Mindfulness to Improve Cognitive Function in Cancer Survivors

Abstract

cognitive function; cancer survivors: cognitive function; cancer survivorsAdvances in chemotherapy and other treatments have increased the survival rates for certain cancers. Yet, for many patients, cancer treatment-related cognitive impairment (i.e., chemo brain) is an unfortunate companion. Researchers at the University of South Florida (USF) are currently conducting a randomized controlled trial among 300 breast cancer survivors to learn if mindfulness-based stress reduction improves their cognitive function. Positive results could point to another avenue for managing this debilitating side effect. Cognitive changes affect a wide swath of breast cancer survivors. “Among patients who have chemotherapy, there is a great prevalence but it depends on the individual,” noted Cecile Lengacher, RN, PhD, FAAN, FAPOS, Faculty Member, Health Outcomes and Behavioral Program, Breast Cancer Clinical Program and Population Sciences Division, USF, Tampa, and principal investigator. One review of studies put the numbers at 17-75 percent (J Clin Oncol 2012;30(30):3675-3686). In another study, 53 breast cancer survivors and 19 healthy women took a neuro-cognitive test. Survivors who had chemotherapy and surgery performed worse than survivors who had surgery only. Women with surgery and chemo who took tamoxifen performed the lowest (J Clin Exp Neuropsychol 2004;26(7):955-969). Such tests are not always necessary to assess cognitive decline. Forty-five percent of patients self-reported a decline from the time of diagnosis to when they finished chemotherapy (J Clin Oncol 2017;35(5):506-514). In the USF randomized controlled trial, which is currently recruiting, participants are entered into the Mindfulness-Based Stress Reduction for Breast Cancer program (MBSR(BC)), the Breast Cancer-Education Support (BCES) program, or the Usual Care (UC) program. The researchers' aim is to evaluate the effectiveness of MBSR compared to the other programs on improving cognitive function of breast cancer survivors. The study is open to female survivors of stage I, II, or III breast cancer who underwent a lumpectomy and/or mastectomy with chemotherapy and/or radiation and are between 2 weeks and 5 years post-treatment. Researchers ask if they have difficulty concentrating, such as when reading or watching television. Those who rate their difficulty four or greater on a scale of 1-10 are eligible. Originally, the entry requirement stopped at 2 years, but patients past that time kept coming into the participating clinics and reporting cognitive problems. “Late effects of chemotherapy, like fatigue and concentration problems, can linger for years or can come and go,” Lengacher said. Opportunities for Outreach There is a marked need for interventions related to cancer-related cognitive impairment. “We have a large population of women who have had chemo in the past 5 years,” said Jean Lucas, RN, PhD, Associate Chief Nursing Officer and study investigator at Sarasota Memorial Hospital, Sarasota, Fla., one of the study sites. Many of those women report concentration and memory problems and are actively seeking interventions. Offering programs on-site prevents patients from traveling to other cancer centers, letting them get the full continuum of care closer to home. “It's a really great academic opportunity as we're expanding and becoming an oncology center of excellence,” said Tamela Fonseca, MSN, RN, CCRC, Senior Clinical Manager-Research, Inpatient & Infusion, Sarasota Memorial Hospital. “Ultimately, we want to provide this to our community and enroll as many women who fit the criteria.” In the clinical trial, women will either participate in the 6-week MBSR program, the 6-week BCES program, or their hospital's UC offering for breast cancer survivors. The UC group is asked not to start any type of mindfulness program during their participation. The BCES program is based on the NIH publication “Support for People with Cancer: Taking Time.” Members of this group will meet for 2 hours each week for a support group. They will reflect on survivorship and coping mechanisms in daily journals and share supportive care situations. The MBSR group will meet weekly for group mindfulness meditation and talks from a psychologist. They will receive at-home self-regulation interventions (NCT02786797). That aspect appeals to the NCI, which is interested in self-regulated interventions that put cost and control in the hands of patients. Effectiveness of MBSR MBSR was founded by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical School, in 1979. It is well-known as a complement to traditional medical treatments across a variety of specialties. The program consists of meditation; gentle hatha yoga; walking meditation; and body scan, which comprises deep breathing and relaxation exercises. A major concept of MBSR is letting things go. “Patients ruminate over and over again about having another occurrence of cancer,” Lengacher explained. “It helps them not let their mind wander into all these fears.” Meditation is suspected to increase concentration. Mindfulness forces the women to focus their thinking. By seeing more clearly, they can pay more attention, thus impacting cognitive activities. The clinical trial will also analyze the impact MBSR(BC) has on health care utilization and costs. Patients will be asked about the cost of coming to the weekly sessions, such as travel and/or child care expenses and the cost of missed work. Researchers will evaluate if patients visit the emergency department or are hospitalized for stress-related occurrences, like panic attacks. “We're hoping patients might not incur further health care costs,” Lengacher said. Preliminary research shows a positive correlation to the reduction of related health care costs. Although there are initial start-up costs to run an MBSR(BC) program, over time it's cost-effective as patients get the resources to apply what they learned throughout their lifetime. Study Outcomes At the start of the study, women take the Stroop Neuropsychological Screening Test to measure their baseline executive function, the ability to create and actively alter plans to reach a goal. They will test again after the 6-week intervention, and then 12 weeks and 6 months after participation. This is the primary outcome measure to assess the effectiveness of the intervention. Secondary outcome measures include: Color Trails Test and Symbol Digit Modalities Test for executive function; Brief Visuospatial Memory Test-Revised for visuospatial memory; Hopkins Verbal Learning Test-Revised for verbal memory; Wechsler Memory Scale-IV for logical memory; Wechsler Adult Intelligence Scale-IV and Part 1 of the Color Trails Test for changes to attention and concentration; Controlled Oral Word Association Test for verbal fluency; and Functional Assessment of Cancer Therapy-Cognitive Function for cognitive function. Participants' genetic profiles will be evaluated at the start of the study. Researchers speculate certain genetic polymorphisms could affect the degree to which patient's cognitive impairment improves with mindfulness-based stress reduction. Although results of this research are still awhile from release, cancer treatment-related cognitive impairment remains a pressing issue. Currently, there are few pharmacological assistance methods available for cancer-related cognitive impairment. Researchers urged oncologists to make patients aware of available mindfulness programs. “Any type of stress reduction would be helpful,” said Lengacher. Exercise and following the Mediterranean diet are also recommended. The clinical trial will collect and analyze data until December 2019. All women will be offered the MBSR(BC) program 4-6 months after participating. “The important thing we teach them is to do something for themselves,” Lengacher noted. “It's important, especially for women, because we're running around, trying to care for loved ones and don't care for ourselves.” Danielle Bullen Love is a contributing writer.