New approaches to understand cognitive changes associated with chemotherapy for non-central nervous system tumors

Characterizing changes in executive functions and performance in daily activities after chemotherapy: A pre-post mixed-methods study protocol

BACKGROUND

Impairments in higher cognitive abilities (termed executive functions (EF) are common among individuals with cancer following chemotherapy and may impact their performance of daily activities. Our aim is to better understand the changes in EF and the impact on performance in daily activities of individuals with cancer pre- and post-chemotherapy.

METHODS

A convergent parallel mixed-method pre-post experimental design. Qualitative and quantitative data will be collected pre- and post-chemotherapy (12 weeks following chemotherapy commencement). Participants will be adult candidates for chemotherapy who are newly diagnosed with non-central nervous system malignancy, stages I-III. The Canadian Occupational Performance Measure will assess the performance of daily activities; secondary measures include EF, cognitive functioning, fatigue, and emotional well-being. Qualitative data will be collected via open-ended questions. Pre- and post-chemotherapy, quantitative and qualitative data will be analyzed separately and merged into an overall interpretation. It is expected that, pre-chemotherapy, no difficulties in performing daily activities will be revealed. Post-chemotherapy EF impairments will be apparent and their impact on the performance of daily activities will be identified.

CONCLUSIONS

Integrating quantitative and qualitative measures will contribute to a comprehensive understanding of the individuals' cognitive needs and may enable the development of effective interventions to minimize deterioration in daily activities after chemotherapy.

Dynamin-1 is a potential mediator in cancer-related cognitive impairment

Dynamin-1 (DNM1) is crucial for synaptic activity, neurotransmission, and associative memory, positioning it as a potential biomarker of cancer-related cognitive impairment (CRCI), a neurological consequence of cancer treatment characterized by memory loss, poor concentration, and impaired executive function. Through a stepwise approach, this study investigated the role of DNM1 in CRCI pathogenesis, incorporating both human data and animal models. The human study recruited newly diagnosed, chemotherapy-naïve adolescent and young adult cancer and non-cancer controls to complete a cognitive instrument (FACT-Cog) and blood draws for up to three time points. Following that, a syngeneic young-adult WT (C57BL/6) female mouse model of breast cancer chemobrain was developed to study DNM1 expression in the hippocampus. Samples from eighty-six participants with 30 adolescent and young adult (AYA) cancer and 56 non-cancer participants were analyzed. DNM1 levels were 32 ​% lower (P ​= ​0.041) among cancer participants compared to non-cancer prior to treatment. After receiving cytotoxic treatment, cognitively impaired cancer patients were found to have 46 ​% lower DNM1 levels than those without impairment (P ​= ​0.049). In murine breast cancer-bearing mice receiving chemotherapy, we found a greater than 40 ​% decline (P ​< ​0.0001) in DNM1 immunoreactivity in the hippocampal CA1 and CA3 subregions concurrent with a deterioration in spatial recognition memory (P ​< ​0.02), compared to control mice without exposure to cancer and chemotherapy. Consistently observed in both human and animal studies, the downregulation of DNM1 is linked with the onset of CRCI. DNM1 might be a biomarker and therapeutic target for CRCI.

Dynamin-1 is a potential mediator in Cancer-Related Cognitive Impairment

Dynamin-1 (DNM1) consolidates memory through synaptic transmission and modulation and has been explored as a therapeutic target in Alzheimer's disease. Through a two-prong approach, this study examined its role in cancer-related cognitive impairment (CRCI) pathogenesis using human and animal models. The human study recruited newly diagnosed, chemotherapy-naïve adolescent and young adult cancer and non-cancer controls to complete a cognitive instrument (FACT-Cog) and blood draws for up to three time points. Concurrently, a syngeneic young-adult WT (C57BL/6 female) mouse model of breast cancer was developed to study DNM1 expression in the brain. Samples from eighty-six participants with 30 adolescent and young adult (AYA) cancer and 56 non-cancer participants were analyzed. DNM1 levels were significantly lower among cancer participants compared to non-cancer prior to treatment. While receiving cancer treatment, cognitively impaired patients were found with a significant downregulation of DNM1, but not among those without impairment. In murine breast cancer-bearing mice receiving chemotherapy, we consistently found a significant decline in DNM1 immunoreactivity in the hippocampal CA1 and CA3 subregions. Observed in both human and animal studies, the downregulation of DNM1 is linked with the onset of CRCI. Future research should explore the potential of DNM1 in CRCI pathogenesis and therapeutics development.

Artificial and natural interventions for chemotherapy- and / or radiotherapy-induced cognitive impairment: A systematic review of animal studies

BACKGROUND

Cancer survivors frequently experience cognitive impairments. This systematic review assessed animal literature to identify artificial (pharmaceutical) or natural interventions (plant/endogenously-derived) to reduce treatment-related cognitive impairments.

METHODS

PubMed, EMBASE, PsycINFO, Web of Science, and Scopus were searched and SYRCLE's tool was used for risk of bias assessment of the 134 included articles.

RESULTS

High variability was observed and risk of bias analysis showed overall poor quality of reporting. Results generally showed positive effects in the intervention group versus cancer-therapy only group (67% of 156 cognitive measures), with only 15 (7%) measures reporting cognitive impairment despite intervention. Both artificial (61%) and natural (75%) interventions prevented cognitive impairment. Artificial interventions involving GSK3B inhibitors, PLX5622, and NMDA receptor antagonists, and natural interventions utilizing melatonin, curcumin, and N-acetylcysteine, showed most consistent outcomes.

CONCLUSIONS

Both artificial and natural interventions may prevent cognitive impairment in rodents, which merit consideration in future clinical trials. Greater consistency in design is needed to enhance the generalizability across studies, including timing of cognitive tests and description of treatments and interventions.

Neuroimaging based biotypes for precision diagnosis and prognosis in cancer-related cognitive impairment

Cancer related cognitive impairment (CRCI) is commonly associated with cancer and its treatments, yet the present binary diagnostic approach fails to capture the full spectrum of this syndrome. Cognitive function is highly complex and exists on a continuum that is poorly characterized by dichotomous categories. Advanced statistical methodologies applied to symptom assessments have demonstrated that there are multiple subclasses of CRCI. However, studies suggest that relying on symptom assessments alone may fail to account for significant differences in the neural mechanisms that underlie a specific cognitive phenotype. Treatment plans that address the specific physiologic mechanisms involved in an individual patient's condition is the heart of precision medicine. In this narrative review, we discuss how biotyping, a precision medicine framework being utilized in other mental disorders, could be applied to CRCI. Specifically, we discuss how neuroimaging can be used to determine biotypes of CRCI, which allow for increased precision in prediction and diagnosis of CRCI via biologic mechanistic data. Biotypes may also provide more precise clinical endpoints for intervention trials. Biotyping could be made more feasible with proxy imaging technologies or liquid biomarkers. Large cross-sectional phenotyping studies are needed in addition to evaluation of longitudinal trajectories, and data sharing/pooling is highly feasible with currently available digital infrastructures.

Assessing cancer-related cognitive function in the context of everyday life using ecological mobile cognitive testing: A protocol for a prospective quantitative study

Objective

Millions of cancer survivors are at risk for cancer-related cognitive impairment (CRCI), yet accurate and accessible assessments of cognitive functioning remain limited. Ecological mobile cognitive testing (EMCT) could offer a solution. This paper presents the protocol for a study that aims to (1) establish the reliability and validity of EMCT to assess CRCI in breast cancer survivors, and (2) prospectively evaluate within-person processes (and interactions) among context, mood, and behavior that explain cognitive variability, everyday functioning, and quality of life of cancer survivors.

Methods

Participants will include breast cancer survivors (>21 years old) who are within 5 years of completing chemotherapy treatment. Participants will complete two virtual visits (baseline, follow-up) 2 months apart to assess self-reported cognitive symptoms and cognitive performance, sociodemographic characteristics, clinical history, everyday functioning, and quality of life. Between virtual visits, EMCT will be used to sample cognitive functioning every other day (28 times total). We will use linear mixed-effect regressions and single-level multiple regression models to analyze the data.

Results

We anticipate a minimum of 124 breast cancer survivors enrolling and completing data collection. Study results will be published in peer-reviewed scientific journals.

Conclusions

Our findings will have broad implications for assessing CRCI in an ecologically valid and person-centered way using EMCT. We aim to provide this protocol to aid researchers who would like to apply this approach to their studies.

Impact of psychosocial, behavioral and lifestyle factors on subjective cognitive complaints and perceived quality of life in a large cohort of Italian breast cancer patients

The impact of psychosocial and behavioral factors on Cancer Related Cognitive Impairment manifestations is still under debate. Study's purpose is to determine the prevalence rate of cancer related cognitive impairment in a cohort of Italian breast cancer patients and to evaluate the implication of specific behavioral factors. For these purposes, a total of 233 women (106 breast cancer patients and 127 age-matched controls without oncological diagnosis) completed a questionnaire investigating cognitive functionality (FACT-Cog v3.0), sociodemographic characteristics, clinical information, psychosocial and behavioral factors (cognitive reserve, sleep quality, dietary habits, physical activity). The results indicated a higher prevalence rate of subjective cognitive complaints in breast cancer patients (37%) compared to a representative sample of women in the same age group without an oncological diagnosis (p < 0.001). Moreover, breast cancer patients showed significantly lower levels of cognitive reserve (p < 0.05) and worse sleep quality (p < 0.01) compared to age-matched controls. Further analysis revealed that breast cancer patients reporting subjective cognitive complaints differed significantly from breast cancer patients without subjective cognitive complaints on measures of perceived cognitive abilities (p < 0.001) and on the impact of cognitive difficulties on perceived quality of life (p < 0.01). Future studies are needed to examine behavioral directed interventions to prevent subjective cognitive deficits in breast cancer patients.

Can neuropsychological testing be improved with model-based approaches?

There has been little impact of cognitive psychology and modeling on neuropsychological testing for over 50 years. There is also a disconnect between those tests and the constructs they are said to measure. We discuss studies at the interface between testing and modeling that illustrate the opportunity for advances.

The Psychological Distress and Quality of Life of Breast Cancer Survivors in Sydney, Australia

In Australia, breast cancer is one of the most common cancers affecting women. Between 1987-1991 and 2012-2016, the five-year survival rate improved from 75% to 91%. The increased chance of survival due to early detection and treatment interventions has resulted in more women living with the diagnosis. This qualitative study was designed to analyse the journey of breast cancer survivors, their experience of psychological distress and changes in quality of life (QOL) due to the increased prevalence amongst Australian women. In-depth interviews were conducted; they lasted over 45 min and comprised 15 participants. The main topics discussed were knowledge of breast cancer prior to diagnosis, psychological distress, QOL and experience of use of healthcare services. The results showed that the process of diagnosis, undergoing treatment and isolation post-treatment resulted in high amounts of psychological distress. A reduction in QOL was also experienced due to treatment and medication side effects, fatigue, cognitive changes, and body-image perception. These findings can assist researchers in providing evidence-based frameworks for policy changes and for further investigation into effective healthcare interventions.

Establishing construct validity of neuropsychological tests in cancer survivors

OBJECTIVE

Cancer-related cognitive impairments (CRCI) are frequently reported among cancer survivors, and attention is the most frequently assessed cognitive domain in CRCI. However, there is no consensus as to whether attention is impaired. We suggest that a major reason for this lack of agreement is a lack of construct validity for neuropsychological attention tests. We propose to assess the construct validity of neuropsychological attention tests with respect to experimental paradigms from cognitive psychology.

METHODS

Self-reported cancer survivors (N = 314) completed an online battery comprising six experimental attention paradigms and eight neuropsychological tests. Confirmatory factor analysis was used to evaluate the fit of five models derived from a general population sample (N = 636) in a previous study ¹ . We then subjected the best-fitting model to a measurement invariance analysis.

RESULTS

The best-fitting model was a six intercorrelated factor structure, comprising Capacity, Search, Digit Span, Arithmetic, Sustained Attention, and Flanker Interference factors. Configural and weak invariance held, indicating that the factor loadings were invariant across groups. Strong invariance, indicating that intercepts were also invariant, held except for the Approximate Number Sense test.

CONCLUSIONS

According to our factor model, Spatial Span and Digit Symbol Coding measure attentional capacity, while the Trail Making Test (A&B) and Letter Cancellation tests measure visual search ability. However, Digit Span and Arithmetic tests do not measure attention. We hope that these results will lead to better scientific models, better patient education, and, ultimately, improved outcomes for survivors. This article is protected by copyright. All rights reserved.

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

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

How do we measure attention? Using factor analysis to establish construct validity of neuropsychological tests

We investigated whether standardized neuropsychological tests and experimental cognitive paradigms measure the same cognitive faculties. Specifically, do neuropsychological tests commonly used to assess attention measure the same construct as attention paradigms used in cognitive psychology and neuroscience? We built on the “general attention factor”, comprising several widely used experimental paradigms (Huang et al., 2012). Participants (n = 636) completed an on-line battery (TestMyBrain.org) of six experimental tests [Multiple Object Tracking, Flanker Interference, Visual Working Memory, Approximate Number Sense, Spatial Configuration Visual Search, and Gradual Onset Continuous Performance Task (Grad CPT)] and eight neuropsychological tests [Trail Making Test versions A & B (TMT-A, TMT-B), Digit Symbol Coding, Forward and Backward Digit Span, Letter Cancellation, Spatial Span, and Arithmetic]. Exploratory factor analysis in a subset of 357 participants identified a five-factor structure: (1) attentional capacity (Multiple Object Tracking, Visual Working Memory, Digit Symbol Coding, Spatial Span), (2) search (Visual Search, TMT-A, TMT-B, Letter Cancellation); (3) Digit Span; (4) Arithmetic; and (5) Sustained Attention (GradCPT). Confirmatory analysis in 279 held-out participants showed that this model fit better than competing models. A hierarchical model where a general cognitive factor was imposed above the five specific factors fit as well as the model without the general factor. We conclude that Digit Span and Arithmetic tests should not be classified as attention tests. Digit Symbol Coding and Spatial Span tap attentional capacity, while TMT-A, TMT-B, and Letter Cancellation tap search (or attention-shifting) ability. These five tests can be classified as attention tests.

Cognitive Perception among Post-Chemotherapy, Non-Chemotherapy Breast Cancer Survivors and Non-Cancer

Objective:

This study aims to compare the cognitive function perceived by post-chemotherapy breast cancer survivors, breast cancer survivors without chemotherapy, and non-cancer woman patients.

Methods:

This study was conducted by a descriptive comparative method. The respondents consisted of 82 survivors of post-chemotherapy breast cancer, 81 non-chemotherapy breast cancer survivors, and 80 non-cancer woman patients who were recruited using consecutive sampling. The data were collected from October until December 2017 by using a FACT-Cog version 3 questionnaire. Data analysis was performed by using a comparative test of Kruskal-Wallis followed by a Mann-Whitney posthoc analysis.

Results:

The results showed that the median of cognitive function perception in breast cancer survivors post-chemotherapy, non-chemotherapy, and non-cancerous women are 94 (52-122), 113 (53-130), and 121 (69-132), respectively. Mann-Whitney’s post-hoc analysis showed a significantly different perception of cognitive function between post-chemotherapy survivors and non-chemotherapy survivors; also between post-chemotherapy survivors and non-cancer women, and between non-chemotherapy survivors with non-cancer women.

Conclusion:

Perceived cognitive impairment, comments from others, perceived cognitive abilities, and effects on quality of life in breast cancer survivors who received chemotherapy are significantly different as compared to the survivor group without chemotherapy and non-cancerous healthy women.

Evaluation of mid-term (6-12 months) neurotoxicity in B-cell lymphoma patients treated with CAR T-cells: a prospective cohort study

BACKGROUND

CAR T-cells are profoundly changing the standard of care in B-cell malignancies. This new therapeutic class induces a significant number of acute neurotoxicity, but data regarding mid and long-term neurological safety are scarce. We evaluated mid-term neurological safety, with special emphasis on cognitive functions, in a series of adults treated with CAR T-cells.

METHODS

Patients treated in a single centre with CD19-targeted CAR T-cells for a relapsing B-cell lymphoma were prospectively followed-up by neurologists. Before CAR T-cells infusion, all patients underwent neurological examinations with neuropsychological testing, and filled out questionnaires assessing anxiety, depression and cognitive complains. Patients surviving without tumour progression were re-evaluated similarly, six to 12 months later.

RESULTS

In this prospective cohort of 56 consecutive adult patients treated with CAR T-cells, 27 were eligible for mid-term evaluation (median time 7.6 months). Twelve patients developed an acute and reversible neurotoxicity with median duration time of 5.5 days. In all patients, neurological examination on mid-term evaluation was similar to baseline. In self-assessment questionnaires, 63% of patients reported clinically meaningful anxiety, depression or cognitive difficulties at baseline, a number reduced to 44% at time of mid-term evaluation. On cognitive assessments, no significant deterioration was found when compared to baseline, in any cognitive functions assessed (verbal and visual memory, executive functions, language and praxis), even in patients who developed acute neurotoxicity.

CONCLUSION

In this cohort of patients treated with CD19-targeted CAR-T cells , we found no evidence for neurological or cognitive toxicity, 6 and 12 months after treatment.

Measuring Self-Reported Cancer-Related Cognitive Impairment: Recommendations From the Cancer Neuroscience Initiative Working Group

Cancer and its treatments are associated with increased risk for cancer-related cognitive impairment (CRCI). Methods and measures used to study and assess self-reported CRCI (sr-CRCI), however, remain diverse, resulting in heterogeneity across studies. The Patient-Reported Outcomes Working Group has been formed to promote homogeneity in the methods used to study sr-CRCI. In this report, using a psychometric taxonomy, we inventory and appraise instruments used in research to measure sr-CRCI, and we consider advances in patient-reported outcome methodology. Given its psychometric properties, we recommend the Patient-Reported Outcome Measurement Information System Cognitive Function Short Form 8a for measurement of sr-CRCI in cancer patients and survivors, at a minimum, to increase scientific rigor and progress in addressing CRCI.

Prevalence of cognitive impairment and change in patients with breast cancer: A systematic review of longitudinal studies

OBJECTIVE

Patients with breast cancer face cognitive impairment that affects their quality of life; partially attributable to treatment. Our aim was to detail the prevalence and change of cognitive impairment during the course of treatment. We also investigated the effect of therapy (chemotherapy [CT]) vs. radiotherapy and/or endocrine therapy vs. healthy controls).

METHODS

This article reviews longitudinal cohort studies published to date in Medline and Embase that (i) assess cognition before and after therapy, (ii) report prevalence cognitive impairment or change, and (iii) use standardized and valid neuropsychological tests. We used the original authors' criteria for cognitive impairment.

RESULTS

The title and abstract of 891 articles were screened, resulting in the identification of 90 potentially relevant articles while applying the eligibility criteria. After full-text examination, 17 studies were included. Prevalence of cognitive impairment range from 25% before therapy, through 24% after therapy to 21% at maximal 1-year follow-up (FU). Compared to their pretreatment cognitive functioning, 24% of patients decline after treatment and 24% at 1-year FU. Some studies also reported cognitive improvement showing that 15% and 31% of patients improve, respectively. In general, patients undergoing CT have a higher chance of cognitive impairment and decline than no-CT patients and healthy controls.

CONCLUSIONS

This study shows that one out of four breast cancer patients shows cognitive impairment prior to treatment administration CT and a significant number of patients decline during the course of disease, suggesting that cognitive impairment is not exclusively related to CT and/or no-CT therapies. This study shows that assessment of cognitive functioning, ideally over time, is crucial and may help the implementation of personalized rehabilitation pathways.

A randomized control trial of meditation compared to music listening to improve cognitive function for breast cancer survivors: Feasibility and acceptability

BACKGROUND

and Purpose: Many breast cancer survivors (BCS) experience persistent cognitive and psychological changes associated with their cancer and/or treatment and that have limited treatment options. Therefore, the purpose of this study was to explore the feasibility and effects of a Kirtan Kriya meditation (KK) intervention on cognitive and psychological symptoms compared to an attention control condition, classical music listening (ML), in BCS.

MATERIALS AND METHODS

A randomized control trial design was used. Participants completed eight-week interventions. Cognitive function and psychological symptoms were measured at baseline and post-intervention. Mixed analysis of variance models were examined for all cognitive and psychological outcomes.

RESULTS

27 BCS completed the study. Intervention adherence was 88%. Both groups improved in perceived cognitive impairments, cognition related quality of life, verbal memory, and verbal fluency (p's < 0.01). There were no significant group by time effects for cognitive and psychological outcomes, except stress. The ML group reported lower stress at time 2 (p < 0.05).

CONCLUSION

KK and ML are feasible, acceptable, and cost-effective interventions that may be beneficial for survivors' cognition and psychological symptoms. Both interventions were easy to learn, low cost, and required just 12 min/day. Meditation or music listening could offer providers evidence-based suggestions to BCS experiencing cognitive symptoms.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03696056.

Heterogeneous Response of Chemotherapy-Related Cognitive Decline in Patients with Breast Cancer: A Prospective Study

OBJECTIVE

A significant proportion of adjuvant-treated breast cancer patients experience cognitive decline, challenging the person's ability to return to normal activities after treatment. However, not every patient experiences cognitive problems, and even in patients with impairments, determining clinically important cognitive decline remains challenging. Our objective was to explore differences in neuropsychological performance following adjuvant chemotherapy (CT) in patients with breast cancer.

METHOD

We conducted a prospective observational study in an Oncology Breast Clinic and assessed neuropsychological performance before and after adjuvant CT and in non-CT-treated women with breast cancer and healthy controls (HCs). Standardised between-group differences and regression-based change scores were calculated.

RESULTS

CT-treated patients (n = 66) performed significantly different from non-CT-treated patients (n = 39) and HCs (n = 56). There was a significant effect on verbal fluency (p = .0013). CT performed significantly worse than non-CT and HC [effect size (ES) = .89, p < .001 and ES = .61, p ≤ .001, respectively] and from HCs with regard to proactive interference (ES = .62, p ≤ .001). Regression-based scores revealed more severe cognitive decline in the CT-treated group [24.24% (16/66)] than in the non-CT-treated group [15.20% (6/39)] and HC group [7.14% (4/56)]. Patients who underwent CT and showed cognitive decline were less educated and older, with significantly lower baseline scores.

CONCLUSIONS

CT-treated patients showed more vulnerability on cognitive control and monitoring than non-CT-treated breast cancer patients and HCs. Older patients with less education and lower baseline cognitive performance represent a group at risk for cognitive decline following CT. Identification of patients at risk for decline could improve targeted support and rehabilitation.

Understanding the Profile of Cancer-Related Cognitive Impairments: A Critique of Meta-Analyses

A large body of evidence indicates that cancer survivors who have undergone chemotherapy have cognitive impairments. Substantial disagreement exists regarding which cognitive domains are impaired in this population. We suggest that is in part due to inconsistency in how neuropsychological tests are assigned to cognitive domains. The purpose of this paper is to critically analyze the meta-analytic literature on cancer-related cognitive impairments (CRCI) to quantify this inconsistency. We identified all neuropsychological tests reported in seven meta-analyses of the CRCI literature. Although effect sizes were generally negative (indicating impairment), every domain was declared to be impaired in at least one meta-analysis and unimpaired in at least one other meta-analysis. We plotted summary effect sizes from all the meta-analyses and quantified disagreement by computing the observed and ideal distributions of the one-way χ2 statistic. The actual χ2 distributions were noticeably more peaked and shifted to the left than the ideal distributions, indicating substantial disagreement among the meta-analyses in how neuropsychological tests were categorized to domains. A better understanding of the profile of impairments in CRCI is essential for developing effective remediation methods. To accomplish this goal, the research field needs to promote better agreement on how to measure specific cognitive functions.

Cellular mechanisms and treatments for chemobrain: insight from aging and neurodegenerative diseases

Chemotherapy is a life-saving treatment for cancer patients, but also causes long-term cognitive impairment, or "chemobrain", in survivors. However, several challenges, including imprecise diagnosis criteria, multiple confounding factors, and unclear and heterogeneous molecular mechanisms, impede effective investigation of preventions and treatments for chemobrain. With the rapid increase in the number of cancer survivors, chemobrain is an urgent but unmet clinical need. Here, we leverage the extensive knowledge in various fields of neuroscience to gain insights into the mechanisms for chemobrain. We start by outlining why the post-mitotic adult brain is particularly vulnerable to chemotherapy. Next, through drawing comparisons with normal aging, Alzheimer's disease, and traumatic brain injury, we identify universal cellular mechanisms that may underlie the cognitive deficits in chemobrain. We further identify existing neurological drugs targeting these cellular mechanisms that can be repurposed as treatments for chemobrain, some of which were already shown to be effective in animal models. Finally, we briefly describe future steps to further advance our understanding of chemobrain and facilitate the development of effective preventions and treatments.

Predicting Patient Reported Outcomes of Cognitive Function Using Connectome-Based Predictive Modeling in Breast Cancer

Being able to predict who will likely experience cancer related cognitive impairment (CRCI) could enhance patient care and potentially reduce economic and human costs associated with this adverse event. We aimed to determine if post-treatment patient reported CRCI could also be predicted from baseline resting state fMRI in patients with breast cancer. 76 newly diagnosed patients (n = 42 planned for chemotherapy; n = 34 not planned for chemotherapy) and 50 healthy female controls were assessed at 3 times points [T1 (prior to treatment); T2 (1 month post chemotherapy); T3 (1 year after T2)], and at yoked intervals for controls. Data collection included self-reported executive dysfunction, memory function, and psychological distress and resting state fMRI data converted to connectome matrices for each participant. Statistical analyses included linear mixed modeling, independent t tests, and connectome-based predictive modeling (CPM). Executive dysfunction increased over time in the chemotherapy group and was stable in the other two groups (p < 0.001). Memory function decreased over time in both patient groups compared to controls (p < 0.001). CPM models successfully predicted executive dysfunction and memory function scores (r > 0.31, p < 0.002). Support vector regression with a radial basis function (SVR RBF) showed the highest performance for executive dysfunction and memory function (r = 0.68; r = 0.44, p's < 0.001). Baseline neuroimaging may be useful for predicting patient reported cognitive outcomes which could assist in identifying patients in need of surveillance and/or early intervention for treatment-related cognitive effects.

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

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

Relationships between self-reported sleep quality components and cognitive functioning in breast cancer survivors up to 10 years following chemotherapy

OBJECTIVE

Links have been made between aspects of sleep quality and cognitive function in breast cancer survivors (BCS), but findings are heterogeneous. The objective of this study is to examine relationships between specific sleep quality components (latency, duration, efficiency, daytime sleepiness, sleep disturbance, use of sleep aids) and cognitive impairment (performance and perceived), and determine which sleep quality components are the most significant contributors to cognitive impairments in BCS 6 months to 10 years post chemotherapy.

METHODS

Women 21 to 65 years old with a history of non-metastatic breast cancer following chemotherapy completion were recruited. Data collection included surveys to evaluate sleep quality and perceived cognitive impairments, and neuropsychological testing to evaluate verbal fluency and memory. Descriptive statistics, bivariate correlations, and hierarchical multiple regression were calculated.

RESULTS

Ninety women (mean age 49) completed data collection. Moderate significant correlations were found between daytime dysfunction, sleep efficiency, sleep latency, and sleep disturbance and perceived cognitive impairment (Rs = -0.37 to -0.49, Ps < .00049), but not objective cognitive performance of verbal fluency, memory, or attention. After accounting for individual and clinical characteristics, the strongest predictors of perceived cognitive impairments were daytime dysfunction, sleep efficiency, and sleep disturbance.

CONCLUSIONS

Findings support links between sleep quality and perceived cognitive impairments in BCS and suggest specific components of sleep quality (daytime dysfunction, sleep efficiency, and sleep disturbance) are associated with perceived cognitive functioning in this population. Findings can assist clinicians in guiding survivors to manage sleep and cognitive problems and aid in the design of interventional research.

Identifying cytokine predictors of cognitive functioning in breast cancer survivors up to 10 years post chemotherapy using machine learning

INTRODUCTION

The purpose of this study is to explore 13 cytokine predictors of chemotherapy-related cognitive impairment (CRCI) in breast cancer survivors (BCS) 6 months to 10 years after chemotherapy completion using a multivariate, non-parametric approach.

METHODS

Cross sectional data collection included completion of a survey, cognitive testing, and non-fasting blood from 66 participants. Data were analyzed using random forest regression to identify the most significant predictors for each of the cognitive test scores.

RESULTS

A different cytokine profile predicted each cognitive test. Adjusted R² for each model ranged from 0.71-0.77 (p's < 9.50^-10). The relationships between all the cytokine predictors and cognitive test scores were non-linear.

CONCLUSIONS

Our findings are unique to the field of CRCI and suggest non-linear cytokine specificity to neural networks underlying cognitive functions assessed in this study.

[Occupational therapy in oncology: experiences in academic practices and literature review]

OBJECTIVE

To inquire about the training of occupational therapists in oncology in a university program, and to identify updated literature as evidence for training and professional practice.

MATERIALS AND METHODS

Cross-sectional exploratory study, with a sample of 29 students of occupational therapy from the National University of Colombia. Systematic review of literature 2010-2015 on occupational therapy interventions in oncology. Results In the survey, less than a quarter of the students reported having received training on clinical management of this diagnosis, and on the intervention of the occupational therapist with such cases (24.1%). Little more than this percentage (27.6%), has had users with cancer in their academic practices. In the literature review no national publications were found, although there were unpublished products from Colombian universities. Fifty-four international publications were recovered, especially in rehabilitation, it followed by psychosocial and socio-occupational areas. The palliative care, the multidisciplinarity, the subjective experience of the patient in relation to the diagnosis and treatment, the humanized and integral care from the different areas of the therapeutic task and work with caregivers are considered as relevant issues in the oncological patient's approach.

CONCLUSIONS

Reference points are made for the occupational therapy curriculum development and for professional updating processes, which are both competence of the academy and of the guild. It is important to intervene in cancer not only during, but in the preparation to treatment and subsequently with survivors. Professional publications should be encouraged, making sure they provide powerful evidence of the impact of occupational therapy and oncological rehabilitation.

What You Do Not Know Could Hurt You: What Women Wish Their Doctors Had Told Them About Chemotherapy Side Effects on Memory and Response to Alcohol

For many patients, a cancer diagnosis is followed by chemotherapy treatment, which works by attacking cells that are growing and dividing throughout the body. Although cancer cells grow and divide more quickly than healthy cells, both are targets. The loss of healthy cells is associated with side effects, such as memory loss and altered response to a variety of food and drugs. In this pilot study, we use the "Survey of female cancer treatments, effects on memory and alcohol awareness" to explore trends in female experience and awareness of side effects associated with chemotherapy. We examined 79 female cancer patients, 46 Spanish-speaking women in Puerto Rico and 33 English-speaking women in the continental United States, and compared the rates of a reported memory loss or an altered ethanol response following chemotherapy, whether or not potential side effects were discussed with a medical professional, and whether they experienced changes in alcohol consumption after treatment. A majority of participants reported having experienced short-term memory loss postchemotherapy. Changes in response to alcohol and an altered sensitivity to alcohol were also reported by 25%-47% of the respondents. Additionally, more than half of all female cancer patients reported that they wished they would have received information on the side effects of chemotherapy and secondary medications prior to treatment. The survey results suggest that medical professionals are not adequately informing women of common, potentially harmful side effects of chemotherapy. Women do wish to be more educated about potential side effects related to memory and alcohol and be given the opportunity to discuss potential outcomes with a medical professional prior to treatment to reduce the negative impact of treatment-related side effects on posttreatment quality of life.

Optimism and Spontaneous Self-affirmation are Associated with Lower Likelihood of Cognitive Impairment and Greater Positive Affect among Cancer Survivors

BACKGROUND

Optimism and self-affirmation promote adaptive coping, goal achievement, and better health.

PURPOSE

The aim of this study is to examine the associations of optimism and spontaneous self-affirmation (SSA) with physical, mental, and cognitive health and information seeking among cancer survivors.

METHODS

Cancer survivors (n = 326) completed the Health Information National Trends Survey 2013, a national survey of US adults. Participants reported optimism, SSA, cognitive and physical impairment, affect, health status, and information seeking.

RESULTS

Participants higher in optimism reported better health on nearly all indices examined, even when controlling for SSA. Participants higher in SSA reported lower likelihood of cognitive impairment, greater happiness and hopefulness, and greater likelihood of cancer information seeking. SSA remained significantly associated with greater hopefulness and cancer information seeking when controlling for optimism.

CONCLUSIONS

Optimism and SSA may be associated with beneficial health-related outcomes among cancer survivors. Given the demonstrated malleability of self-affirmation, these findings represent important avenues for future research.

Affective science perspectives on cancer control: strategically crafting a mutually beneficial research agenda

Cancer control research involves the conduct of basic and applied behavioral and social sciences to reduce cancer incidence, morbidity, and mortality and improve quality of life. Given the importance of behavior in cancer control, fundamental research is necessary to identify psychological mechanisms underlying cancer risk, prevention, and management behaviors. Cancer prevention, diagnosis, and treatment are often emotionally laden. As such, affective science research to elucidate questions related to the basic phenomenological nature of emotion, stress, and mood is necessary to understand how cancer control can be hindered or facilitated by emotional experiences. To date, the intersection of basic affective science research and cancer control remains largely unexplored. The goal of this article is to outline key questions in the cancer control research domain that provide an ecologically valid context for new affective science discoveries. We also provide examples of ways in which basic affective discoveries could inform future cancer prevention and control research. These examples are not meant to be exhaustive or prescriptive but instead are offered to generate creative thought about the promise of a cancer research context for answering basic affective science questions. Together, these examples provide a compelling argument for fostering collaborations between affective and cancer control scientists.

Is Cancer a Risk Factor for Cognitive Decline in Late Life?

With advances in screening and early detection, coupled with improved treatment and care, the number of cancer survivors has risen exponentially over the past several decades. Moreover, because age is the most significant risk factor for cancer, the majority of cancer survivors are over 65 years of age. Finally, cancer survivors often experience significant health issues for many years after the treatment has subsided. In the current article, we describe select research that has focused on changes to cognitive performance associated with cancer and its treatment, i.e., alterations that have been colloquially referred to as chemobrain. Although understanding changes in cognitive performance following cancer treatment is an active area of inquiry, the experience of older adult cancer survivors has been somewhat neglected. For example, evidence is mixed as to whether changes in cognitive performance associated with normal aging are exacerbated by cancer survivorship status. It is also unclear whether a history of cancer makes it more or less likely that a person will be diagnosed with dementia or Alzheimer's disease in the future. Finally, we identify a number of areas where existing cognitive aging research can inform studies on cognitive performance following cancer treatment. Future efforts should be directed towards designing studies that focus on the experience of older adult cancer survivors and are informed by the clinical oncology and cognitive aging literature.

Clinical characteristics, pathophysiology, and management of noncentral nervous system cancer-related cognitive impairment in adults

Answer questions and earn CME/CNE Over the past few decades, a body of research has emerged confirming what many adult patients with noncentral nervous system cancer have long reported-that cancer and its treatment are frequently associated with cancer-related cognitive impairment (CRCI). The severity of CRCI varies, and symptoms can emerge early or late in the disease course. Nonetheless, CRCI is typically mild to moderate in nature and primarily involves the domains of memory, attention, executive functioning, and processing speed. Animal models and novel neuroimaging techniques have begun to unravel the pathophysiologic mechanisms underlying CRCI, including the role of inflammatory cascades, direct neurotoxic effects, damage to progenitor cells, white matter abnormalities, and reduced functional connectivity, among others. Given the paucity of research on CRCI with other cancer populations, this review synthesizes the current literature with a deliberate focus on CRCI within the context of breast cancer. A hypothetical case-study approach is used to illustrate how CRCI often presents clinically and how current science can inform practice. While the literature regarding intervention for CRCI is nascent, behavioral and pharmacologic approaches are discussed.

Cognitive impairment after chemotherapy related to atypical network architecture for executive control

OBJECTIVES

A common complaint of cancer patients is the experience of cognitive difficulty during and after chemotherapy. We hypothesized that cognitive impairment may result from dysfunction in large-scale brain networks, particularly those involved in attentional control.

METHODS

Using a case-control design, this study includes women with a history of invasive ductal or lobular triple-negative breast cancer who completed standard adjuvant chemotherapy within 2 years of study entry. Women who reported cognitive impairment by the Global Rating of Cognition question were considered to be cases (n = 15). Women who reported no cognitive impairment were considered to be controls (n = 13). All enrolled participants were eligible for MRI investigation and underwent resting-state functional connectivity MRI.

RESULTS

Women who self-reported cognitive impairment were found to have disrupted resting-state functional connectivity, as measured by MRI, when compared to women who did not self-report cognitive impairment. These findings suggest that some women may be more sensitive to the standard treatments for breast cancer and that this increased sensitivity may result in functional connectivity alterations in the brain networks supporting attention and executive function.

CONCLUSIONS

Neuroimaging analyses confirmed self-reported cognitive deficits in women with breast cancer treated with chemotherapy.

Neuroimaging biomarkers and cognitive function in non-CNS cancer and its treatment: current status and recommendations for future research

Cognitive changes in patients undergoing treatment for non-central nervous system (CNS) cancers have been recognized for several decades, yet the underlying mechanisms are not well understood. Structural, functional and molecular neuroimaging has the potential to help clarify the neural bases of these cognitive abnormalities. Structural magnetic resonance imaging (MRI), functional MRI (fMRI), diffusion tensor imaging (DTI), MR spectroscopy (MRS), and positron emission tomography (PET) have all been employed in the study of cognitive effects of cancer treatment, with most studies focusing on breast cancer and changes thought to be induced by chemotherapy. Articles in this special issue of Brain Imaging and Behavior are devoted to neuroimaging studies of cognitive changes in patients with non-CNS cancer and include comprehensive critical reviews and novel research findings. The broad conclusions that can be drawn from past studies and the present body of new research is that there are structural and functional changes associated with cancer and various treatments, particularly systemic cytotoxic chemotherapy, although some cognitive and fMRI studies have identified changes at pre-treatment baseline. Recommendations to accelerate progress include well-powered multicenter neuroimaging studies, a better standardized definition of the cognitive phenotype and extension to other cancers. A systems biology framework incorporating multimodality neuroimaging, genetics and other biomarkers will be highly informative regarding individual differences in risk and protective factors and disease- and treatment-related mechanisms. Studies of interventions targeting cognitive changes are also needed. These next steps are expected to identify novel protective strategies and facilitate a more personalized medicine for cancer patients.

Psychoneuroimmunology and cancer: a decade of discovery, paradigm shifts, and methodological innovations

This article introduces the supplement Advances in Cancer and Brain, Behavior, and Immunity and outlines important discoveries, paradigm shifts, and methodological innovations that have emerged in the past decade to advance mechanistic and translational understanding of biobehavioral influences on tumor biology, cancer treatment-related sequelae, and cancer outcomes. We offer a heuristic framework for research on biobehavioral pathways in cancer. The shifting survivorship landscape is highlighted, and we propose that the changing demographics suggest prudent adoption of a life course perspective of cancer and cancer survivorship. We note opportunities for psychoneuroimmunology (PNI) research to ameliorate the long-term, unintended consequences of aggressive curative intent and call attention to the critical role of reciprocal translational pathways between animal and human studies. Lastly, we briefly summarize the articles included in this compilation and offer our perspectives on future research directions.