Exercise

Exercise

PEP Topic 
Cognitive Impairment
Description 

Exercise is physical activity that involves repetitive bodily movement done to improve or maintain one or more of the components of physical fitness: cardiorespiratory endurance (aerobic fitness), muscular strength, muscular endurance, flexibility, and body composition. Exercise interventions in patients with cancer have been provided as home-based, patient self-managed programs, and supervised and unsupervised individual or group exercise sessions of varying duration and frequency. These interventions can include combinations of aerobic and resistance activities.

Exercise has been studied in patients with cancer for anxiety, chemotherapy-induced nausea and vomiting, cognitive impairment, depression, lymphedema, sleep/wake disturbance, pain, and fatigue. Users of this information are encouraged to review exercise intervention details in study summaries; as the interventions and their timing in the trajectory of cancer care vary, these differences can influence effectiveness.

Effectiveness Not Established

Research Evidence Summaries

Baumann, F.T., Drosselmeyer, N., Leskaroski, A., Knicker, A., Krakowski-Roosen, H., Zopf, E.M., & Bloch, W. (2011). 12-week resistance training with breast cancer patients during chemotherapy: Effects on cognitive abilities. Breast Care, 6, 142–143.

10.1159/000327505
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Study Purpose:

 To evaluate the effectiveness of resistance training on cognitive abilities in patients with breast cancer undergoing neoadjuvant chemotherapy   

Intervention Characteristics/Basic Study Process:

The intervention group (IG) participated in 60 minutes of resistance training (three sets of 8–12 reps for 10 different exercises at 55%–75% maximum effort) twice a week for 12 weeks. The control group (CG) did not receive any information. Cognitive evaluations were performed in the IG prior to them receiving the intervention and at study conclusion (one to two weeks after end of chemotherapy) for both groups.

Sample Characteristics:

  • The total number of participants was 17 (9 in intervention group, and 8 in thecontrol group). 
  • The mean age for the IG was 46.6 years (+/- 6.9 years). The mean age for the CG was 52 years (+/- 5.5 years).
  • The percentage of males and females was not provided.
  • Participants had been diagnosed with stage I–III breast cancer and were receiving neo-adjuvant chemotherapy.

Setting:

  • Site was not specified.
  • Patients were recruited from the Breast Center of the University Hospital of Cologne, Germany.

Phase of Care and Clinical Applications:

Patients were undergoing active treatment.

Study Design:

Prospective, non-randomized controlled trial

Measurement Instruments/Methods:

  • Memo memory test (verbal memory)     
  • Wilde Intelligence subtest (working memory)
  • d2 Test of Attention (focused attention and concentration)

Results:

The IG's d2 Test of Attention scores improved (p = 0.049), but no significant differences were observed in comparison to the CG. The IG d2 error rate decreased from baseline by 1.12 points (p = 0.017) but was significantly different from the CG at baseline (p = 0.040) and post-intervention (p = 0.019). The IG short-term verbal memory was marginally improved from baseline (p = NS) but was significantly better than CG scores (p = 0.048). IG Wilde test scores for working memory showed significant improvement from baseline (p= 0.049), but no significant difference existed between IG and CG scores.

Conclusions:

Improvements were seen in focused attention and concentration, working memory, and verbal memory for the IG. Although no differences were observed in verbal memory and attention between the IG and CG, the CG did not have baseline evaluations performed for adequate group comparisons.  

Limitations:

  • The sample size was less than 30.
  • The sample was not randomized.
  • No pre-test was conducted for the CG.
  • No comparative demographics were collected (e.g., education, occupation, information on treatment, previous treatment modalities). 
  • No actual scores or data were presented in the research brief. 

Nursing Implications:

Benefits of physical activity, predominately aerobic exercise, have improved symptoms of fatigue, sleep disturbances, affect, and cognitive function. Using resistance training may improve short-term verbal memory, working memory, attention, and concentration. Further study is warranted.

Korstjens, I., Mesters, I., van der Peet, E., Gijsen, B., & van den Borne, B. (2006). Quality of life of cancer survivors after physical and psychosocial rehabiliation. European Journal of Cancer Prevention, 15(6), 541–547.

doi:10.1097/01.cej.0000220625.77857.95
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Study Purpose:

This 12-week physical fitness and psychoeducational rehabilitation program was conducted to enhance quality of life and recovery among cancer survivors of all types of cancer. Its physical fitness component was aimed at improving movement skills, strength, and endurance; helping participants cope with physical complaints (e.g., fatigue); and enhancing feelings of control and stress reduction. Its psychoeducational component was aimed at providing support in coping with cancer and enhancing self-confidence and autonomy.

Intervention Characteristics/Basic Study Process:

 The intervention had three components.  

1. A physical fitness program involving two hours of training twice weekly with guidance from two expert physiotherapists. Each session consisted of

  • One hour of individual training for endurance and strength or one hour of group sports and games
  • 30 minutes of aqua-aerobics in an indoor pool.

2. A psychoeducational program consisting of seven two-hour sessions aimed at providing support in coping with cancer and enhancing self-confidence and autonomy.

3. Information on cancer-related subjects.

Subjective measures were completed prior to the intervention, 6 weeks into the intervention, and at 12 weeks at the intervention's end. 

Sample Characteristics:

  • The number of enrolled participants was 665. Of the enrolled participants, 658 initiated the program, 634 completed 6 weeks of the program, and 579 completed the program's full 12 weeks. 
  • The average age of the participants was 50.6 ± 9.5 years, with a range of 18–75 years.
  • 54% of the participants had breast cancer. Other cancers included were lymphoma, digestive tract, gynecologic, and lung cancer.
  • 77.8% of the participants were female and 21% were male. Gender was unknown for 1.2% of the participants. 
  • The average time since diagnosis was 2.1 years, with a range of 0–25 years.
  • The average time since end of treatment was 1.3 years, with a range 0–14 years.

Setting:

This was a single-site study. 

Study Design:

This was a prospective trial. 

Measurement Instruments/Methods:

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30) was used to measured global and functional quality of life using 6 subscales (global, physical, role, cognitive, emotional, social functioning) and one symptom scale on fatigue. Scores range from 0–100, with higher scores indicating higher quality of life for the global and functional scales. Higher symptom scores indicate greater fatigue.

The Tampa Kinesophobia Scale was used to measure excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury. Two subscales were used to measure avoidance of activities (7 items) and pathologic somatic focus (4 items).

Results:

As measured by two items on the EORTC QLQ–C30, cognitive function improved at 12 weeks, but not at 6 weeks. There were significant improvements for all quality-of-life domains and fatigue for all cancer patients after 12 weeks (p < 0.05).

Conclusions:

The authors suggest that exercise may improve cognitive functioning as well as other quality-of-life domains.

Limitations:

  • Although subjective cognitive function improved over 12 weeks, this finding was not confirmed by objective cognitive-specific measures.
  • A wide range of ages was included in the sample, but no age breakdown was recorded for the two cohorts; ge-related changes in cognitive function may influence the results between the two cohorts.
  • The authors were unable to determine whether changes in quality of life were a result of the exercise versus the psychoeducational intervention or the combination of both.
  • There was no control group as a comparison. 

Miki, E., Kataoka, T., & Okamura, H. (2014). Feasibility and efficacy of speed‐feedback therapy with a bicycle ergometer on cognitive function in elderly cancer patients in Japan. Psycho‐Oncology, 23, 906–913. 

doi: 10.1002/pon.3501
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Study Purpose:

To determine the feasibility and effectiveness of speed-feedback therapy on improving cognitive function in elderly patients with cancer

Intervention Characteristics/Basic Study Process:

The intervention consisted of subjects pedaling for five minutes on a bicycle ergometer once per week for four weeks compared to usual daily life activities. The bicycle ergometer was linked to a computer with the screen displaying the target speed, revolutions per minute, and a changing path for the subjects to follow. Subject’s actual speed and revolutions were displayed as the subject tried to match the target speed and revolutions on the path on the screen. The exercise load was set at 20 W, and the maximum number of rotations was set at 80 revolutions per minute. Demographic data were collected at baseline. Cognitive function and other assessments were obtained at baseline and at week 4.

Sample Characteristics:

  • N = 78 (38 intervention, 40 control)
  • MEAN AGE = 74.24 years
  • MALES: 45%, FEMALES: 55% 
  • KEY DISEASE CHARACTERISTICS: All participants were diagnosed with either breast or prostate cancer irrespective of stage or treatment modalities. Most subjects were undergoing treatment (53% intervention, 70% control).
  • OTHER KEY SAMPLE CHARACTERISTICS: Average education = 12.11 years

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Hiroshima University Hospital rehabilitation center, Japan

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Elder care  

Study Design:

Randomized, controlled trial design; outcomes evaluator blinded to group assignment

Measurement Instruments/Methods:

  • Frontal Assessment Battery (FAB)
  • Barthel Index (BI)
  • Lawton and Brody Instrumental Activities of Daily Living (IADL)
  • Functional Assessment of Cancer Therapy-General (FACT-G) version 4

Results:

There were more subjects who underwent radiation therapy in the intervention than the control group (p = .01). There were significant differences between groups in the FAB change score for time effect (F = 24.39, p < .001, partial ɳ= .247), group effect (F = 9.26, p = .003, partial ɳ= .109), and interaction (F = 7.88, p = .006, partial ɳ= .094). Younger age was an independent factor associated with greater improvement in FAB scores (p = .018, β = -.264). There were no differences between groups for BI, IADL, or FACT-G scores at baseline or over time.

Conclusions:

Findings from this study suggest that speed-feedback therapy may improve cognitive function. However, this intervention required a bicycle ergometer associated with a computer and training by professionals in a hospital setting, which may impact accessibility and costs. Additional studies in other cancer diagnoses with longitudinal follow-ups to demonstrate sustained cognitive improvements is warranted.

Limitations:

  • Small sample (< 100)
  • Intervention expensive, impractical, or training needs

Nursing Implications:

Speed-feedback therapy with a bicycle ergometer may be a potential intervention to improve cognitive function, particularly sustained attention. Additional research with larger sample sizes and a longer follow-up period is needed to determine the effectiveness and the sustainability of any improvements in cognitive function.

Reid-Arndt, S.A., Matsuda, S., & Cox, C.R. (2012). Tai chi effects on neuropsychological, emotional, and physical functioning following cancer treatment: A pilot study. Complementary Therapies in Clinical Practice, 18, 26–30.

10.1016/j.ctcp.2011.02.005
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Study Purpose:

To examine the effects of tai chi on neuropsychological, psychological, and physical health of female cancer survivors  

Intervention Characteristics/Basic Study Process:

Women participated in an hour-long, twice-weekly Yang-style tai chi course for 10 weeks. They underwent testing prior to the course and then one month following the test.

Sample Characteristics:

  • A total of 23 participants enrolled in the study.  
  • The women's average age was 62.3 years (SD = 10.8 years).
  • The sample was 100% female.
  • The women had been diagnosed with breast (n = 16), ovarian (n = 3), or endometrial (n = 1) cancer; NHL (n = 2); or CLL (n = 1).
  • All had received chemotherapy at least 12 months prior.
  • On average, the women had complete 16.4 years (SD = 2.1 years) of education.
     

Setting:

  • Mutli-site 
  • Mid-Western city
     

Phase of Care and Clinical Applications:

Patients were undergoing long-term follow-up.

Study Design:

Pilot study

Measurement Instruments/Methods:

  • Rey Auditory Verbal Learning Test (memory)    
  • Trail Making Test A
  • Trail Making Test B (executive functioning)
  • Stroop Test (executive functioning)
  • Oral Word Association Test
  • Wechsler Adult Intelligence Scale Third Edition (WAIS-III) Digit Span and Digit Symbol
  • Multiple Abilities Self-Report Questionnaire (MASQ)

Results:

Statistical significant changes were seen in the scores of immediate memory (Rey trial 1, Rey trials 1–5, Logical Memory), delayed memory (logical memory II), verbal fluency (COWAT), attention (Trails A, Digit Symbol) and executive functioning (Trails B, Stroop Test). The Reliable Change Index analyses did not meet the criteria for reliable change as a group. Self-reported cognitive functioning improved for verbal and visual memory in the MASQ (p < 0.05). No significant changes were seen in fatigue. Significant improvements were seen in multiple measures of balance (p < 0.002).

Conclusions:

Tai chi may promote gains in cognitive and physical functioning in cancer survivors.

Limitations:

  • The sample was small at less than 30 participants.
  • It was a well-educated group, all female, with a range of treatment and length from last treatment)
  • No control group was included.
  • Classes were taught in a group setting, so the group support and interaction may have influenced the findings, rather than the tai chi itself.

Nursing Implications:

This is a small pilot study, but it suggests that tai chi may be helpful in improving neurocognitive functioning. Tai chi is a relatively easy exercise to perform for most patients and is readily available in most areas. Further research is needed to verify the benefits of tai chi on cognitive dysfunction.

Schmidt, M.E., Wiskemann, J., Armbrust, P., Schneeweiss, A., Ulrich, C.M., & Steindorf, K. (2015). Effects of resistance exercise on fatigue and quality of life in breast cancer patients undergoing adjuvant chemotherapy: A randomized controlled trial. International Journal of Cancer, 137, 471–480. 

doi: 10.1002/ijc.29383
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Study Purpose:

To evaluate the effects of a 12-week resistance training intervention in patients with breast cancer during adjuvant chemotherapy

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to the intervention or attention control group. The control group received a supervised group muscle relaxation program with the same session schedule as the intervention group. The exercise intervention involved the use of eight different machine-based progressive resistance exercises without an aerobic component. Both interventions were provided in group settings for 60 minutes twice weekly. Study measures were obtained at baseline and at the end of the intervention period.

Sample Characteristics:

  • N = 95
  • MEAN AGE = 52.7 years (range = 30–71 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All participants had breast cancer. The majority of participants had stage 1 or 2 disease. The mean number of days since surgery was 56. All participants were receiving adjuvant chemotherapy.
  • OTHER KEY SAMPLE CHARACTERISTICS: 18% had baseline depression 

Setting:

  • SITE: Single site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Germany

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized, controlled trial

Measurement Instruments/Methods:

  • Fatigue Assessment Questionnaire (FAQ)
  • European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
  • Center for Epidemiologic Studies (CES-D) for depression
  • Trail Making Test (TMT)

Results:

The overall between-group difference in fatigue was –5.8. This difference was not statistically significant. There was no overall effect of the intervention on the affective or cognitive dimensions in the fatigue measure. In a subgroup analysis of women who were not depressed at baseline, the between-group difference was –8.1 (p = –0.039). Fatigue increased in the relaxation group. Cognitive performance on the TMT improved in the exercise group compared to the control group, but the difference was not significant. Depression remained unchanged in both groups.

Conclusions:

The findings of this study show that resistance exercise can be helpful in reducing fatigue during adjuvant chemotherapy, particularly in patients who have depressive symptoms. There were no apparent effects of the resistance exercise program on fatigue or cognitive function.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Key sample group differences that could influence results
  • Other limitations/explanation: A significantly larger proportion of patients in the exercise group had higher depression scores at baseline (p = 0.0098). This difference may have affected overall findings.

Nursing Implications:

Findings showed that resistance exercise reduced fatigue during adjuvant chemotherapy. These effects were more pronounced in women who did not have depressive symptoms at baseline. This points to the potential influence of depression on fatigue and the efficacy of interventions for fatigue. These results suggest the need to ensure the effective management of depressive symptoms to manage fatigue during treatment. The interventions studied here did not show an effect on depression or cognitive function.

Schwartz, A.L., Thompson, J.A., & Masood, N. (2002). Interferon-induced fatigue in patients with melanoma: A pilot study of exercise and methylphenidate. Oncology Nursing Forum, 29(7), E85–E90.

doi:10.1188/02.ONF.E85-E90
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Study Purpose:

This study was conducted to examine the effect of exercise and methylphenidate (MPH) on fatigue, functional ability, and cognitive function in patients with melanoma. It also aimed to determine the percentage of patients who adhered to interferon-alfa, MPH, and exercise treatment.

Intervention Characteristics/Basic Study Process:

The intervention group was given 20 mg of long-acting MPH every morning for four months and took part in at least 15–20 minutes of aerobic exercise four days per week. The duration and intensity of exercise gradually increased over the study's four months.

Assessments were completed prior to the first dose of interferon-alfa. Subsequent assessments of functional ability and cognition function (using Trail Making Test forms) and quality of life were repeated at one and four months after baseline. Subsequent assessments of fatigue scale, body weight, daily activity, and medication logs were submitted monthly.

Sample Characteristics:

  • The total number of individuals involved in the study was 28.
  • There were 12 participants and 16 historic controls. 
  • The average age of the treatment group was 44, with a range of 20–64. Age information for the historic group was not provided.
  • Gender information was not provided.
  • 92% of the participants were Caucasian.
  • The treatment group tended to have completed more years of formal education.
  • Participants had newly diagnosed melanoma with surgical intervention, no prior treatment, and were actively undergoing treatment with interferon-alfa.

Setting:

The study took place at a university-based cancer center.

Study Design:

This was a longitudinal pilot study with descriptive/exploratory design. It made use of a historic control group for comparison.

Measurement Instruments/Methods:

  • The Trail Making Test (TMT) Parts A and B measured visual attention, motor speed, and cognitive flexibility.
  • The Schwartz Cancer Fatigue Scale measured fatigue with 6 items. Scores range from 6–36, with higher scores indicating greater fatigue.
  • The Medical Outcomes Study Short Form (SF-36) measured quality-of-life and global function with physical and mental health subscales. Scores range from 0–100, with higher scores indicating higher functioning.
  • Adherence was measured with daily activity and medication logs.
  • Body weight was measured to the nearest 0.1 kg and obtained monthly.

Results:

Functional ability increased an average of 6% for all participants and 9% for the treatment group. A percent change in a 12-minute walk was negatively related to TMT-A (p = 0.04) and TMT-B (p = 0.05), suggesting a relationship between higher exercise and improved cognitive functioning (indicated by lower scores on TMT). Taking MPH was correlated with improved TMT-B performance at 4 months (r = -0.85, p < 0.001). 

All participants' cognitive function scores were within normal ranges at baseline. Sixty-six percent of participants adhered to MPH at four months; all subjects continued to exercise at four months.

Conclusions:

The combination of exercise and MPH has positive effects on cognitive function, functional ability, and fatigue over time. The authors suggest that MPH may have contributed to better exercise adherence.

Limitations:

  • The study had a small sample size.
  • One-third of the participants stopped taking MPH within the first week; for one participant, this was due to significant side effects related to anxiety.
  • Two participants regularly exercised prior to enrollment, but the study did not address which group they were assigned to, potentially influencing outcomes.

Guideline/Expert Opinion

Denlinger, C.S., Ligibel, J.A., Are, M., Baker, K.S., Demark-Wahnefried, W., Friedman, D.L., . . . National Comprehensive Cancer Network. (2014). Survivorship: Cognitive function [v.1.2014]. Journal of the National Comprehensive Cancer Network, 12, 976–986.

PROFESSIONAL GROUP: National Comprehensive Cancer Network (NCCN)

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Purpose & Patient Population:

PURPOSE: To provide recommendations for the assessment, evaluation, and management of cognitive impairment in survivors of cancer
 
TYPES OF PATIENTS ADDRESSED: Cancer survivors

Type of Resource/Evidence-Based Process:

RESOURCE TYPE: Consensus-based guideline  
 
PROCESS OF DEVELOPMENT: Extent, consistency, and quality of data from articles retrieved in search were used to determine the level of evidence (higher or lower level) and the consensus for recommendations. According to NCCN categories for guidelines, the 2014 Cognitive Function Guidelines are a 2A Category (≥ 85% uniform consensus was reached from lower-level evidence available for the 2014 Cognitive Function Guidelines). 
 
SEARCH STRATEGY:
DATABASES USED: PubMed
KEYWORDS: Neoplasms, cancer, and survivors
INCLUSION CRITERIA: Human, English, clinical trial phases 2–3, practice guideline, randomized, controlled trial, meta-analysis, systematic reviews, and validation studies
 

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship
 
APPLICATIONS: Pediatrics and elder care

Results Provided in the Reference:

A uniform NCCN consensus determined that recommendations were appropriate (NCCN Category of Evidence and Consensus = 2A).

Guidelines & Recommendations:

Nonpharmacologic interventions were recommended as first-line therapies whenever possible. These included specific neuropsychological recommendations based on formal evaluation, cognitive behavioral therapy, self-management and coping strategies, discontinuing or limiting medications that may contribute to cognitive dysfunction, managing medical comorbidities, relaxation, stress management, exercise, occupational therapy strategies, patient and family education and counseling, and managing distress, pain, sleep disturbances, and fatigue.
 
Pharmacologic interventions were recommended as the last line of therapy. These included the use of stimulants (methylphenidate or modafinil).

Limitations:

Some interventions that may be useful to improve or maintain cognitive function might not be included in these guidelines because this manuscript did not detail search strategies, inclusions and exclusions, or the number of articles included in the recommendations.

Nursing Implications:

The NCCN cognitive function algorithm aids healthcare professionals considering the assessment and treatment of cancer-related cognitive function. Nonpharmacologic interventions should be recommended to oncology survivors experiencing cognitive issues. Pharmacologic interventions may be considered when medical conditions permit and potential contributing factors are ruled out or managed.

Systematic Review/Meta-Analysis

Morean, D.F., O'Dwyer, L., & Cherney, L.R. (2015). Therapies for cognitive deficits associated with chemotherapy for breast cancer: A systematic review of objective outcomes. Archives of Physical Medicine and Rehabilitation, 96, 1880–1897. 

doi: 10.1016/j.apmr.2015.05.012
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Purpose:

STUDY PURPOSE: To evaluate the effectiveness of interventions for objectively measured cognitive impairments in women with breast cancer who received chemotherapy
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: CINAHL, Cochrane, EMBASE, PsycINFO, and PubMed
 
KEYWORDS: Breast cancer, chemobrain, chemofog, chemotherapy, and several terms related to cognition and language deficits; appendix 1 described an extensive list of search terms and strategies that were used for PubMed and EMBASE
 
INCLUSION CRITERIA: Objective measurement of cognitive function; sample consisted of women with breast cancer who received or were receiving chemotherapy; experimental design (cross-sectional, longitudinal, or randomized clinical trials) 
 
EXCLUSION CRITERIA: Case studies or series, commentaries, editorials, dissertations not published in a peer-reviewed journal, systematic reviews, and meta-analyses

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 1,745
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Abstracts were screened, and 30 duplicates were eliminated (plus 14 titles without abstracts). Abstracts were reviewed to validate that the studies involved women with breast cancer who were undergoing or received chemotherapy and that they had an objective neuropsychological assessment (1,556 articles excluded). The remaining articles (n = 145) were reviewed to ensure an that an intervention was administered for cognitive impairment (131 articles excluded) and that the studies met specific quality criteria as defined by the Physiotherapy Evidence Database rating scale criteria as well as criteria for treatment fidelity (two articles excluded).  

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 12
  • TOTAL PATIENTS INCLUDED IN REVIEW = 442
  • SAMPLE RANGE ACROSS STUDIES = 12–107 patients
  • KEY SAMPLE CHARACTERISTICS: Although education status may influence neuropsychological test results, only half of the studies provided this information. Likewise, menopausal status may affect cognition, and this was only reported by two thirds of the studies.

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship

Results:

Studies of pharmacologic interventions were not found to be effective in improving cognitive function. Medications reviewed included d-methylphenidate (n = 1), epoetin alfa (n = 2), and ginkgo biloba (n = 1). Evidence for nonpharmacologic interventions was mixed. No improvements in cognitive function were found with Tibetan sound meditation (n = 1). Natural restorative therapy (n = 1) improved attention only when comparing the baseline with the final 90-day evaluation (p = 0.01). Exercise (n = 1) improved attention (p = 0.019) and verbal memory (p = 0.048) but not working memory. Cognitive rehabilitation (n = 1) improved four out of six measures of information processing speed (p < 0.05) but not attention, verbal memory, or executive function. Cognitive behavioral training (n = 2) improved verbal memory (p < 0.05) in both studies and was effective in improving in information processing speed when compared to baseline scores in one study (p ≤ 0.01) but not the other. Computerized cognitive training was effective in one study in improving processing speed (p = 0.009), executive function (p = 0.008), and a measure of executive function and language (p = 0.003) but not verbal memory. However, in another study, there was no difference in verbal memory or information processing speed between the intervention and control groups.

Conclusions:

Nonpharmacologic interventions, especially cognitive training, may have a role for improving attention, information processing speed, and verbal memory. Exercise and computerized cognitive training may be effective for improving executive function. However, additional research validating these findings with larger sample sizes and evaluating other cognitive domains is needed. In addition, studies determining the dose or duration of interventions is required for a durable response.

Limitations:

  • A small number of studies (n = 12) were included in the review for multiple types of interventions.
  • Only one study had a sample size greater than 100 (range = 12–107).
  • Studies of low quality were included. 

Nursing Implications:

These findings suggest that nonpharmacologic, not pharmacologic, interventions may be helpful in managing chemotherapy-induced cognitive impairment in patients with breast cancer. However, these findings were based on a small number of studies per intervention. Additional research validating which interventions might be useful in improving cognitive impairments in women receiving chemotherapy for breast cancer is needed. 

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