemobrain"), a condition that significantly impairs the quality of life of many cancer survivors

Increasing numbers of cancer patients survive and live longer than five years after therapy, but very often side effects of cancer treatment arise at same time. One of the side effects, chemotherapy-induced cognitive impairment (CICI), also called "chemobrain" or "chemofog" by patients, brings enormous challenges to cancer survivors following successful chemotherapeutic treatment. Decreased abilities of learning, memory, attention, executive function and processing speed in cancer survivors with CICI, are some of the challenges that greatly impair survivors' quality of life. The molecular mechanisms of CICI involve very complicated processes, which have been the subject of investigation over the past decades. Many mechanistic candidates have been studied including disruption of the blood-brain barrier (BBB), DNA damage, telomere shortening, oxidative stress and associated inflammatory response, gene polymorphism of neural repair, altered neurotransmission, and hormone changes. Oxidative stress is considered as a vital mechanism, since over 50% of FDA-approved anti-cancer drugs can generate reactive oxygen species (ROS) or reactive nitrogen species (RNS), which lead to neuronal death. In this review paper, we discuss these important candidate mechanisms, in particular oxidative stress and the cytokine, TNF-alpha and their potential roles in CICI.

Monitoring neurocognitive functioning in childhood cancer survivors: evaluation of CogState computerized assessment and the Behavior Rating Inventory of Executive Function (BRIEF)

BACKGROUND

Many childhood cancer survivors develop neurocognitive impairment, negatively affecting education and psychosocial functioning. Recommended comprehensive neuropsychological testing can be time- and cost- intensive for both institutions and patients and their families. It is important to find quick and easily administered surveillance measures to identify those in need of evaluation.

METHODS

We evaluated, individually and in combination, the sensitivity and specificity of the 1) Behavior Rating Inventory of Executive Functioning-Metacognition Index (BRIEF-MCI), and 2) CogState Composite Index (computerized assessment of cognition) in identifying below grade-level performance on state-administered tests of reading and mathematics among childhood cancer survivors.

RESULTS

The 45 participants (39% female) were a mean age of 7.1 ± 4.4 years at diagnosis, 14.0 ± 3.0 at evaluation, with a history of leukemia (58%), lymphoma (9%), central nervous system tumors (20%), and other tumors (13%). Impairment on the BRIEF-MCI was associated with low sensitivity (26% reading, 41% mathematics) but stronger specificity (88% reading, 96% mathematics). We found similar associations for the CogState Composite Index with sensitivity of 26% for reading and 29% for mathematics and specificity of 92% for both reading and mathematics. Combining the two measures did not improve sensitivity appreciably (47% reading, 59% mathematics) while reducing specificity (84% reading, 88% mathematics).

CONCLUSIONS

While individuals identified from the BRIEF-MCI or CogState Composite would likely benefit from a full neuropsychological evaluation given the strong specificity, use of these measures as screening tools is limited. With poor sensitivity, they do not identify many patients with academic difficulties and in need of a full neuropsychological evaluation. Continued effort is required to find screening measures that have both strong sensitivity and specificity.

Changes in health-related quality of life among gynecologic cancer survivors during the two years after initial treatment: a longitudinal analysis

Background: While many cancer survivors experience persistent impairments in health-related quality of life (HRQoL) for extended periods of time, others recover soon after treatment. The aim of this research is to assess changes in health-related quality of life in endometrial and ovarian cancer survivors during two years post initial treatment, and to assess clinical and sociodemographic characteristics associated with those changes. Methods: This prospective population-based cohort study includes longitudinal data of endometrial (N = 221) and ovarian (N = 174) cancer survivors diagnosed between 2011 and 2014. The EORTC QLQ-C30 functioning scales were used to assess HRQoL after initial treatment and after 6, 12 and 24 months. Clinical (stage, treatment and comorbidities) and sociodemographic (age, marital status and socio-economic status) characteristics were obtained from the Netherlands Cancer Registry and through self-administered questionnaires. Linear mixed models were used to assess changes in HRQoL over time and characteristics associated with these changes. Results: Among both endometrial and ovarian cancer patients, HRQoL improved within the first 6 months after initial treatment. Changes in HRQoL were mainly associated with clinical characteristics including comorbidities, treatment and tumor stage, and to a lesser extent with sociodemographic characteristics such as socioeconomic status. However, these associations varied per tumor type. Endometrial cancer survivors, who received radiotherapy and had no comorbidities, reported greater improvements in some HRQoL scales over time. Ovarian cancer patients who received chemotherapy and with advanced tumor stages reported poorer functioning during treatment. Most functioning domains (global health, physical and role functioning) recovered to levels of patients without chemotherapy or with early-stage disease after 12 months, but cognitive and social functioning remained impaired. Conclusion: Some subgroups of patients, including those with multiple comorbidities, with an advanced tumor stage and who received chemotherapy, may be in need of additional support as they are less likely to show improvements in HRQoL over time.

Interactions between antidepressants, sleep aids and selected breast cancer therapy

Depression and insomnia are very significant pathologies in cancer patients as they contribute to the patient’s overall cure and quality of life. Moreover, untreated depression and ongoing insomnia are associated with decreased immune responses and lower survival rates. With all disease states and especially with cancer, close attention to drug-drug interactions and the potential impact on the efficacy of therapy is paramount. One area of particular interest due to the lack of well-done clinical trials is drug-drug interaction(s) between antidepressants and cancer treatment. Pharmacokinetics of a certain drug allows for prediction of certain drug interactions based on chemical properties of the agents involved. If the agents depend on their metabolites for activity, active drug level will be decreased through this enzyme inhibition. In this paper, we looked at the cytochrome-P450 drug interactions between antidepressants and sleep aids with Selective Estrogen Receptor Modulators (SERM). Newer SERM metabolisms are less influenced by interactions with medications used to treat depression. However, tamoxifen metabolism could be severely altered by several antidepressants. This has direct consequences as patients on tamoxifen and antidepressant can have double the risk of relapse to cancer in two years. We discussed those interactions and made recommendations for clinical use.

Ferroptosis in Neurons and Cancer Cells Is Similar But Differentially Regulated by Histone Deacetylase Inhibitors

Ferroptotic death is a mechanism for tumor suppression by pharmacological inhibitors that target the X_c⁻ transporter (cystine/glutamate antiporter) in a host of non-CNS and CNS tumors. Inhibition of this transporter leads to reduction of cystine uptake, cyst(e)ine deprivation, subsequent depletion of the versatile antioxidant glutathione, and reactive lipid species-dependent death. Accordingly, pharmacological inhibitors of the X_c⁻ transporter can also induce neuronal cell death raising concerns about toxicity in the CNS and PNS if these agents are used for chemotherapy. Here, we show that ferroptotic death induced by the canonical ferroptosis inducer erastin is similar in HT1080 fibrosarcoma cells and primary cortical neurons although cell death is mediated more potently in cancer cells. Reducing the toxicity of ferroptosis inducers will require, among other things, the identification of agents that protect neurons from ferroptosis but exacerbate it in tumor cells. Although we show that a number of agents known to block ferroptosis in primary mouse neurons also inhibit ferroptosis in fibrosarcoma cells, class I histone deacetylase (HDAC) inhibitors selectively protect neurons while augmenting ferroptosis in cancer cells. Our results further suggest that cell death pathways induced by erastin in these two cell types are statistically identical to each other and identical to oxidative glutamate toxicity in neurons, where death is also mediated via inhibition of X_c⁻ cystine transport. Together, these studies identify HDACs inhibitors as a novel class of agents to augment tumor suppression by ferroptosis induction and to minimize neuronal toxicity that could manifest as peripheral neuropathy or chemo brain.

Cognitive impairment following chemotherapy for breast cancer: The impact of practice effect on results

Chemotherapy-Related Cognitive Impairment (CRCI) can be an adverse effect in women treated for breast cancer. Some longitudinal studies reported deficits in attention, memory, and executive function following treatment, but other studies did not find cognitive changes. It is known that practice effects (PE) on repeated assessments with cognitive tests contribute to the discrepancies in these results, but its influence on scores has not been systematically explored. The present study examines the impact of PE on retest scores in a group of women with breast cancer treated with chemotherapy and evaluated longitudinally.

METHOD

51 women with breast cancer treated with a combination of 5-fluorouracil, epirubicin, and cyclophosphamide with or without taxanes were assessed after surgery but before chemotherapy (T1), post-chemotherapy (T2), and at one year after T2 (T3). Longitudinal changes on cognitive performance were analyzed twice: when retest scores were not corrected for PE and when correction for PE was applied to T2 and T3 scores.

RESULTS

When PE was not corrected, progressive improvement over time in measures of memory and divided attention at T2 and T3 was observed. In contrast, when PE was corrected, worsening was found in measures of memory, fluency, executive function, and attention at T2 and in attention and executive function at T3. Results after correction for PE are in line with previous longitudinal studies that report cognitive impairment after treatment with chemotherapy for breast cancer.

CONCLUSION

Accounting for PE is recommended to identify true change on cognition through treatment with chemotherapy for breast cancer.

Mindfulness-based interventions and cognitive function among breast cancer survivors: a systematic review

Background

Breast cancer survivors have an elevated risk of cognitive impairment compared to age-matched women without cancer. Causes of this impairment are complex, including both treatment and psychological factors. Mindfulness-based interventions, which have been shown to improve cognitive function in the general population, may be one approach to mitigate cognitive impairment in this survivor population. Our objective was to conduct a systematic literature review of studies on the effect of mindfulness-based interventions on cognition among breast cancer survivors.

Methods

We conducted searches of three electronic databases (Scopus, PubMed and Cochrane Database of Systematic Reviews) in September 2017 for studies pertaining mindfulness and cognitive function among breast cancer survivors. Abstracts were manually searched by two reviewers and additional articles were identified through reference lists.

Results

A total of 226 articles were identified through our systematic search and six met inclusion criteria for this review. The reviewed studies lacked consistency in terms of the cognition domains studied (e.g. executive function, recent memory, etc) and in the measures used to assess cognition. Of the included studies, two found no association between mindfulness interventions and cognitive function, two found improvement that was not sustained at the follow-up, and another two found sustained improvement at 2- or 6-months.

Conclusions

Mindfulness-based interventions have shown some evidence for improving cognition among breast cancer survivors, but further research using validated and comprehensive cognitive assessments is needed. More research is also needed related to the timing, duration and content of mindfulness interventions.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5065-3) contains supplementary material, which is available to authorized users.

Distinct attentional function profiles in older adults receiving cancer chemotherapy

PURPOSE

While attentional function is an extremely important patient outcome for older adults, research on changes in function in this group is extremely limited. The purposes of this study were to: identify subgroups of older patients (i.e., latent growth classes) based on changes in their level of self-reported attentional function; determine which demographic and clinical characteristics were associated with subgroup membership; and determine if these subgroups differed on quality of life (QOL) outcomes.

METHODS

Older oncology outpatients (n = 365) who were assessed for changes in attention and working memory using the Attentional Function Index a total of six times over two cycles of chemotherapy (CTX). QOL was assessed using the Medical Outcomes Study-Short Form 12 and the QOL-Patient Version Scale. Latent profile analysis (LPA) was used to identify subgroups of older adults with distinct attentional function profiles.

RESULTS

Three distinct attentional functional profiles were identified (i.e., low, moderate, and high attentional function). Compared to the high class, older adults in the low and moderate attentional function classes had lower functional status scores, a worse comorbidity profile and were more likely to be diagnosed with depression. In addition, QOL scores followed an expected pattern (low class < moderate class < high attentional function class).

CONCLUSIONS

Three distinct attentional function profiles were identified among a relatively large sample of older adults undergoing CTX. The phenotypic characteristics associated with membership in the low and moderate latent classes can be used by clinicians to identify high risk patients.

Efficacy of Acupuncture Therapy for Chemotherapy-Related Cognitive Impairment in Breast Cancer Patients

Background

Chemotherapy can cause adverse effects such as chemotherapy-related cognitive impairment (CRCI). In this prospective study, the efficacy of traditional Chinese medicine acupuncture therapy in relieving CRCI and its impact on serum brain-derived neurotrophic factor (BDNF) are evaluated.

Material/Methods

Eighty patients were randomly divided into a treatment group and a control group with 40 patients in each group. The treatment group was treated at the following acupuncture points: Baihui (DU20), Sishencong (EX-HN1), Shenting (DU24), Zusanli (ST36), Taixi (K13), Dazhong (K14), and Juegu (GB39). Cognitive function was assessed using the functional assessment of cancer treatment cognition test (FACT-COG, version 3), the auditory-verbal learning test (AVLT), the verbal fluency test (VFT), the symbol digit modality test (SDMT), the clock-drawing test (CDT), and the trail-making test part B (TMT-B). In addition, blood serum levels of BDNF were measured before and after treatment. Correlations between change in BDNF levels and cognitive function were also analyzed.

Results

CRCI was ameliorated in the acupuncture treatment group, with scores on FACT-COG, AVLT-recognition and CDT assessments all significantly increased (P<0.05 in all cases). In addition, serum BDNF levels after acupuncture treatment were significantly higher than before treatment (t=3.242, P<0.01). Moreover, the level of BDNF was positively correlated with the total score of FACT-COG, AVLT-recognition, and CDT (r=0.694, 0.628, and 0.532, respectively; all P<0.05). The control group showed no statistically significant difference in any measures over the same period.

Conclusions

Acupuncture therapy is effective in the treatment of CRCI in breast cancer patients through a mechanism that may be related to an increase of BDNF.

A vanillin-based copper(ii) metal complex with a DNA-mediated apoptotic activity

Vanillin (vanH) is the major component of vanilla and one of the most widely used flavoring agents. In this work the complex [Cu(phen)(van)2] was prepared and characterized by structural (X-ray), spectroscopic (IR, UV-Vis, EPR) and electrochemical techniques. This compound showed an octahedral geometry with an unusual arrangement of the vanillin ligands, where the methoxy groups of the vanillinate ions are coordinated opposite to each other. The compound promoted DNA cleavage in the presence of glutathione (GSH) and H2O2. At 40 μmol L-1 of complex with GSH (10 mmol L-1), there is a complete cleavage of DNA to nicked form II, while only at 10 μmol L-1 of this complex with H2O2 (1 mmol L-1) an extensive cleavage leading to form III took place. Additionally, we have evidences of superoxide generation upon reaction with GSH. Therefore, DNA fragmentation occurs likely through an oxidative pathway. MTT assays indicated that the complex is highly cytotoxic against three distinct cell lines: B16-F10 (IC50 = 3.39 ± 0.61 μmol L-1), HUH-7 (IC50 = 4.22 ± 0.31 μmol L-1) and 786-0 (IC50 = 10.38 ± 0.91 μmol L-1). Flow cytometry studies conducted with 786-0 cell line indicated cell death might occur by apoptosis. Cell cycle progression evaluated at 5 and 10 μmol L-1 resulted in a clear increase of 786-0 cells at G1 phase and depletion of G2/M, while higher doses showed an expressive increase of sub-G1 phase. Altogether, these results pointed out to a promising biological activity and potential as an anti-cancer agent.