Myers, J.S., Mitchell, M., Krigel, S., Steinhoff, A., Boyce-White, A., Van Goethem, K., . . . Bender, C.M. (2019). Qigong intervention for breast cancer survivors with complaints of decreased cognitive function. Supportive Care in Cancer, 27, 1395–1403.
This purpose of the study is to evaluate the feasibility of conducting a three-arm single-blind RCT of an eight-week intervention to improve objectively and subjectively measured cognitive function in breast cancer survivors reporting cognitive complaints.
The study comprised three groups: (a) Qi-gong (Six Healing Sounds form: combination of diaphragmatic breathing, chanting of six healing sounds, and specific gentle arm movements), (b) gentle exercise (gentle arm movements and postures only), (c) attention control (survivorship-focused support group sessions facilitated by a clinical psychologist). Each group met for eight weekly 60-minute sessions. For both the Qi-gong and gentle exercise groups, participants were given instructions to complete 15-minute practice sessions, twice a day, and keep a log. Feasibility was defined by (a) achieving 45 evaluable patients (15 in each group); (b) 75% or greater adherence to weekly attendance for all groups and twice daily home practice for Qi-gong and gentle exercise; (c) 25% or less attrition. Patient-reported outcomes collected at baseline (T1), 8 weeks (T2), and 12 weeks (T3). Neuropsychological testing at T1 and T3 only.
PHASE OF CARE: Transition phase after active treatment
Single-blinded three arm randomized controlled trial (Qi-gong/Gentle Exercise/Attention Control)
Feasibility (primary aim): 36 evaluable patients at T3 (Qi-gong = 15, gentle exercise = 10, Attention control = 11). Adherence was 44%-67% for weekly sessions and 21%-31% for twice-daily home practice. 28% overall attrition rate.
Cognitive function (exploratory aim): Improvements in self-reported cognitive function, as measured by the FACT-Cog, were significantly greater in the Qi-gong group versus gentle exercise between T1 and T2 (perceived cognitive impairments subscale: p = 0.01, d = 1.14; perceived cognitive abilities subscale: p = 0.04, d = 0.75). No significant differences in self-reported cognitive function were noted between the groups from T2 and T3. Improvements on objectively measured processing speed (TMT-A) were significantly greater in the Qi-gong group versus gentle exercise between T1 and T3 (p = 0.07, d = 1.21). The attention control group improved more than the gentle exercise on the F-A-S test of verbal fluency between T1 and T3 (p = 0.02, d = 1.14).
Other: QOL improved for all three groups between T1 and T2. Distress significantly improved in the Qi-gong group compared to the support group (p = 0.05, d = 0.81) between T1 and T2. There was no significant improvement in fatigue or sleep disturbance scores.
This study provides support for the design of large studies to confirm the effectiveness of Qi-gong, which combines mindfulness-based elements with gentle exercise, for the improvement of perceived cognitive function and processing speed.
Interventions that combine mindfulness and gentle exercise, such as Qi-gong, may be feasible for some patients after chemotherapy for breast cancer and may have benefits in reducing cognitive complaints and improving speed in performing mental tasks. However, larger studies are needed to confirm these findings.
Cognitive training is any intervention aimed at improving, maintaining, or restoring mental function through the repeated and structured practice of tasks which pose an inherent problem or mental challenge (Sitzer, Twamley, & Jeste, 2006). Cognitive training can occur in different formats: group, individual, and computerized. Group cognitive training is provided to individuals in a group setting. Individual cognitive training is provided to patients in a one-on-one approach. Computerized cognitive training is the provision of such practice via a computer program.
Wu, L.M., Amidi, A., Tanenbaum, M.L., Winkel, G., Gordon, W.A., Hall, S.J., . . . Diefenbach, M.A. (2018). Computerized cognitive training in prostate cancer patients on androgen deprivation therapy: A pilot study. Supportive Care in Cancer, 26, 1917–1926.
The purpose of this pilot study is to examine the feasibility, acceptability, and preliminary efficacy of a home-based computerized cognitive training program compared to usual care in patients with breast cancer on androgen deprivation therapy (ADT).
BrainHQ, one hour per day, five days per week for eight weeks or 40 hours total
PHASE OF CARE: Late effects and survivorship
This was a two-group pilot study which randomized patients with prostate cancer who had been on ADT three months or longer to BrainHQ or usual care. Patents were screened and outcomes assessed at three time points: baseline (T1), immediately after 8 week intervention (T2), and 8 weeks later (T3). Participants were asked to complete 40 hours of training over 8 weeks.
87 of 174 (50%) were screened and consented. 73 completed baseline and 60 met randomization criteria. Retention was 72.5% for intervention and 100% in usual care at T2 and 72.5% and 100% in usual care at T3.
Overall, 50% randomized; however, less than 70% completed the study (10 hours or greater total of the intervention, results were greater than 70% if non-completers of the intervention were included. Participants were mostly satisfied with training (2.97, SD = 0.53 on scale of 1-4 with 4 being most positive). Most common barriers to training included difficulty finding time to train (n = 16, 52%), tiredness (39%), health problems (35%), boredom (32%), and distraction (16%). Preliminary efficacy of training was mixed: improvement noted in reaction time (p = 0.01); however, was unfavorable on verbal and visual memory. Memory was temporarily suppressed in the training group at T2 but normalized at T3. No effect of training noted on self-reported cognitive functioning, neurobehavioral functioning, nor quality of life.
This study presented tentative support for the feasibility and acceptability of BrainHQ in prostate cancer patients. Preliminary efficacy of BrainHQ was mixed with improvement in reaction times but more research is needed to fully understand efficacy of cognitive training.
Cognitive training using BrainHQ may be feasible and mostly satisfying intervention for prostate cancer survivors. Additional studies are needed to determine efficacy.
Mihuta, M.E., Green, H.J., & Shum, D.H.K. (2018). Web-based cognitive rehabilitation for survivors of adult cancer: A randomised controlled trial. Psycho-Oncology, 27, 1172–1179.
Randomized, wait-list controlled study conducted to evaluate the efficacy of a web-based cognitive rehabilitation therapy (CRT) program for adults with non-central nervous system tumors and cognitive complaints.
The web-based CRT program (eReCog) was adapted from an in-person manualized format (ReCog). Participants completed four 30- to 60-minute online modules (one each week). Learning techniques involved psychoeducation, relaxation, strategy training, and homework. On-line discussion and questions were anonymized. The program content included (a) ageing, health, cancer, cognitive function, (b) memory, (c) attention, (d) fatigue, emotions, and cognition. Module links were emailed to participants. Participant module progression was tracked. Module completion triggered receipt of the next consecutive module. Feedback on individualized goal setting (after Module 1) was provided via email. On-line questionnaires were administered at baseline, four weeks, and three months. Primary endpoint: perceived cognitive impairment. Secondary endpoints: objective cognitive function, psychosocial variables.
PHASE OF CARE: Late effects and survivorship
Randomized, wait-list controlled design. Powered to detect small to moderate interaction effects (80% power, alpha = 0.05) with 20% added to account for attrition (goal: n = 65).
Intervention group reported significant reduction in prospective memory failures post-intervention (p = 0.005) and three months (p < 0.001). Wait list-controls reported a significant reduction at three months (p = 0.02). Intervention group demonstrated clinically meaningful improvement for FACT-Cog PCI subscale scores (minimally important difference > 6.5, actual improvement 8.9 versus 5.6 for controls) post intervention.
Within-group improvement noted for intervention group on FACT-Cog PCA subscale post intervention (p = 0.002, d = 0.3) and three months (p = 0.007, d = 0.42). Controls improved at three months (p = 0.032, d = 0.22). Intervention group reported decrease in impact of cognitive issues on QOL post-intervention (p = 0.007, d = 0.26) and three months (p = 0.005, d = 0.56). Controls reported decreased impact at three months (p = 0.04, d = 0.24). No interactions were noted for objective neurocognitive measures, distress, or BIPQ. Fatigue was reduced postintervention for the intervention group (p = 0.046, d = 0.27), but not at three months. Participants’ satisfaction ratings were high (94%), and 68% reported “a little or a lot” of improvement in cognitive function.
Preliminary evidence demonstrated in support of this web-based CRT (eReCog) as an effective intervention for self-reported issues with cognitive function following primary treatment for breast cancer. Feasibility and satisfaction demonstrated for use of this web-based CRT.
Future research with a larger sample size is needed to confirm the impact of web-base CRT (on both subjective and objective measures of cognitive function) in the breast cancer survivor population. Web-based CRT has the potential to increase access and decrease cost/burden associated with intervention delivery.
Tong, T., Pei, C., Chen, J., Lv, Q., Zhang, F., & Cheng, Z. (2018). Efficacy of acupuncture therapy for chemotherapy-related cognitive impairment in breast cancer patients. Medical Science Monitor, 24, 2919–2927.
To determine the efficacy of acupuncture in decreasing chemotherapy-induced cognitive impairment
Eligibility included self-report of memory concerns prior to chemotherapy. Acupuncture was administered daily for five days for four weeks, followed by a three-day rest period, then this process was repeated for another four weeks for a total of eight weeks. Sterile, disposable needles (40 mm long and 0.25 mm in diameter) were inserted at the following puncture points: Baihui, Sishencong, Taixi as well as other sites as indicated based on patient symptoms. After acupuncture stimulation was initiated, needles remained in situ for 30 minutes. Neurological assessment, incorporating subjective and objective measures of cognition function, as well as serum BDNF levels, were evaluated prior to the initial acupuncture treatment and repeated after the final acupuncture therapy was completed.
PHASE OF CARE: Active anti-tumor treatment
Prospective longitudinal randomized study
The intervention group was observed to have significant improvement from baseline to 8 weeks on FACT-COG scales for perceived cognitive functioning (p < 0.001), perceived cognitive impairments (p = 0.027) and perceived cognitive abilities (p = 0.014) in contrast to the control group. Similarly, although the intervention group improved in CDT (p = 0.002) and one subtest of the AVLT for recognition (AVLT3, p = 0.026), there was no improvement in the control group. However, no differences were found in other objective measurements of cognitive functioning (e.g., VFT, AVLT1, AVLT2, SDMT, TMT-B). Those who completed acupuncture treatment had a significant increase in BDNF expression (p < 0.01). Of note, BDNF expression was found to be positively correlated with the subjective (FACT-COG, PCA) and objective measures (AVLT3, CDT) that improved in the treatment group (p < 0.005).
Acupuncture may be an effective treatment to alleviate cognitive impairment in patients with breast cancer undergoing chemotherapy.
Acupuncture may improve some cognitive functions during the immediate post-chemotherapy interval in patients receiving treatment. Additional research with larger sample sizes and longer follow-up are needed to validate its effectiveness and determine whether these results are sustainable.
Wayne, P.M., Lee, M.S., Novakowski, J., Osypiuk, K., Ligibel, J., Carlson, L.E., & Song, R. (2018). Tai chi and qigong for cancer-related symptoms and quality of life: A systematic review and meta-analysis. Journal of Cancer Survivorship, 12, 256–267.
PURPOSE: The goal of this study was to systematically review and synthesize the evidence for Tai Chi and Qigong interventions for supportive cancer care, specifically focusing on five clinical outcomes (fatigue, sleep difficulty, mood, pain, and quality of life), to identify the strengths and gaps in the evidence for theses interventions, and suggest directions for future research.
TYPE OF STUDY: Meta analysis and systematic review
TCQ interventions varied in content, dosage, duration, and intensity. Of the 22 studies, Tai Chi was applied in 7 studies, Qigong in 10 studies, and Tai Chi and Qigong were explicitly combined in 4 studies. All results based on a random effects model due to statistical heterogeneity. Ten studies pooled for analysis revealed an overall effect size that indicated a beneficial effect of TCQ on fatigue in patients with cancer (Hedges g = − 0.53, 95% CI [−0.97, −0.28], p < 0.001). Six studies pooled for analysis revealed an overall effect size with a beneficial effect of TCQ on sleep difficulty in patients with cancer (Hedges g = − 0.49, 95% CI [−0.89, −0.09], p = 0.018). The overall effect size based on seven studies favored TCQ on depression in patients with cancer (Hedges g = −0.27, 95% CI [−0.44, −0.11], p = 0.001). Four pooled studies suggested that a statistically non-significant trend was in favor of TCQ on cancer-related pain (Hedges g = −0.38, 95% CI [−0.89, 0.12], p = 0.136). Quality of life was assessed with eleven studies and favored TCQ in patients with cancer (Hedges g = 0.33, 95% CI [0.1, 0.56], p = 0.004). Findings from non-RCTs paralleled meta-analysis results. Funnel plots suggest some degree of publication bias.
Findings support that TCQ may be effective in reducing multiple symptoms commonly experienced by cancer survivors. Statistically significant and clinically meaningful medium effect sizes in favor of TCQ were observed for symptoms of fatigue and sleep difficulty. Smaller but statistically significant effect sizes were also observed for QOL and depression, and a non-significant trend in favor of TCQ was observed for pain.
Tai chi and Qigong are mind-body interventions that show promise for reducing cancer-related symptoms, including fatigue, sleep problems, and depression as well as improving quality of life. Evidence from this review comes from a qualitative synthesis as well as a meta-analysis. The review included studies that included patients with different types of cancer.
Brown, J.C., Damjanov, N., Courneya, K.S., Troxel, A.B., Zemel, B.S., Rickels, M.R., . . . Schmitz, K.H. (2018). A randomized dose-response trial of aerobic exercise and health-related quality of life in colon cancer survivors. Psycho-Oncology, 27, 1221–1228.
To determine the dose-response effect of aerobic exercise on health-related quality of life outcomes among colon cancer survivors after treatment completion, including functional status, sleep, fatigue, fear of recurrence, and bowel function.
The intervention was a prescription for home-based aerobic exercise over six months–either low-dose aerobic exercise (150 minutes per week) or high-dose aerobic exercise (300 minutes per week). Each participant received a treadmill and a heart rate monitor. An exercise physiologist provided ongoing in-person, telephone, and email support, individualized to each participant, and monitored adherence to the exercise protocol. Exercise intensity was prescribed at 50%-70% of age-predicted maximum heart rate and gradually increased for each participant to meet their goal.
PHASE OF CARE: Transition phase after active treatment
Randomized controlled trial with three groups: usual care (usual recommendations for activity), low-dose aerobic exercise (150 minutes per week), and high-dose aerobic exercise (300 minutes per week).
Medical Outcomes Survey Short Form (SF-36), Functional Assessment of Cancer Therapy–Colorectal (FACT-C), Pittsburgh Sleep Quality Index (PSQI), Fear of Cancer Recurrence Inventory (FCRI), Fatigue Symptom Inventory (FSI), North Central Cancer Treatment Group questionnaire (bowel function)
Physical health score in SF-36 improved by 1.2 (d = 0.08) in the low-dose group and 13.1 (d = 0.58) in the high-dose group. FACT-C scores increased by 7.6 (d = 0.49) in the low-dose group and 6.8 (d = 0.58) in the high-dose group. PSQI scores decreased by 0.3 in the low-dose group (d = -0.11) and by 1.1 (d = -0.3) in the high-dose group. PSQI subscales of sleep quality and sleep latency showed improvement. FSI scores increased by 0.8 (d = 0.08) in the low-dose group and decreased by 6 (d = -0.75) in the high-dose group. There were no changes observed in mental health scores of SF-36, FCRI scores, or bowel function scores.
The six-month home-based aerobic exercise intervention for survivors of colon cancer improved health-related outcomes, including physical function, quality of life, sleep quality, and fatigue. Improvements were dose-related, such that a higher dose of aerobic exercise resulted in greater improvement in outcomes.
Moderate intensity aerobic exercise in excess of the recommended 150 minutes per week showed clinically meaningful improvements in health-related outcomes, including physical function, quality of life, sleep quality, and fatigue in survivors of colon cancer who have completed treatment.
Armbruster, S.D., Song, J., Gatus, L., Lu, K.H., & Basen-Engquist, K.M. (2018). Endometrial cancer survivors' sleep patterns before and after a physical activity intervention: A retrospective cohort analysis. Gynecologic Oncology, 149, 133–139.
To determine baseline sleep characteristics of endometrial cancer survivors, the impact of demographic and treatment characteristics on sleep quality, the association of sleep quality with quality of life and stress levels, and the impact of physical activities on sleep.
Individualized exercise prescriptions based on baseline function. Adherence to the American College of Sports Medicine Guidelines requiring 30 minutes of moderate exercise five or more days per week or at least 20 minutes of rigorous exercise three or more days per week with telephone-based counseling sessions, printed materials, and pedometers. Decreasing frequency of counseling telephone calls from weekly to twice monthly to monthly over six months.
Secondary analysis of Steps to Health, a single-arm cohort study.
Sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI). Physical activity measured with the Community Health Activities Model Program for Seniors (CHAMPS). Quality of life (QOL) measured with the SF-36.
At baseline, 61% of the sample had poor sleep quality (PSQI > 5). Obese survivors were more likely to have sleep disturbances than were their normal-weight counterparts (p = 0.029). At baseline, poor sleepers had higher stress levels than good sleepers (p = 0.002). Poor sleep quality was associated with lower health-related QOL: vitality (p = 0.001), bodily pain (p = 0.004), general health (p = 0.002), social functioning (p = 0.005), role limitations caused by emotional problems (p = 0.005), mental health (p = 0.002), and the mental component score (p = 0.003). Sleep quality improved in cancer survivors who increased their weekly total physical activity or moderate-vigorous intensity physical activities (MPVA) throughout the intervention (p = 0.004 and 0.05, respectively). Adjusting for covariates (e.g., age, time since diagnosis, obesity status, disease stage, treatment), improvement in sleep quality was associated with increased hours of total activity (p = 0.026).
Poor sleep quality was common in endometrial cancer survivors and an increase in physical activity was associated with improved sleep quality.
Sleep problems are common in women following treatment for endometrial cancer and are associated with stress and poor QOL. Increasing physical activity may improve sleep quality for these women.
Özkaraman, A., Dugum, O., Ozen Yilmaz, H., & Usta Yesilbalkan, O. (2018). Aromatherapy: The effect of lavender on anxiety and sleep quality in patients treated with chemotherapy. Clinical Journal of Oncology Nursing, 22, 203–210.
To determine the effects of lavender oil aromatherapy on anxiety and sleep quality in patients undergoing paclitaxel-based chemotherapy.
Patients were randomized to lavender essential oil (Lavandula hybrid), tea tree oil, or control. During the first chemotherapy infusion, three drops of lavender essential oil or tea tree oil were put onto a piece of cotton that was placed on each patient’s neck and shoulders, about 10 inches below the nose. No aromatherapy was administered to the control group. Patients randomized to lavender and tea tree oils continued to smell the oil for five minutes every night for one month. Lavender and tea tree oil were purchased from a herbal product firm with quality certifications. Tea tree oil does not have a sedative or relaxing effect; therefore, it was used as a placebo. Patients were evaluated at baseline, after the first chemotherapy infusion, and after one month of chemotherapy infusions.
Randomized control trial with three arms (lavender oil, tea tree oil, control)
Pittsburgh Sleep Quality Index (PSQI), State-Trait Anxiety Inventory (STAI), measured before and after chemotherapy treatment
A significant improvement in sleep quality as measured by mean score of PSQI before and after chemotherapy in the lavender group (time, p = 0.001), with group differences between lavender and the other groups based on assessments (group*time, p = 0.001). Trait anxiety values before and after chemotherapy were significantly decreased in the lavender group (p = 0.0003); however, there was no difference state anxiety by time or group.
Lavender oil inhalation at bedtime for outpatients with mixed cancer treated with paclitaxel-based chemotherapy may be useful for improving sleep quality and trait anxiety.
Lavender oil inhaled at bedtime appears to be an acceptable and helpful intervention for adults treated with paclitaxel-based chemotherapy for mixed cancer types with poor sleep quality and medium levels of state and trait anxiety. Additional research in larger samples is warranted before recommending for practice in general oncology populations.
Blackburn, L., Achor, S., Allen, B., Bauchmire, N., Dunnington, D., Klisovic, R. B., . . . Chipps, E. (2017). The effect of aromatherapy on insomnia and other common symptoms among patients with acute leukemia. Oncology Nursing Forum, 44, E185–E193.
To determine if aromatherapy by diffusion of essential oils improves insomnia in hospitalized patients with newly diagnosed acute leukemia undergoing induction chemotherapy.
Patients served as their own controls and were randomized to receive aromatherapy over 3 weeks in the following fashion. 1 week placebo or aromatherapy, followed by a 1 week washout period, and a third week of placebo or aromatherapy. Patients were allowed to choose their preferred essential oil for the aromatherapy, lavender, chamomile, or peppermint. Rose water served as the placebo control. The aromatherapy diffuser was placed in the same location in all hospital rooms. 8 blinded drops of placebo or essential oil were placed in a diffuser each evening at 9 pm and ran until drops were gone (approx. 8 hours). Sleep quality and disturbance were measured at baseline and after each week of the intervention (placebo or aromatherapy), a general symptom assessment was completed daily during the intervention weeks, and the evaluation of aromatherapy was completed at the end of each week of the intervention.
PHASE OF CARE: Active antitumor treatment
Randomized control trial. Trial was a crossover over trial with a washout period in which patients served as own control.
Pittsburgh Sleep Quality Index (PSQI), Edmonton Symptom Assessment Scale-Revised (ESASr), Final evaluation of aromatherapy (FEA)
Sleep quality as measured by mean scores on the PSQI improved with aromatherapy (p=0.0001) with specific improvements in sleep duration (p=0.03), sleep quality (p=0.05), and sleep disturbance (p=0.04). General symptom scores as measured by the EASSr , all subscales, improved with aromatherapy treatment (p=0.0006)
Aromatherapy for hospitalized patients with acute leukemia undergoing induction chemotherapy improves sleep disturbances and other symptoms.
Aromatherapy appears to be an effective intervention for improving sleep wake disturbances and other symptoms in hospitalized patients with acute leukemia. Nurses may want to explore ways to use aromatherapy for patients in their institutions as well as educate patients and families about the potential positive benefits of aromatherapy as a non-pharmacological method to treat sleep wake disturbances as well as a variety of other symptoms.