Long-Term Cognitive Dysfunction in Cancer Survivors

A systematic review of rehabilitation programs for cognitive impairment related to breast cancer: Different programs at different times?

BACKGROUND

"Cancer Related Cognitive Impairment" (CRCI) defines cognitive disorders related to cancer and its treatments. Many people with breast cancer experience signs of CRCI (incidence between 20 and 30 %) and, although several intervention options exist, there is no established standard of care. Our main objective was to provide a detailed description of the methods and results of randomized controlled trials of interventions for CRCI in breast cancer survivors, paying particular attention to the timing of the interventions within the care pathway.

METHODS

We conducted a systematic literature review following the PRISMA guidelines from 01 to 01-2019 to 16-07-2023 and included randomized controlled trials of interventions for CRCI after breast cancer with at least one objective cognitive assessment as a primary or secondary outcome.

RESULTS

Among 228 identified studies, 35 (including 2821 participants) were retained for inclusion. The interventions were classified into 4 categories: cognitive rehabilitation, physical activity, complementary therapy and pharmacological treatment. Our analysis revealed that pharmacological interventions have no effect, whereas physical activity interventions proposed in the months following the initial cancer treatment improve Quality of Life and Speed of Information Processing while interventions proposed later improve Memory and Attention (Cognitive Rehabilitation) and Perceived Cognitive Function and Depression/Anxiety/Mood (Complementary Therapies).

CONCLUSION

CRCI is multifactorial and affected individuals frequently experience high levels of fatigue, pain, anxiety and depression and are most likely to benefit from holistic approaches that include cognition, physical activity, relaxation, psychoeducation, group support and/or psychological counselling. Thus, rehabilitation programs should be designed on multi-modal approaches, using innovative, cost-effective delivery methods that increase access to treatment, and intervention outcomes should be evaluated using measures of participation.

DATABASE REGISTRATION

The review was recorded on Prospero (01-03-2020), with the registration number 135,627.

Role of a mental health physician in the management of oncology patients: a case vignette and the need for collaboration

There is an interplay between oncology and mental health, resulting in a high prevalence of mental disorders among cancer patients. Out of the several interventions developed to target cancer specifics, collaborative care is indicated due to its efficacy. The perspective delves into the efficacy of collaborative care models, spotlighting a culturally informed strategy designed to harmonize mental and physical health interventions to bolster the overall wellbeing and resilience of individuals battling cancer. Central to our discussion is a compelling case vignette of Raliat, a patient diagnosed with ovarian cancer whose narrative exemplifies the multifaceted challenges cancer patients face, including stigma, psychological distress, and social isolation. Raliat's story illuminates the profound impact of cultural beliefs on patient experiences and the critical importance of a sensitive, holistic approach to care that respects cultural contexts. Through this lens, our analysis reveals that addressing emotional and situational stressors through collaborative care can significantly reduce oxidative stress, potentially decelerating the progression of both cancer and accompanying mental health disorders. We advocate for integrating mental health services into oncological care, drawing on the case vignette to argue for policies that facilitate such merger by employing validated collaborative care models. We conclude with a call for public education to diminish cancer stigma and improve social outcomes, emphasizing the use of a culture-informed PACER (physical, affective, cognitive, environmental, and relationship) strategy in providing comprehensive care for cancer patients and their families.

Remission after CAR T-cell therapy: Do lymphoma patients recover a normal life?

Chimeric antigen receptor T cells (CAR T cells) can induce prolonged remission in a substantial subset of patients with relapse/refractory lymphoma. However, little is known about patients' life after CAR T-cell therapy. We prospectively assessed the multidimensional recovery of lymphoma patients in remission, before leukapheresis, before CAR T-cell infusion, and 3, 6, and 12 months thereafter. Validated tools were used to measure lymphoma-related and global health-related quality of life (HRQoL; Functional Assessment of Cancer Therapy-Lymphoma [FACT-Lym] and EQ-5D-5L), cognitive complaint (FACT-Cognition), fatigue (FACIT-Fatigue subscale), psychological status (Hospital Anxiety and Depression Scale, Post-Traumatic Check List Scale), and sexuality (Relationship and Sexuality Scale). Beyond 12 months of remission, we also surveyed physical, professional, sexual, and general life status. At 3, 6, and 12 months, 53, 35, and 23 patients were evaluable, respectively. Improvement in lymphoma-related HRQoL was clinically relevant at 3, 6, and 12 months with a mean change from baseline of 10.9 (95% confidence interval [CI]: 5.8; 16.1), 12.2 (95% CI: 4.2; 20.1), and 11.72 (95% CI: 2.06; 21.38), respectively. Improvement in global HRQoL, fatigue, and anxiety was clinically relevant, but 20%-40% of patients experienced persistent fatigue, psychological distress, and cognitive complaints over time. Beyond 12 months after CAR T cells, 81.8% of 22 evaluable patients were satisfied with their daily life. Physical activity, professional, sexual, and global well-being had returned to prediagnosis levels in nearly half of the patients. We found an improvement in HRQoL after CAR T-cell therapy including anxiety, depression, sexual satisfaction, and general well-being. However, not all patients recover a "normal life." Further research is needed to determine which patients are at risk of quality-of-life impairment to improve recovery after CAR T-cell infusion.

Effects of a self-managed return to work intervention for colorectal cancer survivors: A prospective randomized controlled trial

PURPOSE

The present study aims to assess the efficacy of stage-matched, self-managed Return to Work (RTW) interventions in enhancing RTW outcomes among colorectal cancer (CRC) survivors.

METHODS

This trial, conducted in South Korea, enrolled 58 unemployed survivors of colorectal cancer. Participants were randomly assigned to either an experimental or a control group. The experimental group received a self-managed return-to-work intervention based on the trans-theoretical model, while the control group received an educational booklet. Assessments were conducted at baseline and at 3, 6, and 12 months to measure changes in various factors including return-to-work status and HRQOL.

RESULTS

In the experimental group, 28 participants were randomly assigned, while 30 individuals were allocated to the control group. The experimental group exhibited a higher proportion of individuals achieving RTW (64.5% vs 39.3%, p = 0.013) and demonstrated greater improvements in work ability (p = 0.001), RTW self-efficacy (p = 0.035), readiness for RTW in the prepared-for-action (p < 00.0001), uncertain maintenance (p = 0.033), and proactive maintenance (p < 00.0001) stages, quality of working life (p = 0.003), HRQOL (p < 0.05), and illness perception (p < 0.05) compared to the control group at the 12-month follow-up.

CONCLUSIONS

Stage-matched self-managed RTW interventions incorporating TTM principles may effectively enhance RTW outcomes and work ability among CRC survivors.

Effect of chemotherapy on hippocampal volume and shape in older long-term breast cancer survivors

Purpose

The objective of this study was to assess changes in hippocampal volume and shape in older long-term breast cancer survivors who were exposed to chemotherapy 5-15 years prior.

Methods

This study recruited female long-term breast cancer survivors aged 65 years or older with a history of chemotherapy (C+), age-matched breast cancer survivors who did not receive chemotherapy (C-), and healthy controls (HC). The participants were recruited 5-15 years after chemotherapy at time point 1 (TP1) and were followed up for 2 years at time point 2 (TP2). Assessments included hippocampal volume and shape from brain MRI scans and neuropsychological (NP) tests.

Results

At TP1, each of the three groups was comprised of 20 participants. The C+ group exhibited a hippocampal volume loss estimated in proportion with total intracranial volume (ICV) in both the left and right hemispheres from TP1 to TP2. Regarding the hippocampal shape at TP1, the C+ group displayed inward changes compared to the control groups. Within the C+ group, changes in right hippocampal volume adjusted with ICV were positively correlated with crystalized composite scores (R = 0.450, p = 0.044). Additionally, in C+ groups, chronological age was negatively correlated with right hippocampal volume adjusted with ICV (R = -0.585, p = 0.007).

Conclusion

The observed hippocampal volume reduction and inward shape deformation within the C+ group may serve as neural basis for cognitive changes in older long-term breast cancer survivors with history of chemotherapy treatment.

Role of Chinese Acupuncture in the Treatment for Chemotherapy-Induced Cognitive Impairment in Older Patients With Cancer: Protocol for a Randomized Controlled Trial

BACKGROUND

Older patients with cancer experience cognitive impairment and a series of neurocognitive symptoms known as chemobrain due to chemotherapy. Moreover, older populations are disproportionately affected by chemobrain and heightened negative mental health outcomes after cytotoxic chemical drug therapy. Chinese acupuncture is an emerging therapeutic option for chemotherapy-induced cognitive impairment in older patients with cancer, despite limited supporting evidence.

OBJECTIVE

Our study aims to directly contribute to the existing knowledge of this novel Chinese medicine mode in older patients with cancer enrolled at the Department of Oncology/Chinese Medicine, Nanjing First Hospital, China, thereby establishing the basis for further research.

METHODS

This study involves a 2-arm, prospective, randomized, assessor-blinded clinical trial in older patients with cancer experiencing chemobrain-related stress and treated with Chinese acupuncture from September 30, 2023, to December 31, 2025. We will enroll 168 older patients with cancer with clinically confirmed chemobrain. These participants will be recruited through screening by oncologists for Chinese acupuncture therapy and evaluation. Electroacupuncture will be performed by a registered practitioner of Chinese medicine. The electroacupuncture intervention will take about 30 minutes every session (2 sessions per week over 8 weeks). For the experimental group, the acupuncture points are mainly on the head, limbs, and abdomen, with a total of 6 pairs of electrically charged needles on the head, while for the control group, the acupuncture points are mainly on the head and limbs, with only 1 pair of electrically charged needles on the head.

RESULTS

Eligible participants will be randomized to the control group or the experimental group in 1:1 ratio. The primary outcome of this intervention will be the scores of the Montreal Cognitive Assessment. The secondary outcomes, that is, attentional function and working memory will be determined by the Digit Span Test scores. The quality of life of the patients and multiple functional assessments will also be evaluated. These outcomes will be measured at 2, 4, 6, and 8 weeks after the randomization.

CONCLUSIONS

This efficacy trial will explore whether Chinese electroacupuncture can prevent chemobrain, alleviate the related symptoms, and improve the quality of life of older patients with cancer who are undergoing or are just going to begin chemotherapy. The safety of this electroacupuncture intervention for such patients will also be evaluated. Data from this study will be used to promote electroacupuncture application in patients undergoing chemotherapy and support the design of further real-world studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05876988; https://clinicaltrials.gov/ct2/show/NCT05876988.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53853.

Treatment-Related Cognitive Impairment in Patients with Prostate Cancer: Patients' Real-World Insights for Optimizing Outcomes

Cognitive impairment (CI) is an issue that needs to be at the forefront of unmet healthcare needs in patients with prostate cancer (PCa) as it can negatively impact quality of life during long-term care. CI in patients with prostate cancer is thought to be influenced by treatment, androgen deprivation therapy (ADT), and novel androgen receptor (AR) pathway inhibitors in particular; however, current understanding is limited on how treatment affects cognition. Additionally, the experience of patients with CI who are receiving PCa treatment is not well understood or represented in clinical literature, which is a barrier to optimal patient outcomes in managing prostate cancer treatment-related cognitive impairment (PCa-TRCI). To help understand the patient journey and elucidate management gaps in PCa-TRCI, an international roundtable of healthcare provider and patient panelists was convened. The panelists focused on four key topic areas: (1) the patient experience when afflicted with, or at risk of, PCa-TRCI, (2) the physical, emotional, and social impact of CI on patients' quality of life (QoL), (3) the challenges that patients with PCa-TRCI face, and their impact on clinical decision-making, and (4) ways in which managing PCa-TRCI should evolve to improve patient outcomes. The purpose of the roundtable was to include patients in a direct discussion with healthcare providers (HCPs) regarding the patient journey and highlight real-world evidence of areas where patient outcomes could be improved in the absence of clinical evidence. The resulting discussion highlighted important healthcare gaps for patients with, and at risk of, PCa-TRCI and offered potential solutions as a roadmap to effective medicine.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chemotherapy-induced cognitive impairment in breast cancer survivors: A systematic review of studies from 2000 to 2021

BACKGROUND

Studies have indicated that apart from enhancing patient survival, chemotherapy has adverse side effects on the psychological, social, and cognitive functions of breast cancer survivors.

AIMS

This study was conducted to understand chemotherapy's impact on breast cancer survivors' cognitive functions.

METHODS AND RESULTS

Our study is a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched English databases, including PubMed/MEDLINE, PsycINFO, and Web of Science, and Persian databases, such as Irandoc and Elmnet, using Persian keywords of cancer, breast cancer, chemotherapy, cognitive functions, executive functions, and neuropsychological functions. Two reviewers independently evaluated the full text of the articles according to predefined criteria. Among the 937 available studies, 26 were selected based on the inclusion and exclusion criteria, of which 17 (65%) were longitudinal and 9 (35%) were cross-sectional. The findings indicated a significant relationship between the use of chemotherapy and cognitive impairments, most notably attention, working and short-term memory, and executive functions. However, the studies differed in their findings regarding the long-term persistence of cancer-related cognitive impairment (CRCI), which could be due to the wide range of tools used, different methods to measure cognitive functions, and the difference in the sample size of the studies.

CONCLUSION

Chemotherapy, affecting cortical and subcortical brain structures, causes a set of cognitive impairments that can lead to impairments in social responsibility acceptance, daily functioning, and quality of life of women. Therefore, rigorous and extensive research design is required to understand the causes and consequences of CRCI using standardized and sensitive measures of cognitive functions. Specifically, studies comparing the effects of different chemotherapy regimens on cognition and potential mechanisms and/or moderators of CRCI would be instrumental in designing more effective therapy regimens and evaluating the efficacy and cost-effectiveness of cognitive rehabilitation and supportive care programs.

Neurologic Complications in Adult Cancer Survivorship

Over the past decade, the improvement in cancer diagnostics and therapeutics has extended the overall survival of patients diagnosed with cancer including brain cancer. However, despite these unprecedented medical successes, patients continue to experience numerous neurologic complications after treatment that interfere with their independence, functionality, and overall quality of life. These include, among others, cognitive impairment, endocrinopathies, peripheral and cranial neuropathies, and vasculopathy. This article describes the long-term neurologic complications cancer survivors commonly experience to increase awareness of these complications and discuss treatments when available. Further research is necessary to understanding of mechanisms of neurologic injury and advance diagnosis and treatment. Effective patient education, monitoring, and managing neurologic issues after cancer treatment may improve independence, functionality, and quality of life during survivorship.

The association between inflammation-related biomarkers and the subtypes of cancer-related cognitive impairment in colorectal cancer patients: A latent profile analysis

PURPOSE

Cancer-related cognitive impairment (CRCI) has garnered considerable attention, yet limited research has delved into nuanced distinctions among varying degrees of CRCI in colorectal cancer survivors. This study aimed to identify distinct subgroups based on the patterns of CRCI, assess the heterogeneity among different subgroups, and investigate the potential correlations between the subgroups of CRCI and inflammation-related biomarkers.

METHODS

268 colorectal cancer patients were enrolled in this cross-sectional study, followed by the Functional Assessment of Cancer Therapy-Cognitive Function. The determination of CRCI subgroups was accomplished by the latent profile analysis (LPA). The effects of inflammation-related biomarkers on CRCI were examined using the binary logistic regression analysis. The receiver operating characteristic (ROC) curves assessed the diagnostic efficacy of inflammation-related biomarkers.

RESULTS

Two latent profiles were identified: CRCI (n = 64, 23.88%) and non-CRCI (n = 204, 76.12%). Independent factors for CRCI in colorectal cancer patients were SIRI (OR = 3.248, 95%CI [1.197-8.807], P = 0.021) and ALI (OR = 0.962, 95%CI [0.937-0.989], P = 0.005). The areas under the curve (AUCs) for SIRI and ALI in predicting CRCI were 0.781 and 0.774, with the optimal cut-off values being 0.70 and 37.04, respectively.

CONCLUSIONS

Colorectal cancer patients exhibited divergent cognitive performance profiles, categorized into two subgroups based on LPA. SIRI and ALI were identified as independent factors for CRCI, demonstrating strong diagnostic accuracy. These two inflammation-related biomarkers may potentially be novel indicators to identify and manage the development of CRCI among colorectal cancer patients.

Neurocognitive Dysfunction and predictors in non-CNS cancer patients: Rationale and methods for the neuro-oncology research at a South African academic hospital

Background

The focus on central nervous system (CNS) malignancies has overshadowed scant but substantial research that suggests non-central nervous cancer patients experience cancer-related cognitive impairment (CRCI), which affects higher-order brain function and influences their quality of life. Despite such evidence of the occurrence of CRCI among non-CNS cancer patients, the factors associated with the CRCIs remain a highly debated issue with discrepancies noted. Whether non-CNS cancer itself can affect the brain independent of cancer treatment is an important question to unpack. This necessitates further research, particularly in the sub-Saharan region where the evidence is limited.

Methods

This study aims to assess the effect of chemotherapy-associated cognitive and affective changes in non-CNS cancer patients. A non-experimental, time-series, correlational design will be used, in which a battery of computerized neuropsychological tests will be administered, including the e-MoCA, the CNS Vital Signs, the Patient Health Questionnaire-4, the Center for Epidemiologic Studies Depression Scale, the Hamilton Anxiety Rating Scale, the Functional Assessment of Cancer Therapy-Fatigue, and the Semi-structured Interview Schedule. Descriptive and inferential statistical analysis will be conducted, as well as NVivo thematic analysis of the qualitative data. The scope of the neurocognitive issues and risk factors that may be present in cancer patients and survivors in a developing environment could be determined by this study.

Implications

The study is expected to extend research on the extent at which cancer and cancer treatments are associated with neurocognitive changes among non-CNS cancer patients and their impact on their quality of life in the local context. The results are expected to inform treatment providers to develop treatment guidelines tailored for individuals diagnosed with cancer and who have received cancer treatment, as well as individualized psychosocial interventions aimed at addressing psychological challenges associated with quality of life among cancer survivors.

Associations of brain-derived neurotrophic factor rs6265 polymorphism and cognitive function in breast cancer survivors from a cross-sectional study

BACKGROUND

Breast cancer survivors (BCS) often complain of cancer-related cognitive impairment (CRCI) during and even months after completing primary cancer treatments, particularly chemotherapy. The etiology of CRCI is unknown, but associations of CRCI with germline genetic polymorphisms have been reported, including Brain-Derived Neurotrophic Factor (BDNF) rs6265 polymorphism. The current study investigated the associations of specific BDNF rs6265 with CRCI.

METHODS

Cancer-related cognitive impairment was assessed using subjective reports of cognitive symptoms (the version 1.0, 8-item short-forms of the Patient-Reported Outcomes Measurement Information System®) and computerized objective cognitive function scores (CANTAB®). BDNF rs6265 genotypes were determined from buccal swabs. The associations of specific BDNF rs6265 with CRCI were examined by either one-way analysis of variance or the Kruskal-Wallis test followed by post hoc tests and rank-based regression analysis.

RESULTS

We examined 356 female BCS. The mean (SD) age was 55.6 (9.8) years old, the median (IQR) years since cancer diagnosis were 4.0 (6.0), and 331 (92.7%) were self-described as White. BCS carrying the Met/Met genotype showed poorer results on 'visual episodic memory and new learning' and 'spatial working memory and executive function.' This relationship was observed regardless of prior chemotherapy.

CONCLUSION

Our findings suggest that carrying the BDNF rs6265 Met/Met genotype increases the risk for CRCI in BCS. These results are foundational in nature and provide important information to identify mechanisms underpinning CRCI.

Cognitive impairment experienced by Chinese breast cancer survivors

To identify cognitive function in Chinese breast cancer survivors. Research questions were: is cognitive function was associated with breast cancer and/or chemotherapy treatment and/or psychological functioning:? and did women with breast cancer experience more cognitive and psychological issues than age-matched women without cancer? Breast cancer survivors with chemotherapy (n = 106, mean age = 50.2 ± 9.5), breast cancer survivors without chemotherapy (n = 100, mean age = 50.5 ± 10.0) and matched healthy controls (n = 96, mean age = 47.9 ± 9.1) completed a battery of cognitive and psychosocial functioning. Demographic characteristics were also collected. The Perceived Cognitive Impairment score for cancer groups was significantly higher than for the healthy group (p = 0.04), but not between the cancer groups. Processing speed was significantly slower in the cancer groups than in the healthy group (both p < 0.001), but not between the cancer groups. Age, living status and education were significantly associated with the FACT-Cog (all p < 0.05). The correlations between the FACT-Cog score and BSI score were strong (r = 0.60 p < 0.01), and between the HADS anxiety and depression scales were strong (r = 0.53 and 0.50, p < 0.01) but correlations were weaker between performance based cognitive tests and measures of psychological functioning. Breast cancer groups indicated more cognitive impairment and reduced psychological functioning compared to the healthy group. However, there was no differences between the breast cancer groups. Chinese breast cancer survivors experienced excess cognitive impairment not associated with usual ageing. Assessment and intervention to address cognitive impairment should be made available to breast cancer survivors.

Long-term changes of cognitive impairment among older breast cancer survivors

PURPOSE

Cancer-related cognitive impairment is common during cancer treatment; however, it is unclear whether the impairment persists over time. Our study aimed to examine long-term cognitive impairment among older breast cancer survivors.

METHODS

Participants included 2420 community-dwelling women aged 65 years or older at enrollment (1986-1988) (404 breast cancer cases and 1:5 matched cancer-free controls) from the Study of Osteoporotic Fractures. Participants were followed for 20 years with measured cognitive function repeated up to 6 times. Cognitive impairment was defined by the Modified Mini-Mental State Examination and Trail Making Test B. Generalized linear models were used to model risk of cognitive impairment in relation to breast cancer status and time from breast cancer diagnosis.

RESULTS

Compared with controls, cognitive impairment in women with breast cancer significantly accelerated after cancer diagnosis. We also observed a more pronounced cognitive impairment after cancer diagnosis for women diagnosed with breast cancer at age ≥ 80 years or at advanced stage for both measures.

CONCLUSION

Our study with more than 20 years of follow-up data found that breast cancer survivors had accelerated cognitive impairment after cancer diagnosis, especially among women diagnosed at older age or at advanced stage, relative to women without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivors may be encouraged to engage in both physical activity and cognitive training.

Decrements in Both Physical and Cognitive Function Are Associated With a Higher Symptom Burden in Oncology Patients

OBJECTIVES

Physical and cognitive function are two of the most important patient-reported outcomes. In oncology patients receiving chemotherapy (N = 1331), purposes were to identify subgroups of patients with distinct joint physical and cognitive function profiles and evaluate for differences in demographic and clinical characteristics, severity of common symptoms, and quality of life outcomes.

DATA SOURCES

Measures of physical and cognitive functions were obtained six times over two cycles of chemotherapy. All of the other measures were done prior to the second or third cycle of chemotherapy. Latent profile analysis was done to identify the distinct joint physical and cognitive function profiles. Differences among the profiles were evaluated using parametric and nonparametric tests.

CONCLUSION

Five distinct profiles were identified (ie, Very Low Physical and Low Cognitive Function [18.4%; Both Low], Low Physical and High Cognitive Function [19.8%], Moderate Physical and Low Cognitive Function [26.7%], Changing Physical and Cognitive Function [5.4%], and Normal Physical and Cognitive Function [29.7%]). Patients in the Both Low class had the highest symptom burden and the poorest quality of life. Over 70% of the sample had moderate to severe decrements in one or both of these extremely important patient outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Clinicians need to assess for both physical and cognitive function using simple subjective and objective measures.

Development and psychometric evaluation of item banks for memory and attention - supplements to the EORTC CAT Core instrument

BACKGROUND

Cancer patients may experience a decrease in cognitive functioning before, during and after cancer treatment. So far, the Quality of Life Group of the European Organisation for Research and Treatment of Cancer (EORTC QLG) developed an item bank to assess self-reported memory and attention within a single, cognitive functioning scale (CF) using computerized adaptive testing (EORTC CAT Core CF item bank). However, the distinction between different cognitive functions might be important to assess the patients' functional status appropriately and to determine treatment impact. To allow for such assessment, the aim of this study was to develop and psychometrically evaluate separate item banks for memory and attention based on the EORTC CAT Core CF item bank.

METHODS

In a multistep process including an expert-based content analysis, we assigned 44 items from the EORTC CAT Core CF item bank to the memory or attention domain. Then, we conducted psychometric analyses based on a sample used within the development of the EORTC CAT Core CF item bank. The sample consisted of 1030 cancer patients from Denmark, France, Poland, and the United Kingdom. We evaluated measurement properties of the newly developed item banks using confirmatory factor analysis (CFA) and item response theory model calibration.

RESULTS

Item assignment resulted in 31 memory and 13 attention items. Conducted CFAs suggested good fit to a 1-factor model for each domain and no violations of monotonicity or indications of differential item functioning. Evaluation of CATs for both memory and attention confirmed well-functioning item banks with increased power/reduced sample size requirements (for CATs ≥ 4 items and up to 40% reduction in sample size requirements in comparison to non-CAT format).

CONCLUSION

Two well-functioning and psychometrically robust item banks for memory and attention were formed from the existing EORTC CAT Core CF item bank. These findings could support further research on self-reported cognitive functioning in cancer patients in clinical trials as well as for real-word-evidence. A more precise assessment of attention and memory deficits in cancer patients will strengthen the evidence on the effects of cancer treatment for different cancer entities, and therefore contribute to shared and informed clinical decision-making.

Memory Impairments and Wellbeing in Breast Cancer Patients: A Systematic Review

Breast cancer is one of the most diagnosed cancers among women. Its effects on the cognitive and wellbeing domains have been widely reported in the literature, although with inconsistent results. The central goal of this review was to identify, in women with breast cancer, the main memory impairments, as measured by objective and subjective tools and their relationship with wellbeing outcomes. The systematic literature search was conducted in the PubMed, Scopus, and ProQuest databases. The selected studies included 9 longitudinal and 10 cross-sectional studies. Although some studies included participants undergoing multimodal cancer therapies, most focused on chemotherapy's effects (57.89%; n = 11). The pattern of results was mixed. However, studies suggested more consistently working memory deficits in breast cancer patients undergoing chemotherapy. In addition, some associations have been identified between objective memory outcomes (verbal memory) and wellbeing indicators, particularly depression and anxiety. The inconsistencies in the results could be justified by the heterogeneity of the research designs, objective and subjective measures, and sample characteristics. This review confirms that more empirical evidence is needed to understand memory impairments in women with breast cancer. An effort to increase the homogeneity of study methods should be made in future studies.

Effects of exercise on cancer-related cognitive impairment in breast cancer survivors: a scoping review

BACKGROUND

Cancer-related cognitive impairment (CRCI) is one of the major long-term concerns reported by breast cancer survivors after overcoming the disease. The present study undertakes a scoping review of relevant research publications to explore the effect of increasing physical activity (PA) levels or the use of exercise (EX)-based programs on CRCI in female breast cancer survivors; who have completed neo/adjuvant chemotherapy treatment and are awaiting or receiving hormonal therapy.

METHODS

An electronic search of Pubmed, Embase, Scopus, WOS, and Cochrane databases has been conducted to identify published literature from January 2000 to December 2021.

RESULTS

Of 1129 articles, twenty met the inclusion criteria. The majority of the included observational studies (90%) reported cross-sectional design; meanwhile, 72% of experimental research reported randomized controlled trials (RCTs) or randomized crossover trials. 15 neuropsychological batteries and tests, and 5 self-reported validated questionnaires were employed. Only 27% of the included articles used a combination of the previously mentioned methods. The recorder of moderate-vigorous PA (MVPA), defined as more than 3 METs, or represented as average daily minutes spent (≥ 1952 counts/min) was the most analyzed variable in cross-sectional studies, and EX programs based on aerobic training (AT) were the most proposed by RCTs.

CONCLUSIONS

The exploratory approach of this review demonstrates modest but increasingly promising evidence regarding exercise's potential to improve brain health among breast cancer survivors although these findings highlight the importance of addressing methodological heterogeneity in the same direction with the view of using exercise within the clinic area.

Cognitive intra-individual variability in breast cancer survivors: A systematic review

Subjective and objective cognitive impairments in Breast Cancer Survivors (BCS) often do not correlate. One important contribution to the reported disparities may be the reliance on mean-based cognitive performance. Cognitive intra-individual variability (IIV) may provide important insights into these reported disparities. Cognitive IIV refers to the fluctuation in performance for an individual on either one cognitive task across a trial or dispersed across tasks within a neuropsychological test battery. The purpose of this systematic review was to search for and examine the literature on cognitive IIV in BCS. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to search for all articles related to cognitive IIV in BCS. MEDLINE (via PubMed), Embase, and Scopus databases were searched using detailed search terms and strategies. Initially, 164 articles were retrieved but only 4 articles met the criteria for this systematic review. BCS differed from healthy controls in similar ways across the four studies, generally demonstrating similar performance but showing increased cognitive IIV for the more difficult tasks. Differences were enhanced later during chemotherapy. The four studies provide support for cognitive IIV as a useful measure to detect the subtle objective cognitive change often reported by BCS but frequently not detected by standard normed-based cognitive testing. Unexpectedly, measures of cognitive IIV were not consistently associated with self-reported measures of cognition.

Examining the Mechanisms behind Exercise's Multifaceted Impacts on Body Composition, Cognition, and the Gut Microbiome in Cancer Survivors: Exploring the Links to Oxidative Stress and Inflammation

This review focuses on the effects of exercise on various health-related outcomes in cancer survivors, encompassing body composition, cognitive function (including sleep), and gut microbiome health. By analyzing multiple studies, we aimed to summarize the existing evidence and shed light on underlying mechanisms. The findings strongly suggest that exercise serves as a multifaceted non-pharmacological strategy, playing a significant role in improving the overall health of cancer survivors by effectively reducing inflammation and oxidative stress. Exercise plays a crucial role in preventing muscle wasting, diminishing the presence of reactive oxygen species and pro-inflammatory cytokines, and enhancing antioxidant systems. Furthermore, exercise displays notable benefits in terms of executive cognitive functioning and fatigue alleviation, largely attributed to its anti-inflammatory impact on the central nervous system and its ability to induce neurogenesis via growth factors. Additionally, exercise positively influences microbial diversity, reduces gut inflammation, and enhances neurogenesis through the gut-brain axis. Our key findings underscore the reduction of oxidative stress and inflammation as primary mechanisms by which exercise effectively enhances health outcomes in cancer survivors. By delving deeper into these candidate mechanisms, we aim to provide valuable guidance for future research and interventions targeting the symptoms experienced by cancer survivors.

Research Attitude and Interest among Cancer Survivors with or without Cognitive Impairment

BACKGROUND

We examined the research attitudes and willingness to participate in clinical research among cancer survivors with varying degrees of cognitive function.

METHODS

This is a secondary analysis of data collected through the University of California Irvine Consent-to-Contact registry. Cancer survivors completed the Cognitive Function Instrument (CFI), the Research Attitudes Questionnaire (RAQ), and willingness to participate (WTP) in certain research procedures. Perceived cognitive impairment (CI) was defined as the worst 20% CFI scores.

RESULTS

Here, 265 CI and 909 cognitively non-impaired (CNI) participants' data were analyzed. Mean age and sex distribution were similar, with fewer non-Hispanic Whites and education years among CI participants. More CI participants self-reported past diagnoses of Alzheimer's disease, mild cognitive impairment, stroke, depression, post-traumatic stress disorder, and alcohol abuse (all p < 0.05). CI participants were significantly more interested in studies investigating approved medications (92% vs. 87%, p = 0.030), lumbar puncture (47% vs. 38%, p = 0.027), and autopsy (78% vs. 69%, p = 0.022). After removing survivors with co-existing neuropsychiatric conditions, interest in autopsy studies remained statistically higher among CI (79% vs. 69%, p = 0.022).

CONCLUSIONS

Participants with cancer and CI are open to research procedures and interventions that are traditionally less utilized, which may facilitate the discovery of the pathogenesis and interventions for cancer-related cognitive impairment (CRCI).

Altered gyrification in chemotherapy-treated older long-term breast cancer survivors

Purpose

The purpose of this prospective longitudinal study was to evaluate the changes in brain surface gyrification in older long-term breast cancer survivors 5 to 15 years after chemotherapy treatment.

Methods

Older breast cancer survivors aged ≥ 65 years treated with chemotherapy (C+) or without chemotherapy (C-) 5-15 years prior and age & sex-matched healthy controls (HC) were recruited (time point 1 (TP1)) and followed up for 2 years (time point 2 (TP2)). Study assessments for both time points included neuropsychological (NP) testing with the NIH Toolbox cognition battery and cortical gyrification analysis based on brain MRI.

Results

The study cohort with data for both TP1 and TP2 consisted of the following: 10 participants for the C+ group, 12 participants for the C- group, and 13 participants for the HC group. The C+ group had increased gyrification in 6 local gyrus regions including the right fusiform, paracentral, precuneus, superior, middle temporal gyri and left pars opercularis gyrus, and it had decreased gyrification in 2 local gyrus regions from TP1 to TP2 (p < 0.05, Bonferroni corrected). The C- and HC groups showed decreased gyrification only (p < 0.05, Bonferroni corrected). In C+ group, changes in right paracentral gyrification and crystalized composite scores were negatively correlated (R = -0.76, p = 0.01).

Conclusions

Altered gyrification could be the neural correlate of cognitive changes in older chemotherapy-treated long-term breast cancer survivors.

Neurocognitive test performance following cancer among middle-aged and older adults in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and the SOL-Investigation of Neurocognitive Aging Ancillary Study

BACKGROUND

Cancer patients and survivors often experience acute cognitive impairments; however, the long-term cognitive impact remains unclear particularly among Hispanics/Latinos. We examined the association between cancer history and neurocognitive test performance among middle-aged and older Hispanic/Latinos.

METHODS

Participants included 9639 Hispanic/Latino adults from the community-based and prospective Hispanic Community Health Study/Study of Latinos. At baseline (2008-2011; V1), participants self-reported their cancer history. At V1 and again at a 7-year follow-up (2015-2018; V2), trained technicians administered neurocognitive tests including the Brief-Spanish English Verbal Learning Test (B-SEVLT), Word Fluency Test (WF), and Digit Symbol Substitution Test (DSS). We used survey linear regression to estimate the overall, sex-specific, and cancer site-specific [i.e., cervix, breast, uterus, and prostate] adjusted associations between cancer history and neurocognitive test performance at V1 and changes from V1 to V2.

RESULTS

At V1, a history of cancer (6.4%) versus no history of cancer (93.6%) was associated with higher WF scores (β = 0.14, SE = 0.06; p = 0.03) and global cognition (β = 0.09, SE = 0.04; p = 0.04). Among women, a history of cervical cancer predicted decreases in SEVLT-Recall scores (β = -0.31, SE = 0.13; p = 0.02) from V1 to V2, and among men, a history of prostate cancer was associated with higher V1 WF scores (β = 0.29, SE = 0.12; p = 0.02) and predicted increases in SEVLT-Sum (β = 0.46, SE = 0.22; p = 0.04) from V1 to V2.

CONCLUSION

Among women, a history of cervical cancer was associated with 7-year memory decline, which may reflect the impacts of systemic cancer therapies. Among men, however, a history of prostate cancer was associated with improvements in cognitive performance, perhaps due in part to engaging in health promoting behaviors following cancer.

Psychological distress is involved in CRCI in breast cancer survivors via mediating cytokine levels

BACKGROUND

Cancer-related cognitive impairment (CRCI) is a frequent consequence in breast cancer survivors after chemotherapy and lowers their quality of life (QOL). Psychological distress is frequently experienced by breast cancer survivors. There are currently few studies investigating the role of psychological distress in the genesis of CRCI.

METHODS

In total, 122 breast cancer survivors after standard chemotherapy within a year were recruited and assessed using the Psychological Distress Thermometer (DT). Sixty breast cancer survivors had non-psychological distress (NPD group) and sixty-two breast cancer survivors with psychological distress (PD group). The scores of the Mini-Mental State Examination (MMSE), prospective and retrospective memory (PM and RM) Questionnaire (PRMQ), and Functional Assessment of Cancer Therapy-General (FACT-G) and the levels of cytokines including interleukin-1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α), and interleukin-4 (IL-4) were compared between the two groups. Using PROCESS, we investigated whether psychological distress predicted cognitive function based on MMSE through IL-1β, TNF-α, and IL-4.

RESULTS

The PD group had higher scores on RM, PM, and FACT-G and lower scores on MMSE than the NPD group (t = -11.357, t = -10.720, t = -15.419, t = 10.162, respectively; p < 0.05). Meanwhile, a higher level of IL-1β, TNF-α, and IL-4 was observed in the PD group than in the NPD group (t = -3.961, t = -3.396, t = -3.269, respectively; p < 0.05). The link between psychological distress and cognitive function as measured by the MMSE was also mediated by IL-1β, TNF-α, and IL-4 (effect size: 26%, 25%, and 24%).

CONCLUSION

Breast cancer patients with psychological distress displayed poor cognitive function, poor memory, and inferior quality of life, which was accompanied by higher cytokine levels of IL-1β, TNF-α, and IL-4. This study demonstrated IL-1β, TNF-α, and IL-4 as potential pathways to CRCI in response to ongoing psychological distress, which provided evidence for the involvement of psychological distress in CRCI in breast cancer survivors.

Risk factors for cognitive impairment in radically treated stage III NSCLC: Secondary findings of the NVALT-11 study

AIM

To identify risk factors for self-reported cognitive impairment in radically treated stage III non-small cell lung cancer (NSCLC).

METHODS

Cognitive functioning was assessed using the EORTC-QLQ-C30 at seven pre-specified time points in the phase III NVALT-11 trial (observation versus prophylactic cranial irradiation [PCI] in stage III NSCLC treated with chemo-radiotherapy±surgery). Cognition was analyzed as binary (impairment or not) and continuous outcome, respectively, using generalized estimating equation (GEE) before and after multiple imputation. A score <75 was defined as cognitive impairment. A mean difference by <10, 10-<20, ≥ 20 points was regarded as no, moderate, and large clinical effect, respectively. We categorized the cognitive impairment into four types based on changes over time: sustained, reversible, recurring, and alternating.

RESULTS

In the no-PCI arm, 43/84 [51.2%] reported cognitive impairment at least once, of which 31.4% were sustained, 25.7% reversible, 28.6% recurring, and 14.3% alternating. Results were similar in the PCI arm. Cognitive functioning at baseline was comparable in two arms and a score <75 was a significant risk factor with large effect for subsequent cognitive impairment (no-PCI: β = -22.30, p<0.001; PCI arm: β = -22.34, p<0.001; All: β = -23.47, p<0.001). Younger age (≤ 60y), squamous histology, and PCI were risk factors without clinical relevance (β > -10, p<0.05). Cognitive functioning declined over time (β = -0.26, p=0.001) except for patients with cognitive impairment at baseline (β=0.141, p=0.33).

CONCLUSION

Cognitive impairment is dynamic over time with four types. Baseline cognitive impairment (score <75) is the most important risk factor for subsequent cognitive impairment in stage III NSCLC. Note: This work has been partly reported as an oral presentation at the ESTRO 2021 meeting (OC-0176).

Cognitive impairment after cancer treatment: mechanisms, clinical characterization, and management

Cognitive impairment is a debilitating side effect experienced by patients with cancer treated with systemically administered anticancer therapies. With around 19.3 million new cases of cancer worldwide in 2020 and the five year survival rate growing from 50% in 1970 to 67% in 2013, an urgent need exists to understand enduring side effects with severe implications for quality of life. Whereas cognitive impairment associated with chemotherapy is recognized in patients with breast cancer, researchers have started to identify cognitive impairment associated with other treatments such as immune, endocrine, and targeted therapies only recently. The underlying mechanisms are diverse and therapy specific, so further evaluation is needed to develop effective therapeutic interventions. Drug and non-drug management strategies are emerging that target mechanistic pathways or the cognitive deficits themselves, but they need to be rigorously evaluated. Clinically, consistent use of objective diagnostic tools is necessary for accurate diagnosis and clinical characterization of cognitive impairment in patients treated with anticancer therapies. This should be supplemented with clinical guidelines that could be implemented in daily practice. This review summarizes the recent advances in the mechanisms, clinical characterization, and novel management strategies of cognitive impairment associated with treatment of non-central nervous system cancers.

The Role of Cognitive Dysfunction and Health Literacy on the Quality of Life in Cancer Survivors

Background: Cancer disease is considered one of the basic health problems in the world, which threatens the health of human life. It causes numerous personal, family and social damages in physical, psychological, and social dimensions. Objectives: The present study aimed at investigating health literacy and cognitive dysfunction on the quality of life of cancer survivors to make better decisions for the daily functioning, quality of life, and work capacity of cancer survivors so that their lives can be spent with more peace and less stress. Methods: With a descriptive correlational design, 350 cancer survivors of the Cancer Research Center of Shahid Beheshti University of Medical Sciences (Shohaday Tajrish Hospital) from September to November 2021, who had been treated for at least one year, volunteered online and in person. Cognitive failure (Broadbent et al., 1982), cancer health literacy test (Dumenci et al., 2014), and quality of life of adults surviving cancer (Avis et al, 2005). Results: Pearson correlation showed a negative relationship between cognitive dysfunction and quality of life; so, path analysis showed that 25% of the quality of life is explained by cognitive dysfunction, but cancer health literacy was not correlated with the quality of life of cancer survivors. Conclusions: According to the findings, the optimization of cognitive functions after treatment was emphasized to increase the quality of life of cancer survivors.

A Systematic Review on the Potential Acceleration of Neurocognitive Aging in Older Cancer Survivors

As survival rates increase, more emphasis has gone to possible cognitive sequelae in older cancer patients, which could be explained by accelerated brain aging. In this review, we provide a complete overview of studies investigating neuroimaging, neurocognitive, and neurodegenerative disorders in older cancer survivors (>65 years), based on three databases (Pubmed, Web of Science and Medline). Ninety-six studies were included. Evidence was found for functional and structural brain changes (frontal regions, basal ganglia, gray and white matter), compared to healthy controls. Cognitive decline was mainly found in memory functioning. Anti-hormonal treatments were repeatedly associated with cognitive decline (tamoxifen) and sometimes with an increased risk of Alzheimer's disease (androgen deprivation therapy). Chemotherapy was inconsistently associated with later development of cognitive changes or dementia. Radiotherapy was not associated with cognition in patients with non-central nervous system cancer but can play a role in patients with central nervous system cancer, while neurosurgery seemed to improve their cognition in the short-term. Individual risk factors included cancer subtypes (e.g., brain cancer, hormone-related cancers), treatment (e.g., anti-hormonal therapy, chemotherapy, cranial radiation), genetic predisposition (e.g., APOE, COMT, BDNF), age, comorbidities (e.g., frailty, cognitive reserve), and psychological (e.g., depression, (post-traumatic) distress, sleep, fatigue) and social factors (e.g., loneliness, limited caregiver support, low SES). More research on accelerated aging is required to guide intervention studies.

Associations among hearing loss, multiple co-occurring symptoms, and quality of life outcomes in cancer survivors

PURPOSE

Evaluate for differences in demographic and clinical characteristics, occurrence of common symptoms, symptom severity scores, and quality of life (QOL) outcomes in survivors with (n = 155) and without (n = 118) audiometrically confirmed hearing loss.

METHODS

Survivors, who were recruited from throughout the San Francisco Bay area, completed the self-report questionnaires to obtain the information of demographic and clinical characteristics; the occurrence and severity of depression, anxiety, fatigue, decrements in energy, sleep disturbance, pain, and cognitive impairment; and the general and cancer-specific QOL outcomes. Parametric and non-parametric tests were used to evaluate for differences between the two survivor groups.

RESULTS

Survivors with audiometrically confirmed hearing loss were older, more likely to be male, were more likely to be unemployed, report a lower annual household income, and had a higher comorbidity burden. Except for the severity of worst pain, no between-group differences were found in the occurrence rates for or severity of any of the symptoms. Survivors with hearing loss reported worse physical function and general health scores.

CONCLUSIONS

While no between-group differences in symptom occurrence rates and severity scores were found, across the total sample, a relatively high percentage of survivors who were over 6 years from their cancer diagnosis reported clinically meaningful levels of depression (25%), anxiety (50%), fatigue (40%), decrements in energy (70%), sleep disturbance (58%), cognitive impairment (57%), and pain (60%).

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians need to perform routine assessments of hearing loss, as well as common co-occurring symptoms and initiate individualized symptom management interventions.

Social Wellbeing in Cancer Survivorship: A Cross-Sectional Analysis of Self-Reported Relationship Closeness and Ambivalence from a Community Sample

Improvements in early screening and treatment have contributed to the growth of the number of cancer survivors. Understanding and mitigating the adverse psychosocial, functional, and economic outcomes they experience is critical. Social wellbeing refers to the quality of the relationship with partners/spouses, children, or significant others. Close relationships contribute to quality of life and self-management; however, limited literature exists about social wellbeing during survivorship. This study examined positive and negative self-reported changes in a community sample of 505 cancer survivors. Fourteen items assessed changes in communication, closeness with partner/children, stability of the relationship, and caregiving burden. An exploratory factor analysis was conducted using a robust weighted least square procedure. Differences by sociodemographic and clinical characteristics were investigated. Respondents were mostly male, non-Hispanic white, and ≥4 years since diagnosis. Two factors, labeled Relationship Closeness and Ambivalence, emerged from the analysis. Women, younger survivors, individuals from minority groups, and those with lower income experienced greater negative changes in social wellbeing. Variations by treatment status, time since diagnosis, and institution were also reported. This contribution identifies groups of cancer survivors experiencing affected social wellbeing. Results emphasize the need to develop interventions sustaining the quality of interpersonal relationships to promote long-term outcomes.

Self-Reported Assessment of the Socio-Economic Impact of Anticancer Chemotherapy-Related Neurotoxicity

Chemotherapy-induced neurotoxicity is a well-known complication of several very effective systemic anticancer treatments, mainly presenting as cognitive impairment ("chemo-brain") and peripheral neuropathy. The social and economic effects of long-lasting chemotherapy-induced neurotoxicity on patients' lifestyles and their relationships are under-investigated, and their impact is, therefore, largely unknown. In this study, we used a web-based questionnaire to record the self-reported perception of chemotherapy-induced neurotoxicity on cancer patients' health status, but also on several different aspects of their daily life. From the study results, it emerged that the impact of chemotherapy-induced neurotoxicity on personal, social, and working activities is very high. A similar effect was also observed when the psychological impact is assessed. Moreover, there is evidence suggesting that the management of CIPN is suboptimal; this is partially due to a lack of effective drugs, but also of appropriate advice from healthcare providers. In conclusion, this study provides evidence for the relevance of the impact on the explored aspects of the daily life of cancer patients and spotlights the need for a larger and more structured investigation on these long-term side effects of anticancer chemotherapy.

CanCOG®: Cultural Adaptation of the Evidence-Based UCLA Cognitive Rehabilitation Intervention Program for Cancer Survivors in Portugal

Cognitive difficulties are highly prevalent and negatively impact cancer survivors' quality of life. The UCLA Cognitive Rehabilitation Intervention Program (in short, UCLA program) is an evidence-based intervention developed and tested in the US to address the cognitive complaints of cancer survivors. Since there are no cognitive rehabilitation programs available for Portuguese cancer-related settings, this study aimed to culturally adapt the UCLA program to Portugal. Nine steps were implemented for this cultural adaptation: needs assessment, initial contacts, translation, cultural adaptation, independent review by a panel of experts (n = 6), focus group discussions with cancer survivors (n = 11), systematization of inputs and improvement of the final materials, fidelity check, and preliminary acceptability assessment. The findings suggested that changes to the original materials were needed. A Portuguese name, "CanCOG^®-Reabilitação Cognitiva no Cancro" (in English "CanCOG^®-Cognitive Rehabilitation in Cancer"), and a logo were created to make it more memorable and appealing for the Portuguese population. The language was adjusted to ensure content accessibility and semantic and conceptual equivalence. Finally, references to several cultural aspects, such as habits, customs, and traditions, were adapted to fit the new cultural context. The UCLA program may be a promising tool to help alleviate the cognitive difficulties reported by cancer survivors in different cultural contexts. Future research is needed to confirm the feasibility, acceptability, and preliminary efficacy of its Portuguese version, "CanCOG^®-Reabilitação Cognitiva no Cancro".

A Large Retrospective Cohort Study on the Risk of Alzheimer's Disease and Related Dementias in Association with Vascular Diseases and Cancer Therapy in Men with Prostate Cancer

BACKGROUND

No study was conducted on the long-term risk of Alzheimer's disease (AD) and related dementias (ADRD) in association with vascular diseases in men with prostate cancer.

OBJECTIVES

To determine the 26-year risk of ADRD in association with cardiovascular disease (CVD), stroke, hypertension, and diabetes in a nationwide cohort of men with prostate cancer.

DESIGN

Retrospective cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) areas of the United States.

PARTICIPANTS

351,571 men diagnosed with prostate cancer at age ≥65 years.

MEASUREMENTS

Main exposures were CVD, stroke, hypertension, and diabetes. Main outcome was the incidence of ADRD.

RESULTS

The crude 26-year cumulative incidence of any ADRD was higher in those with versus without CVD (33.80% vs 29.11%), stroke (40.70% vs 28.03%), hypertension (30.88% vs 27.31%), and diabetes (32.23% vs 28.68%). Men with CVD (adjusted hazard ratio: 1.17, 95% CI: 1.15-1.20), stroke (1.59, 1.56-1.61), hypertension (1.13, 1.11-1.14), and diabetes (1.25, 1.23-1.27) were significantly more likely to develop ADRD than those without. Patients with 4 of these vascular diseases were 161% more likely to develop ADRD (2.61, 2.47-2.76) than those without. The risk of AD (0.89, 0.87-0.91) and ADRD (0.91, 0.90-0.93) became significantly lower in men with prostate cancer who received androgen deprivation therapy as compared to those who did not after considering death as a competing risk.

CONCLUSIONS

In men with prostate cancer, vascular diseases were associated with significantly higher risks of developing ADRD. Androgen deprivation therapy was associated with a significantly decreased risk of AD in men with prostate cancer.

A scoping review of cognitive assessment tools and domains for chemotherapy-induced cognitive impairments in cancer survivors

Backgrounds

Cancer survivors suffer from specific symptoms known as chemotherapy-induced cognitive impairments (CICIs). CICIs are difficult to capture with existing assessments such as the brief screening test for dementia. Although recommended neuropsychological tests (NPTs) exist, international consensus and shared cognitive domains of assessment tools are unknown. The aim of this scoping review was as follows: (1) to identify studies that assess CICIs in cancer survivors; (2) to identify shared cognitive assessment tools and domains by mapping the domains reported in studies using the International Classification of Functioning, Disability and Health (ICF) framework.

Methods

The study followed the recommendations made by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We searched the following three databases through October 2021: PubMed, CINAHL, and Web of Science. Prospective longitudinal or cross-sectional studies were selected to determine CICI-specific assessment tools for adult cancer survivors.

Results

Sixty-four prospective studies (36 longitudinal studies and 28 cross-sectional studies) were included after checking for eligibility. The NPTs were divided into seven main cognitive domains. The specific mental functions were often used in the order of memory, attention, higher-level cognitive functions, and psychomotor functions. Perceptual functions were used less frequently. In some ICF domains, shared NPTs were not clearly identified. In some different domains, the same NPTs were used, such as the trail making test and the verbal fluency test. When the association between the publishing year and the amount of NPT use was examined, it was found that the amount of tool use tended to decline over the publication years. The Functional Assessment of Cancer Therapy-Cognitive function (FACT-Cog) was a shared consensus tool among the patient-reported outcomes (PROs).

Conclusion

Chemotherapy-induced cognitive impairments are currently gaining interest. Shared ICF domains such as memory and attention were identified for NPTs. There was a gap between the publicly recommended tools and the tools actually used in the studies. For PROs, a clearly shared tool, FACT-Cog, was identified. Mapping the domains reported in studies using the ICF can help in the process of reviewing consensus on which NPTs may be used to target cognitive domains.

Systematic review registration

https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000053710, identifier UMIN000047104.

Changes in Degree Centrality and Functional Connectivity after the First Cycle of Neoadjuvant Chemotherapy in Newly Diagnosed Breast Cancer: A Longitudinal Study

Purpose

To evaluate the longitudinal changes of brain degree centrality (DC) and functional connectivity (FC) in breast cancer patients after the first cycle of neoadjuvant chemotherapy (NAC).

Methods

Thirty-five breast cancer patients were included in the NAC group. Resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological test were performed at baseline before NAC (time point 0, TP0) and after the first cycle of NAC (time point 1, TP1). The healthy controls (HC) included 30 healthy subjects and received the same rs-fMRI scan and neuropsychological test as the above-mentioned NAC group at one time point. DC and FC analyses were conducted to assess brain connectivity of all participants. Receiver operating characteristic (ROC) curve was used to assess the ability of DC and FC in distinguishing patients before and after chemotherapy.

Results

In the NAC group, the Self-Rating Anxiety Scale scores decreased significantly over time. At TP0 and TP1, the Digital Span Test forward score of the NAC group was significantly lower than that of the HC group. In the NAC group, DC in the right middle frontal gyrus and left precentral gyrus/middle frontal gyrus decreased significantly at TP1, and FC between the left precentral gyrus/middle frontal gyrus and bilateral precuneus was significantly reduced at TP1. Through ROC analysis, we found that the area under the curve (AUC) of DC, FC, and the combined model in distinguishing patients in TP0 or TP1 was 0.7886, 0.7665, and 0.8278, respectively.

Conclusions

Brain connectivity, involving executive and motor function related brain areas, changes in the short term after NAC treatment in breast cancer patients.

Self-reported cognitive impairments and quality of life in patients with gastrointestinal stromal tumor: Results of a multinational survey

BACKGROUND

Cancer-related cognitive impairment (CRCI) has long-term effects on survivor quality of life, but CRCI research on patients with gastrointestinal stromal tumor (GIST) is lacking. The aims of this study were to investigate CRCI and concomitant quality of life among patients with GIST.

METHODS

An online survey was used to assess CRCI in adult patients with GIST using the validated Functional Assessment of Cancer Therapy-Cognitive-v.3. Age, education, demographically indexed IQ, general health, and quality of life factors (e.g., fatigue, emotional distress) were also assessed. The online survey was administered through five international GIST and sarcoma support organizations.

RESULTS

Over the 3-month recruitment period, the survey was completed by 485 participants: mean age, 57.80 (SD, 11.51), median 5 years after diagnosis. A majority (63.91%) reported experiencing cognitive symptoms with a significant negative quality of life impact. Controlling for age, patients with GIST ≥5 years after diagnosis reported worse cognitive function than those <5 years after diagnosis (p < .05) but did not differ in educational level or IQ. Whereas longer term survivors were more likely to have been treated with tyrosine kinase inhibitor (TKI) therapies, there was no observed association of TKI therapy with self-reported cognitive impairments.

CONCLUSIONS

A majority of GIST patients report cognitive symptoms that have a negative impact on quality of life, with longer term survivors (≥5 years) tending to report more cognitive impairments. Given the success of TKI therapy to substantially increase overall survival of patients with GIST, addressing CRCI in clinical practice may improve long-term GIST survivor function and quality of life.

Physical Activity as the Best Supportive Care in Cancer: The Clinician's and the Researcher's Perspectives

Multidisciplinary supportive care, integrating the dimensions of exercise alongside oncological treatments, is now regarded as a new paradigm to improve patient survival and quality of life. Its impact is important on the factors that control tumor development, such as the immune system, inflammation, tissue perfusion, hypoxia, insulin resistance, metabolism, glucocorticoid levels, and cachexia. An increasing amount of research has been published in the last years on the effects of physical activity within the framework of oncology, marking the appearance of a new medical field, commonly known as "exercise oncology". This emerging research field is trying to determine the biological mechanisms by which, aerobic exercise affects the incidence of cancer, the progression and/or the appearance of metastases. We propose an overview of the current state of the art physical exercise interventions in the management of cancer patients, including a pragmatic perspective with tips for routine practice. We then develop the emerging mechanistic views about physical exercise and their potential clinical applications. Moving toward a more personalized, integrated, patient-centered, and multidisciplinary management, by trying to understand the different interactions between the cancer and the host, as well as the impact of the disease and the treatments on the different organs, this seems to be the most promising method to improve the care of cancer patients.

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.

Impact of Adjunct Testosterone on Cancer-Related Fatigue: An Ancillary Analysis from a Controlled Randomized Trial

Many cancer patients undergoing treatment experience cancer-related fatigue (CRF). Inflammatory markers are correlated with CRF but are not routinely targeted for treatment. We previously demonstrated in an NIH-funded placebo-controlled, double-blind, randomized clinical trial (NCT00878995, closed to follow-up) that seven weekly injections of 100 mg adjunct testosterone preserved lean body mass in cancer patients undergoing standard-of-care treatment in a hospital setting. Because testosterone therapy can reduce circulating proinflammatory cytokines, we conducted an ancillary analysis to determine if this testosterone treatment reduced inflammatory burden and improved CRF symptoms and health-related quality of life. Randomization was computer-generated and managed by the pharmacy, which dispensed testosterone and placebo in opaque syringes to the administering study personnel. A total of 24 patients were randomized (14 placebo, 10 testosterone), and 21 were included in the primary analysis (11 placebo, 10 testosterone). Testosterone therapy did not ameliorate CRF symptoms (placebo to testosterone difference in predicted mean multidimensional fatigue symptom inventory scores: -5.6, 95% CI: -24.6 to 13.3), improve inflammatory markers, or preserve health-related quality of life and functional measures of performance in late-stage cancer patients.

The correlation between neutrophil-to-lymphocyte ratio, carcinoembryonic antigen, and carbohydrate antigen 153 levels with chemotherapy-related cognitive impairment in early-stage breast cancer patients

Background

The changes in inflammation and tumor biomarkers are associated with the anti-tumor immunological processes. Early detection and intervention are of great significance to the clinical management of cancer-related diseases. Peripheral blood biomarkers [e.g., neutrophil-to-lymphocyte ratio (NLR), carcinoembryonic antigen (CEA), and carbohydrate antigen 153 (CA153)] are obtained in real-timely, conveniently, and less invasively, and proved to availably predicted the disease states and prognosis of various cancers, including breast cancer (BC). Inflammation and poor disease management promote cognitive impairment. Chemotherapy-related cognitive impairment (CRCI) hazard long-term survival and quality of life (QOL) of BC patients, but its correlation with NLR, CEA, and CA153 is not clear.

Purpose

This study aimed to investigate changes in NLR, CEA, and CA153 levels before and after chemotherapy and their correlation with CRCI in patients with early-stage BC.

Materials and methods

The 187 patients with BC who were measured for NLR, CEA, and CA153 values within the first 24 hours of admission, were assigned into two groups: the before/after chemotherapy group (BCG/ACG). The ACG was assigned into two subgroups based on the cognitive assessment results: the cognitive normal/impaired group (CNG/CIG). Patients’ self-perceived cognitive impairments were evaluated using a mini-mental state examination (MMSE), prospective and retrospective memory (PM and RM) questionnaire (PRMQ), and functional assessment of cancer therapy-cognitive function version 3 (FACT-Cog, version 3, including CogPCI, CogOth, CogPCA, and CogQOL). Their QOL was also evaluated.

Results

The NLR and CA153 levels were elevated after chemotherapy (BCG vs ACG: Z = −1.996 and −1.615, P = 0.046 and 0.106, respectively), and significantly elevated in patients with CRCI (BCG vs CIG: Z = −2.444 and -2.293, P = 0.015 and 0.022; respectively). However, there was not reach significant difference in CEA levels between the four groups. In addition, there was a weak to moderate correlation between peripheral blood biomarkers (NLR, CEA, and CA153) levels and CRCI (r = −0.404, −0.205, −0.322; respectively; P < 0.001). Cognitive impairment scores (MMSE, PM, RM, and FACT-Cog) had a strong correlation with QOL in patients with early-stage BC (r = −0.786, 0.851, 0.849, and 0.938; respectively; P < 0.001).

Conclusion

NLR and CA153 m be valuable diagnostic adjuncts of CRCI, and CRCI has a strong correlation with QOL in patients with early-stage BC.

Cognitive Trajectories in Older Patients with Cancer Undergoing Radiotherapy—A Prospective Observational Study

Cognitive function can be affected by cancer and/or its treatment, and older patients are at a particular risk. In a prospective observational study including patients ≥65 years referred for radiotherapy (RT), we aimed to investigate the association between patient- and cancer-related factors and cognitive function, as evaluated by the Montreal Cognitive Assessment (MoCA), and sought to identify groups with distinct MoCA trajectories. The MoCA was performed at baseline (T0), RT completion (T1), and 8 (T2) and 16 (T3) weeks later, with scores ranging between 0 and 30 and higher scores indicating better function. Linear regression and growth mixture models were estimated to assess associations and to identify groups with distinct MoCA trajectories, respectively. Among 298 patients with a mean age of 73.6 years (SD 6.3), the baseline mean MoCA score was 24.0 (SD 3.7). Compared to Norwegian norm data, 37.9% had cognitive impairment. Compromised cognition was independently associated with older age, lower education, and physical impairments. Four groups with distinct trajectories were identified: the very poor (6.4%), poor (8.1%), fair (37.9%), and good (47.7%) groups. The MoCA trajectories were mainly stable. We conclude that cognitive impairment was frequent but, for most patients, was not affected by RT. For older patients with cancer, and in particular for those with physical impairments, we recommend an assessment of cognitive function.

Long-term neurocognitive function after whole-brain radiotherapy in patients with melanoma brain metastases in the era of immunotherapy

BACKGROUND

Whole-brain radiotherapy (WBRT) used to be standard of care for patients suffering from melanoma brain metastases (MBM) and may still be applicable in selected cases. Deterioration of neurocognitive function (NCF) is commonly seen during and after WBRT. Knowledge on long-term effects in melanoma patients is limited due to short survival rates. With the introduction of immune checkpoint inhibitors, patients may experience ongoing disease control, emphasizing the need for paying more attention to potential long-term adverse effects.

METHODS

In this single-center study, we identified in a period of 11 years all long-term survivors of MBM who received WBRT at least 1 year prior to inclusion. NCF was assessed by Neuropsychological Assessment Battery (NAB) screening and detailed neurological exam; confounders were documented.

RESULTS

Eight patients (median age 55 years) could be identified with a median follow-up of 5.4 years after WBRT. Six patients reported no subjective neurological impairment. NAB screening revealed an average-range score in 5/8 patients. In 3/8 patients a NAB score below average was obtained, correlating with subjective memory deficits in 2 patients. In these patients, limited performance shown in modalities like memory function, attention, and spatial abilities may be considerably attributed to metastasis localization itself. Six out of 8 patients were able to return to their previous work.

CONCLUSION

Five of 8 long-term survivors with MBM after WBRT experienced little to no restriction in everyday activities. In 3 out of 8 patients, cognitive decline was primarily explained by localization of the metastases in functionally relevant areas of the brain. The results of our small patient cohort do not support general avoidance of WBRT for treatment of brain metastases. However, long-term studies including pretreatment NCF tests are needed to fully analyze the long-term neurocognitive effects of WBRT.

Short senolytic or senostatic interventions rescue progression of radiation-induced frailty and premature ageing in mice

Cancer survivors suffer from progressive frailty, multimorbidity, and premature morbidity. We hypothesise that therapy-induced senescence and senescence progression via bystander effects are significant causes of this premature ageing phenotype. Accordingly, the study addresses the question whether a short anti-senescence intervention is able to block progression of radiation-induced frailty and disability in a pre-clinical setting. Male mice were sublethally irradiated at 5 months of age and treated (or not) with either a senolytic drug (Navitoclax or dasatinib + quercetin) for 10 days or with the senostatic metformin for 10 weeks. Follow-up was for 1 year. Treatments commencing within a month after irradiation effectively reduced frailty progression (p<0.05) and improved muscle (p<0.01) and liver (p<0.05) function as well as short-term memory (p<0.05) until advanced age with no need for repeated interventions. Senolytic interventions that started late, after radiation-induced premature frailty was manifest, still had beneficial effects on frailty (p<0.05) and short-term memory (p<0.05). Metformin was similarly effective as senolytics. At therapeutically achievable concentrations, metformin acted as a senostatic neither via inhibition of mitochondrial complex I, nor via improvement of mitophagy or mitochondrial function, but by reducing non-mitochondrial reactive oxygen species production via NADPH oxidase 4 inhibition in senescent cells. Our study suggests that the progression of adverse long-term health and quality-of-life effects of radiation exposure, as experienced by cancer survivors, might be rescued by short-term adjuvant anti-senescence interventions.