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Several studies in cancer research have suggested that cognitive dysfunction following chemotherapy, referred to in lay terms as “chemobrain”, is a serious problem. At present, the changes in integrative brain function that underlie such dysfunction remain poorly understood. Recent developments in neuroimaging suggest that patterns of functional connectivity can provide a broadly applicable neuromarker of cognitive performance and other psychometric measures. The current study used multivariate analysis methods to identify patterns of disruption in resting state functional connectivity of the brain due to chemotherapy and the degree to which the disruptions can be linked to behavioral measures of distress and cognitive performance. Sixty two women (22 healthy control, 18 patients treated with adjuvant chemotherapy, and 22 treated without chemotherapy) were evaluated with neurocognitive measures followed by self-report questionnaires and open eyes resting-state fMRI scanning at three time points: diagnosis (M0, pre-adjuvant treatment), 1 month (M1), and 7 months (M7) after treatment. The results indicated deficits in cognitive health of breast cancer patients immediately after chemotherapy that improved over time. This psychological trajectory was paralleled by a disruption and later recovery of resting-state functional connectivity, mostly in the parietal and frontal brain regions. Mediation analysis showed that the functional connectivity alteration pattern is a separable treatment symptom from the decreased cognitive health. Current study indicates that more targeted support for patients should be developed to ameliorate these multi-faceted side effects of chemotherapy treatment on neural functioning and cognitive health., Highlights • Chemotherapy increases fatigue, depression, cognitive & physical burdens • Patients also show decreased parieto-frontal resting-state functional connectivity • These cognitive and physical burdens are reduced 7 months after treatment • The functional connectivity pattern also returns to baseline levels by 7 months • The functional connectivity fluctuations do not explain the cognitive burdens

Stressful life events are related to negative outcomes, including physical and psychological manifestations of distress, and behavioral deficits. Patients diagnosed with breast cancer report impaired attention and working memory prior to adjuvant therapy, which may be induced by distress. In this article, we examine whether brain dynamics show systematic changes due to the distress associated with cancer diagnosis. We hypothesized that impaired working memory is associated with suppression of “long‐memory” neuronal dynamics; we tested this by measuring scale‐free (“fractal”) brain dynamics, quantified by the Hurst exponent (H). Fractal scaling refers to signals that do not occur at a specific time‐scale, possessing a spectral power curve P(f)∝f−β; they are “long‐memory” processes, with significant autocorrelations. In a BOLD functional magnetic resonance imaging study, we scanned three groups during a working memory task: women scheduled to receive chemotherapy or radiotherapy and aged‐matched controls. Surprisingly, patients' BOLD signal exhibited greater H with increasing intensity of anticipated treatment. However, an analysis of H and functional connectivity against self‐reported measures of psychological distress (Worry, Anxiety, Depression) and physical distress (Fatigue, Sleep problems) revealed significant interactions. The modulation of (Worry, Anxiety) versus (Fatigue, Sleep Problems, Depression) showed the strongest effect, where higher worry and lower fatigue was related to reduced H in regions involved in visuospatial search, attention, and memory processing. This is also linked to decreased functional connectivity in these brain regions. Our results indicate that the distress associated with cancer diagnosis alters BOLD scaling, and H is a sensitive measure of the interaction between psychological versus physical distress. Hum Brain Mapp 36:1077–1092, 2015. © 2014 Wiley Periodicals, Inc.

UNLABELLED [Correction Notice: An Erratum for this article was reported in Vol 33(3) of Health Psychology (see record 2014-07787-001). The name of author Misook Jung was misspelled as Mi Sook Jung. All versions of this article have been corrected.] OBJECTIVE Altered cognitive function has been associated with breast cancer treatment, particularly adjuvant chemotherapy, but the underlying neuropsychological mechanisms are not yet understood. Recent research indicates that compromised attention and working memory can exist before adjuvant treatment, implicating psychological distress, such as worry, as a possible contributor to observed alterations in cognitive function. We hypothesized that worry associated with breast cancer diagnosis might influence neurocognitive responses before any adjuvant therapy. DESIGN Fifty women, 25 due to receive chemotherapy and 25 due to receive radiation therapy, participated in the study. Women performed a verbal working memory task during functional magnetic resonance imaging scanning to assess neurocognitive responses before any adjuvant treatment and to test the relationship of such responses with self-reports of worry. RESULTS Although prechemotherapy participants showed significantly higher levels of worry compared with preradiation participants, higher worry, across both groups, was related to altered brain function. Specifically, increased worry was associated with reduced demand-related deactivation in default-mode regions, such as the precuneus/posterior cingulate. Reduced demand-related deactivation was critically related to worse behavioral performance, which was partially mediated by worry. CONCLUSION Worry appears to be a significant contributor to neurocognitive dysfunction independent of adjuvant treatment for breast cancer. These results suggest that alterations in cognitive function may develop before any chemotherapy treatment and that worry about cancer diagnosis may contribute to reports of "chemo brain" during treatment. Psychological interventions aimed at mitigating worry may help to alleviate cognitive dysfunction associated with life-threatening illness such as breast cancer.

There is growing evidence that fluctuations in brain activity may exhibit scale-free (“fractal”) dynamics. Scale-free signals follow a spectral-power curve of the form P(f ) ∝ f−β, where spectral power decreases in a power-law fashion with increasing frequency. In this study, we demonstrated that fractal scaling of BOLD fMRI signal is consistently suppressed for different sources of cognitive effort. Decreases in the Hurst exponent (H), which quantifies scale-free signal, was related to three different sources of cognitive effort/task engagement: 1) task difficulty, 2) task novelty, and 3) aging effects. These results were consistently observed across multiple datasets and task paradigms. We also demonstrated that estimates of H are robust across a range of time-window sizes. H was also compared to alternative metrics of BOLD variability (SDBOLD) and global connectivity (Gconn), with effort-related decreases in H producing similar decreases in SDBOLD and Gconn. These results indicate a potential global brain phenomenon that unites research from different fields and indicates that fractal scaling may be a highly sensitive metric for indexing cognitive effort/task engagement.

PURPOSE/OBJECTIVES: To assess cognitive function in individuals with colorectal cancer (CRC) and identify factors associated with cognitive effects. DESIGN: Cross-sectional, comparative design. SETTING: Midwest hospital. SAMPLE: Men and women with (n = 50) and without (n = 50) CRC. METHODS: Comparative and regression analyses were performed to assess the relationship between cognition and CRC. MAIN RESEARCH VARIABLES: Attention, cognitive control, and memory function were assessed with neuropsychological tests and self-report. FINDINGS: Compared to healthy volunteers, individuals with CRC performed worse and reported more problems on tasks requiring attention and cognitive control (p < 0.05). After controlling for covariates, poorer performance on tasks of attention and cognitive control was associated (p < 0.001) with having CRC, older age, and less education. In contrast, poorer perceived attention and cognitive control were associated (p < 0.001) with greater fatigue but not CRC. CONCLUSIONS: Individuals with CRC are vulnerable to cognitive problems. In addition, older age, less education, and fatigue can increase risk for worse cognitive performance and self-reported cognition. IMPLICATIONS FOR NURSING: Cognitive problems can profoundly affect an individual’s ability to function in everyday life and cope with cancer. Nurses should assess for cognitive problems in patients with CRC and intervene to reduce distress.

Background: The underlying brain mechanisms of altered cognitive function associated with adjuvant chemotherapy for breast cancer, commonly designated “chemobrain”, have yet to be determined. Recent research indicates that compromised cognitive function may already exist prior to treatment, adding to the complexity of determining the true impact of adjuvant chemotherapy on brain function. We examined whether two common symptoms associated with breast cancer diagnosis, worry and fatigue, might influence neurocognitive responses during functional magnetic resonance imaging (fMRI) before adjuvant therapy. Methods: Seventy five women (29–75 years) awaiting either adjuvant chemotherapy (n=25) or radiation therapy (n=25) for localized breast cancer and age-matched controls without breast cancer (n=25) were enrolled. Participants performed a verbal working memory task (VWMT) with varying levels of demand for cognitive control during fMRI scanning and provided self-reports of worry and fatigue after scanning. Imaging data were analyzed using the general linear model implemented in SPM5; comparative statistics were used to determine group differences in self-report and behavioral measures. Results: In general, the pre-chemotherapy group showed compromised cognitive functioning relative to the other groups. Specifically, they reported higher worry than the pre-radiation therapy (p=.036) and control (p=.047) groups. The pre-chemotherapy group also identified greater fatigue than controls (p=.04); the pre-radiation group reported a fatigue level between the other two groups. In the VWMT, the pre-chemotherapy group was less accurate than controls (p=.05), while the mean accuracy for the pre-radiation group again fell between these two groups. fMRI results showed that the control group selectively increased recruitment of executive control brain regions including the left inferior frontal gyrus (LIFG) and the anterior cingulate cortex (ACC) in response to high vs. low demand conditions. However, recruitment of LIGF and ACC by the control group was greater than that by both the pre-chemotherapy (p=.01 and p=.003 respectively) and the pre-radiation groups (p=.027 and p=.02 respectively). Overall, higher fatigue was correlated with failure to increase recruitment of the LIFG and ACC in high vs. low demand conditions (p=.002 and p=.078 respectively). Greater worry was correlated with failure to suppress task-irrelevant activation of default network regions, particularly the posterior cingulate cortex, in high vs. low demand conditions, and with lower accuracy in the VWMT (p=.01). Thus, fatigue and worry made independent contributions to altered neurocognitive responses prior to any adjuvant treatment. Discussion: These findings suggest that women awaiting adjuvant chemotherapy are vulnerable to compromised cognitive functioning, specifically in the domains of attention and working memory, related to higher worry and fatigue. Worry and fatigue may contribute to the cognitive impact often attributed to adjuvant chemotherapy. Therapeutic interventions to counteract worry and fatigue hold potential for optimizing cognitive function prior to adjuvant treatment for breast cancer. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD04-08.

Objective: Cognitive assessment in individuals with cancer requires both measured performance on neuropsychological tests and self-report of effectiveness in functioning. Few instruments are available to assess the perceived impact of cognitive alterations on daily functioning in individuals treated for cancer. In this study, we investigated the psychometric properties of a theoretically based instrument, and the Attentional Function Index (AFI), designed to measure perceived effectiveness in common activities requiring attention and working memory, particularly the ability to formulate plans, carry out tasks, and function effectively in daily life. Methods: Women (N=172), ages 27–86 years, completed the questionnaire before primary treatment for early stage breast cancer. Construct validity was established using exploratory principal component factor analysis with varimax rotation. Results: A 13-item instrument emerged with 3 subscales, namely effective action, attentional lapses, and interpersonal effectiveness, which explained 74.69% of total variance. The internal consistency coefficients (Cronbach's α) were 0.92 for the total instrument, and ranged from 0.80 to 0.92 for the 3 subscales. Further examination of validity indicated that the scores on the AFI (1) showed expected correlations with established measures of ability to concentrate, cognitive failures, states of confusion, and mental fatigue, and (2) could distinguish differences in perceived cognitive functioning between younger and older age groups. AFI scores were not significantly associated with years of education or presence of comorbid conditions. Conclusion: The brief AFI has demonstrated usefulness for assessment of perceived cognitive functioning in populations with life-threatening and chronic illness, such as breast cancer. Copyright © 2010 John Wiley & Sons, Ltd.

Objective: Cancer patients and partners often report inadequate communication about illness-related issues, although it is essential for mutual support and informal caregiving. This study examined the patterns of change in dyadic communication between patients with prostate cancer and their partners, and also determined if certain factors affected their communication over time. Method: Using multilevel modeling, this study analyzed longitudinal data obtained from a randomized clinical trial with prostate cancer patients and their partners, to examine their communication over time. Patients and partners (N=134 pairs) from the usual-care control group independently completed baseline demographic assessment and measures of social support, uncertainty, symptom distress, and dyadic communication at baseline, and 4-, 8-, and 12-month follow-ups. Results: The results indicated that (1) patients and partners reported similar levels of open communication at the time of diagnosis. Communication reported by patients and partners decreased over time in a similar trend, regardless of phase of illness; (2) phase of illness affected couples' open communication at diagnosis but not patterns of change over time; and (3) couples' perceived communication increased as they reported more social support, less uncertainty, and fewer hormonal symptoms in patients. Couples' demographic factors and general symptoms, and patients' prostate cancer-specific symptoms did not affect their levels of open communication. Conclusions: Perceived open communication between prostate cancer patients and partners over time is affected by certain baseline and time-varying psychosocial and cancer-related factors. The results provide empirical evidence that may guide the development of strategies to facilitate couples' interaction and mutual support during survivorship. Copyright © 2010 John Wiley & Sons, Ltd.

This study aimed at examining the relationship between quality of life (QOL) in prostate cancer (PCa) patients and partners and how baseline demographics, cancer-related factors, and time-varying psychosocial and symptom covariates affect their QOL over time.Guided by a modified Stress-Coping Model, this study used multilevel modeling to analyze longitudinal data from a randomized clinical trial that tested a family-based intervention to improve QOL in couples managing PCa. Patients and partners from the usual-care control group (N = 134 dyads) independently completed the measurements at baseline, and at 4-, 8-, and 12-month follow-ups.Correlations of QOL between patients and partners over time were small to moderate. Patients' lower education level, partners' older age, higher family income, and localized cancer at baseline were associated with better QOL in couples. Over time, couples' QOL improved as their social support and cancer-related dyadic communication increased and as couples' uncertainty, general symptoms, and patients' prostate cancer-related sexual and hormonal symptoms decreased.Evidence indicates that couples' QOL during cancer survivorship is affected by multiple contextual factors (e.g., baseline demographics and time-varying psychosocial factors and symptoms). Intervention research is needed to explore comprehensive strategies to improve couples' QOL during the continuum of PCa survivorship.

Dr. Carmen Escalante, Professor and Chair of General Internal Medicine, Ambulatory Treatment, and Emergency Care at The University of Texas MD Anderson Cancer Center, presents the lecture, “Cancer-related Fatigue.” Cancer-related fatigue is one of the most common symptoms experienced by cancer patients and cancer survivors. Dr. Escalante’s lecture provides a multidisciplinary perspective on cancer-related fatigue and focuses on the prevalence, characteristics, hypothesized pathophysiology, and common causes of this condition. Patient assessment and customized strategies for management, including non-pharmacologic and pharmacologic interventions, are presented. Resumen

Despite clinical reports of cognitive deficits associated with cancer chemotherapy, the underlying brain mechanisms are not clear. This research examined selective attention and working memory using functional magnetic resonance imaging (fMRI) in women before chemotherapy for localized breast cancer. Patients were tested with an established selective attention and working memory task during fMRI. Compared with healthy controls, patients showed (a) bilateral brain activation in high-demand task conditions with recruitment of additional components of attention/working memory circuitry, and (b) less accurate and slower task performance. Results indicate compromised cognitive functioning before any chemotherapy and raise key questions for further research.

Taking CHARGE, a theory-based self-management program, was developed to assist women with survivorship concerns that arise after breast cancer treatment. Few such programs have been evaluated for cultural relevance with diverse groups. This study determined the utility and cultural relevance of the program for African American (AA) breast cancer survivors. Two focus groups were held with AA women (n = 13), aged 41 to 72 years, who had completed primary treatment. Focus group participants assessed the program content, format, materials, and the self-regulation process. Content analysis of audiotapes was conducted using an open, focused coding process to identify emergent themes regarding program relevance and topics requiring enhancement and/or further emphasis. Although findings indicated that the program's content was relevant to participants' experiences, AA women identified need for cultural enhancements in spirituality, self-preservation, and positive valuations of body image. Content areas requiring more emphasis included persistent fatigue, competing demands, disclosure, anticipatory guidance, and age-specific concerns about body image/sexuality. Suggested improvements to program materials included portable observation logs, additional resources, more photographs of younger AA women, vivid colors, and images depicting strength. These findings provide the basis for program enhancements to increase the utility and cultural relevance of Taking CHARGE for AA survivors and underscore the importance of evaluating interventions for racially/ethnically diverse groups.

Although prostate cancer is prevalent, little information is available on how it affects couples' quality of life (QOL) according to their age cohort. The purpose of this study was to examine how quality of life, self-efficacy and appraisal of the illness experience vary among men with prostate cancer and their partners according to age cohort: middle age (50-64); young-old (65-74); and old-old (75-84). Using an Adult Developmental and Family Stress framework, this study focuses on how normative (developmental stage) and non-normative stressors (prostate cancer) may affect a couple's ability to adapt.A descriptive, comparative design was used to examine age-related differences in quality of life and selected psychosocial variables in 69 men with prostate cancer and their spouses. Cross-sectional data were obtained using standardized instruments with adequate reliability and validity. ANCOVA and MANCOVA were used to determine differences among age groups.Findings indicated that patients who were ages 65-74 had better QOL and higher self-efficacy than patients ages 50-64 and less negative appraisal of illness than the other two groups. Spouses ages 50-64 reported the most distress related to sexual changes in their husbands. Spouses in both the middle age and old-old group had more bother related to hormone therapy than the young-old spouses.Findings suggest that interventions should be tailored to dyads' developmental life stage. Younger and older prostate cancer survivors and their partners may benefit from tailored interventions designed to improve their quality of life and confidence in managing their treatment outcomes during the survivorship period.

Neural dysfunction and cognitive complaints are associated with chemotherapy for breast cancer although trajectory and contributory factors remain unclear. We prospectively examined neurocognition using fMRI and self-reported cognitive, physical and psychological symptoms in women treated with adjuvant chemotherapy over one year. Patients treated with (n = 28) or without (n = 34) chemotherapy for localized breast cancer and healthy controls (n = 30) performed a Verbal Working Memory Task (VWMT) during fMRI and provided self-reports at baseline (pre-adjuvant treatment), five- (M5) and 12-months (M12). Repeated measures ANOVA and multivariable regression determined change over time and possible predictors (e.g., hemoglobin, physical symptoms, worry) of VWMT performance, fMRI activity in the frontoparietal executive network, and cognitive complaints at M12. Trajectories of change in VWMT performance for chemotherapy and healthy control groups differed significantly with the chemotherapy group performing worse at M12. Chemotherapy patients had persistently higher spatial variance (neural inefficiency) in executive network fMRI-activation than both other groups from baseline to M12. Cognitive complaints were similar among groups over time. At M12, VWMT performance and executive network spatial variance were each independently predicted by chemotherapy treatment and their respective baseline values, while cognitive complaints were predicted by baseline level, physical symptoms and worry. Executive network inefficiency and neurocognitive performance deficits pre-adjuvant treatment predict cognitive dysfunction one-year post-baseline, particularly in chemotherapy-treated patients. Persistent cognitive complaints are linked with physical symptom severity and worry regardless of treatment. Pre-chemotherapy interventions should target both neurocognitive deficits and symptom burden to improve cognitive outcomes for breast cancer survivors.

Until now, little research has been conducted examining the reactive dimension, or the degree to which a symptom limits an individual's life, in a multiplicity of symptoms. This research examines how problem-solving therapy organizes an intervention to decrease symptom limitations. The purpose was threefold: to determine if a cognitive behavioral intervention decreases the impact of symptom limitations among individuals newly diagnosed with cancer, who are receiving chemotherapy; to determine, after adjusting for covariates, how symptom limitations change over time; and to describe which symptoms are most limiting. This randomized control trial was conducted in two comprehensive and four community cancer centers. Two hundred thirty-seven individuals, aged 31-87, newly diagnosed with solid tumor cancers, participated. The experimental group (118 individuals) received a 10-contact, 18-week cognitive behavioral intervention focused on cancer- and chemotherapy-related symptoms. The control group (119 individuals) received conventional care. Interviews occurred at baseline, 10, 20, and 32 weeks. Data analysis used a two-level hierarchical linear model. Participants receiving the cognitive behavioral intervention had lower scores of symptom limitation than did participants in the control group. At the onset of the study, younger patients reported more symptom limitations than their older counterparts; however, this was reversed by the end of the study. The cognitive behavioral intervention was key to decreasing symptom limitations. Findings also suggest that nursing interventions may be particularly helpful to younger individuals in managing cancer-related symptom limitations.

The purpose of the study was to develop and evaluate Taking CHARGE, a self-management intervention designed to facilitate successful transitions to survivorship after breast cancer treatment. The Taking CHARGE intervention involves a two-pronged approach building on self-regulation principles to (1) equip women with self-management skills to address concerns following breast cancer treatment, and (2) provide information about common survivorship topics. The program involved four intervention contacts, two small group meetings and two individualized telephone sessions, delivered by nurse/health educators. This paper focuses on the process evaluation findings from a preliminary test of the Taking CHARGE intervention conducted with 25 women, aged 34-66 years, completing breast cancer treatment, who were randomly assigned to the intervention group. The process evaluation was conducted to obtain systematic information about the relevance and usefulness of the self-regulation approach, informational aspects, and program delivery. The findings indicated that intervention group participants found the Taking CHARGE program to be timely, relevant, and to have high utility in dealing with concerns that exist following breast cancer treatment. The process evaluation findings provide early evidence of the usefulness of the Taking CHARGE intervention for successful transition to survivorship following breast cancer treatment.

Purpose To describe a randomized trial of a cognitive behavioral intervention on reducing symptom severity among patients diagnosed with solid tumors and undergoing a first course of chemotherapy and to determine whether the intervention had an additive or interactive effect on symptom severity in the presence of supportive care medications. Patients and Methods Patients (N = 237) were accrued from comprehensive and community cancer centers, interviewed, and randomly assigned to either the experimental intervention (n = 118) or conventional care (n = 119). A symptom severity index, based on summed severity scores across 15 symptoms, was the primary outcome. Each patient’s site of cancer, stage at diagnosis, chemotherapy protocols, and use of supportive medications were learned from medical records. Results Groups were equivalent at baseline, and attrition by characteristics by group was not different. The proportion of patients not receiving chemotherapy at 10 and 20 weeks did not differ by group. At the 10- and 20-week observations, there was a significant interaction between the experimental group and baseline symptom severity. Patients in the experimental group who entered the trial with higher symptom severity reported significantly lower severity at 10 and 20 weeks. Controlling for chemotherapy treatment status at follow-up and supportive care medications did not alter the effect of the experimental intervention. Conclusion Compared with conventional care alone, the experimental intervention was effective among patients who entered the trial with higher levels of symptom severity. Age, sex, site or stage of cancer, and supportive medications did not modify the effect of this cognitive behavioral intervention on symptom severity.

Women treated for breast cancer have shown cognitive deficits with reduced capacity to focus and concentrate or to direct attention. This study examined the relationship between cognitive function prior to any treatment for breast cancer and individual factors including age, education, menopausal status, chronic health problems, and distress. Women newly diagnosed with breast cancer (N=184), ages 27–86 years, were assessed with standardized attention tests, self-reports of effectiveness in cognitive functioning, and measures of distress at about 18 days before surgery. Measured performance on the cognitive tests was not significantly correlated to self-reports of effectiveness in cognitive functioning. Age, education, presence of a chronic health problem, and menopausal status, but not distress, were associated with performance on the cognitive tests. Only age and education, however, were significant (p

Cancer patients diagnosed with solid tumors and undergoing a first course of chemotherapy were randomized to either conventional care or a 10 contact 20 week cognitive behavioral intervention designed to reduce emotional distress. Three hypotheses were tested. First, a test for a group effect found that patients in the intervention who entered the trial with higher symptom severity reported significantly lower depression at 10 but not 20 weeks. Patients in the experimental group who entered with higher depression were more depressed at 10 weeks than patients in the control group. The second hypothesis compared the intervention in two sub-indices of symptom severity; one comprised of symptoms with a depressive component, the other of symptoms not associated with depression. The intervention was more effective in lowering depression at 10 weeks through an interaction with the non-depressive symptom sub-index. At 20 weeks, a significant main effect for the intervention on depression was observed. No interaction with either sub-index was observed. The third hypothesis found no main or interaction effect between psychotropic drugs and the intervention. In conclusion, behavioral interventions may influence depression differently over time. Initially, the intervention lowered depression through certain symptoms and only later did it effect depression directly. Symptoms with an affective component are relatively unaffected by the intervention which was independent of the presence of psychotropic medications. Copyright © 2004 John Wiley & Sons, Ltd.

Earlier research indicated that attentional fatigue with reduced capacity to direct attention in women treated for breast cancer may be ameliorated by a theoretically based intervention involving regular exposure to the natural environment. This study tested the efficacy of a natural environment intervention aimed at restoring attention in 157 women with newly diagnosed breast cancer. Capacity to direct attention was assessed with a brief battery of objective measures at two time points: approximately 17 days before surgery (time 1) and 19 days after surgery (time 2). A randomly assigned intervention protocol was initiated after the first assessment and before any treatment. The intervention comprised a home-based program involving 120 minutes of exposure to the natural environment per week. The intervention group (n = 83) showed greater recovery of capacity to direct attention from the pretreatment (time 1) to the preadjuvant therapy period (time 2), as compared with the nonintervention group (n = 74). A significant effect of the natural environment intervention was observed even after control was used for the effects of age, education, attention scores at time 1, other health problems, symptom distress, and extent of surgery. The findings suggest therapeutic benefits for capacity to direct attention from early intervention aimed at restoring attention in women with newly diagnosed breast cancer.

PURPOSE/OBJECTIVES Through a randomized clinical trial, to compare patients undergoing an initial course of chemotherapy who report pain and fatigue at baseline and who are receiving conventional care alone with those receiving conventional care plus a nursing intervention on outcomes reported at 20 weeks. SETTING Chemotherapy clinics of two comprehensive and two community cancer centers. METHODS Interviews were conducted at baseline and 10 and 20 weeks. An 18-week, 10-contact nursing intervention utilizing problem-solving approaches to symptom management and improving physical functioning and emotional health was implemented. SAMPLE The sample consisted of 53 patients in the experimental arm and 60 in the control arm who reported pain and fatigue at baseline. VARIABLES Pain and fatigue, numbers of other symptoms, and physical role impact and social-functioning subscales from the Medical Outcomes Study 36 Short Form. FINDINGS Patients who received the intervention reported a significant reduction in the number of symptoms experienced and improved physical and social functioning. Fewer patients in the experimental arm reported both pain and fatigue at 20 weeks. CONCLUSIONS Behavioral interventions targeted to patients with pain and fatigue can reduce symptom burden, improve the quality of the daily life of patients, and demonstrate the "value-added" role of nursing care for patients undergoing chemotherapy. IMPLICATIONS FOR NURSING These data support the "value-added" role of nursing interventions for symptom management and improved quality of life during the course of cancer treatment.

Stressful life events are related to negative outcomes, including physical and psychological manifestations of distress, and behavioral deficits. Patients diagnosed with breast cancer report impaired attention and working memory prior to adjuvant therapy, which may be induced by distress. In this article, we examine whether brain dynamics show systematic changes due to the distress associated with cancer diagnosis. We hypothesized that impaired working memory is associated with suppression of “long‐memory” neuronal dynamics; we tested this by measuring scale‐free (“fractal”) brain dynamics, quantified by the Hurst exponent (H). Fractal scaling refers to signals that do not occur at a specific time‐scale, possessing a spectral power curve [Formula: see text]; they are “long‐memory” processes, with significant autocorrelations. In a BOLD functional magnetic resonance imaging study, we scanned three groups during a working memory task: women scheduled to receive chemotherapy or radiotherapy and aged‐matched controls. Surprisingly, patients' BOLD signal exhibited greater H with increasing intensity of anticipated treatment. However, an analysis of H and functional connectivity against self‐reported measures of psychological distress (Worry, Anxiety, Depression) and physical distress (Fatigue, Sleep problems) revealed significant interactions. The modulation of (Worry, Anxiety) versus (Fatigue, Sleep Problems, Depression) showed the strongest effect, where higher worry and lower fatigue was related to reduced H in regions involved in visuospatial search, attention, and memory processing. This is also linked to decreased functional connectivity in these brain regions. Our results indicate that the distress associated with cancer diagnosis alters BOLD scaling, and H is a sensitive measure of the interaction between psychological versus physical distress. Hum Brain Mapp 36:1077–1092, 2015. © 2014 Wiley Periodicals, Inc.

The aim of this study is to use functional magnetic resonance imaging (fMRI) to prospectively examine pre-treatment predictors of post-treatment fatigue and cognitive dysfunction in women treated with adjuvant chemotherapy for breast cancer. Fatigue and cognitive dysfunction often co-occur in women treated for breast cancer. We hypothesized that pre-treatment factors, unrelated to chemotherapy per se, might increase vulnerability to post-treatment fatigue and cognitive dysfunction. Patients treated with (n = 28) or without chemotherapy (n = 37) and healthy controls (n = 32) were scanned coincident with pre- and one-month post-chemotherapy during a verbal working memory task (VWMT) and assessed for fatigue, worry, and cognitive dysfunction. fMRI activity measures in the frontoparietal executive network were used in multiple linear regression to predict post-treatment fatigue and cognitive function. The chemotherapy group reported greater pre-treatment fatigue than controls and showed compromised neural response, characterized by higher spatial variance in executive network activity, than the non-chemotherapy group. Also, the chemotherapy group reported greater post-treatment fatigue than the other groups. Linear regression indicated that pre-treatment spatial variance in executive network activation predicted post-treatment fatigue severity and cognitive complaints, while treatment group, age, hemoglobin, worry, and mean executive network activity levels did not predict these outcomes. Pre-treatment neural inefficiency (indexed by high spatial variance) in the executive network, which supports attention and working memory, was a better predictor of post-treatment cognitive and fatigue complaints than exposure to chemotherapy per se. This executive network compromise could be a pre-treatment neuromarker of risk, indicating patients most likely to benefit from early intervention for fatigue and cognitive dysfunction.

Functional brain networks emerge and dissipate over a primarily static anatomical foundation. The dynamic basis of these networks is inter-regional communication involving local and distal regions. It is assumed that inter-regional distances play a pivotal role in modulating network dynamics. Using three different neuroimaging modalities, 6 datasets were evaluated to determine whether experimental manipulations asymmetrically affect functional relationships based on the distance between brain regions in human participants. Contrary to previous assumptions, here we show that short- and long-range connections are equally likely to strengthen or weaken in response to task demands. Additionally, connections between homotopic areas are the most stable and less likely to change compared to any other type of connection. Our results point to a functional connectivity landscape characterized by fluid transitions between local specialization and global integration. This ability to mediate functional properties irrespective of spatial distance may engender a diverse repertoire of cognitive processes when faced with a dynamic environment.

This study examined changes in directed attention and short-term memory in depression using a newly constructed battery of computerized measures. A repeated measures design was used with two sample groups; 25 individuals meeting DSM-IV criteria for Major Depression and a group-matched comparison sample of 27. Both groups were tested at three points in time over a 10-week period. Test-retest reliability of the measures was examined. Profile analysis demonstrated that there were differences between the depressed and comparison groups in both directed attention and short-term memory. Recommendations for specific improvements in the testing battery are discussed. The ability to detect changes in directed attention and short-term memory may have clinical utility in early detection of impending onset of depression or subtle residual symptoms of an acute episode that may impair functioning or signal a relapse.

Women treated for breast cancer have shown attentional fatigue manifested as a decreased capacity to concentrate or direct attention in daily life activities. This study was conducted to determine if age and extent of surgery increase the risk of early development of attentional fatigue in 74 women newly diagnosed with Stage I or II breast cancer. Measures of capacity to direct attention (CDA) were obtained at two time points, about 12 days before, and 15 days after, breast-conserving surgery or mastectomy. ANOVA showed significant age and age by time interaction effects (p < .05). Women aged 65-79 showed a significant mean decline (p < .05) in CDA over time regardless of extent of surgery. Women aged 46-64, who underwent mastectomy, showed a mean loss in CDA, whereas those having breast-conserving surgery showed a significant mean gain (p < .05). Women aged 25-45 showed no significant mean change in CDA over time. Older age and more extensive surgery increase the likelihood of loss of attention due, in part, to greater risk of attentional fatigue.

Background Cognitive deficits have been reported as detrimental side effects in chemotherapy-treated breast cancer patients and survivors. Korean women treated for breast cancer may experience unrecognized cognitive deficits related to their treatment. However, no research has examined cognitive test performance in chemotherapy-treated Korean breast cancer survivors. Objective The objectives of this study were 2-fold: (1) to examine differences in occurrence and severity of cognitive deficits in Korean women treated with adjuvant chemotherapy for breast cancer as compared with a control group of women without breast cancer and (2) to examine the relationship of selected demographic and cultural factors with cognitive test performance. Methods Sixty-four Korean women, 32 women treated for localized breast cancer and 32 healthy controls, were enrolled. Breast cancer participants were assessed with established cognitive measures within 4 months after chemotherapy, and healthy controls, within 6 months after negative screening mammography. Results The breast cancer group showed a significantly higher occurrence and greater severity of cognitive deficits than controls did. Importantly, older age, less education, greater collectivist tendency, and greater childrearing burden were reliably associated with poorer attention and working memory test performance. Conclusions Cognitive deficits were found in chemotherapy-treated Korean women with moderate to large effect sizes compared with controls. Cultural characteristics contributed to worse cognitive performance. Implications for practice Healthcare providers should recognize that Korean women may be highly vulnerable to cognitive deficits. Cultural factors also need to be considered when assessing cognitive function and designing therapeutic interventions to counteract negative cognitive outcomes.

This study is based on a theoretical view which suggests that under increased demands for attention, individuals' capacity to direct attention may become fatigued. Once fatigued, attentional restoration must occur in order to return to an effectively functioning state. An attention-restoring experience can be as simple as looking at nature. The purpose of this study was to explore whether university dormitory residents with more natural views from their windows would score better than those with less natural views on tests of directed attention. Views from dormitory windows of 72 undergraduate students were categorized into four groups ranging from all natural to all built. The capacity to direct attention was measured using a battery of objective and subjective measures. Natural views were associated with better performance on attentional measures, providing support for the proposed theoretical view.

Altered cognitive function can be a distressing side effect of cancer and its treatment. Women diagnosed and treated for breast cancer often report problems with memory, concentration, and other cognitive abilities that can pose significant barriers to full resumption of family, job, and social roles. Despite considerable neuropsychological research, many unanswered questions remain about cancer-related cognitive deficits and the underlying neural bases. Functional magnetic resonance imaging (fMRI) measures brain activation associated with different mental states and has significantly advanced our understanding of cognitive function and dysfunction in healthy and clinical populations. However, to date the application of fMRI to the study of cognitive function in breast cancer is limited. The current review addresses the potential importance of this method for understanding the neurocognitive effects of breast cancer disease and treatment. Along with reviewing published fMRI studies on breast cancer to date, we discuss potential major contributions of this method which include: (a) delineating components of cognitive function and underlying neural processes most affected by cancer and its treatment, (b) uncovering compensatory processes and their limits, (c) identifying altered resting state networks that may relate to subjective complaints and longer term outcomes, and (d) clarifying the relationship between pre-treatment alterations in brain activity and longer term neural and behavioral outcomes. Finally, we pose questions for future research that can be optimally addressed by integrating fMRI and other imaging modalities to clarify the nature and causes of “chemo brain” and guide interventions to improve cognitive function and the quality of breast cancer survivorship.

Cognitive assessment in individuals with cancer requires both measured performance on neuropsychological tests and self-report of effectiveness in functioning. Few instruments are available to assess the perceived impact of cognitive alterations on daily functioning in individuals treated for cancer. In this study, we investigated the psychometric properties of a theoretically based instrument, and the Attentional Function Index (AFI), designed to measure perceived effectiveness in common activities requiring attention and working memory, particularly the ability to formulate plans, carry out tasks, and function effectively in daily life.Women (N=172), ages 27-86 years, completed the questionnaire before primary treatment for early stage breast cancer. Construct validity was established using exploratory principal component factor analysis with varimax rotation.A 13-item instrument emerged with 3 subscales, namely effective action, attentional lapses, and interpersonal effectiveness, which explained 74.69% of total variance. The internal consistency coefficients (Cronbach's α) were 0.92 for the total instrument, and ranged from 0.80 to 0.92 for the 3 subscales. Further examination of validity indicated that the scores on the AFI (1) showed expected correlations with established measures of ability to concentrate, cognitive failures, states of confusion, and mental fatigue, and (2) could distinguish differences in perceived cognitive functioning between younger and older age groups. AFI scores were not significantly associated with years of education or presence of comorbid conditions.The brief AFI has demonstrated usefulness for assessment of perceived cognitive functioning in populations with life-threatening and chronic illness, such as breast cancer.

Worry involving repetitive thoughts about threats and concerns is prevalent when confronted with a life-threatening illness such as cancer. Worry may contribute to the formation of negative cognitive representations of illness that can have a detrimental effect on behavioral and adaptive outcomes. The study examined for the first time (a) the relationship between worry and early formation of cognitive representations of illness in individuals with suspected lung cancer over the presurgical and postsurgical period and (b) associations between worry and anxiety, sex, age, and educational level. Correlational statistical analyses were used to assess worry and cognitive representations in 42 individuals before lung surgery and again 3 weeks postsurgery. Higher worry was significantly related to more threatening content in multiple illness domains. Repeated-measures analysis of variance using high- and low-worry strata showed significant interactions between worry and time on certain illness domains indicating that high worry was associated with increased threat and negative contents in cognitive representations of illness over time. Multiple regression analyses showed that trait anxiety was the only significant predictor of worry in a regression model including age, sex, education, and anxiety before surgery. Findings suggest that higher worry at time of diagnosis is associated with the development of negative and more threatening contents in cognitive representations of illness in individuals with suspected lung cancer.

Promoting attentional health is an important opportunity to support and empower women to actively participate in their own health care and function effectively in multiple roles. Attention, the ability to focus or concentrate, is a necessary cognitive resource used throughout the life span in participating in self-health care. However, women can inadvertently overuse this essential capacity, especially when responding to life’s multiple demands, resulting in mental or attentional fatigue. When women experience this mental fatigue, many daily activities, including self-health care, are more difficult. An attentional perspective in women’s health allows approaches to improve daily functioning and reduce the risk of attentional fatigue. In this article we present the conceptual dimensions of directed attention and its relevance to women’s health; practice and research implications are identified.

BACKGROUND The cognitive capacity to direct attention (CDA) is essential for self-care and independent functioning. Older women may be more vulnerable to fatigue-related losses in CDA following surgery for breast cancer. Normal functional variations in CDA associated with aging might affect attentional responses in older women newly diagnosed with breast cancer, and factors such as extent of surgery or symptom distress might influence CDA over time. OBJECTIVES To examine (a) differences in CDA and symptom distress in older women newly diagnosed with breast cancer as compared to a control group of older women without breast cancer; (b) the pattern of change in CDA and symptom distress from the pretreatment period to 3 months after surgery; and (c) to examine the relationship of CDA with symptom distress and extent of surgery over time. METHODS Women, 55 to 79 years of age, newly diagnosed with breast cancer (N = 47), were assessed with measures of CDA and symptom distress: (a) before surgery, (b) at 2 weeks postsurgery, and (c) 3 months postsurgery. To account for normal variations associated with aging, 48 women of similar age without breast cancer were assessed following a routine screening mammogram and 3 months later. RESULTS Before treatment, the breast cancer group scored significantly lower than the control group (p < .05) on measures of CDA and higher on symptom distress. Repeated measures ANOVA showed significant main effects of group, but not time, for the measures of CDA and symptom distress with the breast cancer group having worse status than the control group. For CDA only, there was a significant group by time interaction effect (p = .005) so that the breast cancer group showed a gradual gain in CDA over time. CONCLUSIONS Reduced performance in a cognitive function was observed before treatment and found to persist over an extended interval in older women newly diagnosed with breast cancer.

Although the initial phase of illness is recognized as important in the overall process of adjustment after a diagnosis of breast cancer, little is known about pretreatment patterns of symptom distress. Seventy-four women ages 25 to 79 years and newly diagnosed with breast cancer were studied to determine physical, cognitive, and affective distress in the pretreatment period. Severity of distress was assessed about 11 days before primary surgery using the Symptom Distress Scale (SDS), Attentional Function Index (AFI), and Profile of Mood States (POMS). Higher levels of distress (SDS) were related to a triad of symptoms, insomnia, fatigue, and loss of concentration. Also, lowered effectiveness in cognitive function (AFI) and significant disturbances in mood state (POMS) were observed. Overall, a greater number of symptoms was associated with lowered cognitive function (r = -0.47; p < 0.01) and greater mood disturbance (r = 0.65; p < 0.01). Younger women younger than 55 years of age (n = 25) reported significantly (p = 0.02) greater overall symptom distress (SDS) than older women (n = 49). Interestingly, severity of distress did not differ in groups anticipating breast-conserving surgery (n = 35) instead of mastectomy (n = 39). The findings showed a discernible pattern of symptom distress before any treatment in women newly diagnosed with breast cancer, indicating a need for early intervention to promote the initial process of adjustment.

A university hospital-based study was conducted to explore factors that influence nurses teaching breast self-examination (BSE) to female clients, using the PRECEDE (Predisposing, Reinforcing, and Enabling factors in Educational Diagnosis and Evaluation) model as an organizing framework. Female registered nurses (N = 140) from adult inpatient and outpatient units completed a questionnaire that included items about frequency of BSE, knowledge of breast cancer screening and BSE technique, health motivation, confidence and competence in performing BSE, and teaching BSE. Data analysis compared the characteristics of nurses who reported teaching BSE with nurses who did not teach. Nurses in the teaching group had more work experience in nursing and were more likely to have a friend with breast cancer than were those in the nonteaching group. The teaching group had more knowledge about breast cancer screening and BSE technique and reported more confidence and competence in performing BSE.

Objective: To review the loss of the ability to concentrate in individuals with cancer, the risk factors, and nursing approaches to support and improve attentional functioning. Data sources: Published articles and books pertaining to concentration, central nervous system toxicity, attentional fatigue, and cognitive dysfunction. Conclusions: Multiple factors related to cancer, its treatment, and the demands of a life-threatening illness increase the risk for loss of concentration and attentional fatigue. Implications for nursing practice: Nurses can assess potential loss of concentration by observation and objective and subjective measures. Attention can be conserved by reducing environmental demands and applying attention-restoring strategies.

Background: Our previous research showed evidence of compromised cognitive function prior to adjuvant chemotherapy for breast cancer, with fatigue as a contributory factor. Fatigue is a common symptom reported by women treated for breast cancer, yet its association with neurocognitive function has not been systematically examined. In this prospective study, we examined possible alterations in neurocognitive responses, namely, working memory, from pre- to post- adjuvant treatment during functional magnetic resonance imaging (fMRI) and further investigated whether early fatigue might be linked to cognitive alterations over time. Methods: Women treated with either adjuvant chemotherapy (anthracyline-based combination regimen, n=29) or radiotherapy (n = 37) for localized breast cancer (Stages 0-IIIa) and age-matched healthy controls (n = 32) were enrolled. Participants performed a verbal working memory task (VWMT) with varying levels of demand for cognitive control during fMRI scanning and provided self-reports of fatigue (FACT-F) at two time points coincident with pre- and one-month post chemotherapy assessments. Imaging data were analyzed with general linear models using SPM5; comparative statistics were used to determine group differences, and correlational analyses addressed relationships of fatigue and neurocognitive measures. Findings: The chemotherapy group reported significantly greater severity of fatigue (p < .05) and performed less accurately on the VWMT both pre- and one-month post-treatment than the other groups. Greater fatigue was correlated with poorer performance on the VWMT at both time points across groups, with stronger correlation post-treatment (r = −.22, p = .03). A 2 time-point (pre- vs. post-treatment) × 2 group (chemotherapy vs. controls) × 2 demand-level contrasts (high minus low vs. medium minus low) analytic model showed a significant group × time interaction (p < .05), mainly due to lower pre-treatment activation in an area of the prefrontal cortex supporting working memory, the anatomical left inferior frontal gyrus (LiFG), at higher task demand in the chemotherapy group. The radiotherapy group scored between the other two groups with intermediate activation of those contrasts. Of interest, lower pre-treatment activation in the LiFG in the high-low demand contrast predicted severity of fatigue across all participants at the post-treatment assessment (r = −.27, p < .01), linking early compromise in neurocognitive performance with greater fatigue over time. Discussion: Neurocognitive alterations during a working memory task and greater fatigue were evident before any adjuvant chemotherapy for breast cancer. Notably, functional alterations in working memory processes were evident with fMRI before adjuvant chemotherapy and predicted severity of post-treatment fatigue. Importantly, across all participants, greater fatigue over time was correlated with reduced cognitive performance. Taken together, these findings indicate that pre-treatment neurocognitive compromise and fatigue are key contributors to the cognitive impact often attributed solely to chemotherapy. Early therapeutic interventions targeting fatigue may improve cognitive function and reduce the distress of “chemo brain” throughout the course of adjuvant treatment. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S6-3.

Multiple sclerosis (MS) entails various cognitive and psychological changes. The capacity to direct attention (CDA) is the ability to inhibit competing and distracting stimuli while processing information from the environment. A strong CDA is essential for effective functioning in daily life. The CDA may be reduced by MS lesions and by excessive attention-draining demands imposed by the disease. The purpose of this study was to assess CDA using a one-group descriptive correlational design. The sample consisted of 33 outpatients in symptom remission with relapsing-remitting MS who had virtually no physical disability. As theorized, the MS group presented with attentional deficits of varying severity, despite the presence of few physical symptoms. These deficits were unrelated to depressive symptoms. Findings indicate that nurses need to consider attentional problems even in the most early disease states. Further research is needed to better understand the impact of attentional deficits on daily life functioning and to develop nursing interventions for conservation or restoration of CDA in individuals with relapsing-remitting MS.

Attentional fatigue usually follows intense use of mental effort and is manifested as a decreased capacity to concentrate, that is, to direct attention. The purpose of this study was to examine the capacity to direct attention in persons with cancer during the initial phase of illness. The sample consisted of 32 women without cognitive or affective disorders who underwent surgery for localized (Stage I or II) breast cancer. Subjects manifested attentional deficits of varying intensity on a battery of tests of directed attention on the day before discharge from the hospital, which was a mean of 3 days following mastectomy or breast conservation surgery. Unexpectedly, the two surgical groups did not differ significantly in attentional capacity and functioning. Attentional test scores were not significantly correlated with narcotic pain medication interval, mood state, or self-ratings of attentional functioning. However, as number of days postsurgery increased, attentional performance decreased. The theoretical basis for further examination of attentional fatigue in people with cancer or other life-threatening illnesses is discussed.

Understanding how people learn is critical to effective patient education. This article addresses the central role of attentional processes in supporting effective mental functioning and learning. The theoretical perspective provides a basis for examining attentional requirements associated with illness and the detrimental effects of multiple mental demands on attentional capacity and learning. Through therapeutic approaches that conserve and restore attentional capacity, patient teaching and learning can be improved.

Fatigue is a common symptom in patients with cancer and is nearly universal in those undergoing cytotoxic chemotherapy, radiation therapy, bone marrow transplantation, or treatment with biologic response modifiers. The problem, which affects 70% to 100% of cancer patients, has been exacerbated by the increased use of fatigue-inducing multimodal treatments and dose-dense, dose-intense protocols. In patients with metastatic disease, the prevalence of cancer-related fatigue exceeds 75%, and cancer survivors report that fatigue is a disruptive symptom months or even years after treatment ends. Patients perceive fatigue to be the most distressing symptom associated with cancer and its treatment, more distressing even than pain or nausea and vomiting, which, for most patients, can generally be managed with medications. For the most recent version of the guidelines, please visit NCCN.org

Developing interventions to maintain or restore attentional capacity during demanding phases of illness will help promote effective functioning in people with cancer. This study tested the effects of an experimental intervention aimed at maintaining or restoring attentional capacity in 32 women during the 3 months after surgery for localized (Stage I or II) breast cancer. The intervention was designed to minimize or prevent attentional fatigue through regular participation in activities that engage fascination and have other restorative properties. Attentional capacity was assessed using objective and subjective measures at four time points, approximately 3, 18, 60, and 90 days after breast cancer surgery. After the first observation, subjects were randomly assigned to receive the intervention (n = 16) or not to receive intervention (n = 16). Repeated measures ANOVA showed a significant interaction of experimental intervention and time on attentional capacity. Specifically, subjects in the intervention group showed significant improvement in attentional capacity over the four time points, while the nonintervention group showed a pattern of inconsistent performance over time. Findings suggest that nurses can intervene to maintain or restore attentional capacity in women after surgery for localized breast cancer. The theoretical basis for further development of attention-restoring interventions in patients with cancer is discussed.