Effects of anastrozole on cognitive performance in postmenopausal women: a randomised, double-blind chemoprevention trial (IBIS II)

Neuropsychological assessment, intervention, and best practices for women with non-Central nervous system cancer: A scoping review of current standards

Objective: Existing literature has sought to characterize the broad cognitive impact of non-central nervous system cancer and its treatment, including chemotherapy, radiation, surgery, and hormonal regulation. However, despite the frequency of women that are diagnosed with breast and gynecological cancer, there is limited research on the specific cognitive experiences of women undergoing cancer treatment. Presently, the current literature lacks concise guidance for neuropsychologists to support the cognitive health of women facing cancer, despite the acknowledged impact of cancer interventions and chronic illness on cognitive outcomes. Method: Applying scoping review criteria outlined by Peters et al. (2015) and adhering to Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a comprehensive examination of literature spanning multiple databases (Google Scholar, PubMed, PsychINFO) with a focus on the cognitive impact of cancer treatment on women. Conclusions: Women are subject to unique treatment-related outcomes due to the impact of hormonal alterations, differences in metabolization of certain chemotherapies, and psychosocial risk factors. Despite the known impact of cancer intervention, chronic illness, and cancer-related sequelae on cognitive outcomes, the current literature does not parsimoniously outline best practices for neuropsychologists to promote the health of women experiencing cancer. The current paper (1) provides an overview of the cognitive implications of cancer treatment with an intentional focus on cancers that are more prevalent in women versus men, (2) addresses the characteristics of this impact for women undergoing cancer intervention(s), and (3) provides possible intervention and treatment strategies for mental health providers and neuropsychologists.

Letrozole delays acquisition of water maze task in female BALB/c mice: Possible involvement of anxiety

Letrozole, an aromatase inhibitor preventing estrogen synthesis from testosterone, is used as an adjuvant therapy in estrogen receptor-positive breast cancer patients. However, like other aromatase inhibitors, it induces many side effects, including impaired cognition. Despite its negative effect in humans, results from animal models are inconsistent and suggest that letrozole can either impair or improve cognition. Here, we studied the effects of chronic letrozole treatment on cognitive behavior of adult female BALB/c mice, a relevant animal model for breast cancer studies, to develop an appropriate animal model aimed at testing therapies to mitigate side effects of letrozole. In Morris water maze, letrozole 0.1 mg/kg impaired reference learning and memory. Interestingly, most of the letrozole 0.1 mg/kg-treated mice were able to learn the new platform position in reversal training and performed similar to control mice in a reversal probe test. Results of the reversal test suggest that letrozole did not completely disrupt spatial navigation, but rather delayed acquisition of spatial information. The delay might be related to increased anxiety as suggested by increased thigmotactic behavior during the reference memory training. The learning impairment was water maze-specific since we did not observe impairment in other spatial tasks such as in Y-maze or object location test. In contrast, the dose of 0.3 mg/kg did not have effect on water maze learning and facilitated locomotor habituation and recognition in novel object recognition test. The current study shows that letrozole dose-dependently modulates behavioral response and that its effects are task-dependent.

Tamoxifen Effects on Cognition and Language in Women with Breast Cancer

Cognitive changes following adjuvant treatment for breast cancer (BC) are well documented following chemotherapy. However, limited studies have examined cognitive and/or language functions in chemotherapy-naive women with BC taking tamoxifen (TAM). Using ambulatory cognitive assessment, we investigated the trajectory of cognitive and language changes during early period of adjuvant endocrine treatment (TAM) in women with BC at two time periods (pretreatment and 2 months after treatment began). Four women with BC and 18 cognitively healthy age-matched controls completed three cognitive tasks using smartphones, during a short time period (5 days) and repeated them at two time periods. To determine language ability, language samples were collected at two time periods, where the participants described two stories from two wordless picture books and samples were assessed using core lexicon analyses. Wilcoxon-signed rank tests were computed to identify differences in linguistic and cognitive performances of both the groups at two time periods. No significant within-group or between-group differences were seen on the cognitive and language tasks at the two time periods; however, women with BC performed more poorly compared to the control group. We did see decline in some women with BC and not in others, in cognition and language during initial course of TAM treatment. However, the approach we used to assess these changes is valuable and innovative. This approach will help refine current research paradigms for determining cognitive and linguistic changes and will help determine if women with BC might require language intervention in the future.

Association between endocrine therapy and cognitive decline in older women with early breast cancer: Findings from the prospective CLIMB study

INTRODUCTION

Studies investigating the long-term effects of breast cancer treatment on cognition in older women with breast cancer are lacking, even though preserving cognition is highly valued by the older population. Specifically, concerns have been raised regarding the detrimental effects of endocrine therapy (ET) on cognition. Therefore, we investigated cognitive functioning over time and predictors for cognitive decline in older women treated for early breast cancer.

METHODS

We prospectively enrolled Dutch women aged ≥70 years with stage I-III breast cancer in the observational CLIMB study. The Mini-Mental State Examination (MMSE) was performed before ET initiation and after 9, 15 and 27 months. Longitudinal MMSE scores were analysed and stratified for ET. Linear mixed models were used to identify possible predictors of cognitive decline.

RESULTS

Among the 273 participants, the mean age was 76 years (standard deviation 5), and 48% received ET. The mean baseline MMSE score was 28.2 (standard deviation 1.9). Cognition did not decline to clinically meaningful differences, irrespective of ET. MMSE scores of women with pre-treatment cognitive impairments slightly improved over time (significant interaction terms) in the entire cohort and in women receiving ET. High age, low educational level and impaired mobility were independently associated with declining MMSE scores over time, although the declines were not clinically meaningful.

CONCLUSION

Cognition of older women with early breast cancer did not decline in the first two years after treatment initiation, irrespective of ET. Our findings suggest that the fear of declining cognition does not justify the de-escalation of breast cancer treatment in older women.

Effects of Endocrine Therapy on Cognitive Function in Patients with Breast Cancer: A Comprehensive Review

Simple Summary

Many persons diagnosed with breast cancer are treated with endocrine therapy and will experience the side effects of endocrine therapy. Cognitive adverse effects of endocrine therapy are increasingly being recognised, and can significantly affect quality of life, adherence and treatment outcome. This review aims to discuss the nature of cognitive dysfunction associated with endocrine therapy, the mechanisms underpinning its development, and evidence-based management strategies.

Abstract

Endocrine therapy forms the backbone of systemic therapy for the majority of persons with early and late-stage breast cancer. However, the side effects can negatively affect quality of life, and impact treatment adherence and overall oncological outcomes. Adverse effects on cognition are common, underreported and challenging to manage. We aim to describe the nature, incidence, risk factors and underlying mechanisms of endocrine therapy-induced cognitive dysfunction. We conducted a comprehensive literature review of the studies reporting on cognitive dysfunction associated with endocrine therapies for breast cancer. We also summarise prevention and treatment strategies, and ongoing research. Given that patients are taking endocrine therapies for longer durations than ever before, it is essential that these side effects are managed pro-actively within a multi-disciplinary team in order to promote adherence to endocrine therapy and improve patients’ quality of life.

Concurrent chemo-endocrine treatment for early hormone-positive breast cancer: a no-go???

PURPOSE

Endocrine therapy is one of the cornerstones of early breast cancer treatment. While this medication could be initiated on the day of diagnosis, it is often postponed until after completion of surgery, radiotherapy, and chemotherapy. This practice is based on preclinical data suggesting an antagonistic effect between endocrine therapy and cytostatic agents, and on the interpretation of clinical trials comparing concurrent versus sequential use of tamoxifen and chemotherapy. These clinical trials, however, have never shown a statistically significant difference in overall survival or disease-free survival and focused on tamoxifen rather than aromatase inhibitors. Nevertheless, sequentially administered endocrine and chemotherapy have become standard of care worldwide.

RESULTS

We performed a literature review and conclude that concurrent endocrine chemotherapy is at least as effective as sequential treatment. In fact, higher response rates have been observed in trials with aromatase inhibitors rather than tamoxifen in a neoadjuvant setting.

CONCLUSION

We encourage breast cancer oncologists to re-consider concurrent endocrine chemotherapy as a possible treatment strategy enabling early start of potentially curative endocrine treatment.

The effect of using adjuvant aromatase inhibitors on cognitive functions in postmenopausal women with hormone receptor-positive breast cancer

Introduction

Breast cancer is the most frequently diagnosed cancer in women worldwide. Aromatase inhibitors (AIs) are effective treatment options for both early-stage and advanced hormone receptor-positive breast cancer. Because of AIs are used long term in adjuvant therapy, side effects are also very important. It is considered that AIs may affect cognitive functions by decreasing the level of estrogen in the brain. The purpose of our study is that evaluate the relationship between duration of treatment and cognitive functions in patients with breast cancer who use AIs in adjuvant therapy.

Methods

Two-hundred patients diagnosed with breast cancer who were treated with AIs as adjuvant treatment were included. The patients were surveyed for demographic characteristics. Montreal Cognitive Assessment (MoCA) and Standardized Mini-Mental State Examination (SMMT) tests were performed to evaluate patients' cognitive functions. The total scores of the tests and the orientation, short-time memory, visuospatial functions, attention, language, executive functions which are the MoCA subscales were evaluated separately. Patients were grouped as 0-6, 6-12, 12-24, 24-36, 36, and more months according to the duration of AIs using time.

Results

The total MoCA and SMMT scores were affected by factors such as age, education level, and employment status. There was no relationship between duration of treatment and cognitive functions in patients with breast cancer who use AIs in adjuvant therapy (P > 0.05). In addition, no statistically relationship was found in the evaluation of MoCA subscales (P > 0.05).

Discussion

Prolonged adjuvant treatment with AIs does not affect cognitive functions in hormone receptor-positive breast cancer patients.

Endocrine Therapy With or Without CDK4/6 Inhibitors in Women With Hormone-receptor Positive Breast Cancer: What do we Know About the Effects on Cognition?

Adjuvant endocrine therapy (ET) is the cornerstone of treatment for hormone-receptor positive breast cancer. Recently, ET is increasingly combined with "cyclin-dependent kinases 4 and 6'' (CDK4/6) inhibitors. Given the importance of estrogens in neural processes and the role of cyclin D in hippocampal cell proliferation, it is plausible that these therapies affect cognition, but studies on these potential cognitive effects are sparse. In this review, we summarize existing knowledge on the cognitive effects of ET and CDK4/6 inhibitors in pre-, peri- and postmenopausal patients with breast cancer. We show that several clinical studies support adverse cognitive effects, especially on verbal memory, after ET-induced decrease of estrogen-levels or inactivation of estrogen-receptors. Clinical studies on the cognitive effects of CDK4/6 inhibitors are virtually non-existent and no conclusions can yet be drawn. Longitudinal studies on the cognitive effects of the combined ET-CDK4/6 inhibitors are highly needed to properly inform patients about potential short-term and long-term cognitive side effects. These studies should preferably include cognitive assessments (including a measurement prior to ET), and be designed in such a way that they can account for variables such as type and duration of ET, CDK4/6 inhibition, menopausal status, and other disease- and treatment-related symptoms that can impact cognition, such as fatigue and distress.

Estrogen pendulum in schizophrenia and Alzheimer's disease: Review of therapeutic benefits and outstanding questions

Although produced largely in the periphery, gonadal steroids play a key role in regulating the development and functions of the central nervous system and have been implicated in several chronic neuropsychiatric disorders, with schizophrenia and Alzheimer's disease (AD) most prominent. Despite major differences in pathobiology and clinical manifestations, in both conditions, estrogen transpires primarily with protective effects, buffering the onset and progression of diseases at various levels. As a result, estrogen replacement therapy (ERT) emerges as one of the most widely discussed adjuvant interventions. In this review, we revisit evidence supporting the protective role of estrogen in schizophrenia and AD and consider putative cellular and molecular mechanisms. We explore the underlying functional processes relevant to the manifestation of these devastating conditions, with a focus on synaptic transmission and plasticity mechanisms. We discuss specific effects of estrogen deficit on neurotransmitter systems such as cholinergic, dopaminergic, serotoninergic, and glutamatergic. While the evidence from both, preclinical and clinical reports, in general, are supportive of the protective effects of estrogen from cognitive decline to synaptic pathology, numerous questions remain, calling for further research.

Effects of tamoxifen on cognition and language in women with breast cancer: A systematic search and a scoping review

OBJECTIVE

Breast cancer treatments bring adverse consequences that interfere with everyday functioning. Importantly, some of these treatments are associated with cognitive and language changes. Tamoxifen is a selective estrogen receptor modulator and is a common endocrine therapy treatment for breast cancer. The current review examines the specific domains of cognition and language affected by the use of tamoxifen in women with breast cancer.

METHODS

We conducted a systematic search that examined cognitive and/or language functions in chemotherapy-naïve women with breast cancer taking tamoxifen. PubMed, Cochrane CENTRAL, CINAHL Complete, PsycINFO, Scopus, EMBASE, and the Grey Literature Report (greylit.org) were searched. Covidence Systematic Review software (covidence.org) was used to manage the screening process of study titles and abstracts as well as full texts. A total of 17 studies were included in the review.

RESULTS

A range of cognitive and language domains were reported. These were grouped into seven broad domains: attention, memory, speed, executive functioning, verbal abilities, visual abilities, and language abilities. Results showed that there is compelling evidence that specific domains of memory and speed are negatively affected by the use of tamoxifen. In addition, there was a pattern of change in domains of executive functions and verbal abilities.

CONCLUSIONS

Tamoxifen affects specific cognitive and language domains. Language domains beyond semantics have not been studied and thus conclusions related to these domains, and language in general, could not be made. Studies exploring the effects of tamoxifen on the different domains of language are recommended.

Oncology Advanced Practitioners and Breast Cancer Prevention

One in eight American women will be diagnosed with breast cancer. Advanced practitioners in oncology can offer risk assessments, counseling, genetic testing, and make both behavioral and pharmacologic recommendations for breast cancer risk reduction. The role of oncology advanced practitioners in conjunction with genetic counselors is key in what is now considered the standard of care. This article will summarize the current state of breast cancer prevention and the role of oncology advanced practitioners.

Chemotherapy-induced cognitive impairment (CICI): An overview of etiology and pathogenesis

Many cancer patients treated with chemotherapy develop chemotherapy-induced cognitive impairment (CICI), often referred to as chemo-brain, which manifest during or post-treatment with variable degrees, onset and duration thereby affecting the patients' quality of life. Several chemotherapeutic agents have been studied to determine its possible association with cognitive impairment and to fully comprehend their contribution to CICI. A vast number of studies have emerged proposing several candidate underlying mechanisms and etiologies contributing to CICI such as direct neurotoxicity, BBB disruption, decreased hippocampal neurogenesis, white matter abnormalities, secondary neuro-inflammatory response and increased oxidative stress; however, the exact underlying mechanisms are still not well defined. This review summarizes CICI associated with most commonly used chemotherapeutic agents with emphasizes the possible underlying pathogenesis in both animal and clinical studies.

Neuroimmunology of the female brain across the lifespan: Plasticity to psychopathology

The female brain is highly dynamic and can fundamentally remodel throughout the normal ovarian cycle as well as in critical life stages including perinatal development, pregnancy and old-age. As such, females are particularly vulnerable to infections, psychological disorders, certain cancers, and cognitive impairments. We will present the latest evidence on the female brain; how it develops through the neonatal period; how it changes through the ovarian cycle in normal individuals; how it adapts to pregnancy and postpartum; how it responds to illness and disease, particularly cancer; and, finally, how it is shaped by old age. Throughout, we will highlight female vulnerability to and resilience against disease and dysfunction in the face of environmental challenges.

The Relationship Between Insomnia and Cognitive Impairment in Breast Cancer Survivors

Background

Cancer-related cognitive impairment is an emerging public health burden. Growing research suggests that sleep disturbances contribute to poor cognition. Our study aimed to evaluate the association between insomnia and cognitive impairment in breast cancer survivors.

Methods

We analyzed cross-sectional data from a cohort study of postmenopausal women with stage 0–III hormone receptor-positive breast cancer on aromatase inhibitor therapy. The study was conducted between November 2011 and April 2015 at an academic cancer center (Philadelphia, PA). Insomnia was assessed with the Insomnia Severity Index. Perceived cognitive impairment was assessed with the cognitive subscale of the Breast Cancer Prevention Trial Symptom Checklist. We used linear regression to evaluate the association between insomnia and perceived cognitive impairment.

Results

Among 1072 patients, 556 (51.9%) reported insomnia and 847 (79.0%) were bothered by cognitive symptoms (forgetfulness, difficulty concentrating, distractibility). Greater perceived cognitive impairment was reported by patients with mild insomnia (regression coefficient [β] = 0.35, 95% confidence interval [CI] = 0.23 to 0.46, P < .001), moderate insomnia (β = 0.51, 95% CI = 0.36 to 0.65, P < .001), and severe insomnia (β = 0.94, 95% CI = 0.67 to 1.21, P < .001), compared with those without insomnia. Greater perceived cognitive impairment was also associated with patients younger than 55 years (β = 0.30, 95% CI = 0.15 to 0.45, P < .001), taxane-based chemotherapy (β = 0.11, 95% CI = 0.004 to 0.22, P = .04), anxiety (β = 0.47, 95% CI = 0.30 to 0.64, P < .001), and depression (β = 0.65, 95% CI = 0.35 to 0.94, P < .001).

Conclusions

Among postmenopausal breast cancer survivors receiving aromatase inhibitor therapy, insomnia and cognitive impairment are prevalent and characterized by a graded association, in which severity of perceived cognitive impairment increases as insomnia severity increases. Our findings warrant further research to determine whether addressing sleep is a strategy to improve management of cancer-related cognitive impairment.

The cognitive effects of endocrine therapy in survivors of breast cancer: A prospective longitudinal study up to 6 years after treatment

BACKGROUND

After treatment of primary breast cancer, endocrine therapy (ET) is prescribed for patients with hormone receptor-positive cancers. Despite ET recommendations of 5 to 10 years of treatment, to the authors' knowledge there is little prospective study of its impact on cognitive function over an extended period of time. ET has known pharmacologic effects on the brain. Cognitive side effects are a concern for many women, with mixed findings reported in various studies. The current prospective longitudinal study examined the neuropsychological effects of ET over time, up to 6 years after treatment.

METHODS

A total of 189 survivors of early-stage breast cancer enrolled in the study prior to initiating ET if prescribed, and were followed at 6 months (175 patients), 12 months (173 patients), and for 3 to 6 years (102 patients) with self-report and neuropsychological assessments. Using linear mixed models, the authors examined whether neuropsychological performance or impairment rates differed over time based on whether or not ET was received.

RESULTS

The authors did not find any effect of ET on neuropsychological performance or impairment at any time point among survivors who received it compared with women who did not. However, those who participated in the 3-year to 6-year year visit demonstrated better executive function at baseline.

CONCLUSIONS

In the current observational cohort study, no detrimental effect of ET on cognitive function was identified in survivors of early-stage breast cancer receiving treatment with ET compared with those who were not.

Exploratory Study of Associations Between DNA Repair and Oxidative Stress Gene Polymorphisms and Cognitive Problems Reported by Postmenopausal Women With and Without Breast Cancer

PURPOSE

Women with breast cancer report varying frequencies of cognitive problems during adjuvant systemic therapy. This variability suggests latent subgroups. Therefore, we identified latent subgroups of self-reported cognitive problems among postmenopausal women with and without breast cancer. We explored associations between membership in these subgroups and (a) demographic, clinical, and symptom characteristics and (b) variations in candidate gene polymorphisms.

METHODS

We evaluated frequency of cognitive problems using the Patient Assessment of Own Functioning Inventory. Growth mixture modeling identified latent subgroups over 18 months of adjuvant systemic therapy and at matched time points for women without cancer ( N = 331). We evaluated for differences among subgroups in demographic, clinical, and symptom characteristics and in 41 single nucleotide polymorphisms in 10 candidate genes involved in DNA repair and oxidative stress pathways ( n = 199). We modeled associations between genotypes and subgroup membership using multinomial logistic regression.

RESULTS

We identified three latent subgroups: more frequent, persistent, and almost never. Receipt of chemotherapy plus anastrozole, depressive symptoms, and baseline neuropathic symptoms increased the odds of belonging to the more frequent subgroup. Anxiety and depressive symptoms increased the odds of belonging to the persistent subgroup. With covariates controlled for, carrying the ERCC5 rs873601 G minor allele increased the odds of reporting more frequent cognitive problems.

CONCLUSIONS

Chemotherapy plus anastrozole, depressive symptoms, and presence of neuropathic symptoms may predict more frequent cognitive problems during systemic therapy that later resolve. Mood dysregulation before therapy may predict persistent cognitive problems during therapy. ERCC5 genotype may influence frequency of cognitive problems after controlling for these risk factors.

In case of anastrozole-related hallucinations, can switching to letrozole be a treatment option? A case report and literature review

Arthralgia, myalgia, paresthesia, reduced bone mineral density, vasomotor side effects including hot flashes and night sweats, genitourinary symptoms including decreased libido, vaginal dryness and dyspareunia are common side effects of aromatase inhibitors. Unlike the common side effects, the information on neurological side effects like hallucination of aromatase inhibitor was limited in literature cases. Herein, we reported a case of hallucination related to anastrozole in a patient with metastatic breast cancer. A 62-year-old female patient with breast cancer developed repetitive hallucinations on the following days of anastrozole initiation. There was no other significant finding in the differential diagnosis of hallucination. Neurological symptoms disappeared after termination of anastrozole. The patient had no neuropsychiatric complaints during letrozole treatment. We aimed to emphasize that neurological side effect like hallucination may rarely occur during the treatment of anastrozole and in case of aromatase inhibitor-related hallucinations, switching to another aromatase inhibitor (letrozole) can be a treatment option.

Cognitive Effects of Aromatase and Possible Role in Memory Disorders

Diverse cognitive functions in many vertebrate species are influenced by local conversion of androgens to 17β-estradiol (E2) by aromatase. This enzyme is highly expressed in various brain regions across species, with some inter-species variation in terms of regional brain expression. Since women with breast cancer and men and women with other disorders are often treated with aromatase inhibitors (AI), these populations might be especially vulnerable to cognitive deficits due to low neuroE2 synthesis, i.e., synthesis of E2 directly within the brain. Animal models have been useful in deciphering aromatase effects on cognitive functions. Consequences of AI administration at various life cycle stages have been assessed on auditory, song processing, and spatial memory in birds and various aspects of cognition in rodent models. Additionally, cognitive deficits have been described in aromatase knockout (ArKO) mice that systemically lack this gene throughout their lifespan. This review will consider evidence to date that AI treatment in male and female rodent models, birds, and humans results in cognitive impairments. How brain aromatase regulates cognitive function throughout the lifespan, and gaps in current knowledge will be considered, along with future directions to better define how aromatase might guide learning and memory from early development through the geriatric period. Better understanding the importance of E2 synthesis on neurobehavioral responses at various ages will likely aid in the discovery of therapeutic strategies to prevent potential cognitive deficits, including Alzheimer's Disease, in individuals treated with AI or those possessing CYP19 gene polymorphisms, as well as cognitive effects of normal aging that may be related to changes in brain aromatase activity.

Cognitive Effects of Chemotherapy and Cancer-Related Treatments in Older Adults

Advances in cancer treatment are producing a growing number of cancer survivors; therefore, issues surrounding quality of life during and following cancer treatment have become increasingly important. Chemotherapy-related cognitive impairment (CRCI) is a problem that is commonly reported following the administration of chemotherapy treatment in patients with cancer. Research suggests that CRCI can persist for months to years after completing treatment, which has implications for the trajectory of normal and pathologic cognitive aging for the growing number of long-term cancer survivors. These problems are particularly relevant for older individuals, given that cancer is largely a disease of older age, and the number of patients with cancer who are aged 65 years or older will increase dramatically over the coming decades. This review will briefly summarize empirical findings related to CRCI, discuss CRCI in older patients with cancer, propose potential causative hypotheses, and provide a canonical patient case to illustrate how CRCI presents clinically. Finally, potential intervention strategies for CRCI will be highlighted and issues to consider when evaluating older patients with a history of cancer will be discussed.

Treatments for Breast Cancer That Affect Cognitive Function in Postmenopausal Women

About one of every eight women will develop breast cancer during her lifetime. Approximately a quarter of a million new cancer cases are expected in 2017. Of those breast cancers, 60% to 75% will have characteristics suggesting that estrogens are likely to promote growth of those tumors. Consequently, inhibiting estrogen synthesis is one of the main treatments of choice. Therefore, women must understand the potential adverse effects of those treatments on quality of life. This review discusses (a) the role of estrogens locally synthesized in the brain in laboratory animals and women, (b) the effects of estrogens and blockers of estrogen synthesis on cognitive function, and (c) the limitations in experiments on women taking inhibitors. This article aims to provide women and oncologists with information that will encourage them to consider side effects of aromatase inhibitors (AIs) treatment on the brain.

Effect of aromatase inhibitors on learning and memory and modulation of hippocampal dickkopf-1 and sclerostin in female mice

BACKGROUND

There has been conflicting reports on the effect of third generation aromatase inhibitors on cognition in estrogen-deficient states. Since aromatase inhibitors themselves cause estrogen deprivation, the present work was designed to evaluate the comparative effect of three aromatase inhibitors on behavioral measures of learning and memory in female mice. Further, in view of the reports of estrogen and Wnt signaling pathway in cognition, the role of two Wnt signaling antagonists (dickkopf-1 and sclerostin) in mediation of cognitive effects of aromatase inhibitors was evaluated.

METHODS

Three behavioral paradigms were used for evaluating cognitive functions viz. Morris water maze, active avoidance learning and spontaneous alternation behavior following 10-15days of administration with aromatase inhibitors and the levels of dickkopf-1 and sclerostin were evaluated in hippocampus of female mice.

RESULTS

Anastrozole and letrozole (but not exemestane) impaired learning and memory as indicated by increase in escape latency and path length during spatial acquisition, reduction of % quadrant dwell time in Morris water maze, reduction of % avoidance and increase in escape responses in active avoidance learning and decrease in % alternation in a cross maze. The behavioral effects correlated well with the levels of dickkopf-1 and sclerostin in the mouse hippocampus. The highest impairment in learning and memory occurred with letrozole followed by anastrozole while exemestane was without such effects.

CONCLUSION

The present study demonstrates that aromatase inhibitors have adverse impact on cognition. Furthermore, modulation of Wnt signaling following estrogen depletion possibly contributed to observed effects in case of anastrozole and letrozole.

Memory and Spatial Cognition in Breast Cancer Patients Undergoing Adjuvant Endocrine Therapy

INTRODUCTION

It is generally accepted that estrogens play a protective role in cognitive function. Therefore, it can be expected that subtotal estrogen deprivation following aromatase inhibition will alter cognitive performance.

METHODS

In a cross-sectional study we investigated 80 postmenopausal women with breast cancer. Memory and spatial cognition were compared across 4 treatment groups: tamoxifen only (TAM, n = 22), aromatase inhibitor only (AI, n = 22), TAM followed by AI ('SWITCH group', n = 15), and patients with local therapy (LT) only (surgery and radiation, n = 21). Duration of the 2 endocrine monotherapy arms prior to the assessment ranged from 1 to 3 years. The 'SWITCH group' received 2-3 years TAM followed by at least 1 year and at most 3 years of AI. Memory and spatial cognition were investigated as planned comparisons. Investigations of processing speed, attention, executive function, visuoconstruction and self-perception of memory were exploratory.

RESULTS

With regard to general memory, AI patients performed significantly worse than the LT group (p = 0.013). Significant differences in verbal memory did not remain significant after p-value correction for multiple testing. We found no significant differences concerning spatial cognition between the groups.

CONCLUSION

AI treatment alone significantly impairs general memory compared to the LT group.

Adjuvant ovarian function suppression and cognitive function in women with breast cancer

BACKGROUND

To examine the effect on cognitive function of adjuvant ovarian function suppression (OFS) for breast cancer.

METHODS

The Suppression of Ovarian Function (SOFT) trial randomised premenopausal women with hormone receptor-positive breast cancer to 5 years adjuvant endocrine therapy with tamoxifen+OFS, exemestane+OFS or tamoxifen alone. The Co-SOFT substudy assessed objective cognitive function and patient reported outcomes at randomisation (T0), and 1 year later (T1); the primary endpoint was change in global cognitive function, measured by the composite objective cognitive function score. Data were compared for the pooled tamoxifen+OFS and exemestane+OFS groups vs the tamoxifen alone group using the Wilcoxon rank-sum test.

RESULTS

Of 86 participants, 74 underwent both T0 and T1 cognitive testing; 54 randomised to OFS+ either tamoxifen (28) or exemestane (26) and 20 randomised to tamoxifen alone. There was no significant difference in the changes in the composite cognitive function scores between the OFS+ tamoxifen or exemestane groups and the tamoxifen group (mean±s.d., -0.21±0.92 vs -0.04±0.49, respectively, P=0.71, effect size=-0.20), regardless of prior chemotherapy status, and adjusting for baseline characteristics.

CONCLUSIONS

The Co-SOFT study, although limited by small samples size, provides no evidence that adding OFS to adjuvant oral endocrine therapy substantially affects global cognitive function.

Trajectories of self-reported cognitive function in postmenopausal women during adjuvant systemic therapy for breast cancer

OBJECTIVE

In a sample of 368 postmenopausal women, we (1) determined within-cohort and between-cohort relationships between adjuvant systemic therapy for breast cancer and self-reported cognitive function during the first 18 months of therapy and (2) evaluated the influence of co-occurring symptoms, neuropsychological function, and other covariates on relationships.

METHODS

We evaluated self-reported cognitive function, using the Patient Assessment of Own Functioning Inventory (PAOFI), and potential covariates (e.g., co-occurring symptom scores and neuropsychological function z-scores) in 158 women receiving aromatase inhibitor (AI) therapy alone, 104 women receiving chemotherapy followed by AI therapy, and 106 non-cancer controls. Patients were assessed before systemic therapy and then every 6 months, for a total of four assessments over 18 months. Controls were assessed at matched time points. Mixed-effects modeling was used to determine longitudinal relationships.

RESULTS

Controlling for covariates, patients enrolled before chemotherapy reported poorer global cognitive function (p < 0.001), memory (p < 0.001), language and communication (p < 0.001), and sensorimotor function (p = 0.002) after chemotherapy. These patients reported poorer higher-level cognitive and intellectual functions from before chemotherapy to 12 months after initiation of AI therapy (p < 0.001). Higher levels of depressive symptoms (p < 0.001), anxiety (p < 0.001), and fatigue (p = 0.040) at enrollment were predictors of poorer cognitive function over time. PAOFI total score was a predictor of executive function (p = 0.048) and visual working memory (p = 0.005) z-scores, controlling for covariates.

CONCLUSIONS

Findings provide further evidence of poorer self-reported cognitive function after chemotherapy and of relationships between co-occurring symptoms and cognitive changes. AI therapy alone does not have an impact on self-reported cognitive function. Copyright © 2015 John Wiley & Sons, Ltd.

Cognitive functioning during long-term tamoxifen treatment in postmenopausal women with breast cancer

OBJECTIVE

Endocrine therapy is widely used-often for many years-in women with breast cancer. Yet little is known about cognitive functioning after long-term use of tamoxifen. We examine cognitive sequelae, approximately 3 years after diagnosis, in postmenopausal women with breast cancer who were treated with adjuvant tamoxifen.

METHODS

Data from participants who underwent surgical operation with or without radiotherapy, participants who received adjuvant tamoxifen, and healthy controls were collected. Neuropsychological tests were administered, and participants completed questionnaires on health-related quality of life (Quality of Life Questionnaire Core 30 and Breast Cancer-Specific Quality-of-Life Questionnaire), menopausal symptoms (Functional Assessment of Cancer Therapy-Breast endocrine symptom subscale), and anxiety and depression (Hopkins Symptom Checklist).

RESULTS

In total, 107 women participated (adjuvant tamoxifen group, n = 20; surgical operation/radiotherapy group, n = 43; healthy control group, n = 44). Women in the adjuvant tamoxifen group had received tamoxifen for a mean (SD) of 31.5 (18.6) months (range, 15-79 mo) and performed worse on verbal memory than the surgical operation/radiotherapy group (P < 0.05) and the healthy control group (P < 0.05). Participants in the adjuvant tamoxifen group performed worse on measures of fluency than healthy controls (P < 0.05). Furthermore, women in the adjuvant tamoxifen group reported worse cognitive functioning (P < 0.05) than women in the surgical operation/radiotherapy group or the healthy control group.

CONCLUSIONS

Our results provide insights into cognitive functioning in women who receive long-term adjuvant tamoxifen treatment. By adding the surgical operation/radiotherapy group, we could control for the mental and physical influences of the diagnosis and treatment of breast cancer. Cognitive domains that rely on verbal abilities (verbal memory and fluency) seem to be at risk for deterioration after treatment with tamoxifen.

Patterns of change in cognitive function with anastrozole therapy

BACKGROUND

The purpose of this study was to examine and compare the effects of the first 18 months of anastrozole therapy on cognitive function in women with breast cancer.

METHODS

This large, longitudinal cohort study was composed of postmenopausal women with early-stage breast cancer who received chemotherapy plus anastrozole (n = 114) or anastrozole alone (n = 173) and a control group (n = 110). Cognitive function was assessed before systemic therapy and 6, 12, and 18 months after therapy initiation and at comparable time points in controls.

RESULTS

The chemotherapy-anastrozole and anastrozole-alone groups had poorer executive function than the controls at nearly all time points (P < .0001 to P = .09). A pattern of deterioration in working memory and concentration was observed during the first 6 months of anastrozole therapy for the chemotherapy-anastrozole group (P < .0001 and P < .0009, respectively) and the anastrozole-alone group (P = .0008 and P = .0002, respectively). This was followed by improved working memory and concentration from 6 to 12 months in both groups. The anastrozole-alone group had a second decline in working memory and concentration from 12 to 18 months after the initiation of therapy (P < .0001 and P = .02, respectively).

CONCLUSIONS

Women with breast cancer had poorer executive functioning from the period before therapy through the entire first 18 months of therapy. A pattern of decline in working memory and concentration with initial exposure to anastrozole was observed. Women receiving anastrozole alone had a second deterioration in working memory and concentration from 12 to 18 months after therapy initiation. The longer term effects (>18 months) of anastrozole on cognitive function remain to be determined.

Structure-function-behavior relationship in estrogen-induced synaptic plasticity

This article is part of a Special Issue "Estradiol and Cognition". In estrogen-induced synaptic plasticity, a correlation of structure, function and behavior in the hippocampus has been widely established. 17ß-estradiol has been shown to increase dendritic spine density on hippocampal neurons and is accompanied by enhanced long-term potentiation and improved performance of animals in hippocampus-dependent memory tests. After inhibition of aromatase, the final enzyme of estradiol synthesis, with letrozole we consistently found a strong and significant impairment of long-term potentiation (LTP) in female mice as early as after six hours of treatment. LTP impairment was followed by loss of hippocampal spine synapses in the hippocampal CA1 area. Interestingly, these effects were not found in male animals. In the Morris water maze test, chronic administration of letrozole did not alter spatial learning and memory in either female or male mice. In humans, analogous effects of estradiol on hippocampal morphology and physiology were observed using neuroimaging techniques. However, similar to our findings in mice, an effect of estradiol on memory performance has not been consistently observed.

Long-term subjective cognitive functioning following adjuvant systemic treatment: 7-9 years follow-up of a nationwide cohort of women treated for primary breast cancer

Background:

There is growing concern among breast cancer (BC) patients and survivors about cognitive impairment following systemic treatments. The aim of the present study was to investigate the long-term effects of standard systemic adjuvant therapies on subjective cognitive impairment (SCI) in a large nationwide cohort of BC survivors 7–9 years after primary surgery.

Methods:

Participants were recruited from the nationwide Psychosocial Factors and Breast Cancer inception cohort of Danish women treated for primary BC. SCI was assessed with the Cognitive Failures Questionnaire and women allocated to systemic treatment according to nationwide standard protocols were compared with women who had not received any systemic treatments.

Results:

A total of 1889 recurrence-free survivors were eligible for analysis. No difference in SCI was found between survivors across standardized systemic treatment protocols when analyses were stratified by menopausal status and adjusted for possible sociodemographic and treatment-related confounders. The frequency of significant SCI in a subgroup of survivors in the age range 65–74 years was ∼7%.

Conclusions:

No differences in long-term SCI at 7–9 years post surgery were found between women who had received systemic therapies and those who had not. Furthermore, the observed proportion of survivors with significant SCI was comparable to normative data. These results are important to communicate to patients, survivors, and clinicians alike, especially in the light of increasing concern about cognitive impairment following systemic therapies.

Safety of aromatase inhibitor therapy in breast cancer

INTRODUCTION

Aromatase inhibitor (AI) therapy is the current preferred choice of endocrine therapy in postmenopausal estrogen receptor-positive breast cancer patients thanks to their improved effectiveness compared to tamoxifen. Despite the absence of increased endometrial pathology and deep venous thrombosis seen in tamoxifen-users, the safety profile of AIs consists of a variety of bothersome side effects negatively influencing daily functioning.

AREAS COVERED

Besides the well-known adverse effects on joints and bone and the vasomotor system, more neglected and latent toxicity like cognitive problems and vulvovaginal atrophy will be discussed. Concern has been raised in terms of increased risk of fractures and cardiovascular events with chronic AI use.

EXPERT OPINION

Placebo-controlled long-term studies carefully monitoring these adverse events, together with more extensive research in the etiologies, are warranted.

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.

Psychosocial/survivorship issues in breast cancer: are we doing better?

Modern breast cancer treatment offers many women greater prospects of cure or lengthier, good quality survival than was possible in the past. Advances include improved diagnostic and staging procedures, sophisticated onco-plastic surgery, enhanced radiotherapy techniques, and targeted systemic therapies. Much more attention has also been paid to cancer care delivery and access to specialist nurses, counsellors, support groups, and services provided by breast cancer charities. However, there are some concerns that these considerable improvements in treatment delivery and clinical outcomes have not led to similar benefits in the psychosocial, functional, and sexual well-being of women. The impact that non-life threatening, long-term iatrogenic harms of otherwise efficacious anticancer treatments has on patients is often overlooked; this is in part because of the emphasis given to physician-reported safety data in trials and the general exclusion of patient-reported outcomes (PROs). A failure to utilise reliable PRO measures has meant that some problems are underreported, which consequently has hampered much-needed research into ameliorative interventions. Systematic monitoring of quality of life-threatening side effects would permit early implementation of effective interventions and enhance long-term survivorship. Some examples of the pervasive difficulties that continue to affect survivors and evidence that certain interventions might help are provided in this commentary.

Cognitive effects of cancer systemic therapy: implications for the care of older patients and survivors

The number of patients with cancer who are age 65 years or older (hereinafter "older") is increasing dramatically. One obvious aspect of cancer care for this group is that they are experiencing age-related changes in multiple organ systems, including the brain, which complicates decisions about systemic therapy and assessments of survivorship outcomes. There is a consistent body of evidence from studies that use neuropsychological testing and neuroimaging that supports the existence of impairment following systemic therapy in selected cognitive domains among some older patients with cancer. Impairment in one or more cognitive domains could have important effects in the daily lives of older patients. However, an imperfect understanding of the precise biologic mechanisms underlying cognitive impairment after systemic treatment precludes development of validated methods for predicting which older patients are at risk. From what is known, risks may include lifestyle factors such as smoking, genetic predisposition, and specific comorbidities such as diabetes and cardiovascular disease. Risk also interacts with physiologic and cognitive reserve, because even at the same chronological age and with the same number of illnesses, older patients vary from having high reserve (ie, biologically younger than their age) to being frail (biologically older than their age). Surveillance for the presence of cognitive impairment is also an important component of long-term survivorship care with older patients. Increasing the workforce of cancer care providers who have geriatrics training or who are working within multidisciplinary teams that have this type of expertise would be one avenue toward integrating assessment of the cognitive effects of cancer systemic therapy into routine clinical practice.

Brain sex matters: estrogen in cognition and Alzheimer's disease

Estrogens are the primary female sex hormones and play important roles in both reproductive and non-reproductive systems. Estrogens can be synthesized in non-reproductive tissues such as liver, heart, muscle, bone and the brain. During the past decade, increasing evidence suggests that brain estrogen can not only be synthesized by neurons, but also by astrocytes. Brain estrogen also works locally at the site of synthesis in paracrine and/or intracrine fashion to maintain important tissue-specific functions. Here, we will focus on the biology of brain estrogen and its impact on cognitive function and Alzheimer's disease. This comprehensive review provides new insights into brain estrogens by presenting a better understanding of the tissue-specific estrogen effects and their roles in healthy ageing and cognitive function.

Aromatase inhibitors in the breast cancer clinic: focus on exemestane

Breast cancer is the most prevalent type of cancer in women and responsible for significant female cancer-related mortality worldwide. In the Western world, over 80% of breast cancers are hormone-receptor positive for which endocrine therapy is administered. The main anti-estrogen treatments in use consist of selective estrogen-receptor modulators, such as tamoxifen, and third-generation aromatase inhibitors (AIs), such as exemestane, letrozole, and anastrozole. In this review, the focus will lie on exemestane, its clinical use, and its side-effect profile. Exemestane is the only third-generation steroidal AI. Its efficacy as a first-line treatment in metastatic breast cancer has been demonstrated. Therefore, exemestane could be considered a valid first-line therapeutic option, but it also can be used in second-line or further situations. Exemestane is mostly used as part of sequential adjuvant treatment following tamoxifen, but in this setting it is also active in monotherapy. Furthermore, this AI has been studied in the neoadjuvant setting as presurgical treatment, and even as chemoprevention in high-risk healthy postmenopausal women. It may reverse side effects of tamoxifen, such as endometrial changes and thromboembolic disease but may also cause some inconvenient side effects itself. Additionally, there is a lack of total cross-resistance between exemestane and nonsteroidal AIs as far as their anti-tumoral efficacy is concerned; moreover the two classes of AIs display a nontotal overlapping toxicity profile. Taking together, exemestane can be considered as a useful treatment option at all stages of breast cancer.

Effect of endocrine therapy on quality of life and cognitive functions in patients with breast cancer

BACKGROUND

The use of endocrine therapy (ET) in postmenopausal breast cancer patients may affect their cognitive status. This study aims to assess the effects of tamoxifen and aromatase inhibitors (Als) on quality of life (QoL) and cognitive functions in breast cancer patients.

PATIENTS AND METHODS

The study included 101 patients receiving tamoxifen, 97 patients receiving Als, and 95 patients without any ET. All patients completed both the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the Short Form-12 (SF-12) questionnaires.

RESULTS

The patients' characteristics were similar between the groups. The mean duration of ET was 2.6 years for tamoxifen and 2.5 years for Als. EORTC QLQ-C30 global scores and cognitive functioning scores as well as SF-12 mental scorings (mcs) were found not significantly different between patients without any ET and those receiving tamoxifen or Als (p = 0.529, p = 0.333, and p = 0.452, respectively). SF-12 mcs correlated moderately with EORTC QLQ-C30 global scores for the 3 treatment groups (all p values < 0.001).

CONCLUSION

Our study suggests that QoL and cognitive functions are similar in patients receiving Als or tamoxifen. Moreover, it appears that these parameters also do not differ in patients with respect to the use of ET.

Cognitive effects of cancer and its treatments at the intersection of aging: what do we know; what do we need to know?

There is a fairly consistent, albeit non-universal body of research documenting cognitive declines after cancer and its treatments. While few of these studies have included subjects aged 65 years and older, it is logical to expect that older patients are at risk of cognitive decline. Here, we use breast cancer as an exemplar disease for inquiry into the intersection of aging and cognitive effects of cancer and its therapies. There are a striking number of common underlying potential biological risks and pathways for the development of cancer, cancer-related cognitive declines, and aging processes, including the development of a frail phenotype. Candidate shared pathways include changes in hormonal milieu, inflammation, oxidative stress, DNA damage and compromised DNA repair, genetic susceptibility, decreased brain blood flow or disruption of the blood-brain barrier, direct neurotoxicity, decreased telomere length, and cell senescence. There also are similar structure and functional changes seen in brain imaging studies of cancer patients and those seen with "normal" aging and Alzheimer's disease. Disentangling the role of these overlapping processes is difficult since they require aged animal models and large samples of older human subjects. From what we do know, frailty and its low cognitive reserve seem to be a clinically useful marker of risk for cognitive decline after cancer and its treatments. This and other results from this review suggest the value of geriatric assessments to identify older patients at the highest risk of cognitive decline. Further research is needed to understand the interactions between aging, genetic predisposition, lifestyle factors, and frailty phenotypes to best identify the subgroups of older patients at greatest risk for decline and to develop behavioral and pharmacological interventions targeting this group. We recommend that basic science and population trials be developed specifically for older hosts with intermediate endpoints of relevance to this group, including cognitive function and trajectories of frailty. Clinicians and their older patients can advance the field by active encouragement of and participation in research designed to improve the care and outcomes of the growing population of older cancer patients.

The effect of aromatase inhibition on the cognitive function of older patients with breast cancer

INTRODUCTION

This study evaluated the association between aromatase inhibitor (AI) therapy and cognitive function (over a 6-month period) in a cohort of patients aged ≥ 60 years compared with an age-matched healthy control group, and it evaluated changes in regional cerebral metabolism as measured by positron emission tomography (PET) scans of the brain done in a subset of the patient cohort.

PATIENTS AND METHODS

Thirty-five patients (32 evaluable) and 35 healthy controls were recruited to this study. Patients with breast cancer completed a neuropsychological battery, self-reported memory questionnaire, and geriatric assessment before initiation of AI therapy and again 6 months later. Age-matched healthy control participants completed the same assessments at the same time points as the patient group.

RESULTS

No significant decline in cognitive function was seen among individuals receiving an AI from pretreatment to 6 months later compared with healthy controls. In the PET cohort over the same period, both standardized volume of interest and statistical parametric mapping analyses detected specific changes in metabolic activity between baseline and follow-up uniquely in the AI patients, most significantly in the medial temporal lobes.

CONCLUSION

Although patients undergoing AI treatment had few changes in neuropsychological performance compared with healthy controls over a 6-month period, regionally specific changes in cerebral metabolic activity were identified during this interval in the patient group. Additional longitudinal follow-up is needed to understand the potential clinical implications of these findings.

Early discontinuation of adjuvant hormone therapy is associated with a poor prognosis in Japanese breast cancer patients

PURPOSE

It is important for patients to complete the planned hormone therapy to reduce both the recurrence and mortality rates of hormone receptor-positive breast cancer. We investigated the rates and factors related to the early discontinuation of adjuvant hormone therapy at our institution.

METHODS

We identified 145 females prescribed adjuvant hormone therapy who were followed up for longer than 5 years. The rate of completing the planned hormone therapy and factors related to early discontinuation were examined. The relapse-free survival rate was examined between the completion group and the discontinuation group.

RESULTS

The completion rate was 90.6 %. The primary reason for discontinuing hormone therapy within 5 years was side effects, such as arthritic pain. The primary factor related to early discontinuation was a significantly younger age. The relapse-free survival rate was significantly lower in the discontinuation group (p = 0.025).

CONCLUSIONS

More than 90 % of the patients completed the planned adjuvant hormone therapy, and early discontinuation was related to a shorter RFS. To improve the rate of the successful completion of adjuvant hormone therapy, it is important to provide supportive care to reduce the occurrence of side effects and to care for young females with a desire to become pregnant.