Ercoli, L.M., Petersen, L., Hunter, A.M., Castellon, S.A., Kwan, L., Kahn-Mills, B.A., . . . Ganz, P.A. (2015). Cognitive rehabilitation group intervention for breast cancer survivors: Results of a randomized clinical trial. Psycho-Oncology, 24, 1360–1367.

The purpose was to evaluate the efficacy of a cognitive rehabilitation intervention on self-report of cognitive dysfunction, performance on neuropsychological tests, and brain functioning.

Five weekly, manualized, two-hour sessions included two difficulty levels of in-class cognitive training and three levels of homework exercises that 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. Participants received a training manual workbook, auditory exercises CDs, answer keys, and a stopwatch. In-class education also included instruction on coping strategies to minimize anxiety (e.g., deep breathing, relaxation, pacing, countering negative thoughts). Goal attainment was discussed during the group sessions to facilitate setting individual short-term and long-term goals. These specific intervention details were published in 2013 with the results of the single-arm pilot study and not iterated in the 2015 article. Neurocognitive testing, self-report instruments, and qEEG (substudy) were administered at baseline (T0), within one week (T1), and two (T2) and four (T3) months from completing the intervention.

• N = 48; 29 in EEG substudy   
• AGE: mean = 53.8 years, SD = 8.2
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors within 18 months to 5 years after initial treatment completion who reported persistent cognitive complaints that interfered with daily activities and scored at least one item on the memory scale of the PAOFI as moderately severe. Ongoing endocrine therapy was allowed. Inclusion requirements were within 21-75 years of age and stage 0-III breast cancer. 
• OTHER KEY SAMPLE CHARACTERISTICS: Participants primarily were Caucasian (90%), married (79%), well educated (54% had postcollege degrees), status postchemotherapy (77%) and radiation therapy (75%), and were currently receiving endocrine therapy (71%). Exclusion criteria included uncontrolled depression, current psychiatric disorder, chronic concurrent use of psychoactive medications, central nervous system (CNS) disorders, previous intrathecal chemotherapy or cranial radiation, previous head trauma, seizures, or learning disability, or substance abuse disorder.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: UCLA, Los Angeles, CA

PHASE OF CARE: Late effects and survivorship

Randomized, wait-list controlled, interventional study. Powered on previous single-arm pilot study. Used block randomization (2:1). Intent-to-treat analyses

CNS vital signs computerized testing platform

•     Finger tapping dominant, finger tapping nondominant
•     Shifting attention test
•     Stroop reaction time
•     Continuous performance test
•     Symbol digit test

Rey Auditory Verbal Learning Test (RAVLT) 

Brief Visuospatial Memory Test, Revised

Verbal fluency test

Trail Making Tests A and B

Paced Auditory Serial Addition Test

Wechsler Test of Adult Reading (WTAR)

Patient’s Assessment of Own Functioning Inventory (PAOFI)

Beck Depression Inventory, 2nd edition (BDI-II)

Awake and resting state quantitative electroencephalography (qEEG)

Improvement in PAOFI total scores and memory scale scores were significant for the intervention group (p = 0.01, Effect size (ES) 0.90 and 1.10 respectively). The intervention group improved on RAVLT total scores (trials I-V, p = 0.02, ES = 0.57) and delayed recall (p = 0.007, ES = 0.29). Both groups improved on BDI-II scores at T2 and T3 without significant group differences. The qEEG substudy demonstrated intervention group changes (T1 to T2) for global absolute delta power (p = 0.02) and absolute alpha power (AP, p = 0.04). Decreased delta power did not predict PAOFI improvement at T2 (p = 0.971), nor did increased AP (p = 0.137). However, increased AP predicted improved self-report of cognitive dysfunction at T3 (p = 0.012), even controlling for age and IQ (p = 0.011).

The intervention was associated with improved self-report of cognitive function and neuropsychological test performance sustained up to two months. The qEEG substudy demonstrated preliminary evidence of an overall decrease in delta power and increase in AP for the intervention group, suggesting qEEG may serve as a biomarker of intervention efficacy.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable

Study findings provided further evidence that cognitive rehabilitation is beneficial to improving perceived and actual cognitive function in breast cancer survivors. qEEG may be promising as an early biomarker of intervention effectiveness.