Web-Based Exercises Effective in Improving Cognitive Impairment Following Chemotherapy

Victoria J. Bray, MD

Victoria J. Bray, MD

Patients with symptoms of cognitive impairment who practiced web-based memory and mental processing exercises over a period of 15 weeks experienced marked improvement in their cognitive function, according to results published in the Journal of Clinical Oncology.¹

According to study author Victoria J. Bray, MD, this research is the first of its kind to show a benefit for patients with persistent cognitive symptoms following treatment with chemotherapy—also known as “chemobrain”—which is a problem that affects approximately 70% of cancer survivors. Bray is a medical oncologist and PhD candidate at the University of Sydney in Australia, where the study was carried out at 18 sites between 2009 and 2014.

"Cognitive rehabilitation should be a core part of cancer survivorship care, as cognitive symptoms are very common and have a profound effect on people's lives,” Patricia Ganz, MD, of UCLA’s Jonsson Comprehensive Cancer Center and ASCO expert in survivorship, noted in a statement. "This study points to a simple tool that may help alleviate mild cognitive problems."

The randomized trial enrolled 242 patients with solid tumors: 89% had breast cancer, 5% colorectal cancer, and 95% of the participants were women; the median age of all participants was 53 years. Eligible patients had to have completed at least 3 cycles of adjuvant chemotherapy in the prior 6 months to 5 years and rated their cognitive complaints (changes in concentration and/or memory) “quite a bit” or more along a cognitive function scale. Patients were evaluated at baseline, 15 weeks, and 6 months after the intervention.

For the study, participants were evenly randomized to standard oncology care or cognitive rehabilitation using Insight (brainHQ, Posit Science)²—a computerized program that employs adaptive exercises targeted at areas of cognition often impacted in patients with cancer, such as divided attention, working memory, and visual processing speed. Those assigned to the intervention arm were asked to do 40 hours of the exercises over 15-weeks, which is equivalent to 4, 40-minute sessions each week.

Among the program’s advantages cited by researchers is that it is home-based, relatively inexpensive, and empowers participants to direct their own treatment.

To measure the tool’s effectiveness, researchers used assessments previously validated in the oncology setting. For the primary outcome of perceived cognitive impairment (PCI) after 15 weeks, participants answered the 37-item questionnaire FACT-COG. For the main secondary outcome of neuropsychological function, they completed Cogstate, a battery of 7 tests that can be performed on the computer at home. That assessment takes about 18 minutes and gauges cognition in such areas as processing speed, working memory, decision making, and executive function.

Researchers found that after 15 weeks, patients who did the exercises had a reduction of 7.47 in PCI compared with those in the control arm (95% CI, range: —10.8 to –4.13; P <.001), and this difference persisted after 6 months, when a —6.48 reduction in PCI was observed in the intervention arm (95% CI, –9.85 to –3.11; P <.001).

Perceived cognitive abilities at 15 weeks also significantly improved (3.34; 95% CI, 1.98 to 4.70; P <.001) among those doing the web exercises and continued to be better after 6 months (2.88; 95% CI, 1.50 to 4.25; P <.001). In addition, participants' quality of life was improved 6 months after participants finished the program.

Objective neuropsychological function test results were not significantly different between the intervention cohort and the control arm. However, the researchers suggested caution in interpreting this finding, as several participants had difficulty installing and re-accessing Cogstate.

Researchers were also interested to find out what, if any, effect the intervention had on participants’ levels of anxiety/depression, fatigue, and stress, as all have been shown to be associated with patients’ assessments of their cognitive impairment. Each of these symptoms improved among those doing the web-based exercises.

In the intervention arm, reductions in anxiety/depression and fatigue were reported at 15 weeks, but the differences were not significant at 6 months. On the measure of perceived stress, however, the intervention yielded a significant reduction at both time points.

Study authors note that longer follow-up is needed to determine if the effects of the training are long-lasting. In addition, a number of unanswered questions remain for future research, including how to tailor intervention approaches to specific survivors. For example, a self-directed program such as this one may be suitable for some survivors, whereas a group-based program may work better for others. The ideal length and "dose" of cognitive training also has not yet been determined.

"If we could identify patients who are at risk of cognitive impairment, we could intervene earlier, and possibly achieve even better results. We would also like to explore whether there is added benefit from combining cognitive training with physical exercise," said Bray.

References

1. Bray VJ, Dhillon HM, Bell ML, et al. Evaluation of a web-based cognitive rehabilitation program in cancer survivors reporting cognitive symptoms after chemotherapy [published online ahead of print October 31, 2016]. J Clin Oncol.
2. Brain HQ. Brain Training That Works. http://www.brainhq.com. Accessed October 31, 2016.