Editor’s note: This text-based course is a transcript of the webinar, Cognition and Cancer, Part 2, presented by Theresa Marie Smith, OTR, PhD, CLVT.
- After this course, participants will be able to recognize common assessments used to determine executive function problems for many breast cancer survivors.
- After this course, participants will be able to identify outcomes of cognitive interventions for breast cancer survivors.
- After this course, participants will be able to recognize how to apply cognitive interventions for breast cancer survivors in clinical practice.
- Content from Part 1 focused on affected cognitive skills of breast cancer survivors (BCS) from the cancer diagnosis and/or treatment
- Memory- working memory is affected
- Processing speed (highly correlated to working memory; Kim & Park, 2018)
- Executive function
- As well as
- Contributing factors to cognitive impairment
You will remember the content from part one focused on effective cognitive skills of breast cancer survivors from the cancer diagnosis to treatment. We talked about how working memory is affected. Attention and processing speed are also affected and highly correlated with working memory and executive function. There were also other contributing factors to cognitive impairment that we touched upon, like depression, age, and others.
- BCS have long reported cognitive deficits, but perceived cognitive deficits have not been correlated with objective measures (Olson et al., 2016).
- It is beneficial to have a quick cognitive screen to determine client cognitive deficits.
- The MMSE has been recommended by the International Society of Geriatric Oncology and used with BCS for that purpose (Rambeau et al., 2019)
- Studies comparing the sensitivity of the MMSE to the MoCA demonstrated greater sensitivity of the MoCA for cognitive deficits in BCS (Baxter et al., 2011; Rambeau et al., 2019)
- The MoCA may present weaknesses when used with higher cognitive functioning individuals (Arcuri et al., 2015).
Most of us do a screen when we are either asked or suspect cognitive impairment. I suggest that we screen all breast cancer survivors since up to 75% of them have a cognitive impairment. And, we know that up to 20 years later, they still have cognitive impairment. As we continue to monitor this trend, we may find that cognitive impairments last even longer.
We need to correlate what the perceived cognitive deficits of breast cancer survivors are by using objective measures. Personal reports from cancer survivors are helpful, but we need to determine the clients' specific cognitive deficits.
The MMSE has been recommended by the International Society of Geriatric Oncology and used with breast cancer survivors for that purpose. However, in a study comparing the sensitivity of the MMSE to the MoCA, the MoCA demonstrated that it was more sensitive than the MMSE for breast cancer survivors (Baxter et al., 2011). I was a researcher in this study and am one of the "et al. s." Rambeau et al. found the same issue in 2019.
The MoCA may present weaknesses when used with higher cognitive functioning individuals (Arcuri et al., 2015). There is a ceiling effect meaning that one could still have cognitive issues that the MoCA will not pick up, which has indeed been shown in recent studies. But, it is better than nothing. In our screens, we discover what deserves more investigation.
- The focus of this presentation is on common BCS cognitive domains affected and the assessments used.
- Working memory is frequently assessed using the Digit Span and Corsi Block-Tapping tasks (de Paula et al., 2016).
- Attention is measured by many with the Functional Assessment of Attention-Cognitive Function (FACT-Cog).
- Processing speed has been measured with the Useful Field of Vision (UFOV; Meneses et al., 2018).
This presentation focuses on common breast cancer survivors' affected cognitive domains and the assessments that we use. I already mentioned working memory, and it is frequently assessed using the Digit Span and the Corsi Block-Tapping tasks (de Paula et al., 2016). I have used the Digit Span, but I am not sure I would use it in the future. We will look a little later at what type of assessments that you should use.
Attention is measured by many with the Functional Assessment of Attention-Cognitive Function, called the FACT-Cog. I have also used this.
Processing speed has been measured with the Useful Field of Vision UFOV), but that assessment does not stand on its own today. Still, it is frequently included within computer software for assessing cognitive deficits.
- Executive function for decision making and judgment, Olson et al. (2016) listed:
- Stroop Test
- Trail Making Part B
- Wisconsin Card Sorting Test (WCST)
- Paced Auditory Serial Addition Test (PASAT) (Olson et al., 2016)
- Contributing factors have associated assessments hopefully normed for BCS.
As occupational therapists, we focus on occupational performance and participation and use assessments that give us information about those. Listed are some other assessments that occupational therapists use. I use the Trail Making Part B and the Wisconsin Card Sorting Test. Many of you may not be familiar with the Paced Auditory Serial Addition Test or the Stroop Test that uses words. For example, in the Stroop Test, the word blue may be written in yellow font, causing the brain to get two different sets of input. The word is telling us one thing, and the color is telling us another. There are also behavioral assessments like the Rivermead Behavioral Memory Tests and the Behavioral Assessment of Dysexecutive Syndrome (BADS).
Assessments looking at contributing factors are also available, but it is important to see if they are normed for breast cancer survivors. An excellent example of this is assessments looking at the quality of life. I use a quality of life measure that has been normed for breast cancer survivors. I am sure we would all agree that breast cancer survivors have different factors than someone with a spinal cord injury.
The Issue with Assessing Cognitive Function
- Determining the best practices for assessing the cognitive function of BCS is difficult.
- There are several cognitive domains (Vardy et al., 2006) and contributing factors that might be considered for assessment and different assessments to use.
- The National Institutes of Health has a toolkit with a battery of cognitive assessments, the NIH Toolbox Cognition Battery (NIHTB‑CB; Menses et al., 2018)
- Generally, clinicians and researchers build their own toolkit of cognitive assessments.
What are some of the issues that we face when assessing cognitive function? What is the best practice? I highlighted several assessments, but there are a few that I would probably not use again as there are many factors to consider. First is the ease of use and how hard it is to give the assessment. How long does it take? I have decided not to use an evaluation based on time. We do generally get faster after administering a test a few times. Some assessments require training and/or qualification. I think everyone should be trained on every evaluation. My students must always be trained to give a particular type of assessment.
Other assessments require that you are qualified to administer it, like the Assessment of Motor and Process Skills (AMPS). I would not use the AMPS with breast cancer survivors as I do not think it is appropriate for this population. Likewise, you may find that an assessment tool does not fit well in your clinic.
An assessment may require interpretation. For example, several items are reversed scored, and if you do not do that, your findings will be incorrect.
Another factor in choosing assessment tools is the meaning and relevance of findings. There is plenty that we can measure but is that really what you want. Are you going to be addressing that in your intervention? We do not want to waste our time or the client's time.
There are several cognitive domains and contributing factors that might be considered for assessment and different assessments to use. The National Institutes of Health has a tool kit. They are very well-respected, and that tool kit has a battery of different cognitive assessments. However, in general, clinicians and researchers build their own toolkits of cognitive assessments.
Focus of Occupational Therapists and Assessments
This list is not all-inclusive!
- Role competence- Role Checklist (Scott et al., 2017)
- Occupational performance- COPM (Law et al., 1990); consider using more targeted occupation such as work
- Occupational participation- see L’Hotta et al. (2020) for a list
- Pain - Brief Pain Inventory (Ferreira et al., 2011)
I want you to know this list in no way is inclusive. I will give you some ideas of what I have used, would use again, and those I would not use again. Number one is role competence. This is an outcome measure for occupational therapy and is now in its third edition. I have not used the Role Checklist with breast cancer survivors, but I have used it in other studies. It is a good measure of role competence.
For occupational performance, the COPM is well-recognized and has lots of evidence behind it. I would not use the COPM with breast cancer survivors, not because I do not like it. I just feel that in the case of somebody with a cognitive deficit, I would want to know with what occupation they are having difficulty. Work is a big one for breast cancer survivors, and it affects people's financial stability. So if they were having issues at work that I would have found out in the occupational profile, I would use a more targeted assessment such as a work assessment through the Model of Human Occupation or MOHO.
L'Hotta et al., in 2020, looked at occupational participation, and you can go to that article for a list. An issue often with occupational therapy assessments is, do the assessments measure what we do? For example, in my first study, a group intervention, I used the Activity Card Sort, but it did not show any change in pre- and post-test measurements. The study was nine weeks in total, and while the before and after measurements were not exactly equal, there was no significant change. In another study, I used the Engagement in Meaningful Activities Survey (EMAS). It sounds like an occupational therapy assessment, but it only focused on how much time someone spent in a preferred activity. I would not use it again. I am not trying to bias you with this discussion. Instead, I am trying to explain why I would or would not make similar decisions. In my previous study, I used the Model of Human Occupation Screening Tool (MOHOST). Both groups that I treated had increased scores for the patterns of occupation and environmental factors. Still, the group that had the best improvement did not improve in their occupational participation. We will look at the other results of that study later on. One assessment that has worked relatively well is the Reintegration to Normal Living Index, the RNLI-P, used with another researcher. Breast cancer survivors had more difficulty with this.
We also measure pain. I would not use the McGill Pain Scale with a breast cancer survivor. Commonly, we use the Brief Pain Inventory. This is also an excellent example of timing and using assessments because one would hypothesize that there would be more pain immediately following surgeries. Besides having lumpectomies, lumpectomies, and mastectomies, some women have reconstructive surgery. I am not trying to make one type of surgery more painful than the other, but I think a lot of pain can resolve. This, if we are working with a new breast cancer survivor, we would want to measure and treat their pain.
- Depression- Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001)
- Cognition- FACT-Cog (Wagner et al., 2004)
- Quality of Life- Quality of Life Instrument for cancer survivors (QOL-CS; Ferrel et al., 1995)
- Fatigue- Cancer Fatigue Scale (CFS; Okuyama et al., 2000)
Another area is depression, and the Patient Health Questionnaire, PHQ-9, is a pretty quick questionnaire that has been used with several different populations. I have not measured depression, but I am partial to this. For cognition, I use the FACT-Cog. I also use the Quality of Life Instrument for Cancer Survivors, QOL-CS, and the Cancer Fatigue Scale (CFS). However, I have not measured fatigue because it is one of those issues that the longer somebody is away from a treatment, the less impact it has. I do not want to state that equivocally because one could have fatigue for a long time, which can affect occupational participation. And I also mentioned that it is hard to return to the same level of work.
Interventions and Outcomes
- Nonpharmaceutical interventions
- Different formats have been utilized to deliver cognitive rehabilitation to BCS.
- Group intervention (Ercoli et al., 2015; King & Green, 2015; Schuurs & Green, 2013; Smith et al., 2019; Von Ah et al., 2012)
- Individual (Ferguson et al., 2007; Meneses et al., 2018; Root et al., 2016)
- Telephone (Hegel et al., 2011)
- Web-based (Bray et al., 2016; Kesler et al., 2013; Smith & Ratcliff, 2019; Smith & Wang, 2021; Von Ah et al., 2012)
We are not involved in pharmaceutical intervention. However, we can encourage a client to follow their doctor's orders. For example, I have had participants taking oral chemotherapy with resultant cognitive issues that need encouragement to continue.
How are interventions delivered? I have listed different studies that have used both group and individual interventions. There is also one telephone intervention listed. I am a web-based interventionist. I am trying to say that some of these researchers could fit in more than one category.
We know that evidence-based practice is the best available, but we can only address our evidence. I gave you the earlier example where the MoCA was more sensitive than the MMST. We know this now because of that study. As time goes by, testing, technology, interventions, and pharmaceuticals are advancing, so the outcomes are also changing.
EBP Interventions for BCS Related Cognitive Impairment
- In a study by Von Ah et al. (2014), they found:
- Cognitive training programs (group or individual) have been shown to increase attention & memory (Poppelreuter et al., 2009; Von Ah et al., 2012), speed of processing (Von Ah et al., 2012), and executive function (Kesler et al., 2013; Von Ah et al., 2014)
- Two physical activity interventions improved executive function and concentration, biking and hatha yoga (Chan et al., 2015).
Von Ah et al. (2020) looked at different types of interventions. They found that cognitive training programs, whether they were grouped or individual, increased attention and memory. This is great as these areas are common cognitive deficits that we see with breast cancer survivors. I want to mention that it is essential to know who is researching and if they are top of the literature if you will.
Speed of processing and executive function was addressed by Kesler et al. (2013) and Von et al. (2012, 2014). They saw improvements with the interventions that they used.
There have also been two physical activity interventions (biking and yoga) that improved executive function and concentration (Chan et al., 2015). Across the board, exercise, unless there are precautions, helps cognition.
- Effectiveness has not been established for the following interventions:
- Cognitive-behavioral training
- Natural restorative environment interventions
- Effectiveness is unlikely for:
- Gingko Biloba
(Von Ah et al., 2014)
Several interventions have not been established for cognitive deficits like behavioral training and meditation. During part one, I had someone specifically ask if there was a type of meditation that I would recommend? Although I had had clients use meditation to different kinds of issues when I was treating them, I would not recommend it at this time. There is much literature about a natural restorative or enriched environment. Often we think about enriched environments helping children cognitively. I have not investigated these areas, but the effectiveness has not been established yet. Lastly, it was found that the effectiveness of the Ginkgo Biloba intervention was unlikely.
Studies After 2014
- Ercoli et al. (2015) determined improved memory for BCS with a 5-week cognitive intervention.
- Root et al. (2016) compared results for learning and memory of BCS to a healthy control group and concluded BCS problems were with initial coding of the information.
- Processing speed
- Menses et al. (2018) found a home-based speed of processing (SOP) program for BCS improved SOP and executive function.
- King and Green (2015) used a 4-week cognitive intervention for cancer survivors and established positive findings of increased SOP and visual scanning.
Following the Von Ah et al. study, there is one in 2015 (Ercoli et al.) where they determined there was improved memory for breast cancer survivors with a five-week cognitive intervention. Root et al. in 2016 compared results for learning and memory of breast cancer survivors to a healthy control group. They concluded breast cancer survivors had problems with the initial coding of the information. Let's think back to part one where we discussed that memory is a three-part process. We have to learn information, our working memory, we then code the information, and then later retrieve it. Root et al. determined that the "coding" of the information was the problem. How do we improve initial coding? One of the things that I think would affect coding would be the study participants' attention. Were they paying attention, to the information? You will see my bias as we go forward.
Menses et al. looked at processing speed in 2018 and used a home-based speed of processing program for breast cancer survivors. Speed of processing is another area that affects somebody's ability to perform their work responsibilities and can impact occupational performance. King and Green (2015) used a four-week cognitive intervention for cancer survivors that showed an increased speed of processing and visual scanning. If we put our OT hats on, we know that vision gives a person about 90%, of our input of information.
- Quality of life
- Improved for BCS in studies by Bray et al. (2016) and Wolf et al. (2016)
- Improved perceived cognitive was found for BCS by King and Green, Bray et al. (2016), and Von Ah et al. (2016)
There were also studies on quality of life for breast cancer survivors by Bray et al. and Wolf et al. in 2016. Additionally, improved perceived cognition was found by King and Green, Bray et al., and Von Ah et al.
My Research on Cognitive Rehabilitation for BCS
- Co-researchers and I (Smith et al., 2019) conducted a study with five BCS.
- Participants attended 5 two-hour group sessions on attention, memory, problem-solving, planning and organization, and compensation techniques. Participants rated their satisfaction with group sessions 4/4.
- They then had access to a self-directed computer-assisted cognitive training program for 4 weeks.
- In a focus group afterward, participants reported they did not feel that their recovery journey was over. They were motivated to find a new normal, and they welcomed novel strategies to do so.
In this next section, I hope to give you some findings from my studies. The first was a group intervention with five breast cancer survivors. They attended five, two-hour group sessions on attention, memory, problem-solving, planning and organization, and compensation techniques. Participants rated their satisfaction with group sessions four out of four for every session. They then had access to a self-directed computer-assisted, cognitive training program for four weeks. So, in total, the intervention was nine weeks.
I want you to notice that I said "self-directed" computer program. It did not work. I did not plan very well letting participants with cognitive deficits self-direct this program. These consisted of online games specific to the person's cognitive deficits. Rather than using ones to address their specific cognitive deficits, some may have been more attracted to ones that they liked or were easier.
In a focus group afterward, participants reported they did not feel that their recovery journey was over. They were motivated to find a new normal, and they welcomed novel strategies to do so. This was a big takeaway for me. For example in stroke clients after six months, we may stop intervention due to a decrease in performance gains or have difficulty with referrals and reimbursement. Here we have breast cancer survivors saying that treatment was not over for them.
Now, I am going to explain the five group sessions in more detail. In group session 1, we focused on attention. At the beginning of the session, we practiced deep breathing. We had them breathe in for a certain amount of time and then breathe out. The purpose was to decrease anxiety and to increase their focus and attention. My treatment was targeted to their problems, and we did a game or an activity to increase their attention and focus. The group consisted of each participant, two researchers, and three students. Each group member had to name a vegetable using the first letter of their name. I was "Theresa tomato." As we went around the circle, each member stated the members' names and vegetables that preceded them, then introduced themselves, and added their vegetables. The vegetable game requires a lot of attention. Many participants wrote down notes to try to remember. We also had a home program for each group. For example, the home program for the attention group was an activity focused on decluttering as there is a lot of evidence on clutter and how it affects one's attention. The researchers thought that a simple suggestion would be for them to organize the coffee-making area in the kitchen. However, not one participant chose to do anything in the kitchen, but they chose other areas instead. The most emotional one for me was one of the ladies who decided to clean off half of her bed that had been housing many items. She had been sleeping on one half of her bed for a long time. Her self-efficacy of doing that activity was really impactful.
The second group was on memory. One activity that is very popular is called the mind palace. You can Google this. You have participants envision a room of their house in their mind. One of the most impactful takeaways from this group was that one of the participants used her bedroom that included her closet. We were using this exercise to help them remember a shopping list. This lady imagined dog food had spilled in her closet so that she would remember to buy dog food.
The third group focused on problem-solving. The participants decided on a problem that they currently had, and then they wrote what they would have to do to make the problem worse. The third thing was to imagine what the opposite of making it worse would be.
The fourth group session was on organization principles. We used the hand technique. The participant raises their hand and has a prompt for each digit. For example, they touch the thumb and think, "I'm stopping for a moment." On the index figure, "What am I doing right now?" The middle finger prompt is, "What should I be doing right now?" Touching the ring finger they think, "What do I want to do next?" Lastly, on the pinky finger, 'What does that have to do with something?" We have all walked into a room and could not remember why. The hand technique can be very helpful for this. One of our participants in her home program caught herself cleaning the toilet again. Using the hand technique, she stopped and figured out her next plan. Also in that session, we had them plan a busy day incorporating some energy conservation.
The last group looked at compensation techniques for cognitive deficits. I am sure that most of you have very good ideas for compensation that you have used with other clients.
- In a study performed with Dr. Ratcliff (Smith & Ratcliff, 2019), we compared outcomes for two different computer-assisted cognitive training programs for 24 BCS. One program used primarily visual computer exercises, and the other used audio and visual exercises.
- The program consisting of primary visual computer exercises resulted in higher scores for improved perceived cognitive function and quality of life for BCS.
- The visual plus audio training program did not appear to improve perceived cognitive function.
I did a study with Dr. Ratcliff on a computer-assisted program that used primarily visual computer exercises. It had 24 participants divided into two groups. One group did visual exercises while the other did vision plus audio training. We wanted to look at vision and then a combination of two senses, vision and hearing. The group that only used visual computer exercises had higher scores, improved perceived cognition, and quality of life. These results were not expected, and the study still did not change my mind that two senses are better than one. I felt instead that I did not set up the intervention correctly. As we do with goals, we may need to modify them along the way.
- In a study performed with Dr. Wang (Smith & Wang, 2021), we had 25 BCS divided into two groups. Both groups participated in the same computer-assisted cognitive training (CACT) program, but one group also listened to music designed to increase their focus and concentration (CACT+A)
- The group with the CACT+A program self-reported significantly improved perceived cognitive function and expressed experiencing greater ratios of improvements for memory and QOL.
- CACT+A is an intervention option for BCS who self-report cognitive issues. It is convenient to participate at home and allows BCS to safely self isolate if need be.
So, in 2021, I tried again using the same visual computer program. One of my groups did the regular program, and the other group did the computer-assisted cognitive training plus music designed to increase their focusing and concentration. The group with the audio input reported increased focus and concentration, improved perceived cognition function, and experienced greater ratios of improvements for memory and quality of life. This was a mixed-methods study, and this was not contradictory so it made me happy.
But remember, we need to interpret our results. In the qualitative portion of the study, I asked an open-ended question that matched each of the areas that I was trying to improve upon. For example, for occupational participation, I asked, "Did this program improve your occupational participation?" Well, this was a hard question for people. It is like when you introduce yourself as an occupational therapist, and the person thinks it is related to work. It was difficult to discriminate a good word to use, and the question was problematic.
Another finding was that those that had the music intervention improved in all areas, but qualitatively, they reported that their quality of life had not improved. There was both an objective test and a subjective report. My interpretation had to do with the interview and qualitative questions after the study concluded. For the study, I had them use headphones and a USB with music to increase concentration and focus. They had to fit that into their everyday life, and it took planning of where to plug in the USB and how to put on the headphones, and potentially mess up their hair, or whatever. It required more planning on their part so I surmise that is why the subjective findings were lower.
- Occupational therapists are treating more cancer survivors although not necessarily for cognitive deficits.
- Screen for cognitive deficits.
- Treat known cognitive issues of BCS.
- Assign computer home programs to improve known cognitive issues and track progress.
- Treat cognitive related issues of depression, anxiety, fatigue, & pain.
Occupational therapists are treating more cancer survivors although not necessarily for cognitive deficits. We need to be aware that a person could have cognitive deficits and screen for them. Often, cognitive deficits are found during an occupational profile. Perhaps, they have not returned to work or report having issues with certain tasks. It is important to treat known cognitive issues of breast cancer survivors.
I also strongly encourage everybody to assign a computer home program to improve known cognitive issues and track their progress. Let's compare this to a splint-wearing schedule where you ask, "Did you wear your splint last night? Can I see how you put your splint on?" This would be the same concept with the computer home program. You would assign them exercises or games that fit the deficits that you discover. It is also important to be aware of cognitive related issues. Some common ones are depression, anxiety, fatigue, or pain.
I also want to step back and go over a couple more things that could affect whether our interventions work or not. These factors do not change even from a patient with an orthopedic problem. For example, what is the length of the treatment? If we had somebody with high tone and decided to splint or cast them and placed this on the area for half an hour, would we expect to get any type of results? You might want to reflect back on some of the studies to see what the researchers found. For example, one of my studies started at eight weeks. Then, my later study was four weeks. Did I get the results or not? It is also important to know when to intervene. I talked a little bit about this. We may need to look at the client's fatigue and pain. They may have anxiety due to a pending mammogram. The pandemic has added a whole other layer of anxiety for folks. You need to take all of these factors into consideration.
Research: Future Directions
- Determine the most appropriate occupational participation assessment for this population
- Correlate more objective assessments with perceived function
- Conduct studies that address not just cognitive issues but contributing factors
- Perform more fMRI studies
- Conduct studies on other cancers that include similar treatments to BCS
For future directions, it is crucial to determine the most appropriate occupational participation assessment for this population. Perhaps, it has not been developed yet. Remember, there were some issues that I faced. So, I would continue to measure deficits in different ways. We need to correlate more objective assessments with the perceived function. This is what is in the literature today and where cognitive impairment for breast cancer survivors' research is going.
It is imperative that we conduct studies that address not just cognitive issues but also the contributing factors. How much is depression affecting cognition? How much are fatigue, pain, and anxiety taking a toll on the client?
We need to have more fMRI studies of the brain to see the activity of the brain and what areas can be improved? There are even some studies where they intervene while the client is having an fMRI. We also need to conduct studies on other cancers that include similar treatments to those of breast cancer survivors. The cancer physician that I work with has a lot of patients with head and neck cancers from the HPV virus.
Lastly, it would be great to include more men. Men have more head and neck cancers than women so that might be a way to go.
- There are screens and assessments available to determine cognitive issues of BCS and contributing factors.
- Cognitive rehabilitation can be delivered to BCS in several different formats.
- Occupational therapists are skilled in rehabilitation for cognitive deficits and contributing factors.
- There are computer programs that can be used to provide home programs of cognitive training for specific deficits of BCS.
- The best practice for BCS is to treat the whole person.
There are screens and assessments, and cognitive rehab can be delivered in several formats. We are great at rehab and treating cognitive deficits and any contributing factors. There are public available computer programs. The best practice is to treat the whole person.
Questions and Answers
What is next for you in your research? What are you planning on doing next?
I have a study looking at a group intervention for decreased body image with younger cancer survivors. This is not saying that older cancer survivors do not have body images difficulties because they do, but the younger clients can be more affected especially in their roles. They may want to get married or have children. They may want to feel sexy or attractive and, they need to be able to have self-confidence.
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