Ercoli, L.M., Castellon, S.A., Hunter, A.M., Kwan, L., Kahn-Mills, B.A., Cernin, P.A., . . . Ganz, P.A. (2013). Assessment of the feasibility of a rehabilitation intervention program for breast cancer survivors with cognitive complaints. Brain Imaging and Behavior, 7, 543–553.

To evaluate the feasibility of a cognitive rehabilitation intervention for persistent post-treatment cognitive issues in survivors of breast cancer and to conduct a substudy to garner preliminary data related to the use of quantitative electroencephalography (qEEG) to assess changes in cognitive function

Five weekly, manualized, two-hour sessions were provided to five cohorts of four to nine participants. The last cohort participated in the qEEG substudy. Two difficulty levels of in-class cognitive training and three levels of homework exercises were designed to build skills in the targeted areas of attention, executive function, and memory. Participants were encouraged to do four 20-minute sessions of homework exercises per week and log their time. Participants received a training manual workbook, CDs for auditory exercises, answer keys, and a stopwatch. In-class education focused on a specified targeted area and instructions on coping strategies to minimize anxiety (such as deep breathing, relaxation, pacing, and countering negative thoughts). Goal attainment was discussed during the group sessions to facilitate setting individual short-term and long-term goals. Neurocognitive testing, self-report instruments, and the qEEG (substudy) were administered at baseline (T0), within one week (T1), and at two (T2), and four (T3) months after completing the intervention.

• N = 27 (8 in substudy)  
• MEDIAN AGE = 54.1 years (SD = 6.3 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors within 18 months to five years after initial treatment completion who reported persistent cognitive issues that interfered with daily activities. Ongoing endocrine therapy and HER2-targeted adjuvant therapy were allowed. Inclusion requirements: 18–75 years old and stages 0–III breast cancer.
• OTHER KEY SAMPLE CHARACTERISTICS: Participants primarily were Caucasian, married, and well-educated (mean 16.4 years of education). The majority received chemotherapy (89%), radiation (63%), or endocrine therapy (67%). Exclusion criteria included untreated depression, psychiatric disorders, and disorders of the central nervous system (CNS) (i.e., CNS cancer, CNS treatment with intrathecal chemotherapy, surgery, radiotherapy, traumatic brain injury, seizures, intellectual disabilities, substance abuse disorder).

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: University of California, Los Angeles, United States

• PHASE OF CARE: Late effects and survivorship

Prospective trial

• CNS Vital Signs Computerized Testing Platform
  • Finger tapping dominant, finger tapping nondominant
  • Shifting attention test
  • Stroop reaction time
  • Continuous performance test
  • Symbol digit test
• Hopkins Verbal Learning Test, Revised (HVLT-R) (total recall, delayed recall)
• Brief Visuospatial Memory Test, Revised (BVMT-R)
• Trail Making Tests (TMT) A and B
• Paced Auditory Serial Addition Test (PASAT) Trial 1
• Judgment of Line Orientation (JLO) test
• Patient’s Assessment of Own Functioning Inventory (PAOFI)
• Beck Depression Inventory, Second Edition (BDI-II)
• Spielberger State-Trait Anxiety Inventory (STAI)
• Resting quantitative electroencephalography (qEEG)

PAOFI totals and memory complaint scores decreased between T0 and T1 (p = .031 and p = .009, respectively) and were maintained at T3 (p < .0001 in both). Decreases in high-level cognitive functions (PAOFI scale) were demonstrated at T3 (p = .005). Significant short- and long-term improvements were observed for the symbol digit, Stroop reaction time, and trail A tests (p < .05). Meaningful improvement by a reliable change index (RCI) occurred for 19% of patients (n = 5) between T0 and T1, and 30% of patients (n = 8) by T3. RCI improvement (in ≥ 2 of 16 tests) predominantly occurred for verbal learning and memory (HVLT-R), processing speed (symbol digit), and divided attention (shifting attention test). Absolute alpha power increase (qEEG) was associated with PAOFI improvements at T1 (p = .014). Change in alpha power correlated with change in PAOFI memory subscale at T1 (p = .021) and T2 (p = .004). Correlation also was noted with the PAOFI HLC subscale at T2 (p = .030) and T3 (p = .048).

This study's results demonstrated the feasibility of this cognitive rehabilitation intervention and preliminary evidence for the improvement of subjective and objective cognitive function. Larger randomized, controlled trials are necessary to further determine efficacy. Preliminary results supported the potential use of qEEG as a measure of change in cognitive function. An additional randomized, controlled trial is underway.

• Small sample (< 30)
• Risk of bias (no control group)
• Findings not generalizable
• Other limitations/explanation: Sample primarily was Caucasian, married, and well-educated. Results may not be generalizable to other demographics.

Cognitive rehabilitation interventions appear to be promising. Nurses should maintain an awareness of research results in this area and consider suggesting appropriate clinical trials to eligible survivors.