The potent paracrine effect of umbilical cord mesenchymal stem cells mediates mitochondrial quality control to restore chemotherapy-induced damage in ovarian granulosa cells

The basic principle of chemotherapy is to attack cells with fast growth, and cancer cells are targeted by anticancer drugs because they have a faster growth rate than normal cells. High doses of anticancer drugs may cause an irreversible decline in reproductive capacity, and novel approaches for fertility preservation and/or restoration after anticancer treatment are urgently needed. Here, we provide important insights into the recovery of human reproductive cells damaged by chemotherapy. We performed a detailed screening of the cytokines of various human mesenchymal stem cells (hMSCs) to select superior MSCs. Also, we analyzed the Ovarian granulosa cell (OGC)-)-specific functions for restoring function, apoptosis, and mitochondrial functions to confirm the recovery mechanism in damaged OGCs. As a result, we demonstrated that conditioned media (CM) of Umbilical cord mesenchymal stem cells (UC-MSCs) could restore the functions of damaged OGCs primarily through antiapoptotic and antioxidant effects. Furthermore, CM changed the phenotype of damaged OGCs to an energetic status by restoring mitochondrial function and enhanced the mitochondrial metabolic activity decreased by chemotherapy. Finally, we demonstrated that the restoration of mitochondrial function in damaged OGCs was mediated through mitochondrial autophagy (mitophagy). Our findings offer new insights into the potential of stem cell-based therapy for fertility preservation and/or restoration in female cancer patients.

Cultural Adaptation of the Younger Women's Wellness After Cancer Program for Younger Chinese Women With Breast Cancer: A Pilot Randomized Controlled Trial

BACKGROUND

The incidence of breast cancer in younger women, that is, aged 50 years or younger, in Hong Kong is increasing. The Internet-based Younger Women's Wellness After Cancer Program (YWWACP) is a whole-lifestyle intervention that can help young women to manage their health and risks of chronic diseases.

OBJECTIVES

The study aimed to test the acceptability and feasibility of the culturally adapted YWWACP in Hong Kong (YWWACPHK) and to evaluate its preliminary effects in improving health-related quality of life, distress, sexual function, menopausal symptoms, dietary intake, physical activity, and sleep among younger Chinese women with breast cancer.

INTERVENTION/METHODS

Women aged 18 to 50 years with breast cancer were recruited from an oncology outpatient department. The participants in the intervention group received the 12-week YWWACPHK, whereas the control group received standard care.

RESULTS

Sixty women consented to participate. At 12 weeks after intervention completion, the intervention group showed a significant increase in the pain subscale scores of sexual function and more improvement in the level of physical activity than the control group, with Hedge g effect sizes 0.66 and 0.65, respectively. Nineteen intervention group participants reported that they were satisfied with the program and suggestions for improvement were provided.

CONCLUSION

The implementation of YWWACPHK is feasible. The preliminary findings suggest that YWWACPHK could increase the level of physical activity among the participants.

IMPLICATIONS FOR PRACTICE

Nurses could utilize YWWACPHK to support younger Chinese patients with breast cancer to maintain a healthy lifestyle, subject to wider confirmation of these results through a larger study.

Longitudinal evaluation of dehydroepiandrosterone (DHEA), its sulfated form and estradiol with cancer-related cognitive impairment in early-stage breast cancer patients receiving chemotherapy

The purpose of this study is to elucidate how patient-reported cognitive symptoms manifest from variations in hormone levels or precursors such as dehydroepiandrosterone (DHEA) and its sulfated form [collectively termed as DHEA(S)] and to investigate their association in breast cancer survivors. Levels of estradiol and DHEA(S) were compared between early-stage breast cancer patients with and without cancer-related cognitive impairment (CRCI) during adjuvant chemotherapy. Data were analyzed from 242 patients (mean age ± SD = 50.8 ± 9.2 years) who had completed FACT-Cog v.3.0, blood draws and questionnaires. Regression model was used to fit the magnitude of change in each respective biomarker levels against overall cognitive impairment status while adjusting for clinically important covariates. There was reduction in mean plasma levels of estradiol and DHEAS during and towards the end of chemotherapy (p-values < 0.001). Compared to non-impaired patients, smaller magnitude of decline was observed in DHEA(S) levels in patients reporting CRCI, with significant association between decline in DHEAS levels and acute onset of CRCI at 6 weeks from baseline (adjusted β of 0.40, p-value of 0.02). In contrast, patients reporting CRCI showed greater magnitude of decline in estradiol compared to non-impaired patients, although this was not found to be statistically significant. There was an association between magnitude of change in biomarker levels with self-reported CRCI which suggests that the hormonal pathway related to DHEAS may be implicated in acute CRCI for breast cancer survivors. Our findings help to improve biological understanding of the pathway from which DHEAS may correlate with cognitive dysfunction and its impact on cancer survivors.

Understanding the barriers to, and facilitators of, ovarian toxicity assessment in breast cancer clinical trials

BACKGROUND

Detailed toxicity data are routinely collected in breast cancer (BC) clinical trials. However, ovarian toxicity is infrequently assessed, despite the adverse impacts on fertility and long-term health from treatment-induced ovarian insufficiency.

OBJECTIVES

To determine the barriers to and facilitators of ovarian toxicity assessment in BC trials of anti-cancer drugs.

METHODS

Semi-structured interviews were conducted with purposively selected stakeholders from multiple countries involved in BC clinical trials (clinicians, consumers, pharmaceutical company representatives, members of drug-regulatory agencies). Participants were asked to describe the perceived benefits and barriers to evaluating ovarian toxicity. Interviews were transcribed verbatim, coded in NVivo software and analysed using inductive thematic analysis.

RESULTS

Saturation of the main themes was reached and the final sample size included 25 participants from 14 countries (9 clinicians, 7 consumers, 5 members of regulatory agencies, 4 pharmaceutical company representatives); half were female. The main reported barrier to ovarian toxicity assessment was that the issue was rarely considered. Reasons included that these data are less important than survival data and are not required for regulatory approval. Overall, most participants believed evaluating the impact of BC treatments on ovarian function is valuable. Suggested strategies to increase ovarian toxicity assessment were to include it in clinical trial design guidelines and stakeholder advocacy.

CONCLUSION

Lack of consideration about measuring ovarian toxicity in BC clinical trials that include premenopausal women suggest that guidelines and stronger advocacy from stakeholders, including regulators, would facilitate its more frequent inclusion in future trials, allowing women to make better informed treatment decisions.

Long-term health-related quality of life of breast cancer survivors remains impaired compared to the age-matched general population especially in young women. Results from the prospective controlled BREX exercise study

OBJECTIVE

To investigate long-term health-related quality of life (HRQoL) changes over time in younger compared to older disease-free breast cancer survivors who participated in a prospective randomized exercise trial.

METHODS

Survivors (aged 35-68 years) were randomized to a 12-month exercise trial after adjuvant treatment and followed up for ten years. HRQoL was assessed with the generic 15D instrument during follow-up and the younger (baseline age ≤ 50) and older (age >50) survivors' HRQoL was compared to that of the age-matched general female population (n = 892). The analysis included 342 survivors.

RESULTS

The decline of HRQoL compared to the population was steeper and recovery slower in the younger survivors (p for interaction < 0.001). The impairment was also larger among the younger survivors (p = 0.027) whose mean HRQoL deteriorated for three years after treatment and started to slowly improve thereafter but still remained below the population level after ten years (difference -0.017, 95% CI: -0.031 to -0.004). The older survivors' mean HRQoL gradually approached the population level during the first five years but also remained below it at ten years (difference -0.019, 95% CI: -0.031 to -0.007). The largest differences were on the dimensions of sleeping and sexual activity, on which both age groups remained below the population level throughout the follow-up.

CONCLUSIONS

HRQoL developed differently in younger and older survivors both regarding the most affected dimensions of HRQoL and the timing of the changes during follow-up. HRQoL of both age groups remained below the population level even ten years after treatment.

Physical activity and menopausal symptoms in women who have received menopause-inducing cancer treatments: results from the Women's Wellness After Cancer Program

OBJECTIVE

This randomized controlled trial tested a digitally-delivered whole-of-lifestyle program for women previously treated for cancer. We investigated (1) associations between self-reported physical activity (PA) and menopausal symptoms and (2) if the intervention was associated with beneficial changes in PA and menopausal symptoms.

METHODS

Women were randomized to intervention (n = 142) or control (n = 138). The intervention targeted lifestyle behavior including PA. Self-reported PA (International Physical Activity Questionnaire - Short Form) and menopausal symptom (Green Climacteric Scale, GCS) data were collected at baseline, with measures repeated at 12 weeks (end of intervention) and 24 weeks (to assess sustainability). Generalized estimating equation models explored associations between PA and GCS scores. Mixed-effects generalized equation models analyzed changes within and between groups in PA and GCS scores.

RESULTS

Total GCS scores were 1.83 (95% CI: 0.11-3.55) and 2.72 (95% CI: 1.12-4.33) points lower in women with medium and high levels of PA, respectively, than in women with low levels of PA. Total average GCS scores were 1.02 (0.21-2.26) and 1.61 (0.34-2.87) points lower in those undertaking moderate or vigorous intensity PA, respectively. Time spent walking, and performing moderate and vigorous PA were not different between intervention and control. The average GCS decrease of 0.66 points (95% CI: 0.03-1.29; p time = 0.03) over 24 weeks was not different between groups.

CONCLUSION

This exploratory study established a stepwise association between moderate and vigorous PA and a lower total menopausal symptom score. The intervention did not appear to increase self-reported PA in women treated for early stage breast, reproductive, and blood cancers.

Impact of Vulvovaginal Symptoms in Women Diagnosed with Cancer: A Psychometric Evaluation of the Day-to-Day Impact of Vaginal Aging Questionnaire

Background: Vulvovaginal symptoms (VVS), such as dyspareunia, dryness, and itching, are common following cancer treatment and can negatively impact sexual well-being, daily activities, mood, self-concept, and overall quality of life. Information about the impact of VVS after cancer treatment is scarce, mainly because of a dearth of validated measures. This study aimed to validate the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire, which assesses impact of VVS on women's lives, in a sample of women with cancer. Methods: Women diagnosed with cancer (n = 202) completed a questionnaire package, including the DIVA and measures of VVS, sexual function, and sexual distress. Data were collected as part of study evaluating an educational workshop. Confirmatory factor analysis (CFA) was used to examine whether the factor structure of the DIVA in this population reflected that of the original validation study. Results: CFA showed that the DIVA assesses VVS impact on four domains: activities of daily living, sexual functioning, emotional well-being, and self-concept and body image. All subscales showed excellent internal consistency reliability; however, item analyses indicated that items in the activities of daily living subscale showed very low means. Correlations with sexual function and distress provided evidence that the DIVA assesses impact of VVS. Conclusions: This is the first study aimed at validating the DIVA in women treated for cancer. Results provide evidence of the DIVA's utility in assessing the impact of VVS on four relevant domains. Although issues with certain scale items need to be resolved in future research, the DIVA provides opportunity to understand the impact of VVS after cancer treatment, to address unmet needs of cancer survivors.

Cognitive-Behavioral Therapy to Alleviate Treatment-Induced Menopausal Symptoms in Women With Breast Cancer: A Systematic Review

BACKGROUND

Numerous women with breast cancer (BC) exhibit early menopausal symptoms after undergoing cancer treatments. Medications that control menopausal symptoms can cause severe side effects and are contraindicated for patients with BC. Therefore, complementary and alternative medicines should be used. This study investigates the use of cognitive-behavioral therapy (CBT) for patients with menopausal symptoms after BC treatment.

OBJECTIVE

A systematic review was conducted to determine the efficacy and availability of CBT interventions in reducing treatment-induced menopausal symptoms in female patients with BC.

METHODS

Keywords were searched in Medical Subject Headings and 5 databases. The search criteria included randomized controlled trials (RCTs), non-RCTs, and single-group pre- and post-studies. Because of the risk of bias in non-RCTs using Joanna Briggs Institute's critical appraisal tools and single-group studies, the Critical Appraisal Skills Programme checklist for qualitative studies and RCTs was appraised using the Jadad scale.

RESULTS

After the review, 9 suitable studies were identified. Standard CBT programs lasted for 6 consecutive weeks, with 1 session of 1.5 hours weekly. The follow-up time was approximately 9 to 26 weeks. Women receiving CBT exhibited improvement in physical function and psychological state. This review supported the use of CBT to effectively improve the mental health of and reduce treatment-induced menopausal symptoms in BC survivors.

CONCLUSIONS

Cognitive-behavioral therapy interventions yielded positive outcomes in patients with BC, particularly in those experiencing menopausal symptoms.

IMPLICATIONS FOR PRACTICE

Cancer treatment generated severe menopausal symptoms in patients with BC. However, health professionals may use CBT to alleviate patients' menopausal symptoms.

Preventing ovarian failure associated with chemotherapy

Alkylating chemotherapy is often used to treat pre-menopausal women for various malignancies and autoimmune diseases. Chemotherapy-associated ovarian failure is a potential consequence of this treatment which can cause infertility, and increases the risk of other long term adverse health sequelae. Randomised trials, predominantly of women undergoing alkylating chemotherapy for breast cancer, have shown evidence for the efficacy of gonadotropin-releasing hormone agonists (GnRHa) in preventing chemotherapy-associated ovarian failure. The European St Gallen and United States National Comprehensive Cancer Network guidelines recommend the use of concurrent GnRHa to reduce the risk of ovarian failure for pre-menopausal women undergoing chemotherapy for breast cancer. The GnRHa goserelin, a monthly 3.6 mg depot subcutaneous injection, has recently been listed on the Australian Pharmaceutical Benefits Scheme to reduce risk of ovarian failure for pre-menopausal women receiving alkylating therapies for malignancy or autoimmune disease. The first dose of goserelin should ideally be administered at least 1 week before commencement of alkylating treatment and continued 4-weekly during chemotherapy. Concurrent goserelin use should now be considered for all pre-menopausal women due to commence alkylating chemotherapy (except those with incurable cancer), regardless of their childbearing status, in an effort to preserve their ovarian function. For women who have not completed childbearing, consideration of other fertility preservation options, such as cryopreservation of embryos or oocytes, is also important.

Conservative management of reproductive cancers. Ovarian protection during treatment

Globally, breast cancer is the most common female reproductive cancer. Although alkylating chemotherapy is not part of initial curative-intent treatment in women with other reproductive cancers, it is often used to treat women with curable breast cancer. Chemotherapy-associated ovarian failure (COF) is a potential consequence of this treatment and can cause infertility and increase the risk of cognitive impairment, cardiovascular disease and fractures from reduced bone mineral density. Although cryopreservation of embryos and oocytes is often effective for fertility preservation, this does not prevent COF and its associated complications. Randomised trials, predominantly of women undergoing alkylating chemotherapy for breast cancer, have shown evidence for the efficacy of gonadotropin-releasing hormone agonists (GnRHa) in reducing the risk of COF. Concurrent GnRHa use should be considered for all premenopausal women planned to commence alkylating chemotherapy for curable cancer, regardless of their childbearing status, to further improve survivorship for women diagnosed with cancer.

Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis

Background

During menopause women experience vasomotor and psychosexual symptoms that cannot entirely be alleviated with hormone replacement therapy (HRT). Besides, HRT is contraindicated after breast cancer.

Objectives

To review the evidence on the effectiveness of psychological interventions in reducing symptoms associated with menopause in natural or treatment‐induced menopausal women.

Search strategy

Medline/Pubmed, PsycINFO, EMBASE and AMED were searched until June 2017.

Selection criteria

Randomised controlled trials (RCTs) concerning natural or treatment‐induced menopause, investigating mindfulness or (cognitive‐)behaviour‐based therapy were selected. Main outcomes were frequency of hot flushes, hot flush bother experienced, other menopausal symptoms and sexual functioning.

Data collection and analysis

Study selection and data extraction were performed by two independent researchers. A meta‐analysis was performed to calculate the standardised mean difference (SMD).

Main results

Twelve RCTs were included. Short‐term (<20 weeks) effects of psychological interventions in comparison to no treatment or control were observed for hot flush bother (SMD −0.54, 95% CI −0.74 to −0.35, P < 0.001, I² = 18%) and menopausal symptoms (SMD −0.34, 95% CI −0.52 to −0.15, P < 0.001, I² = 0%). Medium‐term (≥20 weeks) effects were observed for hot flush bother (SMD −0.38, 95% CI −0.58 to −0.18, P < 0.001, I² = 16%). [Correction added on 9 July 2018, after first online publication: there were miscalculations of the mean end point scores for hot flush bother and these have been corrected in the preceding two sentences.] In the subgroup treatment‐induced menopause, consisting of exclusively breast cancer populations, as well as in the subgroup natural menopause, hot flush bother was reduced by psychological interventions. Too few studies reported on sexual functioning to perform a meta‐analysis.

Conclusions

Psychological interventions reduced hot flush bother in the short and medium‐term and menopausal symptoms in the short‐term. These results are especially relevant for breast cancer survivors in whom HRT is contraindicated. There was a lack of studies reporting on the influence on sexual functioning.

Tweetable abstract

Systematic review: psychological interventions reduce bother by hot flushes in the short‐ and medium‐term.

Systematic review: psychological interventions reduce bother by hot flushes in the short‐ and medium‐term.

Psychometric Evaluation of the Chinese Breast Cancer Prevention Trial Symptom Scale

BACKGROUND

Women with breast cancer experience a wide spectrum of symptoms after diagnosis and treatment. Symptoms experienced by this specific population might not be fully assessed using available traditional Chinese-language symptom measures.

OBJECTIVES

The aim of this study was to examine the latent constructs and psychometric properties of the Chinese Breast Cancer Prevention Trial (C-BCPT) Symptom Scale.

METHODS

Two hundred women with breast cancer were recruited in Taiwan. Psychometric properties, including construct validity, internal consistency, and test-retest reliability, of the C-BCPT Symptom Scale were tested after translating the original instrument.

RESULTS

A 21-item C-BCPT Symptom Scale, with 7 extracted factors accounting for 72.26% of the total variance, resulted from an exploratory factor analysis. Construct validity was confirmed by significant correlations between scores on the C-BCPT Symptom Scale and the Taiwan-version Short Form-36 Health Survey (r = -0.49 to -0.53)/Greene Climacteric Scale (r = 0.81). Reliability coefficients for the overall scale/6 extracted factors (Cronbach's α = 0.72-0.88) and test-retest reliability (intraclass correlation coefficients = 0.77-0.94) of the translated instrument were satisfactory, whereas 1 reliability coefficient for 1 extracted factor was inadequate (Cronbach's α = 0.57).

CONCLUSION

An interpretable structure with preliminary acceptable psychometric properties of the C-BCPT Symptom Scale was obtained; the C-BCPT can help traditional Chinese-speaking healthcare professionals perform adequate assessments of the symptoms experienced by women with breast cancer.

IMPLICATIONS FOR PRACTICE

The C-BCPT Symptom Scale can be used in clinical practice and research to assess symptoms experienced by this specific population or effects of related interventions.

How Menopause Symptoms and Attitude Impact Korean Women's Quality of Life After Adjuvant Treatment for Breast Cancer

BACKGROUND

Attitudes toward menopause vary across cultures and influence women's experiences of menopausal symptoms, possibly leading to reduced posttreatment quality of life in breast cancer survivors.

OBJECTIVE

The aim of this study is to examine the effects of menopausal symptoms and attitudes on health-related quality of life in breast cancer survivors who were premenopausal at the time of diagnosis.

METHODS

A total of 139 women receiving chemotherapy with/without endocrine therapy were assessed with self-report questionnaires of established reliability and validity. Hierarchical regression was conducted to assess the impact of menopausal symptoms and attitudes on quality of life, while controlling for demographic characteristics.

RESULTS

Overall, participants endorsed more than half of 46 symptoms, most at the level of mild symptoms, and most reported a less positive attitude toward menopause. Lower quality of life was significantly predicted by more menopausal symptoms endorsed and more negative attitudes when controlling for demographic factors associated with quality of life (R = 26.1%). Most participants experienced change from premenopause to postmenopause after the completion of adjuvant chemotherapy with or without tamoxifen.

CONCLUSIONS

The results suggest that more menopausal symptoms and negative attitudes toward menopause may affect health-related quality of life considerably in chemotherapy-treated Asian breast cancer survivors.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should develop a better understanding of the effects of menopausal symptoms and attitudes on quality of life by using a culturally relevant perspective based on patients' sociocultural backgrounds. Furthermore, these findings help healthcare professionals communicate with their Asian clients in a more informed way and provide culturally appropriate and individualized care.

Armodafinil for fatigue associated with menopause: an open-label trial

OBJECTIVE

This study aims to obtain preliminary data on the efficacy of armodafinil for improving menopause-related fatigue and quality of life.

METHODS

Women (aged 40-65 y) experiencing menopause-related fatigue received open-label armodafinil therapy (up to 150 mg/d) for 4 weeks. Changes from baseline in Brief Fatigue Inventory score and Menopause-Specific Quality of Life (MENQOL) physical domain score were examined using the Wilcoxon signed rank test. Exploratory analyses examined the effects of armodafinil on hot flashes, overall quality of life, insomnia, depression, anxiety, and perceived cognitive performance. After open-label treatment, participants were randomized to double-blind continuation of armodafinil versus placebo for 2 weeks to examine whether treatment discontinuation would precipitate symptom recurrence.

RESULTS

Of 29 eligible participants, 20 women (69.0%) completed the trial. During treatment with armodafinil (mean dose, 120 mg/d), median Brief Fatigue Inventory scores decreased by 57.7% from 5.2 (interquartile range [IQR], 4.6-6.2) to 2.2 (IQR, 1.1-4.4; P = 0.0002), and median MENQOL physical domain scores decreased by 51.3% from 3.9 (IQR, 2.3-4.8) to 1.9 (IQR, 1.3-2.7; P = 0.0001). Median hot flashes for 24 hours decreased by 48.3% from 2.9 (IQR, 1.1-4.6) to 1.5 (IQR, 0.4-2.4; P = 0.0005). Improvements in MENQOL total score (49%; P = 0.0001), cognitive function (59.2%; P = 0.0002), depressive symptoms (64.7%; P = 0.0006), insomnia (72.7%; P = 0.0012), and excessive sleepiness (57.1%; P = 0.0006) were noted. Randomized continuation (n = 10) or discontinuation (n = 10) did not indicate group differences. Armodafinil was well-tolerated; three women (12%) were withdrawn for adverse events.

CONCLUSIONS

These preliminary results suggest a therapeutic effect of armodafinil on fatigue affecting quality of life during menopause, and a potential benefit for other menopause-related symptoms.

Management of breast cancer in very young women

Breast cancer is the leading cause of cancer-related deaths in women age 40 and younger in developed countries, and although generally improving, survival rates for young women with breast cancer remain lower than for older women. Young women are more likely to develop more aggressive subtypes of breast cancer (more triple negative and more Human Epidermal Growth Factor Receptor 2 [HER2]-positive disease) and present with more advanced stage disease. Previous research has demonstrated that young age is an independent risk factor for disease recurrence and death, although recent data suggest this may not be the case in certain tumor molecular subtypes. Recent preliminary evidence suggests potential unique biologic features of breast cancer that occurs in young women although this has yet to have been translated into treatment differences. There are clearly host differences that affect the management of breast cancer for young patients including generally being premenopausal at diagnosis, and fertility, genetics, and social/emotional issues in particular should be considered early in the course of their care. Despite an increased risk of local recurrence, young age alone is not a contraindication to breast conserving therapy given the equivalent survival seen in this population with either mastectomy or breast conservation. However, many young women in recent years are choosing bilateral mastectomy, even without a known hereditary predisposition to the disease. For those who need chemotherapy, multi-agent chemotherapy and biologic therapy targeting the tumor similar to the treatment in older women is the standard approach. Select young women will do well with hormone therapy only. Recent data from the TEXT and SOFT trials evaluating the optimal endocrine therapy for the first 5 years, and the ATTom and ATLAS trials demonstrating benefit from extended duration of tamoxifen (10 vs. 5 years), have further defined options for adjuvant endocrine therapy for young women with early breast cancer. Attention to adherence with endocrine therapy may be particularly important to improve outcomes in this population who are at increased risk of non-adherence compared to older women.

Acupuncture As an Integrative Approach for the Treatment of Hot Flashes in Women With Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT)

PURPOSE

To determine the effectiveness of acupuncture for the management of hot flashes in women with breast cancer.

PATIENTS AND METHODS

We conducted a pragmatic, randomized controlled trial comparing acupuncture plus enhanced self-care versus enhanced self-care alone. A total of 190 women with breast cancer were randomly assigned. Random assignment was performed with stratification for hormonal therapy; the allocation ratio was 1:1. Both groups received a booklet with information about climacteric syndrome and its management to be followed for at least 12 weeks. In addition, the acupuncture group received 10 traditional acupuncture treatment sessions involving needling of predefined acupoints. The primary outcome was hot flash score at the end of treatment (week 12), calculated as the frequency multiplied by the average severity of hot flashes. The secondary outcomes were climacteric symptoms and quality of life, measured by the Greene Climacteric and Menopause Quality of Life scales. Health outcomes were measured for up to 6 months after treatment. Expectation and satisfaction of treatment effect and safety were also evaluated. We used intention-to-treat analyses.

RESULTS

Of the participants, 105 were randomly assigned to enhanced self-care and 85 to acupuncture plus enhanced self-care. Acupuncture plus enhanced self-care was associated with a significantly lower hot flash score than enhanced self-care at the end of treatment (P < .001) and at 3- and 6-month post-treatment follow-up visits (P = .0028 and .001, respectively). Acupuncture was also associated with fewer climacteric symptoms and higher quality of life in the vasomotor, physical, and psychosocial dimensions (P < .05).

CONCLUSION

Acupuncture in association with enhanced self-care is an effective integrative intervention for managing hot flashes and improving quality of life in women with breast cancer.

The pharmacological and hormonal therapy of hot flushes in breast cancer survivors

The side effects of oncological treatment, which appear during or after therapy, are sometimes very annoying for patients and are not adequately treated by physicians. Among the symptoms experienced by breast cancer patients are hot flushes, which result from a natural or cancer therapy-induced menopause. The intensity of hot flushes in breast cancer patients may be more severe than those experienced by women undergoing a natural menopause. Taking into account the incidence of breast cancer and long-lasting hormone-suppression therapies, the problem of hot flushes will affect many women. Hormonal replacement therapy, the most effective therapeutic means for alleviating hot flushes, is usually contraindicated for breast cancer patients. For intense and severe hot flushes, pharmacological treatment using agents from a group of selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors such as venlafaxine or citalopram may be introduced. Other agents from different pharmacological groups, such as clonidine, gabapentin, or pregabalin, have also proved to be effective in treating hot flushes. The efficacy of phytoestrogens has not been proven in randomized clinical trials. The importance of the placebo effect in decreasing vasomotor symptoms has also been reported in many research papers. Educating breast cancer patients in lifestyle changes which decrease the frequency and intensity of vasomotor symptoms can offer significant help too. This paper reviews the current state of research in order to assess the options for the treatment of hot flushes in breast cancer survivors.

Brain network alterations and vulnerability to simulated neurodegeneration in breast cancer

Breast cancer and its treatments are associated with mild cognitive impairment and brain changes that could indicate an altered or accelerated brain aging process. We applied diffusion tensor imaging and graph theory to measure white matter organization and connectivity in 34 breast cancer survivors compared with 36 matched healthy female controls. We also investigated how brain networks (connectomes) in each group responded to simulated neurodegeneration based on network attack analysis. Compared with controls, the breast cancer group demonstrated significantly lower fractional anisotropy, altered small-world connectome properties, lower brain network tolerance to systematic region (node), and connection (edge) attacks and significant cognitive impairment. Lower tolerance to network attack was associated with cognitive impairment in the breast cancer group. These findings provide further evidence of diffuse white matter pathology after breast cancer and extend the literature in this area with unique data demonstrating increased vulnerability of the post-breast cancer brain network to future neurodegenerative processes.

The association of cognitive fatigue with menopause, depressive symptoms, and quality of life in ambulatory breast cancer patients

BACKGROUND

The causes of cancer-related fatigue, which can influence patients' activities, are multidimensional; however, little is known about the cognitive dimension. We examined the association of cognitive fatigue with menopause, depressive symptoms, and quality of life in ambulatory breast cancer patients after primary treatment.

METHODS

This descriptive, cross-sectional study recruited 20-64-year-old breast cancer patients in an outpatient setting. The patients (N = 93; mean age = 53 years) were divided into low (L-CogF) and high-cognitive fatigue (H-CogF) groups according to their scores on the cognitive fatigue subscale of the Cancer Fatigue Scale. We compared the groups on their sociodemographic and medical characteristics and scores on the Functional Assessment of Cancer Therapy-Breast (FACT-B) [a measure of quality of life (QOL)], Simplified Menopausal Index (SMI), and Self-Rating Questionnaire for Depression (SRQ-D).

RESULTS

The L-CogF (n = 55) and H-CogF (n = 38) patients did not differ in age, years since diagnosis, marital status, educational background, or treatment history. Total and subscale FACT-B scores, except for physical well-being, were significantly lower in H-CogF participants than in L-CogF participants. SMI and SRQ-D scores were significantly higher in H-CogF participants. Employed H-CogF participants were concerned about keeping their jobs (p < 0.05).

CONCLUSIONS

Breast cancer patients with high-cognitive fatigue suffer from severe menopause and depressive symptoms, and deteriorating QOL. Cognitive fatigue should be considered when interpreting patients' cognitive complaints.

Multivariate pattern analysis of FMRI in breast cancer survivors and healthy women

Advances in breast cancer (BC) treatments have resulted in significantly improved survival rates. However, BC chemotherapy is often associated with several side effects including cognitive dysfunction. We applied multivariate pattern analysis (MVPA) to functional magnetic resonance imaging (fMRI) to find a brain connectivity pattern that accurately and automatically distinguishes chemotherapy-treated (C+) from non-chemotherapy treated (C-) BC females and healthy female controls (HC). Twenty-seven C+, 29 C-, and 30 HC underwent fMRI during an executive-prefrontal task (Go/Nogo). The pattern of functional connectivity associated with this task discriminated with significant accuracy between C+ and HC groups (72%, p = .006) and between C+ and C- groups (71%, p = .012). However, the accuracy of discrimination between C- and HC was not significant (51%, p = .46). Compared with HC, behavioral performance of the C+ and C- groups during the task was intact. However, the C+ group demonstrated altered functional connectivity in the right frontoparietal and left supplementary motor area networks compared to HC, and in the right middle frontal and left superior frontal gyri networks, compared to C-. Our results provide further evidence that executive function performance may be preserved in some chemotherapy-treated BC survivors through recruitment of additional neural connections.

Premature menopause in young breast cancer: effects on quality of life and treatment interventions

Many young women are at increased risk for premature menopause following adjuvant treatment for breast cancer. These women must deal with consequences of menopause, including loss of fertility and physiologic symptoms such as night sweats, hot flashes, vaginal dryness, and weight gain. These symptoms can be particularly distressing for young women and can adversely affect both health-related and psychosocial quality of life (QOL). While there are a wide range of pharmacologic and non-pharmacologic interventions available to help with these symptoms and in turn, improve QOL, there is little data available about the use and efficacy of these interventions in younger women who become menopausal as a result of their breast cancer treatment. Future studies should focus on this vulnerable population, with the goal of identifying effective strategies to relieve symptoms and improve quality of life in young breast cancer survivors.

Default mode network connectivity distinguishes chemotherapy-treated breast cancer survivors from controls

Breast cancer (BC) chemotherapy is associated with cognitive changes including persistent deficits in some individuals. We tested the accuracy of default mode network (DMN) resting state functional connectivity patterns in discriminating chemotherapy treated (C+) from non-chemotherapy (C-) treated BC survivors and healthy controls (HC). We also examined the relationship between DMN connectivity patterns and cognitive function. Multivariate pattern analysis was used to classify 30 C+, 27 C-, and 24 HC, which showed significant accuracy for discriminating C+ from C- (91.23%, P < 0.0001) and C+ from HC (90.74%, P < 0.0001). The C- group did not differ significantly from HC (47.06%, P = 0.60). Lower subjective memory function was correlated (P < 0.002) with greater hyperplane distance (distance from the linear decision function that optimally separates the groups). Disrupted DMN connectivity may help explain long-term cognitive difficulties following BC chemotherapy.

Ovarian Damage During chemotherapy in Autoimmune Diseases: Broad Health Implications beyond Fertility

Women with autoimmune diseases such as lupus, scleroderma, and vasculitis receiving cyclophosphamide for severe disease manifestations risk primary ovarian insufficiency(POI) due to gonadotoxicity of this therapy. In addition to loss of reproductive potential, POI is associated with increased risk of morbidity and mortality. Practitioners caring for women requiring gonadotoxic therapies should be familiar with long-term health implications of POI and strategies for ovarian preservation. Accumulating evidence supports the effectiveness of adjunctive gonadotropin releasing hormone analog (GnRH-a) for ovarian protection during gonadotoxic therapy in cancer and autoimmune populations. GnRH-a is less costly and invasive than assisted reproductive technologies used for achievement of future pregnancies, but is not Food and Drug Administration approved for ovarian preservation. This review focuses on POI comorbidities and strategies for mitigation of related sequelae, which can accumulate over decades of hypoesteogenism. These issues are arguably more pronounced for women with chronic autoimmune diseases, in whom superimposed POI further heightens risks of cardiovascular disease and osteoporosis. Therefore, even if future pregnancy is not desired, ovarian protection during gonadotoxic therapy should be a major goal of disease management.

Altered resting state functional brain network topology in chemotherapy-treated breast cancer survivors

Many women with breast cancer, especially those treated with chemotherapy, experience cognitive decline due in part to neurotoxic brain injury. Recent neuroimaging studies suggest widespread brain structural abnormalities pointing to disruption of large-scale brain networks. We applied resting state functional magnetic resonance imaging and graph theoretical analysis to examine the connectome in breast cancer survivors treated with chemotherapy relative to healthy comparison women. Compared to healthy females, the breast cancer group displayed altered global brain network organization characterized by significantly decreased global clustering as well as disrupted regional network characteristics in frontal, striatal and temporal areas. Breast cancer survivors also showed significantly increased self-report of executive function and memory difficulties compared to healthy females. These results suggest that topological organization of both global and regional brain network properties may be disrupted following breast cancer and chemotherapy. This pattern of altered network organization is believed to result in reduced efficiency of parallel information transfer. This is the first report of alterations in large-scale functional brain networks in this population and contributes novel information regarding the neurobiologic mechanisms underlying breast cancer-related cognitive impairment.

Cancer-related fatigue in women with breast cancer: outcomes of a 5-year prospective cohort study

PURPOSE

Prolonged and disabling fatigue is prevalent after cancer treatment, but the early natural history of cancer-related fatigue (CRF) has not been systematically examined to document consistent presence of symptoms. Hence, relationships to cancer, surgery, and adjuvant therapy are unclear.

PATIENTS AND METHODS

A prospective cohort study of women receiving adjuvant treatment for early-stage breast cancer was conducted. Women (n = 218) were enrolled after surgery and observed at end treatment and at 1, 3, 6, 9, and 12 months as well as 5 years. Structured interviews and self-report questionnaires were used to record physical and psychologic health as well as disability and health care utilization. Patients with CRF persisting for 6 months were assessed to exclude alternative medical and psychiatric causes of fatigue. Predictors of persistent fatigue, mood disturbance, and health care utilization were sought by logistic regression.

RESULTS

The case rate for CRF was 24% (n = 51) postsurgery and 31% (n = 69) at end of treatment; it became persistent in 11% (n = 24) at 6 months and 6% (n = 12) at 12 months. At each time point, approximately one third of the patients had comorbid mood disturbance. Persistent CRF was predicted by tumor size but not demographic, psychologic, surgical, or hematologic parameters. CRF was associated with significant disability and health care utilization.

CONCLUSION

CRF is common but generally runs a self-limiting course. Much of the previously reported high rates of persistent CRF may be attributable to factors unrelated to the cancer or its treatment.

Hot flashes: a review of pathophysiology and treatment modalities

Many therapies are being studied for the treatment of hot flashes for individuals with cancer, yet few studies have demonstrated safe and effective clinical benefit for those who suffer from this distressing symptom. The purpose of this paper is to assess the current options for the management of hot flashes, examining key endpoints from recent clinical trials and reviewing future directions. Hot flashes are a common stressful symptom for individuals with cancer, particularly women with a history of breast cancer and men with prostate cancer. Lifestyle modifications are proposed as the first step in the management of less severe hot flashes. Several publications have addressed nonhormonal agents as a treatment option for hot flashes. Newer antidepressant and anticonvulsant agents have been studied and show potential in treating vasomotor symptoms. Although many complementary and alternative therapies, including herbal medications and phytoestrogens, have been studied for the treatment of hot flashes, none are clinically recommended at this time. Additionally, further evidence is needed for supportive exercise such as yoga and relaxation techniques. Acupuncture may warrant further investigation in the reduction and severity of hot flashes in both men and women. Hormonal therapies, including estrogens and progestogens, are the most well-known and efficient agents in alleviating hot flashes; however, the safety of these agents is disputable.

Management of Hot Flashes in Patients Who Have Breast Cancer With Venlafaxine and Clonidine: A Randomized, Double-Blind, Placebo-Controlled Trial

Purpose

Therapies for breast cancer may induce hot flashes that can affect quality of life. We undertook a double-blind, placebo-controlled trial with the primary objective of comparing the average daily hot flash scores in the twelfth week among patients treated with venlafaxine, clonidine, and placebo. Additional analyses of the hot flash score over the full 12 weeks of treatment were performed.

Patients and Methods

In all, 102 patients with a history of breast cancer were randomly assigned (2:2:1) to venlafaxine 75 mg, clonidine 0.1 mg, or placebo daily for 12 weeks. Questionnaires at baseline and during treatment assessed daily hot flash scores, sexual function, sleep quality, anxiety, and depression.

Results

After 12 weeks, a total of 80 patients were evaluable for the primary end point. During week 12, hot flash scores were significantly lower in the clonidine group versus placebo (P = .03); for venlafaxine versus placebo, the difference was borderline not significant (P = .07). However, hot flash scores were equal in the clonidine and venlafaxine groups. Over the course of 12 weeks, the differences between both treatments and placebo were significant (P <.001 for venlafaxine v placebo; P = .045 for clonidine v placebo). Frequencies of treatment-related adverse effects of nausea (P = .02), constipation (P = .04), and severe appetite loss were higher in the venlafaxine group.

Conclusion

Venlafaxine and clonidine are effective treatments in the management of hot flashes in patients with breast cancer. Venlafaxine resulted in a more immediate reduction of hot flash scores when compared with clonidine; however, hot flash scores at week 12 were lower in the clonidine group than in the venlafaxine group.