The Relationship Between Insomnia and Cognitive Impairment in Breast Cancer Survivors

Sleep oscillations related to memory consolidation during aromatases inhibitors for breast cancer

Aromatase inhibitors (AIs) are associated with sleep difficulties in breast cancer (BC) patients. Sleep is known to favor memory consolidation through the occurrence of specific oscillations, i.e., slow waves (SW) and sleep spindles, allowing a dialogue between prefrontal cortex and the hippocampus. Interestingly, neuroimaging studies in BC patients have consistently shown structural and functional modifications in these two brain regions. With the aim to evaluate sleep oscillations related to memory consolidation during AIs, we collected polysomnography data in BC patients treated (AI+, n = 17) or not (AI-, n = 17) with AIs compared to healthy controls (HC, n = 21). None of the patients had received chemotherapy and radiotherapy was finished since at least 6 months, that limit the confounding effects of other treatments than AIs. Fast and slow spindles were detected during sleep stage 2 at centro-parietal and frontal electrodes respectively. SW were detected at frontal electrodes during stage 3. Here, we show lower frontal SW densities in AI + patients compared to HC. These results concord with previous reports about frontal cortical alterations in cancer following AIs administration. Moreover, AI + patients tended to have lower spindle density at C4 electrode. Regression analyses showed that, in both patient groups, spindle density at C4 electrode explained a large variance of memory performances. Slow spindle characteristics did not differ between groups and sleep oscillations characteristics of AI- patients did not differ significantly from those of both AI + patients and HC. Overall, our results add to the compelling evidence of the systemic effects of AIs previously reported in animals, with deleterious effects on cortical activity during sleep and associated memory consolidation in the current study. There is thus a need to further investigate sleep modifications during AIs administration. Longitudinal studies are needed to confirm these findings and investigation in other cancers on this topic should be conducted.

Exploration of effects of galvanic vestibular stimulation on circadian rhythms and its associations with sleep and spatial memory in patients with breast cancer: The ICANSLEEP-2 protocol

BACKGROUND

Patients with breast cancer (BC) exhibit circadian rhythm disruptions, mainly of rest-activity rhythm (RAR), of which sleep is an essential component, and cortisol rhythm. Sleep complaints such as insomnia and cognitive impairments are prevalent in BC. In general population, sleep is known to contribute greatly to cognition. Thus, improving RAR (and particularly sleep) could help limiting cognitive impairments in BC patients. It has recently been suggested that, in addition to its essential role in spatial memory, the vestibular system contributes to RAR synchronization. Its stimulation could therefore limit both sleep disturbances and spatial memory deficits in BC.

OBJECTIVES

The main aim of the ICANSLEEP-2 study is to assess the effects of galvanic vestibular stimulation (GVS) on circadian rhythms. The secondary aim is to assess whether GVS improves sleep and spatial memory in BC patients.

METHODS

Two groups with insomnia complaints (Insomnia Severity Index > 7) will be included: a patients' group with BC (n = 50) and a healthy control group without history of cancer (n = 25). There will be two assessment sessions, before and after 2 weeks of GVS. Patients will be randomly assigned to either a GVS group or a sham group (noneffective stimulation). Controls will receive GVS. GVS effects will be quantified and compared between groups. Assessments will include actigraphy, salivary cortisol, polysomnography, a cognitive test battery (including a computer-based task for spatial memory) and validated questionnaires (for psychological functioning and sleep complaints).

DISCUSSION

Current methods for improving sleep in BC have had controversial outcomes regarding sleep structure. We expect GVS to offer a new mean of directly targeting RAR disruptions in BC patients, with beneficial effects on sleep structure. Given the crucial impact of sleep on cognitive functioning, notably spatial memory, improving sleep of BC patients should enhance their cognitive functioning.

ETHICS AND DISSEMINATION

This study received ethical approval from the Ile de France IV institutional review board on 19 April 2022 (no. ID-RCB: 2022-A00437-36). The findings yielded by this protocol will be presented at various conferences and in peer-reviewed journals.

CLINICALTRIALS.GOV REGISTRATION NUMBER

NCT05414357.

Randomized Controlled Trial of Virtually Delivered Cognitive Behavioral Therapy for Insomnia to Address Perceived Cancer-Related Cognitive Impairment in Cancer Survivors

PURPOSE

Comorbid insomnia and cancer-related cognitive impairment (CRCI) are experienced by up to 26% of individuals diagnosed with cancer. This study examined the efficacy and durability of cognitive behavioral therapy for insomnia (CBT-I) on perceived CRCI in cancer survivors.

METHODS

Atlantic Canadian cancer survivors with insomnia and CRCI were randomly assigned to receive seven weekly virtual CBT-I sessions (n = 63) or placed in a waitlist control group (n = 69) to receive treatment after the waiting period. Participants completed assessments at baseline, 1 month (mid-treatment), and 2 months (post-treatment). Age- and education-adjusted mixed-effects models using intention-to-treat principles assessed change at post-treatment. Data from both groups were then pooled to assess the durability of effects at 3 and 6 months. A mediation analysis examined whether change in insomnia symptoms mediated the effect of CBT-I on cognitive outcomes.

RESULTS

The mean age of the sample was 60 years, 77% were women, and breast cancer was the most common diagnosis (41%). The treatment group reported an 11.35-point reduction in insomnia severity, compared with a 2.67-point reduction in the waitlist control group (P < .001). The treatment group had a greater overall improvement than the waitlist control on perceived cognitive impairment (P < .001; d = 0.75), cognitive abilities (P < .001; d = 0.92), and impact on quality of life (P < .001; d = 1.01). These improvements were maintained at follow-up. Change in insomnia symptoms fully mediated the effect of CBT-I on subjective cognitive outcomes.

CONCLUSION

Treating insomnia with CBT-I produces clinically meaningful and durable improvements in CRCI. There is an urgent need increase access to evidence-based treatment for insomnia in cancer centers and the community.

Is poor sleep quality associated with poor neurocognitive outcome in cancer survivors? A systematic review

PURPOSE

Cancer-related neurocognitive impairment and poor sleep are prevalent in cancer survivors and have a negative impact on their quality of life. This systematic review studies the association between sleep disturbance and neurocognitive functioning, as well as the potential positive effects of sleep interventions on neurocognitive functioning in cancer survivors. In addition, we aimed at determining the potential positive effects of sleep interventions on neurocognitive functioning in this population.

METHODS

Following PRISMA guidelines for reporting systematic reviews and meta-analyses, a comprehensive PubMed, Embase, PsycINFO, and CINAHL search was performed. Inclusion criteria were adult cancer survivors, self-reported or objective measures of neurocognitive functioning and sleep quality, or reports on the association between sleep and neurocognitive functioning.

RESULTS

Of the 4,547 records retrieved, 17 studies were retained for this review. Twelve studies were correlational, and five reported on interventions aimed at improving sleep quality. All studies that included self-reported neurocognitive functioning found that poorer sleep was associated with worse neurocognitive functioning. In four out of eight studies, poorer sleep was associated with objective neurocognitive impairment. Three out of five interventional studies showed neurocognitive functioning improved with improved sleep.

CONCLUSIONS

While poor sleep in cancer survivors is associated with self-reported neurocognitive impairment, the association between poor sleep and objective neurocognitive impairment is less evident.

IMPLICATIONS FOR CANCER SURVIVORS

It is important that care providers are aware of the association between sleep and neurocognitive functioning and that improving sleep quality can be a way to decrease neurocognitive impairment in cancer survivors.

Prediction of cognitive decline in older breast cancer survivors: the Thinking and Living with Cancer study

PURPOSE

Cancer survivors commonly report cognitive declines after cancer therapy. Due to the complex etiology of cancer-related cognitive decline (CRCD), predicting who will be at risk of CRCD remains a clinical challenge. We developed a model to predict breast cancer survivors who would experience CRCD after systematic treatment.

METHODS

We used the Thinking and Living with Cancer study, a large ongoing multisite prospective study of older breast cancer survivors with complete assessments pre-systemic therapy, 12 months and 24 months after initiation of systemic therapy. Cognition was measured using neuropsychological testing of attention, processing speed, and executive function (APE). CRCD was defined as a 0.25 SD (of observed changes from baseline to 12 months in matched controls) decline or greater in APE score from baseline to 12 months (transient) or persistent as a decline 0.25 SD or greater sustained to 24 months. We used machine learning approaches to predict CRCD using baseline demographics, tumor characteristics and treatment, genotypes, comorbidity, and self-reported physical, psychosocial, and cognitive function.

RESULTS

Thirty-two percent of survivors had transient cognitive decline, and 41% of these women experienced persistent decline. Prediction of CRCD was good: yielding an area under the curve of 0.75 and 0.79 for transient and persistent decline, respectively. Variables most informative in predicting CRCD included apolipoprotein E4 positivity, tumor HER2 positivity, obesity, cardiovascular comorbidities, more prescription medications, and higher baseline APE score.

CONCLUSIONS

Our proof-of-concept tool demonstrates our prediction models are potentially useful to predict risk of CRCD. Future research is needed to validate this approach for predicting CRCD in routine practice settings.

Perceived Executive Functioning Deficits After Diagnosis in Women with Non-Metastatic Breast Cancer Prior to Adjuvant Therapies

BACKGROUND

Perceived deficits in executive functioning are among the many difficulties that women diagnosed with breast cancer experience. This study assessed the presence of perceived deficits in executive functioning among women with breast cancer prior to systemic treatment and radiation and associations between perceived deficits in executive function and comorbid fatigue, sleep, and mood disturbance.

METHOD

Participants were recruited following their breast cancer diagnosis and assessed using the Behavior Rating Inventory of Executive Function for Adults (BRIEF-A), subjective and objective measures of sleep duration and efficiency, and self-report measures of insomnia severity, sleep quality, fatigue, and mood disturbance. Hierarchical regression was used to examine associations between symptoms, adjusting for age and education.

RESULTS

The final sample included 92 women with a mean age of 60.7 years and 13.5 years of education. Thirteen percent of participants reported global executive dysfunction. After partitioning out variability from other independent variables, fatigue (p = < .001), perceived sleep quality (p = .030), and symptoms of insomnia (p = .008) accounted for 13.3%, 5.7%, and 8.5% of unique variance in perceived executive functioning, respectively. Emotional fatigue was most strongly associated with perceived deficits in executive functioning. Neither subjective or objective sleep duration or efficiency was associated with perceived deficits in executive functioning.

CONCLUSION

Fatigue, particularly emotional fatigue, insomnia, and poor sleep quality had the strongest associations with perceived deficits in executive functioning. Sleep interventions and fatigue management strategies may prove useful for women who seek to improve their perceived executive functioning.

Effects of sleep disturbances and circadian rhythms modifications on cognition in breast cancer women before and after adjuvant chemotherapy: the ICANSLEEP-1 protocol

BACKGROUND

Many patients treated for breast cancer (BC) complain about cognitive difficulties affecting their daily lives. Recently, sleep disturbances and circadian rhythm disruptions have been brought to the fore as potential contributors to cognitive difficulties in patients with BC. Yet, studies on these factors as well as their neural correlates are scarce. The purpose of the ICANSLEEP-1 (Impact of SLEEP disturbances in CANcer) study is to characterize sleep using polysomnography and its relationship with the evolution of cognitive functioning at both the behavioral and the neuroanatomical levels across treatment in BC patients treated or not with adjuvant chemotherapy.

METHODS

ICANSLEEP-1 is a longitudinal study including BC patients treated with adjuvant chemotherapy (n = 25) or not treated with adjuvant chemotherapy (n = 25) and healthy controls with no history of BC (n = 25) matched for age (45-65 years old) and education level. The evaluations will take place within 6 weeks after inclusion, before the initiation of chemotherapy (for BC patients who are candidates for chemotherapy) or before the first fraction of radiotherapy (for BC patients with no indication for chemotherapy) and 6 months later (corresponding to 2 weeks after the end of chemotherapy). Episodic memory, executive functions, psychological factors, and quality of life will be assessed with validated neuropsychological tests and self-questionnaires. Sleep quantity and quality will be assessed with polysomnography and circadian rhythms with both actigraphy and saliva cortisol. Grey and white matter volumes, as well as white matter microstructural integrity, will be compared across time between patients and controls and will serve to further investigate the relationship between sleep disturbances and cognitive decline.

DISCUSSION

Our results will help patients and clinicians to better understand sleep disturbances in BC and their relationship with cognitive functioning across treatment. This will aid the identification of more appropriate sleep therapeutic approaches adapted to BC patients. Improving sleep in BC would eventually help limit cognitive deficits and thus improve quality of life during and after treatments.

TRIAL REGISTRATION

NCT05414357, registered June 10, 2022.

PROTOCOL VERSION

Version 1.2 dated March 23, 2022.

Global prevalence of sleep disturbances among breast cancer survivors: A systematic review with meta-analysis

Breast cancer is a common cancer in which patients are highly susceptible to different sleep disturbances. However, current evidence lacked consistency in methodologies in investigating the prevalence of sleep disturbances among breast cancer survivors. The review aims to (1) investigate the global prevalence of sleep disturbances among breast cancer survivors; and (2) investigate the factors influencing the prevalence estimates. A comprehensive search was conducted in 8 databases using a 3-step approach, up to January 2022. The Newcastle-Ottawa Scale and Cochrane risk of bias tool were used to evaluate the quality of individual studies. Meta-analysis, meta-regression, and subgroup analysis were performed using R software. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations criteria. A total of 51 studies were selected involving 28,036 breast cancer survivors across 17 countries. The global prevalence of poor sleep quality was 62%, different severities of insomnia were 3%-32%, and excessive daytime sleepiness was 24%. Subgroup analyses showed that a significantly higher prevalence of poor sleep quality was found in breast cancer survivors during treatment compared with pre- or post-treatment. No significant covariates were found in a series of meta-regression analyses. The majority (73.5%) of individual studies were high quality but the certainty of the evidence was low or very low according to Grading of Recommendations, Assessment, Development, and Evaluations criteria. More than half of breast cancer survivors have sleep disturbances, so developing a strategic intervention is warranted. Given the low or very low certainty of the evidence, a robust design for large-scale research is crucial in the future.

Understanding sleep quality in a national cohort of young adult cancer survivors: Results from the YACPRIME study

PURPOSE

A cancer diagnosis in young adulthood can negatively impact sleep quality. The present study describes sleep issues in young adults (YAs) and analyzes potential demographic and clinical characteristics related to sleep quality.

METHODS

Canadian YAs (n = 359) diagnosed with cancer between ages 15-39 participated in the study. Pittsburgh Sleep Quality Index (PSQI) items were examined to identify specific sleep issues that occurred 3+ times per week. Logistic regression was used to examine demographic, clinical, and symptom-related variables associated with poor sleep quality (defined as a PSQI global score >8) and sleep medication use.

RESULTS

Participants were predominantly female (87.5%) with an average age of 32 years. Of the sample, 52% had poor sleep quality, 55.5% took >30 min to fall asleep, 32.9% slept <7 h, and 54.6% reported a habitual sleep efficiency of <85%. YAs with poor sleep quality were 5.7 times more likely to report severe distress (p=<.001), as well as 1.8 times more likely to report poorer mental (p = .03) and physical functioning (p = .05). Nearly half (44%) of YAs used sleep medication to help them sleep. YAs who reported severe psychological distress were 2.4 times more likely to use sleeping medication (p = .01), whereas those with a household income ≥$100,000/year were half as likely to use medication to help with sleep (p = .04).

CONCLUSION

Psychological distress is associated with worse sleep quality and sleep medication use in YA cancer survivors. Sleep quality may be a possible target for future research and intervention to promote long-term function and recovery.

Study protocol for Cognitive Behavioral Therapy for Insomnia in patients with primary brain tumor: A single-arm phase 2a proof-of-concept trial

Background

Sleep disturbance is among the most common symptoms endorsed by patients with primary brain tumor (PwPBT), with many reporting clinically elevated insomnia and poor management of their sleep-related symptoms by their medical team. Though Cognitive Behavioral Therapy for Insomnia (CBT-I) remains the front-line treatment for sleep disturbance, CBT-I has yet to be evaluated in PwPBT. Thus, it is unknown whether CBT-I is feasible, acceptable, or safe for patients with primary brain tumors.

Methods

PwPBT (N = 44) will enroll and participate in a six-week group-based CBT-I intervention delivered via telehealth. Feasibility will be based on pre-determined metrics of eligibility, rates and reasons for ineligibility, enrollment, and questionnaire completion. Acceptability will be measured by participant retention, session attendance, satisfaction ratings, and recommendation to others. Safety will be assessed by adverse event reporting. Sleep will be measured both objectively via wrist-worn actigraphy and subjectively via self-report. Participants will also complete psychosocial questionnaires at baseline, post-intervention, and three-month follow-up.

Conclusion

CBT-I, a non-pharmacological treatment option for insomnia, has the potential to be beneficial for an at-risk, underserved population: PwPBT. This trial will be the first to assess feasibility, acceptability, and safety of CBT-I in PwPBT. If successful, this protocol will be implemented in a more rigorous phase 2b randomized feasibility pilot with the aim of widespread implementation of CBT-I in neuro-oncology clinics.

Validation of the Lee-Jones theoretical model of fear of cancer recurrence among breast cancer survivors using a structural equation modeling approach

OBJECTIVE

The Lee-Jones model posits that antecedent individual and interpersonal factors predicate the development of fear of cancer recurrence (FCR) through cognitive and emotional processing, which further to behavioral, emotional, and/or physiological responses. We analyzed data from FoRtitude, a FCR intervention grounded in the Lee-Jones FCR model, to evaluate associations between FCR antecedents, resources (e.g., breast cancer self-efficacy, BCSE) and psychological and behavioral consequences.

METHODS

Women with breast cancer who completed treatment and reported clinically elevated levels of FCR were randomized into a 4-week online psychosocial intervention or contact control group. We assessed BCSE, FCR, and physical activity, anxiety and depression, or symptoms at baseline, 4 and 8 weeks. Separate structural equation models were constructed with both baseline data and change scores (baseline-8 weeks) to examine the pathways linking BCSE, FCR and: (1) physical activity; (2) anxiety and depression; and (3) symptoms (fatigue, sleep disturbance, cognitive concerns).

RESULTS

At baseline, higher levels of BCSE were associated with lower levels of FCR. Higher FCR was associated with worse psychological effects and symptoms but not behavioral response. Change models revealed that an increase in BCSE was associated with a decrease in FCR at 8-week assessment, which was associated with reductions in psychological effects. A change in BCSE was also directly associated with reductions in psychological effects.

CONCLUSIONS

Results support the Lee-Jones model as a foundation for FCR interventions among breast cancer survivors. Replicability among varied populations is needed to examine effects on behavioral outcomes of FCR such as health care utilization.

CLINICAL TRIALS REGISTRATION

NCT03384992.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development of the Breast Cancer Survivors Symptom Checklist for Use in Follow-Up Multidisciplinary Appointments

Background

Breast cancer survivors are primarily followed up to monitor the effectiveness of treatment and complications and to detect recurrences. Many breast cancer survivors may experience prolonged adverse physical and psychological effects, which should also be addressed at follow-ups. The objective of this study was to develop a brief symptom assessment tool for breast cancer survivors to be used as a guideline for the survivors and all health care professionals conducting the routine follow-up. The second objective was to describe the women's individual experiences with follow-ups.

Methods

A literature review, a focus group of 6 healthcare professionals using a nominal group technique process, and the experience and feedback via qualitative interviews with 16 breast cancer survivors was used to develop the Breast Cancer Survivors Symptom Assessment Checklist (BCS-SC).

Results

The BCS-SC consists of a set of 13 symptoms/burdens and one question. On a scale from 0 (no symptom) to 10 (worst imaginable), survivors indicated the extent to which they experience each symptom. All survivors perceived the annual follow-ups as important, but none prepared for them. Eight of the 16 survivors reported that they had 2 or more of the symptoms/burdens listed in the BCS-SC. However, only one of the survivors had mentioned her symptom to the doctor at follow-up.

Conclusion

The BCS-SC is a comprehensive assessment tool for symptoms/burdens that are common among breast cancer survivors and can aid efforts to optimize their follow-up. Furthermore, the BCS-SC allows for a more patient-initiated and focused consultation, leading to more patient-centered quality care.

Clinical and genetic factors associated with self-reported cognitive deficits in women with breast cancer: the "CAGE-Cog" study

Background

Breast cancer patients undergoing chemotherapy treatment are at particular risk of experiencing acute cognitive impairment leading to daily challenges in decision-making and reduced quality of life and functional autonomy. The aim was to assess the relationship between clinical and genetic factors and cognitive function in a sample of patients with breast cancer undergoing chemotherapy.

Methods

A cross-sectional study was carried out between November 2017 and June 2019 on women (N = 112) treated for breast cancer by intravenous chemotherapy at the oncology outpatient unit of Hôtel-Dieu de France Hospital, Beirut. Patients were evaluated with the 37-item Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog). Other validated scales were also used to assess depression, anxiety, sleep disorders, pain, and fatigue. DNA was obtained by a buccal swab (FTA®technology) for genotyping of different genes (ABCB1, COMT, DRD2, OPRM1, CLOCK, CRY2, and PER2) using the Lightcycler®(Roche).

Results

The mean age of participants was 56.04 years. Multivariable analysis, taking the four FACT-Cog subscores as the dependent variables, showed that the mean cognitive score decreased with higher depression, anxiety, and insomnia scores. Patients with university education levels had better perceived cognitive abilities than those with primary education. Moreover, carrying the G allele for the OPRM1 polymorphism (c.118A > G;rs197791) was significantly associated with a better cognitive function compared to AA patients (B = 2.05; p = 0.038).

Conclusions

A comprehensive oncological care plan should include a personalized assessment of all factors related to cognitive functioning in cancer patients, particularly anxiety and depression, to achieve an optimal patient outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10077-6.

A Telehealth-Based Cognitive-Adaptive Training (e-OTCAT) to Prevent Cancer and Chemotherapy-Related Cognitive Impairment in Women with Breast Cancer: Protocol for a Randomized Controlled Trial

Background: Many women with breast cancer experience a great number of side effects, such as cognitive impairment, during and after chemotherapy that reduces their quality of life. Currently, research focusing on the use of non-pharmacological, and specifically telehealth interventions to prevent or mitigate them has been insufficient. Methods: This protocol describes a randomized controlled trial aimed at studying the preventive effects of a videoconferenced cognitive-adaptive training (e-OTCAT) program (ClinicalTrials.gov NCT04783402). A number of 98 eligible participants will be randomized to one of the following groups: (a) the experimental group receiving the e-OTCAT program during 12 consecutive weeks since the beginning of chemotherapy; and (b) the control group receiving and educational handbook and usual care. The primary outcome will be the cognitive function. Secondary measures will be psychological distress, fatigue, sleep disturbance, quality of life and occupational performance. The time-points for these measures will be placed at baseline, after 12 weeks and six months of post-randomization. Conclusion: This trial may support the inclusion of multidimensional interventions through a telehealth approach in a worldwide growing population suffering from breast cancer, emphasizing the prevention of cognitive impairment as one of the side effects of cancer and its treatments.

Prevalence of Sleep Disturbance in Patients With Cancer: A Systematic Review and Meta-Analysis

Sleep disturbance is one of the most common and troubling symptoms that harm the quality of life throughout all phases of treatment and stages of the illness among patients with cancer. The aim of this meta-analysis is to examine the present status of sleep disturbance prevalence in patients with cancer. The following databases were searched: PubMed, CINAHL, MEDLINE, EMBASE, PsycINFO, from inception to April 2021. Prevalence rates were pooled with meta-analysis using a random-effects model. A total of 160 studies (N = 46,279) published between 1998 and 2021 met the inclusion criteria. The overall prevalence of sleep disturbance was 60.7% (26,448/46,279 participants, 95% CI 58.1–63.3%) with significant heterogeneity between studies (p < .000, τ² = .0000, I² = 96.4%). This meta-analysis highlights the importance of developing optimal monitoring strategies to reduce sleep disturbance and improve the quality of life of cancer patients.

Effects of Baduanjin exercise on cognitive function and cancer-related symptoms in women with breast cancer receiving chemotherapy: a randomized controlled trial

PURPOSE

Cognitive decline is one of the main side effects of breast cancer patients after relevant treatment, but there is a lack of clear measures for prevention and management without definite mechanism. Moreover, postoperative patients also have a need for limb rehabilitation. Whether the cognitive benefits of Baduanjin exercise can improve the overall well-being of breast cancer patients remains unknown.

METHODS

This randomized controlled trial was conducted on 70 patients with breast cancer receiving chemotherapy who were randomly assigned and allocated to (1:1) a supervised Baduanjin intervention group (5 times/week, 30 min each time) or a control group for 3 months. The effects of Baduanjin exercise intervention were evaluated by outcome measures including subjective cognitive function, symptoms (fatigue, depression, and anxiety), and health-related quality of life at pre-intervention (T0), 4 weeks (T1), 8 weeks (T2), and 12 weeks (T3). The collected data were analyzed by using an intention-to-treat principle and linear mixed-effects modeling.

RESULTS

Participants in the Baduanjin intervention group had a significantly greater improvement in terms of FACT-Cog (F = 14.511; p < 0.001), PCI (F = 15.789; p < 0.001), PCA (F = 6.261; p = 0.015), and FACT-B scores (F = 8.900; p = 0.004) compared with the control group over the time. The exercise-cognition relationship was significantly mediated through the reduction of fatigue (indirect effect: β = 0.132; 95% CI 0.046 to 0.237) and the improvement of anxiety (indirect effect: β =  - 0.075; 95% CI - 0.165 to -0.004).

CONCLUSIONS

This pilot study revealed the benefits of Baduanjin exercise for subjective cognition and health-related quality of life of Chinese breast cancer patients receiving chemotherapy and outlined the underlying mediating mechanism of exercise-cognition. The findings provided insights into the development of public health initiatives to promote brain health and improve quality of life among breast cancer patients.

TRIAL REGISTRATION NUMBER

ChiCTR 2,000,033,152.

Impact of taxane-based chemotherapy among older women with breast cancer on cognition and quality of life: a longitudinal pooled analysis

PURPOSE

Older cancer patients are susceptible to long-term effects of chemotherapy, including cancer-related cognitive decline and impairments to quality of life. Taxane-based chemotherapies are associated with physical declines among older women and may negatively impact cognitive performance. We sought to examine whether changes in objective and subjective measures of cognitive performance and well-being differ among older breast cancer survivors as a function of taxane-based chemotherapy treatment regimens.

METHODS

Individual-level data were pooled and harmonized from two large prospective studies of older (greater than 60 years) breast cancer survivors. Assessments were conducted prior to systemic therapy and up to 36 months after. Cognitive performance was assessed with objective (working memory, processing speed, and executive functions) and subjective tests and physical, emotional, and functional well-being were also assessed.

RESULTS

One hundred and sixty-seven (M age = 67.3 years) women with 116 receiving chemotherapy with taxanes and 51 without taxanes contributed data. Declines in subjective cognition for both groups were significant between pre-treatment and 12-month follow-up. Significant improvements were seen on a measure of objective cognition (working memory) from 12 to 36 months. Measures of well-being improved from prior to systemic therapy to 12 months. Longitudinal changes across all measures did not vary as a function of receipt of taxane-based treatment.

CONCLUSION

Older women who received treatment with taxanes did not have greater declines in cognitive performance or well-being than women receiving other chemotherapy regimens. Despite older cancer survivors being at greater risk for negative outcomes, treatment with taxane-based chemotherapies does not appear to exacerbate these health consequences.

Identification of Breast Cancer Survivors With High Symptom Burden

BACKGROUND

While women diagnosed with breast cancer have increased survival when compared with other cancers, survivorship may include residual symptom burden from treatment and continuing endocrine therapies.

OBJECTIVE

The objective of this study was to identify subgroups of breast cancer survivors experiencing similar symptom severity.

METHODS

Participants were 498 women with breast cancer, not on active treatment. Symptom severity was self-reported using the MD Anderson Symptom Inventory. Target symptoms were included in a latent profile analysis. Factors related to subgroup membership and differences in quality of life (QOL) and functioning were explored using logistic regression.

RESULTS

Mean age was 60.11 (SD, 11.32) years, 86.1% were white, and 79.1% were receiving endocrine therapy. Target symptoms included fatigue (reported at ≥5 by 22.8% of women), sleep disturbance (24.8%), and trouble remembering (17.2%). Two subgroups were identified: low symptom severity (77.0% of women) and high (23.0%). Older women (odds ratio [OR], 0.971; 95% confidence interval [CI], 0.952-0.989) and employed women (OR, 0.621; 95% CI, 0404-0.956) were less likely to be in the high subgroup; women with poorer performance status (OR, 1.653; 95% CI, 1.188-2.299) were more likely to be in the high subgroup. Women in the high subgroup reported lower QOL (P = .000) and greater interference with functioning (P = .000).

CONCLUSIONS

Two subgroups of women with distinct symptom severity were identified.

IMPLICATIONS FOR PRACTICE

Identification of women at risk for high symptoms during survivorship may allow clinicians to intensify their approach to symptom management, thereby mitigating poor outcomes and impairments in QOL.

Rest activity rhythms characteristics of breast cancer women following endocrine therapy

Rest-activity rhythm (RAR) disruptions are frequently associated with chemotherapy in breast cancer (BC), but they are less known in BC with endocrine therapy. The aim of this ancillary study was to characterize the RAR and estimated sleep characteristics from actigraphy in BC patients either treated (ET+) or untreated with endocrine therapy (ET-), compared to healthy controls (HC) and using a cross-sectional design. Eighteen ET+, 18 ET- and 16 HC completed questionnaires and wore wrist actigraphs at home for 2 weeks. Parametric and non-parametric RAR, sleep parameters, and quality of life were compared between groups (p<0.05). BC groups presented lower daytime activity than HC according to RAR analysis (mesor and M10 parameters). Compared to HC, ET- had lower inter-daily stability and ET+ had greater sleep complaints. Compared to ET-, ET+ had lower sleep efficiency, more time awake and higher activity levels at night, as assessed with actigraphy. Our results suggest an effect of cancer independent of treatment on RAR in BC, highlighting the need for further investigation of this topic. In contrast, sleep as assessed with actigraphy seems modified only during ET which matches with patients' sleep complaints. Further longitudinal studies would aid in confirming the latter hypothesis.

Cognitive effects of chemotherapy: An integrative review

PURPOSE

An estimated 18.1 million new cancer cases (excluding nonmelanoma skin cancers) were diagnosed worldwide in 2020. Despite a rising incidence of cancers worldwide, in developed countries with strong healthcare systems, survival rates are improving as a result of early detection, improved treatments and survivorship care (World Health Organisation (WHO), 2021). Whilst living longer, cancer survivors are often living with side effects of treatment, including chemotherapy related cognitive impairment, often termed "chemobrain".

METHOD

An integrative review of contemporary literature answering the research question how does chemotherapy affect cognitive function? was undertaken utilising three computerised databases CINAHL, Medline and PUBMED, between 2015 and 2021. Data was thematically analysed to identify themes within published literature.

RESULTS

Thematic analysis identified four broad themes within the literature regarding chemotherapy induced cognitive impairment. Identified themes included; cognition as part of a complex scenario, proof of existence and searching for the cause, learning to play the game and timing of cognitive impairment.

CONCLUSIONS

Aggressive treatment with chemotherapy in the adjuvant setting has drastically improved the survival of cancer patients. Subsequent to aggressive treatments, side effects such as cognitive impairment have presented, which may persist in the long term. Despite the exact aetiology of chemotherapy induced cognitive impairment being largely unknown, the consequences of the condition are impacting cancer survivors and their quality of life.

Are Sleep Complaints Related to Cognitive Functioning in Non-Central Nervous System Cancer? A Systematic Review

Patients with non-central nervous system (CNS) cancer frequently report cognitive complaints, that are recurrent and affect their quality of life. In order to improve supportive care of these cognitive difficulties, it is important to identify associated factors. Sleep disturbance is a good candidate to study, as patients with non-CNS cancer frequently report sleep disorders, and sleep plays a key role in cognitive functioning. The objective of the present systematic review was to summarize the results of studies evaluating the relationship between cognition and sleep in non-CNS cancer, and to highlight the need for further studies. PubMed [Medline] and Scopus databases were screened from April to November 2020 for studies published in English evaluating the association between cognition and sleep in adults with non-CNS cancer. The characteristics and risk of bias for each of the 30 included studies have been reported. Greater cognitive complaints in patients with non-CNS cancer were related to poorer self-reported sleep quality in almost all studies (n = 22/24). By contrast, around half of the studies reported a significant association between poorer neuropsychological performances and sleep complaints (n = 5/11). The studies were found to have several limitations, such as the lack of a control group, which would have shed the light on the period of occurrence of this association (e.g. after cancer diagnosis or after cancer treatments). Our review also identified factors that may influence the relationship between cognition and sleep. Recommendations are given for improving the methodology of future studies and extending the impact of their results.

The Promise of Nutrient-Derived Bioactive Compounds and Dietary Components to Ameliorate Symptoms of Chemotherapy-Related Cognitive Impairment in Breast Cancer Survivors

OPINION STATEMENT

One of the most burdensome symptoms reported by breast cancer patients is chemotherapy-related neurocognitive impairment. It is estimated that of the 11 million cancer survivors in the USA, 22% of them are breast cancer patients. The National Cancer Institute classified chemotherapy-related cognitive impairment (CRCI) as one of the most debilitating sequelae of cancer therapy, limiting this patient population from recommencing their lives prior to the diagnosis of breast cancer. Currently, there are no strategies that are established to prevent, mitigate, or treat CRCI. In addition to surviving cancer, quality of life is critical to cancer survivors. Based on the multiple and complex biological and psychosocial etiology, the varying manifestation and extent of cognitive decline documented in breast cancer survivors, possibly attributed to varying combinations of chemotherapy and dose and duration of therapy, multimodal interventions combining promising nutrient-derived bioactive compounds with antioxidant and anti-inflammatory properties, in addition to structured cognitive training and exercise regimens, can work synergistically to reduce inflammation and oxidative stress with significant improvement in cognitive function resulting in improvements in quality of life of breast cancer survivors.

Sleep and endocrine therapy in breast cancer

Sleep disturbances and insomnia are common among breast cancer survivors, and can have a significant effect on quality of life and numerous other significant outcomes. Among risks for sleep disturbance is the introduction of anti-estrogen endocrine therapies. The possible contributing factors to sleep disturbance in endocrine therapy are complex, and include pre-existing sleep disorders, the effects of chemotherapy and other treatments, and concurrent symptoms such as hot flashes. In addition, sleep disturbance in menopause, the natural downregulation of reproductive hormones in older age, is a common occurrence, and can offer a model for understanding the high prevalence of sleep problems in breast cancer survivors on endocrine therapy, as well as suggesting possible treatments such as behavioral interventions and pharmaceuticals. Altogether, significantly more research is needed to better understand and address sleep disturbance in breast cancer survivors on endocrine therapy in order to support quality of life and treatment adherence.

Does circadian rhythm disruption during their early development have lasting effects on cognition of the elder rats?

OBJECTIVES

This study aimed to investigate the changes in learning and memory after chronic circadian disruption followed by a long period of circadian recovery.

MATERIALS AND METHODS

Eleven adult male spontaneously hypertensive rats were randomly divided into control group, 12-h light/12-h dark circadian disruption group (12L/12D) and 6-h light/6-h dark circadian disruption group (6L/6D). Rats in control group remained under the original 12-h light/12-h dark cycle throughout the experiment; rats in the 12L/12D group were exposed to 12-h light/12-h dark cycle with light-dark order changed every 3 days; rats in the 6L/6D group were exposed to 6-h light/6-h dark cycle. The disruption period continued for 18 weeks. Then after 8 weeks and 32 weeks of circadian re-entrainment, all animals were tested by Morris Water Maze (MWM), respectively, followed by an MRI examination.

RESULTS

Rats in the 12L/12D group demonstrated longer escape latency and swim distance in the MWM test than rats in the other two groups (P < 0.05). The MRI results showed volume% reduction and concentration% decrease of brain regions in the two circadian disruptive groups, while the changes were more significant and comprehensive in the 12L/12D group (P < 0.05).

CONCLUSIONS

Circadian disruption during early life accelerates cognition decline in later life in rats. Frequent light-dark order shift is more harmful.

A Web-Based Lifestyle Intervention Aimed at Improving Cognition in Patients With Cancer Returning to Work in an Outpatient Setting: Protocol for a Randomized Controlled Trial

Background

A high percentage of patients with cancer experience cognitive impairment after cancer treatment, resulting in a decreased health-related quality of life and difficulty returning to work. Consequently, there is a need for effective treatment options to improve cognitive functioning in these patients. In a healthy aging population, multidomain web-based lifestyle interventions have been found to be effective in preventing cognitive decline and improving cognitive functioning.

Objective

This study aims to investigate the feasibility and effectiveness of the web-based lifestyle intervention Mijn Fitte Brein (My Fit Brain [MFB]) on cognitive functioning in patients with cancer returning to work.

Methods

The study consists of a feasibility study (N=10), followed by a randomized controlled trial (RCT; N=220). Patients will be recruited by their occupational physicians after their return to work following cancer treatment. Mijn Fitte Brein is organized into 4-week cycles in which patients set a lifestyle goal using the Goal Attainment Scale, receive weekly tips and support, and finally evaluate whether they succeeded in achieving this goal. Lifestyle goals are based on 6 domains: physical exercise, diet, sleep, stress, alcohol use, and smoking. In the feasibility study, data on user experience (structured interview) and usability, assessed with the Post-Study System Usability Scale, will be collected and used to optimize Mijn Fitte Brein. In the RCT, patients will be randomized 1:1 between an intervention group and a control group. Patients will be assessed at baseline, 3 months, and 6 months. The primary outcome measure is subjective cognitive functioning, assessed with the Functional Assessment of Cancer Therapy–Cognitive Function (FACT-Cog). Secondary outcome measures are lifestyle, objective cognitive functioning, and work and psychosocial factors.

Results

Recruitment for the feasibility study has started in February 2020. As of July 2020, however, no patients have been enrolled (due to COVID-19 restrictions). The findings of the feasibility study will be used to optimize the Mijn Fitte Brein intervention. Enrollment for the RCT will continue when possible. The feasibility study will take 6 months (including making adjustments to the intervention), and the RCT will take 2 years. The final results are expected in 2024. The results of the feasibility study and the RCT will be published in peer-reviewed journals.

Conclusions

This is the first time the feasibility and efficacy of a multidomain web-based lifestyle intervention will be studied in patients with cancer. If Mijn Fitte Brein is found to be effective in decreasing cognitive complaints in these patients returning to work, it will be a promising treatment option because of being both affordable and accessible.

Trial Registration

Netherlands Trial Register NL8407; https://www.trialregister.nl/trial/8407

International Registered Report Identifier (IRRID)

DERR1-10.2196/22670

Pilot randomized sham-controlled trial of self-acupressure to manage the symptom cluster of insomnia, depression, and anxiety in cancer patients undergoing chemotherapy

PURPOSE

Current evidence for using self-acupressure to manage the cancer-related symptom cluster of insomnia, depression, and anxiety, while promising, is unknown. This study evaluated the feasibility of self-acupressure to manage this symptom cluster and to explore its potential effectiveness.

METHODS

Participants were assigned randomly to three study groups, namely the true acupressure (TAP), the sham acupressure (SAP), and the enhanced standard care group (ESC). Participants in the TAP and SAP groups received a training session on acupressure and were required to practice self-acupressure at home once per day for 28 days. The duration of participant involvement was 8 weeks. Patients completed a Numerical Rating Scale (NRS) for each symptom, the Insomnia Severity Index, the Hospital Anxiety and Depression Scale, and the Functional Assessment of Cancer Therapy-General at baseline (T1), post-intervention (T2, week 4), and post follow-up (T3, week 8).

RESULTS

The results indicated that the intervention had clinical significance in improving the targeted symptoms and quality of life. In the TAP group, the symptom cluster severity was significantly lower than in the other groups at T2 (p < 0.05). The insomnia severity and anxiety scores in the TAP and SAP groups were significantly lower than those in ESC at T2 and T3 (p < 0.05).

CONCLUSION

The trial was feasible. The promising results of the study suggest that further testing of self-acupressure is warranted to inform its effectiveness on the targeted symptom cluster in patients with cancer. A placebo effect was evident alongside therapeutic effects.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT03823456) on January 30th, 2019.

Feasibility of a video-based cognitive behavioral therapy for insomnia in French adult cancer outpatients: results from the Sleep-4-All-1 study

BACKGROUND

Insomnia affects up to 63% of patients with cancer. Cognitive behavioral therapy for insomnia (CBT-I) is considered to be the non-pharmacological gold standard treatment, but it remains underutilized in France. Self-administered interventions offer new ways to overcome some of the barriers that restrict access to efficacious supportive care.

OBJECTIVE

To assess the feasibility, among French adult cancer outpatients, of a validated Quebec video-based, self-administered, cognitive behavioral therapy for insomnia (VCBT-I).

METHODS

A pre-post design with quantitative measures (Insomnia Severity Index, Edmonton Symptom Assessment System, Treatment Perception Questionnaire) and qualitative measures (semi-structured interviews) was used.

RESULTS

One hundred and seventy-three cancer outpatients were self-screened for insomnia, and 57% (n=99) reported significant symptoms. Among them, 80% (n=79) agreed to participate in the VCBT-I. The download rate of the VCBT-I was 78% (n=62/79). Several technical and contextual barriers to the delivery and the applicability of the VCBT-I emerged. However, participants reported a high level of satisfaction, and some valuable benefits at post-immediate intervention (increased knowledge about sleep, better quality of sleep, and higher acceptance of the burden of insomnia), regardless of whether or not they still had insomnia.

DISCUSSION

This study confirms that there is a demand for a VCBT-I, which was perceived as appropriate by a sample of French cancer outpatients with insomnia, but it also highlights some limitations in terms of implementation and practicality. Remote professional support appears to be a core need in order to address these issues and personalize the guidance process.

A randomized trial of physical activity for cognitive functioning in breast cancer survivors: Rationale and study design of I Can! Improving Cognition After Cancer

INTRODUCTION

Difficulties with cognition are extremely common among breast cancer survivors and can significantly impact quality of life, daily functioning, and ability to return to work. One promising intervention is increasing physical activity, as it has been effective in improving cognition in non-cancer populations. Few physical activity intervention trials with cognition outcomes have included cancer survivors. This project builds upon our previous work indicating that increased physical activity can improve objectively measured processing speed and self-reported cognition among breast cancer survivors.

METHODS

The I Can! study will examine whether a physical activity intervention improves cognition among 250 post-treatment breast cancer survivors (Stages I-III, <5 years post-treatment) who are reporting cognitive difficulties. This 2-arm randomized controlled trial comparing a 6-month physical activity intervention (Exercise Group) to a health & wellness attention-comparison condition (Health & Wellness Group) will examine intervention effects on cognition (at 3 and 6 months) and maintenance of effects at 12 months. The primary aim is to investigate the impact of exercise on objectively measured processing speed and self-reported cognition. Secondary aims are to investigate maintenance of cognitive changes and examine candidate biological mechanisms and psychological mediators.

CONCLUSION

The I Can! study will contribute to the scientific, public health, and survivorship intervention literature by providing new information on the impact of physical activity for cognitive impairment in breast cancer survivors. Findings from this study will inform guidelines for physical activity to improve the lives of millions of breast cancer survivors.

Factors associated with cognitive impairment during the first year of treatment for nonmetastatic breast cancer

Background

Women with breast cancer are more likely to develop cognitive impairment (CI), insomnia, fatigue, and mood disturbance than individuals with other cancers. The main objectives of this study were to establish the prevalence of CI and examine the relationships between CI, insomnia, fatigue, and mood over the first year of breast cancer treatment.

Methods

Participants were recruited after diagnosis and completed validated measures of insomnia, objective and perceived CI, fatigue, and mood disturbance at four time points during the first year of treatment. A random intercepts cross‐lagged panel model assessed relationships among symptoms over time.

Results

The sample included 98 women. Prevalence of objective CI ranged from 3.1% to 8.2% throughout the year, whereas 36.7% demonstrated a clinically meaningful decline in perceived CI from baseline to 4 months, which remained relatively stable. Greater perceived CI was associated with more fatigue (β = −0.78, z = 17.48, p < .01) and symptoms of insomnia (β = −0.58, z = 5.24, p < .01). Short‐term fluctuations in perceived CI (p < .05), but not fatigue or insomnia, predicted future perceived CI. Fatigue (p < .001) was a significant predictor of future reported symptoms of fatigue and insomnia.

Conclusion

Subjective CI is more prevalent than objective impairments. Fatigue, insomnia, and perceived CI remain stable and are associated during the first year of treatment. Changes in insomnia and fatigue may have little effect on future perceived cognition. Women with breast cancer likely require targeted intervention for these side effects.

A narrative review of risk factors and interventions for cancer-related cognitive impairment

Cancer-related cognitive impairment (CRCI) refers to a series of cognitive impairment symptoms associated with alternations in brain structure and function, caused by a non-central nervous system malignant tumor and its related treatment. CRCI may present as memory loss, impaired concentration, difficulty in multitasking and word retrieval, and reduced comprehension speed. CRCI has become one of the prevalent factors that compromise the quality of life for cancer survivors. Different treatments, including surgery, chemotherapy, radiotherapy, endocrine therapy, and targeted drugs, may contribute to CRCI. Meanwhile, patients’ factors, including emotional challenges and genetic makeup, also contribute to the development of CRCI. The condition can be treated with using stimulants methylphenidate and modafinil, metabolites of nicotine: cotinine, antidepressants of fluoxetine and fluvoxamine, dementia drug of donepezil, and antioxidants ZnSO4, n-acetyl cysteine, propofol, and Chinese herbal of silver leaf medicine. Psychotherapies, including meditation and relaxation, cognitive rehabilitation training, along with physical therapies, including aerobic exercise, resistance training, balance training, yoga, qigong, tai chi electroencephalogram biofeedback, and acupuncture, are also beneficial in alleviating cancer-related cognitive impairment symptoms. In recent years, researchers have focused on factors related to the condition and on the available interventions. However, most research was conducted independently, and no review has yet summarized the latest findings. This review details and discusses the status of related factors and potential treatments for CRCI. We also supply specific recommendations to facilitate future research and integration in this field.

Effects of acupuncture versus cognitive behavioral therapy on cognitive function in cancer survivors with insomnia: A secondary analysis of a randomized clinical trial

BACKGROUND

Cancer-related cognitive impairment is a prevalent, disruptive condition potentially exacerbated by sleep disturbances. The current study was performed to evaluate the effects of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on objective and subjective cognitive function in cancer survivors with insomnia.

METHODS

Using data from a randomized clinical trial (160 survivors) that compared acupuncture versus CBT-I for insomnia occurring in cancer survivors, the authors analyzed cognitive outcomes and their relationship to insomnia symptoms. Analysis was limited to 99 patients who reported baseline cognitive difficulties. Interventions were delivered over 8 weeks. Objective attention, learning, and memory were evaluated using the Buschke Selective Reminding Test. Subjective cognitive function was assessed using the Brown Attention-Deficit Disorder Scales. Insomnia symptoms were assessed using the Insomnia Severity Index. All outcomes were collected at baseline, week 8, and week 20.

RESULTS

From baseline to week 8, acupuncture produced statistically significant within-group improvements in objective attention (Cohen D, 0.29), learning (Cohen D, 0.31), and memory (Cohen D, 0.33) that persisted to week 20 (all P < .05), whereas CBT-I produced a statistically significant within-group improvement in objective attention from baseline to week 20 (Cohen D, 0.50; P < .05); between-group differences were not statistically significant. Both interventions produced statistically significant within-group improvements in subjective cognitive function at weeks 8 and 20 compared with baseline (all P < .001); between-group differences were not statistically significant. In the acupuncture group, patients with clinically meaningful responses with regard to insomnia symptoms demonstrated a significantly greater improvement in subjective cognitive function compared with those without clinically meaningful insomnia responses (P = .006).

CONCLUSIONS

Among cancer survivors with insomnia, both acupuncture and CBT-I produced significant improvements in objective and subjective cognitive function. However, the effect sizes varied and only survivors in the acupuncture group demonstrated a significant relationship between cognitive and sleep outcomes. These preliminary findings warrant further investigation to guide the personalized management of patients with cancer-related cognitive impairment.

Sleep disturbance and neurocognitive outcomes in older patients with breast cancer: Interaction with genotype

BACKGROUND

Sleep disturbance and genetic profile are risks for cognitive decline in noncancer populations, yet their role in cancer-related cognitive problems remains understudied. This study examined whether sleep disturbance was associated with worse neurocognitive outcomes in breast cancer survivors and whether sleep effects on cognition varied by genotype.

METHODS

Newly diagnosed female patients (n = 319) who were 60 years old or older and had stage 0 to III breast cancer were recruited from August 2010 to December 2015. Assessments were performed before systemic therapy and 12 and 24 months later. Neuropsychological testing measured attention, processing speed, executive function, learning, and memory; self-perceived cognitive functioning was also assessed. Sleep disturbance was defined by self-report of routine poor or restless sleep. Genotyping included APOE, BDNF, and COMT polymorphisms. Random effects fluctuation models tested associations of between-person and within-person differences in sleep, genotype, and sleep-genotype interactions and cognition and controlled for age, reading level, race, site, and treatment.

RESULTS

One-third of the patients reported sleep disturbances at each time point. There was a sleep-APOE ε4 interaction (P = .001) in which patients with the APOE ε4 allele and sleep disturbances had significantly lower learning and memory scores than those who were APOE ε4-negative and without sleep disturbances. There was also a sleep disturbance-COMT genotype interaction (P = .02) in which COMT Val carriers with sleep disturbances had lower perceived cognition than noncarriers.

CONCLUSIONS

Sleep disturbance was common and was associated with worse cognitive performance in older breast cancer survivors, especially those with a genetic risk for cognitive decline. Survivorship care should include sleep assessments and interventions to address sleep problems.

Long-Term Fatigue and Cognitive Disorders in Breast Cancer Survivors

Survivors of early-stage breast cancer may report treatment-related side effects that persist for several years after the end of primary treatment. Among these, fatigue and cognitive disorders are frequent complaints and can negatively impact quality of life. Cancer-related fatigue is a very prevalent and distressing long-term side effect among breast cancer survivors that typically improves after completion of treatment, although many patients report severe fatigue several years post-treatment. Cognitive disorders are also common among survivors of breast cancer, especially if treated with chemotherapy. These symptoms are usually mild-to-moderate and often transient. Cognitive recovery is frequently observed within months or a few years after completion of chemotherapy or endocrine therapy. However, some breast cancer survivors may have persistent cognitive difficulties. Several types of interventions have proved to be beneficial in reducing cancer-related fatigue and cognitive difficulties. Most of these interventions for cancer-related fatigue are thought to be effective by reducing inflammation or disrupting pro-inflammatory circuits. Further studies are needed on cognitive management that has showed promising results. This narrative review summarizes the state of the art regarding long-term fatigue and cognitive disorders in patients with early breast cancer, describing prevalence, impact, pathophysiology, and risk factors, and focusing on available interventions.