Cognitive training programs for childhood cancer patients and survivors: A critical review and future directions

Engaging carers in neuropsychological rehabilitation for brain cancer survivors: The "I'm aware: Patients And Carers Together" (ImPACT) program

BACKGROUND

Cognitive impairment is a common late effect in child and adult brain cancer survivors (BCS). Still, there is a dearth of research aimed at therapeutic interventions and no standard treatment options for most BCS.

OBJECTIVE

To describe 1) a novel neuropsychological rehabilitation program for BCS - the "I'm aware: Patients And Carers Together" (ImPACT) program, and 2) two studies that aim to assess the feasibility of the ImPACT program in child and adult BCS, respectively. The program adapts the holistic neuropsychological approach pioneered by Leonard Diller and Yehuda Ben-Yishay to an outpatient setting.

METHODS

Two feasibility studies are described: 1) A single-armed study with 15 child BCS (10-17 years) (ImPACT Child); and 2) a randomized waitlist-controlled trial with 26 adult BCS (>17 years) (ImPACT Adult). In both studies, patients will undergo an 8-week program together with a cohabiting carer. Primary outcomes (i.e., cognitive and neurobehavioral symptoms), and secondary outcomes (i.e., behavioral and psychological symptoms, e.g., quality of life, fatigue) will be assessed at four time points: pre-, mid-, and post intervention, and 8 weeks follow-up. Adult waitlist controls will be assessed at equivalent time points and will be included in the intervention group after all study assessments. Semi-structured interviews will be conducted at follow-up.

EXPECTED OUTCOMES

Results will provide feasibility data in support of future larger scale trials.

DISCUSSION

The findings could potentially improve the management of cognitive impairment in BCS and transform available services. The program can be delivered in-person or remotely and harnesses existing resources in patients' lives.

Cognitive and behavioural rehabilitation interventions for survivors of childhood cancer with neurocognitive sequelae: A systematic review

There is considerable interest in cognitive and behavioural interventions to manage and improve neurocognitive (dys)functions in childhood cancer survivors and the literature is rapidly growing. This systematic review aimed to examine the literature of such interventions and their impact on executive functions (EFs) and attention. A search of relevant manuscripts was performed in PubMed, PsycINFO, and Web of Science in March 2023 in accordance with the PRISMA statement. After screening 3737 records, 17 unique studies published between 2002 and 2022 were charted and summarized. Participants (N = 718) were mostly children (M = 12.2 years), who were long-term survivors (M = 5.0 years post treatment) of brain or CNS tumours (48%). Identified interventions included computerized cognitive training, physical activity, and cognitive interventions with compensatory strategy training. The highest quality RCT studies included computerized training (i.e., Cogmed), neurofeedback, and exergaming. Evidence suggests that Cogmed may improve the performance of certain working memory tasks (near transfer) and possibly improve visual attention tasks for individuals with working memory impairments. However, the evidence did not support far transfer of effects to real life. No significant effects (near or far-transfer) were found following neurofeedback and exergaming interventions. Finally, a knowledge gap was identified for interventions directed at long-term survivors in adulthood.

Holistic rehabilitation for children with cancer: The Chilean model

The increasingly positive outcomes of childhood cancer treatments are among the most inspiring stories in modern medicine. Many of the children and adolescents surviving cancer will have a healthy life; however, many others will suffer from physical, cognitive, psychological, and social sequelae. During treatment, many children experience multiple temporary and permanent side effects which negatively impact their quality of life. Low- and middle-income countries where childhood cancer treatment outcomes are improving are facing the reality of a growing population of teenagers and young adults suffering from long-term disease- and treatment-related consequences. In Chile, 500 children are diagnosed with cancer each year. Treatment is granted for all through public health policies and NGO collaboration. In order to address the complex problems from acute and long-term consequences of disease and treatment, the Oncological Rehabilitation Center Fundación Nuestros Hijos (CROFNH) provides multidisciplinary attention to an extensive variety of rehabilitation needs for children and adolescents with cancer. With its integrated services in the medical treatment of children and adolescents with cancer, the CROFNH helps reduce the impact of treatment-related side effects in children's daily lives, improves quality of life, and aims at contributing to these children becoming independent and functional adults to the maximum of their capacities. The aim of this article is to show the experience of the Chilean Oncological Rehabilitation Centre and its unique multidisciplinary approach. In addition, we discuss the successful telerehabilitation strategy implemented in response to the COVID-19 pandemic in order to secure continuity of treatment.

Cerebellar lesions at a young age predict poorer long-term functional recovery

Early studies on long-term functional recovery after motor and premotor lesions showed better outcomes in younger monkeys than in older monkeys. This finding led to the widespread belief that brain injuries cause less impairment in children than adults. However, this view has limitations and a large body of evidence now indicates that cerebral damages can be more harmful when inflicted at young age, during critical periods of neural development. To date, this issue has been mainly investigated in the context of focal and diffuse cortical lesions. Much less is known about the potential influence of early cerebellar damages. Several studies exist in survivor of posterior fossa tumours. However, in these studies, critical confounders were not always considered and contradictory conclusions were provided. We studied the impact or early cerebellar damage on long-term functional recovery in three groups of 15 posterior fossa survivors, comparable with respect to their tumour characteristics (type, size and location) but operated at different ages: young (≤7 years), middle (>7 and ≤13 years) and older (>13 years). Daily (health-related quality of life scale, performance status scale), motor (International Cooperative Ataxia Rating Scale, Pegboard Purdue Test) and cognitive (full-scale intelligence quotient) functioning were assessed. A general linear model controlling for age at surgery, radiotherapy, preservation of deep cerebellar nuclei, tumour volume and delay between surgery and assessment was used to investigate significant variations in outcome measures. Early age at surgery, lesion of deep cerebellar nuclei and postoperative radiotherapy had a significant, independent negative influence on long-term recovery. Tumour volume and delay between surgery and assessment had no statistically detectable impact. The negative influence of early age at surgery was significant in all domains: daily functioning (health-related quality of life scale, performance status scale), motor functioning (International Cooperative Ataxia Rating Scale, Pegboard Purdue Test) and cognitive functioning (full-scale intelligence quotient). These results support the existence of an early critical period of development during which the cerebellar ‘learning machine’ is of critical importance. Although the extent to which the early deficits here observed can be reversed needs now to be established, our data plead for the implementation of prompt and intense rehabilitation interventions in children operated before 7 years of age.

A nationwide, population-based study of school grades, delayed graduation, and qualification for school years 10-12, in children with brain tumors in Sweden

BACKGROUND

As many as 95.7% of children diagnosed with a brain tumor will experience persistent late effects as adults. These include difficulties with general executive functions, lower IQ, and mental fatigue, which may negatively affect school performance.

METHODS

Through the Swedish Childhood Cancer Registry, we identified 475 children born between 1988 and 1996, diagnosed with a brain tumor before their 15th birthday. School grades in "Swedish," "mathematics," and "English," if their graduation was delayed, and qualification for school years 10-12 were compared with 2197 matched controls. Furthermore, we checked for interaction effects between sex and age at diagnosis, and possible effects of tumor grade (high or low) as well as parents' education.

RESULTS

Children treated for a brain tumor performed worse in the subjects compared to controls and also had delayed graduation to a greater extent. Fewer children treated for a brain tumor than controls qualified for school years 10-12. Children treated at a young age, especially females, and children whose parents have low education seem to be at particular risk. Unexpectedly, there were no differences in outcomes between survivors with high- and low-grade tumors.

CONCLUSIONS

It is important that schools provide regular pedagogical assessment and individualized support to meet the different needs of children treated for a brain tumor. Children treated for low-grade tumors do not perform better than children treated for high-grade tumors, despite the lighter treatment, and hence require the same attention and support.

Late effects of pediatric brain tumors

PURPOSE OF REVIEW

Adverse late effects of pediatric brain tumors can be numerous and complex and potentially alter the life trajectories of survivors in a multitude of ways. We review these inter-related late effects that compromise neurocognitive function, general health, social and psychological adjustment, and overall adaptive and vocational outcomes, and threaten to undermine the ability of survivors to transition independently into adulthood and effectively manage their care. Intervention/prevention strategies and advances in treatment that may reduce such late effects are discussed.

RECENT FINDINGS

Studies of neuropsychological late effects have revealed specific deficits in core cognitive functions of attention, working memory and processing speed, with many survivors demonstrating decline in working memory and processing speed over time, irrespective of tumor type or treatment. This in turn affects the ongoing development of higher order neurocognitive skills. Research also highlights the increasing burden of health-related, neuropsychological and psychosocial late effects into adulthood and impact across life outcomes.

SUMMARY

Pediatric brain tumor survivors require coordinated interdisciplinary care, ongoing evaluation and management of late effects, and timely interventions focused on mitigating the impact of late effects. The transition to adulthood can be especially vulnerable and addressing barriers to care is of paramount importance.

Future considerations for pediatric cancer survivorship: Translational perspectives from developmental neuroscience

Breakthroughs in modern medicine have increased pediatric cancer survival rates throughout the last several decades. Despite enhanced cure rates, a subset of pediatric cancer survivors exhibit life-long psychological side effects. A large body of work has addressed potential mechanisms for secondary symptoms of anxiety, post-traumatic stress, impaired emotion regulation and cognitive deficits in adults. Yet, absent from many studies are the ways in which cancer treatment can impact the developing brain. Additionally, it remains less known whether typical neurobiological changes during adolescence and early adulthood may potentially buffer or exacerbate some of the known negative cancer survivorship outcomes. This review highlights genetic, animal, and human neuroimaging research across development. We focus on the neural circuitry associated with aversive learning, which matures throughout childhood, adolescence and early adulthood. We argue that along with other individual differences, the precise timing of oncological treatment insults on such neural circuitry may expose particular vulnerabilities for pediatric cancer patients. We also explore other moderators of treatment outcomes, including genetic polymorphisms and neural mechanisms underlying memory and cognitive control. We discuss how neural maturation extending into young adulthood may also provide a sensitive period for intervention to improve psychological and cognitive outcomes in pediatric cancer survivors.

The Effects of Radiation and Sex Differences on Adaptive Functioning in Adult Survivors of Pediatric Posterior Fossa Brain Tumors

OBJECTIVE

Radiation therapy (RT) improves rates of survival of patients with childhood brain tumors but increases deficits in cognition and independent living skills. Previous literature has studied difficulties in basic cognitive processes, but few explore impairment in higher-order skills such as adaptive functioning. Some studies identify females as at risk for cognitive deficits due to RT, but few investigate sex differences in adaptive functioning. It was hypothesized that females would exhibit poorer long-term independent living skills and core cognitive skills relative to males following RT.

METHODS

Forty-five adult survivors of posterior fossa childhood brain tumors (24 females) completed the Wechsler Abbreviated Scale of Intelligence (WASI-II), Wechsler Memory Scale, Third Edition (WMS-III) Digit Span Forward (DSF) and Backward (DSB), and Oral Symbol Digit Modalities Test (OSDMT). Informants completed the Scales of Independent Behavior-Revised (SIB-R).

RESULTS

DSF and OSDMT were positively correlated with all five SIB-R domains, full-scale IQ (FSIQ) was positively correlated with four SIB-R domains, and DSB was positively correlated with three SIB-R domains. There was an interaction between sex and RT for OSDMT and community living skills with trend level interactions for personal living skills and broad independent living skills, where females without RT had higher scores than females with RT.

CONCLUSIONS

Female survivors were more affected by RT than males across the community living skills domain of adaptive functioning as well as processing speed. Processing speed deficits may have a cascading impact on daily living skills. Future studies should investigate how clinical and biological factors may contribute to personalized treatment plans between sexes. (JINS, 2019, 25, 729-739).

Interactions between visual working memory and visual attention among survivors of pediatric acute lymphoblastic leukemia (ALL) and their healthy peers

Introduction: There is increasing concern for adverse cognitive late effects among survivors of pediatric acute lymphoblastic leukemia (ALL) given the widespread impact they have on academic achievement, particularly working memory and attention. We assessed performance among survivors and their healthy peers on a dual task paradigm measuring visual working memory (VWM) and visual attention independently and the dynamic relationship between the two. Assessing specific subsets within cognitive domains allows for understanding the distinct nature of cognitive impairments. Method: Participants were 34 survivors of ALL who have been off-treatment and disease free for 7.5 years; and 20 healthy controls, all between the ages of 10 and 18 years. We utilized behavioral single- and dual-task paradigms. In the dual tasks, participants maintained several items in VWM while performing a visual attention task (Eriksen Flanker Task) that required processing of a target stimulus while inhibiting the processing of distractor stimuli. The single tasks involved performing only the VWM task or only the visual attention task. Results: Results revealed survivors of ALL performed significantly worse than their healthy peers on the single visual attention task but not the single VWM task. Of particular interest, group differences were obtained on the dual VWM and visual attention tasks, such that the VWM and attention tasks reciprocally interfered with each other only among survivors and not their healthy peers. Conclusions: Our results highlight a core deficit in visual attention that is exacerbated by VWM demands among survivors of ALL. The implementation of tasks from cognitive neuroscience paradigms may be sensitive to cognitive impairments experienced by cancer survivors. Assessment and intervention practices among survivors of pediatric ALL are discussed.

Neurocognitive and Psychosocial Outcomes in Pediatric Brain Tumor Survivors

The late neurocognitive and psychosocial effects of treatment for pediatric brain tumor (PBT) represent important areas of clinical focus and ongoing research. Neurocognitive sequelae and associated problems with learning and socioemotional development negatively impact PBT survivors' overall health-related quality of life, educational attainment and employment rates. Multiple factors including tumor features and associated complications, treatment methods, individual protective and vulnerability factors and accessibility of environmental supports contribute to the neurocognitive and psychosocial outcomes in PBT survivors. Declines in overall measured intelligence are common and may persist years after treatment. Core deficits in attention, processing speed and working memory are postulated to underlie problems with overall intellectual development, academic achievement and career attainment. Additionally, psychological problems after PBT can include depression, anxiety and psychosocial adjustment issues. Several intervention paradigms are briefly described, though to date research on innovative, specific and effective interventions for neurocognitive late effects is still in its early stages. This article reviews the existing research for understanding PBT late effects and highlights the need for innovative research to enhance neurocognitive and psychosocial outcomes in PBT survivors.

Neurocognitive deficits in children with chronic health conditions

Over 4 million children in the United States suffer from chronic health conditions, including cancer, sickle cell disease, and diabetes. Because of major advances in the early identification and treatment of these conditions, survival rates for these children continue to rise, and the majority now lives into adulthood. However, increases in survival have come with costs related to long-term effects of disease processes and treatments. Foremost among these consequences is impairment in brain development and neurocognitive function that may affect a substantial portion of children with chronic health conditions and follow many into adulthood. Impaired cognitive function may contribute to impairment in educational and occupational attainment, mental health, and quality of life for children with chronic conditions. Despite the significance and scope of this problem, advances in the identification and understanding of neurocognitive problems and the delivery of effective clinical care have been hindered in part because research has been "siloed"-conducted on each chronic condition in isolation. This review examines, for the first time, neurocognitive problems in a selected set of 6 chronic pediatric health conditions-leukemia, brain tumors, sickle cell disease, congenital heart disease, Type 1 diabetes, and traumatic brain injury-to define the magnitude of the problem and identify directions for future research and clinical care. Psychologists from many areas of specialization, including pediatric psychology, educational and school psychology, neuropsychology, behavioral medicine, and adult primary care, are uniquely positioned to contribute to every phase of this work, including research, identification, and intervention. (PsycINFO Database Record

Declines Noted in Cognitive Processes and Association With Achievement Among Children With Leukemia

PURPOSE/OBJECTIVES

To assess change in specific cognitive processes during treatment with chemotherapy only among children with acute lymphoblastic leukemia (ALL). 
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DESIGN

A prospective, repeated measures design.
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SETTING

Pediatric oncology treatment centers at Banner-University Medical Center Tucson/Banner Children's-Diamond Medical Center (University of Arizona) and Texas Children's Cancer and Hematology centers (Baylor College of Medicine) in Houston. 
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SAMPLE

71 children with ALL, with a mean age of 6.18 years at the time of diagnosis. 
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METHODS

Using mixed-effects latent growth curve modeling with time since diagnosis as a fixed effect, age-adjusted standardized measures of working memory, processing speed, executive function, and attention were obtained and repeated about one and two years later. A subsample was tested for academic achievement at the end of treatment.
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MAIN RESEARCH VARIABLES

Verbal working memory, visual spatial memory, processing speed, academic achievement, age, and gender. 
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FINDINGS

A significant main effect was observed for age at diagnosis on decline in verbal working memory during treatment. Planned contrasts revealed greater decline among children who were diagnosed when aged younger than five years compared to those diagnosed when aged five years or older. Decline in verbal working memory and achievement in letter-word identification and calculation skills were associated, and decline in spatial memory was associated with calculation. A main effect of gender was observed on processing speed, with female patients showing greater decline than male patients. 
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CONCLUSIONS

Findings from this study may guide the timing of interventions that could improve school achievement among survivors. 
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IMPLICATIONS FOR NURSING

Children undergoing treatment for ALL may experience issues with verbal working memory and increased difficulty in school. Nurses are in a position to refer parents and children to school resources for additional academic support.

Behavioral Effects of Focal Irradiation in a Juvenile Murine Model

Chemotherapy has been successfully used to reduce radiation dose and volume for most pediatric patients. However, because of the failure of chemotherapeutic agents to cross the blood-brain barrier and the lack of response of some brain tumors to these agents, radiation therapy is still used to treat many childhood cancers with CNS involvement. In this study, we investigated the radiation effects on cognition and dendritic structure in the hippocampus in juvenile male mice. Twenty-one-day-old male C57BL/6 mice were irradiated using the small animal radiation research platform (SARRP). Animals were exposed to either a 10 Gy single dose or 10 Gy × 2 fractionated doses of X-ray cranial radiation. Five weeks after irradiation, animals were tested for hippocampus-dependent cognitive performance in the Morris water maze. Significant impairment in spatial memory retention was observed in the probe trial after the first day of hidden-platform training (first probe trial) in animals that received either 10 Gy single-dose or 10 Gy × 2 fractionated doses. However, by day 5, mice that received a 10 Gy single dose showed spatial memory retention in the probe trials, whereas mice that received the 20 Gy fractionated doses remained impaired. During Y-maze testing, animals exposed to radiation were impaired; the irradiated mice were not able to distinguish among the three Y-maze arms and spent approximately the same amount of time in all three arms during the retention trial. Radiation significantly compromised the dendritic architecture and reduced spine density throughout the hippocampal trisynaptic network.

The Brainfit study: efficacy of cognitive training and exergaming in pediatric cancer survivors - a randomized controlled trial

BACKGROUND

Cancer survival comes at a price: pediatric cancer survivors bear a high risk for a wide range of cognitive difficulties. Therefore, interventions targeting these difficulties are required. The aim of the present clinical trial is to extend empirical evidence about efficacy of cognitive and physical training in pediatric cancer survivors. It is hypothesized that early cognitive and physical interventions affect the remediation of pediatric cancer survivors in terms of improved executive functions (primary outcome). Additional positive effects of cognitive and physical intervention to other areas such as memory and attention are expected (secondary outcome). Changes in cognitive performance are expected to be associated with structural and functional changes in the brain.

METHODS

Overall, 150 pediatric cancer survivors and 50 matched controls will be included in this trial. The cancer survivors will be randomly assigned to either a computerized cognitive training, a physical training (exergaming) or a waiting control group. They will be assessed with neuropsychological tests, tests of sport motor performance and physical fitness before and after 8 weeks of training and again at a 3-months follow-up. Moreover, neuroimaging will be performed at each of the three time points to investigate the training impact on brain structure and function.

DISCUSSION

With increasing cancer survival rates, evidence-based interventions are of particular importance. New insights into training-related plasticity in the developing brain will further help to develop tailored rehabilitation programs for pediatric cancer survivors.

TRIAL REGISTRATION

KEK BE 196/15; KEK ZH 2015-0397; ICTRP NCT02749877 ; date of registration: 30.11.2016; date of first participant enrolment: .18.01.2017.

Brain structure, working memory and response inhibition in childhood leukemia survivors

INTRODUCTION

Survival rates for children with acute lymphoblastic leukemia (ALL) approach 95%. At the same time, there is growing concern that chemotherapy causes alterations in brain development and cognitive abilities. We performed MRI measurements of white and gray matter volume to explore how variation in brain structure may be related to cognitive abilities in ALL survivors and healthy controls.

METHODS

The sample included 24 male ALL survivors who had completed contemporary treatment 3-11 years prior, and 21 age- and sex-matched controls. Participants were between 8 and 18 years old. Working memory and motor response inhibition were measured with the N-Back and Stop Signal Tasks (SST), respectively. Participants underwent 3T structural MRI to assess white and gray matter volumes overall, lobe-wise, and in cortical and atlas-identified subcortical structures. Mental health was assessed with the Child Behavioral Checklist.

RESULTS

ALL survivors performed more poorly on measures of working memory and response inhibition than controls. Frontal and parietal white matter, temporal and occipital gray matter volume, and volumes of subcortical white and gray matter structures were significantly reduced in ALL survivors compared with controls. Significant structure-function correlations were observed between working memory performance and volume of the amygdala, thalamus, striatum, and corpus callosum. Response inhibition was correlated with frontal white matter volume. No differences were found in psychopathology.

CONCLUSIONS

Compared with controls, a reduction in volume across brain regions and tissue types, was detectable in ALL survivors years after completion of therapy. These structural alterations were correlated with neurocognitive performance, particularly in working memory. Confirming these observations in a larger, more representative sample of the population is necessary. Additionally, establishing the time course of these changes-and the treatment, genetic, and environmental factors that influence them-may provide opportunities to identify at-risk patients, inform the design of treatment modifications, and minimize adverse cognitive outcomes.