Cognitive Behavioral Interventions/Approach

• FINAL NUMBER STUDIES INCLUDED = 13
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,138
• SAMPLE RANGE ACROSS STUDIES = 20–210 patients
• KEY SAMPLE CHARACTERISTICS: Most studies included only women with breast cancer. All participants received chemotherapy with or without radiation therapy or hormonal therapy. Most participants were aged about 55 years. The majority of studies were conducted in the United States. Most outcomes were evaluated in the short-term (i.e., less than three months).

PHASE OF CARE: Late effects and survivorship

Risk of bias was high in 11 studies but unclear in  two studies that evaluated psychostimulants.

Pharmacologic interventions: No improvements in cognitive function were found using psychostimulants (four studies) or ginkgo biloba. Patients reported better cognitive function using epoetin alfa with doses titrated for hemoglobin levels (p < 0.05). However, a death caused by a cerebrovascular accident was noted.

Nonpharmacologic interventions: Small-group memory training improved self-reported cognitive function, and both memory and speed of processing after small-group training improved immediate and delayed recall (p < 0.05). Home-based online executive function training improved verbal function and attention (p < 0.05). Speed-feedback therapy during biking improved executive and motor function (p < 0.05). Cognitive behavioral therapy-based interventions (two studies), Tibetan sound meditation, and hatha yoga did not improve cognitive function.

The pharmacologic studies reviewed did not support the use of psychostimulants or ginkgo biloba to improve cognitive function after chemotherapy for breast cancer. Epoetin alfa was not recommended for practice because of safety concerns. The nonpharmacologic studies reviewed provided some evidence that cognitive training and speed-feedback therapy might improve cognitive function for breast cancer survivors.

The risk of bias was high for most studies. Therefore, although positive results were found, well-designed, prospective RCTs need to be completed to confirm these findings. It is unclear how sustainable the positive results of the cognitive training and exercise interventions might be because follow-up was limited to less than three months.

This systematic review provided limited support for cognitive training and structured exercise to improve cognitive function after chemotherapy for breast cancer. Cognitive training is currently categorized as likely to be effective for cognitive impairment.

• FINAL NUMBER STUDIES INCLUDED = 6
• TOTAL PATIENTS INCLUDED IN REVIEW = 812
• KEY SAMPLE CHARACTERISTICS: Five studies (two ongoing at the time of publication) were designed to investigate cognitive behavioral training (CBT). One study involved an intervention based on CBT. A meta-analyses was conducted for two of the studies for which the authors provided additional data. Participants were primarily female, and the mean age range was 49.2–60.4 years.

PHASE OF CARE: Late effects and survivorship

The authors indicated that there was insufficient evidence to recommend these interventions and concluded that future research involving CBT interventions for CRCD are unlikely to yield different findings. However, this systematic review and meta-analysis is limited because CBT and neuropsychological interventions and instruments differed, resulting in the inability to pool results.

• The meta-analysis was conducted on only two studies.
• More studies with long-term follow-up periods are needed to draw conclusions about the efficacy of CBT. Additional information regarding intervention descriptions, subject characteristics, and the instruments used for outcome measures are necessary to complete this review for comparison.

The authors indicated that additional research using CBT for CRCD is unlikely to indicate efficacy. However, this review was limited by the limited number of studies reviewed, its lack of longitudinal timepoints, and the differences between the CRCD interventions.  

• 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: Late effects and survivorship

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.

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.

• 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. 

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. 

STUDY PURPOSE: To determine the effectiveness of nonpharmacologic interventions for minimizing chemotherapy-induced cognitive impairment in adult patients with breast cancer.

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE, Embase, PubMed, CINAHL, PsycINFO, and CENTRAL (Cochrane Centre Register of Controlled Trials) 

YEARS INCLUDED: (Overall for all databases) 1980 through September 29, 2015

INCLUSION CRITERIA: Randomized controlled trials evaluating the effectiveness of nonpharmacologic interventions on maintaining or improving cognitive function in cancer survivors who completed chemotherapy (including those currently on hormonal therapy)  

EXCLUSION CRITERIA: Studies involving participants with primary or metastatic central nervous system (CNS) disease, nonmelanoma skin cancer, and/or patients in nursing home or residential care settings

TOTAL REFERENCES RETRIEVED: 255 screened (plus 47 additional records), but 40 assessed for study eligibility 

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias tool was utilized to evaluate study quality.

FINAL NUMBER STUDIES INCLUDED: 5

TOTAL PATIENTS INCLUDED IN REVIEW: 235

SAMPLE RANGE ACROSS STUDIES: 100% female; all patients received chemotherapy and/or hormonal therapy 

KEY SAMPLE CHARACTERISTICS: Breast cancer survivors

PHASE OF CARE: Transition phase after active treatment

Five randomized clinical trials compared an intervention with wait-list controls to improve various cognitive functions (i.e., memory, information processing speed [IPS], executive functioning [EF]). Nonpharmacologic interventions included cognitive behavioral therapy (n = 1), cognitive training (n = 2), meditation through Tibetan sound therapy (n = 1), and aerobic exercise (n = 1).

• Cognitive behavioral therapy significantly improved verbal memory (p < 0.05), but not IPS or patients' perceived cognitive functioning.  
• Two trials evaluated cognitive training. The first study compared cognitive training in IPS or memory to controls and found improved immediate and delayed memory (p < 0.01) in the IPS group as well as better immediate (p = 0.036) and delayed memory (p = 0.013) in the memory group. In addition, both intervention groups found improved subjective cognitive functioning (p < 0.05). The second study used computerized cognitive training and found significant improvements in IPS (p = 0.009) as well as some measures of EF (p = 0.008; p = 0.003).  
• Tibetan sound therapy resulted in no differences for either objective or subjective measures of cognitive function.
• Similarly, no differences were observed between intervention and control groups evaluating aerobic exercise.  

Although cognitive training and cognitive behavioral therapy may be beneficial in improving cognitive functioning, there is insufficient evidence for exercise and meditation. The overall quality of the evidence was determined to be low for all studies included.

Findings from this study revealed that there is insufficient good-quality evidence to determine whether cognitive training, cognitive behavioral interventions, exercise, or meditation may improve cognitive functioning in breast cancer survivors who have received chemotherapy with or without hormonal therapy. However, cognitive training and cognitive behavioral interventions were associated with improvements in objective and subjective measures of cognitive function, so further research including multisite studies with large sample sizes and higher-quality evidence may confirm their effectiveness. Further studies are needed to determine whether exercise and/or meditation might have a role in alleviating cognitive impairment.

Limited number of studies included

Mostly low quality/high risk of bias studies

Study findings do not support recommending cognitive training, cognitive behavioral interventions, exercise, or meditation for improving cognitive impairment in breast cancer survivors. However, additional research using these interventions are recommended to further determine their effectiveness.

Test the effects of a group cognitive rehabilitation program on memory and attention in cancer survivors

Patients randomly were assigned to the treatment or a wait-list control group. The intervention consisted of hourly trainings that incorporated didactic teaching methods, focusing primarily on memory aids and skills, as well as mindfulness meditation. A portion of each session was dedicated to reviewing and practicing skills.  The intervention was offered weekly over seven consecutive weeks, delivered in a group format. Homework was assigned to the participants with the expectation that they practice the intervention independently at home. Objective measures were evaluated twice at baseline (in an attempt to eliminate potential practice effects) and one month after completion of the intervention. Subjective measures were evaluated at baseline and one month after completion of the intervention. Control group participants underwent subsequent testing seven to eight weeks after their initial evaluation.

• N = 28    
• MEAN AGE: 58.9 years (SD = 2.4 years)
• MALES: 7%, FEMALES: 93%
• KEY DISEASE CHARACTERISTICS: All subjects had completed cancer therapy at least six months ago and had concerns about their cognitive functioning.

• SITE: Single site  
• SETTING TYPE: Outpatient    
• LOCATION: Fred Hutchison Cancer Research Center, Seattle, WA

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Late effects and survivorship

Randomized clinical trial

• Functional Assessment of Cancer Therapy-Cognition (FACT-Cog)
• Rey Auditory Verbal Learning Test
• Stroop Color and Word Test
• Wechsler Adult Intelligence Scale (WAIS)-Digit Symbol Subtest
• WAIS-Digit Span Subtest
• Patient Health Questionnaire-9 (PHQ-9)
• Beck Anxiety Inventory (BAI)
• Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue)

Patients who received the cognitive rehabilitation intervention had improvements in perceived cognitive function (p < 0.01), perceived cognitive abilities (p < 0.01), and cognitive quality of life (p < 0.01) as measured by the FACT-Cog and in one measure of attention, digit span backward (p < 0.01). In contrast, differences were not found between the treatment and control groups in other objective measures of cognition. No significant differences between groups over time were found for anxiety, depression, or fatigue.

Findings from this study suggest that cognitive rehabilitation may improve attention and perceived cognitive functioning, but not memory, in patients with cancer. The fact that significant differences were not found in anxiety, depression, or fatigue suggests that they were not related to the any improved cognitive functioning.

• Small sample (< 30)
• Risk of bias (no appropriate attentional control condition)
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%
• Feasibility may be an issue. In addition, the results may be influenced by subject withdrawal prior to the completion of the intervention as well as variability in the number of sessions attended (may indicate that the “treatment” is too burdensome).

Although this study found improvements in perceived cognitive function and one objective measure of attention, it was underpowered and patient compliance was inconsistent. Further research with larger sample sizes is warranted to determine effectiveness. In addition, longer follow-up is required to determine the sustainability of any improvements in cognitive functioning.

The study was conducted to examine Memory and Attention Training (MAAT) as a possible intervention for cognitive dysfunction. MAAT consists of four cognitive-behavioral components.

1. Education on memory and attention
2. Self-awareness training
3. Self-regulation emphasizing arousal reduction through relaxation training, activity scheduling, and pacing
4. Cognitive compensatory strategies training, which consists of self-instructional training, verbal rehearsal of auditory information, schedule-making, external cueing, and outlining written material

The MAAT intervention contained

1. Workbooks with written information about chemotherapy and memory difficulty, and step-by-step guides on how to practice and apply compensatory strategies
2. Four monthly visits, lasting 30–50 minutes, that focused on knowledge of chemotherapy-associated memory problems, identification of at-risk situations where memory failures arise, and learned and rehearsed compensatory strategies relevant to participants' difficulties
3. Three interim phone calls to assist participants in applying compensatory strategies
4. Homework between phone calls to further apply the compensatory strategies.

• The number of participants was 29.
• All participants were Caucasian and female.
• All participants had breast cancer.
• The average participant age was 56.
• Participants had an average of 15.40 years of education, and their mean IQ was 112.82.
• Participants were an average of 8 years post-chemotherapy and had reported memory and attention problems.
• Telephone screenings were completed for psychiatric disorders using PRIME-MD.
• Participants who had previous central nervous system (CNS) radiation or intrathecal therapy were excluded from the study. Those who had psychiatric mental health issues or neurologic, CNS-related, or neuroehavioral risk factors were also excluded.

• Rural
• Regional academic cancer center (Dartmouth-Hitchcock Medical Center)
• Private oncology offices in Northern New England

This was a prospective, longitudinal, single-arm pilot study.

• California Verbal Learning Test-II (CVLT-II) for verbal memory
• Logical Memory I and II for memory
• Digit Symbol for graphomotor skills
• Trail Making Test (TMT), Parts A and B, for visual attention, motor speed, and cognitive flexibility
• Stroop Color-Word Interference Task for executive function
• Center for Epidemiologic Studies Depression Scale for depression
• State-Trait Anxiety Inventory for anxiety
• Quality of Life-Cancer Survivors (QOL-CS) for cancer-related quality of life
• Multiple Ability Self-Report Questionnaire (MASQ)

Participants rated the MAAT program with high levels of general satisfaction post-treatment, and reported that it was helpful with improving memory, attention, and compensatory skills.

Neuropsychological test results revealed improvement on verbal memory (p = 0.001), executive functioning (p < 0.001), and psychomotor functioning (p = 0.001). Moderate to large treatment effect sizes (0.47 to 0.67) were observed in the MASQ total score and subscales immediately post-treatment, and the visual perceptual scale (0.63) was significant at the two month follow-up. Self-report in cognitive function in participants’ daily lives improved significantly over baseline and was sustained across all follow-up periods (p = 0.001). Similar patterns of improvement were observed on MASQ subscales of attention and concentration, spatial memory, verbal memory, and language. 

MAAT is a feasible and possibly effective cognitive-behavioral, non-pharmacologic management approach to a common problem for many cancer survivors.

• The sample size was small and lacked diversity. 
• The study had no comparison control group or randomization. 
• Participants were highly educated, limiting the generalizability of study findings.
• Neuropsychiatric scores fell within normal range after conversion of the raw scores to standardized scores, despite patient complaints of cognitive issues. This may reflect the measure’s insensitivity or specificity or imply that the participants did not have mild impairments in their memory or attention.
• Measurements were not acquired before chemotherapy treatments for a true baseline measure.
• Differences in chemotherapies or other treatments for the participants were not reported.

To evaluate the efficacy of a brief cognitive behavioral therapy to manage chemotherapy-related cognitive dysfunction

• Participants were randomized into a memory and attention adaptation training (MAAT) group or a waitlist to receive the intervention.
• Pre- and post-intervention cognitive testing was performed.
• The intervention consisted of 30- to 50-minute biweekly individual office visits of brief cognitive behavioral therapy to enhance cancer survivor skills for self-managing and coping with cognitive failures of daily life. The sessions included how to self-awareness training and compensatory strategies.
• Follow-up contact between visits was conducted by telephone.
• The intervention lasted eight weeks, for a total of four office visits.
• Participants in the intervention arm received a workbook.
   

• The sample consisted of 40 participants whose mean age was 50.3 years (SD = 6.4).
• The sample was 100% female.
• Participants had been diagnosed with stage I and II breast cancer.
• Participants had completed a mean total of 16.38 years of education (SD = 2.4).
• All participants were postmenopausal. 
• All received chemotherapy. 
• Twenty-three participants were taking hormonal therapy during study (30% waitlist group, 27.5% MAAT group).  
   

• Single site
• Outpatient setting
• Lebanon, New Hampshire, USA
   

• Patients were in the transition phase after initial treatment.
• The clinical applications are for late effects and survivorship.
   

Randomized clinical trial

• Multiple Ability Self-Report Questionnaire (MASQ)    
• California Verbal Learning Test-2 (CVLT-II)
• Trail Making Number-Letter Trial from the Delis Kapan Executive Function System (DKEFS)
• Color-Word-Interference from the DKEFS
• Color-Word and Switching Trials from the DKEFS
• Digit Symbol-Coding form the Wechsler Adult Intelligence Scale-III (WAIS-III)
   

Participants who received the intervention experienced a significant improvement in verbal memory, as measured by the CVLT-II total score (p < 0.05). In contrast, no difference was found in either information processing speed (DKEFS scales and WAIS-III subscale) or patients’ self-report (MASQ) of their cognitive functioning.

Although the cognitive behavioral therapy intervention was formulated to assist patients in dealing with memory and attention problems, significant improvement in total score was found only in verbal memory. Because improvement was not found in information processing speed, alternative strategies may need to be developed to help patients compensate in other cognitive domains. Although patients reported high satisfaction with the intervention, self-report scores did not indicate any improvement in their cognitive functioning.

• The sample size was less than 100.
• The number of intervention sessions was limited, which limited the generalizability of results and the feasibility of the intervention.
• No attentional control condition was used.
   

Ongoing cognitive problems have been reported by many patients after completion of cancer treatment. Cognitive behavioral training has been suggested as a strategy to assist patients in dealing with the impact of these problems. However, further studies are needed to determine strategies for specific cognitive domains that are feasible in the outpatient setting.

To determine whether cognitive behavioral therapy (CBT) for post-cancer fatigue has an effect on patients’ perceived cognitive functioning and/or neuropsychological test performance

Subjects were randomly assigned to intervention (CBT) or wait-list control (WLC) group. Participants were evaluated on six perpetuating factors of fatigue: inadequate coping with the cancer experience, fear of recurrence, dysfunctional beliefs concerning fatigue, sleep dysregulation, activity dysregulation, and low social support and negative social interactions. Results were used to customize the standardized modules for an individualized CBT intervention. Each hour-long CBT session was delivered by one of three trained therapists over a six-month interval. The number of sessions varied per participant since it was dependent upon when therapeutic goals were met. Participants were offered up to two booster sessions over an additional six months. Measurements were performed at baseline (T1) and at six months (T2).

• N = 98 (50 CBT and 48 WLC)    
• MEAN AGE = 44.9 years
• MALES: 51%, FEMALES: 49%
• KEY DISEASE CHARACTERISTICS: Primarily solid tumors (predominately breast and testicular cancer) as well some hematologic cancers
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were included in the study if they were severely fatigued as defined by a score of ≥ 35 on the fatigue severity subscale of the Checklist Individual Strength scale and without evidence of a somatic origin. Additional eligibility criteria were completed last cancer treatment at least one year prior to study enrollment, had no evidence of cancer recurrence, and were not currently receiving psychological or psychiatric treatment.

• SITE:  Not stated/unknown   
• SETTING TYPE: Outpatient   
• LOCATION: Netherlands

PHASE OF CARE: Late effects and survivorship

Randomized clinical trial with waitlist control group

• Checklist Individual Strength (Concentration subscale)
• Sickness Impact Profile (Alertness Behavior subscale)
• Computerized simple-reaction time and choice-reaction time tasks
• Wechsler Adult Intelligence Scale (Symbol Digit Modalities Test)
• Checklist Individual Strength (Fatigue Severity subscale)

At baseline, most participants (78%) had clinically relevant difficulties with concentration as indicated by scores on the reaction time tasks; however, no differences existed between the intervention and control group. In contrast, the CBT group reported greater cognitive disability at baseline than WLC, as measured the CIS-concentration subscale (p = 0.04) and SIP-alertness subscale (p = 0.015). After intervention completion, there was a significant improvement in concentration and alertness behavior (p < 0.05) in participants who received CBT as compared to WLC. For CBT group, the improvements in self-reported concentration and alertness behavior were significantly associated with their decrease in fatigue severity (p < 0.001; p < 0.02); SDMT scores and computerized reaction time tests were slightly improved but not significant.

Individualized CBT may be an effective intervention in reducing self-reported fatigue. Although improvements in concentration and alertness behaviors were found, it is difficult to differentiate if they were related to reduced fatigue, CBT, or both. Improvements in perceived cognition were not associated with either depression or anxiety.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: 16% of subjects did not complete neuropsychological tests at T2; not statistically significant between groups; significantly higher number of WLC subjects received chemotherapy, which could possibly influence results; while CBT program was tailored for individual needs, the administration over a six-month interval by a trained therapist may limit general applications or feasibility in the clinical setting.

CBT decreased fatigue and improved perception of cognitive functioning over a six-month interval; however, the durability of those results are unknown. Further research is warranted to validate these findings and to determine whether this intervention can be adapted for general clinical use.

1. Six sessions (50 minutes) of cognitive rehabilitation focused on purpose of a memory notebook and a calendar with a specific format as an external aid to compensate for cognitive symptoms.   
2. Six sessions of problem-solving therapy over two weeks focused on the ABC method of constructive thinking and problem solving.

• Enrolled: 7 control and 12 Tx
• Completed CRP: 6 control and 8 Tx
• Three-month F/U: 5 control and 8 Tx

*Withdrawals were due to tumor progression; new onset seizures; time commitment; caregiver issues; and fatigue.

• Tx group: 7 men, 5 women
• Controls: 4 men, 3 women

1. Newly diagnosed PBT prior to or during XRT
2. 18 years of age or older
3. Mild or moderate cognitive impairment based on neuropsych testing from the clinical assessment of the neuropsychologist
4. Prognosis of at least six months
5. Ability to attend sessions at the institution for two weeks
6. Designated caregiver must attend all sessions.

• SITE: Single site  
• LOCATION: Mayo Clinic

Randomized controlled trial; longitudinal

1. Baseline cognitive function (R-BANS) showed that control group scored lower than intervention group for memory.
2. Baseline cognitive function was used only as a comparison for those who completed all time points in the study as compared to those who did not.

1. Implementation of compensation strategies was used by 88% of subjects several times/week to several times/day after intervention completion; reduced to 50% at three-month follow-up (88% used at least once/week at three months).
2. 88% found intervention somewhat helpful to very helpful; 50% found cognitive intervention helpful, whereas 25% found problem-solving most helpful and 25% found both equally helpful; 88% would recommend to another PBT patient; caregivers had similar feedback about the program.

1. Study demonstrated feasibility of patient participation and satisfaction with cognitive rehabilitation and problem-solving therapies; despite low accrual, most completed program.
2. Most intervention subjects reported continued use of compensation strategies to some degree at three months.
3. This sample reported relative stable measures for QOL.
4. Recommend targeting patients reporting poor QOL, poor day-to-day functional performance, or emotional distress for the intervention.
5. Recommend larger stratified study to control for varying tumor characteristics and treatment differences (chemotherapy).

1. Small sample size with low accrual over two years. This altered randomization with the last three dyads placed into the intervention group.
2. Low accrual may have occurred due to the definition used for cognitive impairment as 38% of potential subjects referred for enrollment were not eligible.
3. Intervention occurred concurrently during radiation therapy treatments for two consecutive weeks, which most likely contributed to low accrual and can increase burden (especially for some who may have continued to work).
4. Cognitive measure (R-BANS) was utilized for a comprehensive assessment of cognitive function only at baseline. Long-term follow-up was not performed as originally planned with study design.
5. No educational level was reported for subjects.

The study was conducted to determine the effect of a rehabilitative intervention on cognitive function, depression, and functioning.

The study framework included two intervention groups and one wait-list control group. Participants were randomized into intervention group 1 (receiving eight classes and a memory book) or the wait-list control group (Group 3). Wait-list control group participants were further randomized into intervention group 2 (receiving only the memory book) or group 3.

Intervention group 1 received a memory book and classes on day 1; intervention group 2 received a memory book on day 1 and began classes four weeks later. Wait-list control group participants received a memory book on day 1. Participants from intervention group 2 and the wait-list control group were placed in classes together based on location. All classes were identical.

• The total number of participants was 78.
• The average partcipant age was 82.
• There were 58 women and 20 men in the study. 
• Participants were divided into four groups of chronic conditions for analysis: arthritis (n = 16), cancer (n = 11), heart disease (n = 32), and other (n = 19).
• On average, participants had attained 15 years of education. 

The study took place at a comprehensive retirement community in the Midwest that included independent and assisted-living dwellers.

The study utilized a randomized, controlled trial.

• Mini-Mental State Examination (MMSE) for global cognitive functioning
• Geriatric Depression Scale for depression
• Instrumental Activities of Daily Living Scale (IADL) for functional ability
• Multi-Level Assessment Instrument (MAI) as a health subscale
• Rivermead Behavioral Memory Test (RBMT)
• The Metamemory in Adulthood Questionnaire (MIA) was utilized. This 108-item assessment tool has 7 subscales assessing strategy, task, capacity, change, anxiety, achievement, and locus.

Cancer survivors showed significant improvements after the intervention in

• Memory efficacy (p = 0.05)
• Metamemory change (p = 0.0001)
• RBMT Immediate Story Recall (p = 0.006)
• RBMT Delayed Story Recall (p = 0.002)
• RBMT Belonging (p = 0.05).

The cancer survivors scored higher on managing finances (p = 0.01). They had lower total IADL scores compared with the control group, and scored lower on baseline metamemory capacity, with an average score of 2.5 (p = 0.03). They showed worsening after the intervention on the RBMT Immediate Route test (p = 0.03) and the RBMT Delayed Route test (p = 0.0001). The cancer survivors were older, with an average age of 84.12 years (p = 0.02). 

Significant associations were observed for the total sample between 

• IADL scores and memory performance on the RBMT (r = -0.44, p < 0.05)
• IADL scores and metamemory subscale of change (r = -0.33, p < 0.05)
• IADL scores and external memory strategy (r = -0.29, p < 0.05)
• Depression and memory performance on the RBMT (r = -0.31, p < 0.05).

There were no significant pre-test differences between groups on memory performance, memory self-efficacy scores, or MMSE scores. The total sample had a relatively high perception of health status and a low incidence of depression (13%). 

Post-intervention tests showed no improvements in objective memory performance, despite reported improvements in subjective memory and memory self-efficacy.

• This was not a cancer-specific study and had only a small sample of cancer survivors.
• Cancer diagnoses were not reported, and no information regarding cancer-related treatments was provided.
• Participants were assigned to the chronic illness categories by the researchers.
• No listing was provided of the medications taken between groups, which could affect cognitive performance.
• It was reported that many participants began practicing mental activities and exercises prior to the intervention's initiation, potentially affecting baseline scores for cognitive performance.
• A documentation of when the post-test was performed was not found.

To evaluate effectiveness of a memory training intervention as compared to a health training group intervention for management of cognitive impairment in older adult cancer survivors

Measures were performed pre-intervention, post-intervention, post-booster intervention, and six months afterwards. The memory training intervention consisted of eight sessions incorporating 20 minutes of relaxation, a targeted memory topic, and 30 minutes of targeted practice with role model. Participants received a memory improvement book at end of the memory intervention. The health training consisted of providing 18 health-related topics over two months; the frequency of the training was not provided. Booster sessions consisted of four weekly mandatory two-hour sessions over one month conducted within three months after completion of initial training. 

• A total of 22 patients participated in the study. Eight received the memory intervention, and 14 received health training.
• Participants' mean age was 73.8 years(SD = 4.82 years).
• The sample was 41% male and 59% female.
• Participants had been diagnosed with breast cancer (n = 8), prostate cancer (n = 5), facial or nose basal cell carcinoma (n = 3), uterine cancer (n = 2), leukemia/lymphoma (n = 2), throat cancer (n = 1), or lung cancer (n = 1).
• 86% of the sample was Caucasian.
• On average, participants had completed 16 years of education.
• Socioeconomic status varied among the sample.
• The length of time from oncology treatment was unknown.

• Mutli-site
• Outpatient setting
• Austin, TX

• Patients were undergoing long-term follow-up.
• The study has clinical applicability for older adult care.

Randomized clinical trial

• Hopkins Verbal Learning Test–Revised (HVLT-R)     
• Brief Visuospatial Memory Test–Revised (BVMT-R)
• Rivermead Everyday Behavioural Memory Test (REBMT)
• Metamemory in Adulthood QuestionnaireDirect Assessment of Functional Status
• Memory Self-Efficacy Questionnaire
• Mini-Mental Status Examination

Visual memory as measured by the BVMT-R was improved (p < 0.1 for the group by time interaction) for participants who received the memory training intervention. Trends toward improvement in verbal memory as measured by the HVLT-R and overall memory as measured on the standardized profile scale of the REBMT were observed for participants who received the memory intervention, but they were not significant. Improvements were seen in self-reported memory components in locus, capacity, and control (p < 0.05 for the group by time interaction) and use of internal strategies (p < 0.1 for time). Memory complaints decreased (p < 0.05 for the group by time interaction). 

Significant improvements in visual memory were obtained and sustained, and trends for improving verbal and global memory were observed in those who participated in the memory training. In addition, those who participated in memory training maintained their use of internal compensatory strategies and reported significant improvements in subjective aspects of cognitive function, including increased confidence, greater capacity, belief that they could better manage issues with their memory, and decreased complaints of their memory performance.

• The sample was small at less than 30 participants.
• The generalizability of the results was limited.
• The feasibility of replicating the memory training intervention was limited.

Cognitive impairments present ongoing symptom management issues for older adult cancer survivors. Memory training has been effective in older individuals and may offer opportunities for improvements in memory difficulties for older adult cancer survivors. The authors suggested that their memory training intervention may be adjusted to meet the specific cognitive issues that older cancer survivors report. Further studies are needed to determine feasibility and generalizability to patients with cancer.

• To evaluate the effectiveness of a group rehabilitation intervention in improving cognitive function in cancer survivors
• To explore the phenomenon of cognitive impairment and the relationship between objective and subjective measurements of cognition

The intervention, based on self-regulatory cognitive rehabilitation and cognitive behavioral principles, consisted of four weekly two-hour group sessions with between-session homework. Each session consisted of psycho-education, group discussion, and reinforcement of the content by skill development and application. Subject matter included overall information on cognition with specific information on memory, attention, and the impact of fatigue and emotions on cognition. Application exercises focused on goal setting, problem solving, relaxation, compensatory and enhancement strategies, and cognitive-behavioral strategies related to emotional adjustment, fatigue, sleep, and self-care.

All participants receiving the intervention were assessed at baseline, post-treatment (six weeks after the baseline assessment), and follow-up (three months after the second assessment). Study participants not receiving the intervention were assessed at similar time frames but only for the first two time periods.

• A total of 53 patients participated in the study. Their ages ranged from 34–84 years with a mean age of 58.3 years.
• The sample was 40% male and 60% female.
• Breast, colorectal, and prostate cancers accounted for 84.5% of the sample; the remaining 15.5% included ovarian, testicular, neck, and mixed cancers.
• All patients had undergone treatment with surgery, radiation, and/or chemotherapy and completed treatment a minimum of four months prior. Patients' education level ranged from 9–25 years with a mean level of 15.2 years.

• Single site
• Outpatient
• Australia

The clinical application is for late effects and survivorship.

The study consisted of a controlled trial with repeated measures.

• Objective Measurement: Repeatable Battery for Assessment of Neuropsychological Status (RBANS)
• Trail Making Test (TMT)
•  Subjective Measurement: Multiple Ability Self-Report Questionnaire (MASQ)
• The Functional Assessment of Cancer Therapy–Cognitive Scale (FACT-Cog volume 3)

In contrast to the cancer and community comparison groups, the intervention group had a significant improvement in immediate memory (p < 0.01), visuospatial skill (p < 0.001), language (p < 0.001), attention/concentration (p < 0.05), delayed memory (p < 0.001), and total cognitive score (p < 0.001) over the six-week time interval as measured by the RBANS. No change was found in either information processing speed as measured by the TMT-A or executive function as measured by the TMT-B. 

The intervention group was re-evaluated three months later; improvements remained, or were sustained, in immediate memory (p < 0.001), visuospatial skill (p < 0.001), delayed memory (p < 0.001), and total cognitive score (p < 0.001), but not in language or attention/concentration. At the final assessment, a significant improvement was also found on the TMT-A (p < 0.01). Although no change was found in self-report of cognitive function as measured by the MASQ, a significant improvement was found over time as measured by the FACT-Cog (p < 0.05).

Significant improvement was found in several cognitive domains for patients who received the group intervention. Many of these improvements were sustained three months after the completion of the intervention. The results of the subjective measures of cognitive function were mixed. This study found that a short group intervention may improve cognitive ability for cancer survivors over a limited period of time.

• The study was at risk for bias because no control group, random assignment, or appropiate attentional control condition existed.
• The intervention was expensive and impractical and required special training needs.

Further research is indicated, with larger sample sizes and longer follow-up, to determine whether group cognitive rehabilitation might be warranted to treat cognitive impairments. More detailed information regarding the intervention is needed to determine whether it could be facilitated by nurses rather than the clinical psychologists in the study.

The study was conducted to determine

• Whether patients with brain tumors could benefit from rehabilitative interventions already shown to be effective for patients with traumatic brain injury (TBI)
• Whether the resources expended on the rehabilitation of patients with brain tumors compare favorably with those expended on patients with head trauma
• Whether the benefits gained would suggest that the availability of such services on a broader scale should be encouraged.

Interventions were individualized after initial evaluation of each participant’s cognitive, behavioral, affective, and social functioning. This initial evaluation included an interview with the participant and at least one significant other. In some cases, home visits or observations of the participant in a community setting (e.g., work site) were performed.

Interventions were provided by various professionals (e.g., psychologists, speech pathologists, occupational therapists, and vocational specialists). Therapy was conducted in both individual and group settings, with a typical therapy day lasting five hours. Participants and their significant others received concurrent education and counseling services.

Measures were taken upon admission to the program, at discharge, and at follow-up (an average of eight months after discharge).

• The number of participants was 13.
• All participants had a primary malignant brain tumor. 
• All participants underwent surgical resection and radiation therapy; 12 also received chemotherapy.
• There were 8 male and 5 female participants.
• The average participant age was 34.3 ± 10 years.
• The average years of education per participant was 15.1 ± 1.7 years.
• The average time from diagnosis to admission to program was 75.4 ± 87.9 months.
• Participants were selected retrospectively based on diagnosis and availability of adequate medical records to characterize their tumors and courses of therapy.

The study took place at the Institute for Rehabilitation and Research Challenge Program in Houston, TX. 

This was a retrospective study. 

A neuropsychological test battery was conducted, with tests for the following domains: intellectual, verbal memory, visual memory, executive functions, language, visual perception, motor, and mood. The measurement instruments were unnamed.

Independence and productivity status rating scales were completed on admission, discharge, and follow-up to the program. Rating scales were shown to be sensitive to patient improvement in previous studies of patients with TBI. Specifics include:

1. An independence rating scale ranging from maximal independence, selected monitoring, and frequent monitoring to attendant care
2. A productivity status rating scale ranging from competitive employment, a modified job, educational or vocational training, homemaker role, and avocational pursuits to non-productive status.

Improved independence for six patients and improved productivity status for eight patients was demonstrated from baseline measurements. The average cost of treatment was $5,471.19 ± $3,200.73. The average number of treatment days was 20 ± 12.85.

The study provides preliminary support for the use of treatment approaches originally designed for patients with TBI.

• The study had a small sample size, with substantial variability in participants' diseases and treatment.
• The sample may not be representative of other groups of patients with brain tumors.
• The sample was based on a referral method.
• There was a short average time from treatment to follow-up.
• Participants had varied days of treatment and treatment duration.
• Ratings of independence and productivity status were potentially subject to bias.
• The study did not evaluate the means by which the rehabilitation program improved patient functioning.

PHASE OF CARE: Late effects and survivorship

All recommendations were based on lower level evidence and consensus.

Physical activity and memory aids were recommended for cognitive impairment. SSRIs and SNRIs were recommended for depression as first-line treatment, and benzodiazepines were recommended as first-line treatment for anxiety. Physical activity, cognitive behavioral therapy, psychoeducation, and the consideration of psychostimulants were recommended for fatigue.

• Mainly consensus for most recommendations
• Limited database use  
• Full results of search not provided

This guideline gave numerous recommendations and suggestions for various aspects of patient needs. Most recommendations were consensus-based.