Interventions to Address Cancer-Related Cognitive Impairment (2018–2022)

Abstract

Systematic review briefs provide a summary of the findings from systematic reviews evaluated in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings related to cancer-related cognitive impairment in adults living with and beyond cancer.

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation for adults living with cancer?”

Current Theme Reported

The main theme of the studies presented in this systematic review brief includes rehabilitation interventions to address cancer-related cognitive impairment in adults.

Clinical Scenario

Cancer-related cognitive impairment (CRCI) is a common side effect of cancer treatment and impacts up to 75% of adults living with and beyond cancer (Mackenzie & Marshall, 2022). CRCI can potentially develop during all stages of cancer treatment and may be the result of the primary cancer diagnosis or subsequent treatments used to irradicate or control the disease. Many adults with cancer report a change in their cognition during or upon completion of chemotherapy, affecting interpersonal relationships, work performance, and caregiver roles (Alwi et al., 2021). Subjective and objective cognitive changes most commonly reported by adults during and after cancer treatment include impaired memory, attention, verbal fluency, and executive functions (Binarelli et al., 2021). There is no gold standard for therapeutic interventions to address CRCI. However, several methods such as strengthening cognitive abilities, modifying behaviors, or incorporating physical activity have been evaluated to determine the most effective interventions to optimize cognitive functions and improve the quality of life of adults with cancer (Binarelli et al., 2021; Mackenzie & Marshall, 2022).

Summary of Key Findings

Two systematic reviews were included related to interventions focusing on improving subjective and objective cognitive changes as a result of a cancer diagnosis and subsequent treatment. They were divided into two subthemes: cognitive training interventions and exercise to address cognitive function (Table 1). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018). We used the Oxford Centre for Evidence-Based Medicine (2009) levels of evidence for this review.

Table 1.

Evidence Table for Interventions to Address Cancer-Related Cognitive Impairment

Author, YearLevel of EvidenceRisk of Bias (RoB)Setting	Systematic Review Details	Findings From Reviews
Subtheme: Cognitive Training One Level 1a and one Level 2a systematic reviews provided moderate strength of evidence to support cognitive training/rehabilitation interventions delivered individually or in a group format to reduce CRCI for people with multiple types of cancer.
Mackenzie & Marshall (2022) Level 1a—SR with meta-analysis RoB Low Setting Home and community	Participants N = 4,727 total, n = 1,130 for this subtheme; participants from 15 countries overall. Mean age = 44–74. Breast cancer (N = 7) and mixed cancer types (N = 9). Number of Articles 16/45 RCTs addressed cognitive retraining/cognitive rehabilitation Databases Searched Medline, Scopus, CINAHL, AMED, PsychINFO, OTseeker, and the Cochrane Database of Systematic Reviews Outcome(s) of Interest Cognitive performance through self-reported cognitive measures and objective measurement tools. Intervention(s) of Interest Cognitive retraining or rehabilitation (n = 16), including a cognitive training video game, Web-based cognitive training, cognitive behavioral model of everyday memory, speed of processing training, and individual or group cognitive training sessions Delivery Methods Individual in-person training, group interventions, and online interventions with phone/Web-based support. Dose Ranges 4–15 wk; frequency of 1–5 sessions/week; 30 min–2 hr	The cognitive training interventions resulted in significant improvement in cognitive performance (p < .05). There was a standardized mean difference of 0.407 (95% CI: 0.283–0.531), p = .001. The studies with breast cancer participants had a standardized mean difference of 0.455 (95% CI: 0.244–0.665) and between-study heterogeneity of Q = 54.995, p = .0001, I2 = 87.271%.
Binarelli et al. (2021) Level 2b—Systematic review RoB Low Setting Home and community	Participants N = 1,630 total participants with n = 1,366 in the theme reported; included studies had a variety of types of cancer: Breast cancer studies (n = 5), mixed cancer types studies (n = 6), brain cancer studies (n = 4), and prostate cancer studies (n = 1). Number of Articles Of 20 articles, 16 evaluated computerized-cognitive stimulation. Ten were RCTs and six were feasibility/pilot studies. Databases Searched PUBMED and WOS Outcome(s) of Interest Cognitive performance and efficacy of the interventions were evaluated at the end of the intervention by objective and subjective cognitive assessment. Of 16 studies, 12 investigated longer term maintenance of the efficacy of intervention on cognition (6-mo follow-up or greater). Intervention(s) of Interest Computerized-cognitive stimulation: home-based with mail or telephone support (N = 9) and onsite computerized intervention (N = 7). Included studies were based on the neuroplasticity model. Cognitive training was sometimes combined with coaching, psychoeducation, or metacognition. Delivery Method Individual, remote, or onsite Dose Ranges 3–24 wk; frequency of 1–5 sessions per week; 20 min–2 hr.	Eleven of the 16 studies showed significant postintervention improvement in objective cognitive domains, specifically memory, attention, processing speed, and executive functions.
Subtheme: Physical Activity to Improve Cognitive Function One Level 1a and one Level 2a systematic reviews provided moderate strength of evidence to support physical activity interventions to improve cancer-related cognitive impairment in adults.
Mackenzie & Marshall (2022) Level 1a—SR of RCT with meta-analysis RoB Low Setting Home and community	Participants N = 4,727 total participants, and n = 1,268 specific to this subtheme; from 15 countries overall. Mean age = 44–74. The majority of studies represent breast cancer (n = 13), with mixed cancer types in some studies (n = 3). Number of Articles Of 45 RCT studies, 16 are included in this subtheme focusing on physical activity interventions. Databases Searched Medline, Scopus, CINAHL, AMED, PsychINFO, OTseeker, and the Cochrane Database of Systematic Reviews Outcome(s) of Interest Cognitive performance through self-reported cognitive measures. Intervention(s) of Interest Aerobic and resistance exercise, interval training, walking, use of a treadmill, speed-feedback ergometer, qigong, and yoga. Delivery Methods In-person (supervised activity), self-paced activity (home program), or group format. Dose Ranges 4–26 wk; frequency of 1–5 days/week, 30–150 min.	Eight of the 16 studies showed significant improvement compared with the control group in cognitive performance (p ≥ 0.05). Despite inconsistencies in findings, the summary effect size for the 16 studies indicated a standardized mean difference of 0.272 (95% CI: 0.199–0.346), p = .001, favoring the interventions overall.
Binarelli et al. (2021) Level 2b—SR RoB Low Setting Home and community	Participants N = 1,630 total with n = 264 represented in this subtheme. Breast cancer (N = 1), breast and prostate (N = 1), mixed cancer types (N = 1), and brain cancer (N = 1). Number of Articles Of 20 articles, 4 are included in this subtheme addressed physical activity interventions. Databases Searched PUBMED and WOS Outcome(s) of Interest Cognitive performance using self-reported cognitive measures and objective measurement tools. Intervention(s) of Interest Three of four studies proposed a physical activity program composed of aerobic exercises: internet-based tailored exercise program, resistance and aerobic exercises performed at home with Web-support and bicycle ergometer. The fourth study involved an intervention group that received educational materials, an active monitor, and access to a website where they uploaded their physical activity data. Delivery Method Group or individual, in person or remote Dose Ranges Three sessions/week (90 min) over 8-wk internet-based tailored exercise program; 6-mo intervention with three aerobic sessions/week (20–45 min); 24 wk Web-delivered physical activity intervention; 1× week for 4 wk on-site intervention (5 min) with a bicycle ergometer.	Two of four studies reported a significant improvement in attention, information processing speed, verbal memory, and executive functions. One of those studies also reported a significant improvement in cognitive complaints.

Note. CI = confidence interval; CRCI = cancer-related cognitive impairment; RCT = randomized controlled trial; RoB = risk of bias; SR = systemic review; WOS = Web of Science.

Bottom Line for Occupational Therapy Practice

Occupational therapy practitioners will encounter adults living with and beyond cancer who present with CRCI following a cancer diagnosis throughout the continuum of care. CRCI can negatively impact occupational performance patterns and alter how adults with cancer are able to fulfill their self-care, work, family, and leisure roles. It is important for occupational therapy practitioners to have access to effective treatment interventions for CRCI to maximize cognitive function in all aspects of occupational performance in a variety of clinical settings.

Occupational therapy practitioners could use cognitive training interventions and physical activity provided individually or in group format to address subjective and objective changes in cognitive function for adults with cancer. The use of computerized cognitive stimulation or online cognitive interventions delivered in person or with phone/Web support could be used to improve subjective cognitive complaints, as well as attention, memory, and executive functions. The challenge with using computerized or online interventions is to ensure generalizability and adaptability to everyday occupational performance. Physical activity and exercise can also be used to facilitate subjective improvement in attention, information processing speed, verbal memory and executive function through self-reported cognitive measures.