To investigate the effectiveness of cryotherapy to prevent paclitaxel-induced peripheral neuropathy.

Each patient wore frozen flexible gloves and socks on their dominant hand and foot (15 minutes before paclitaxel administration to 15 minutes after the infusion was complete: 90 minutes total). Gloves were replaced after the first 45 minutes.

• N = 36   
• AGE: Mean age = 56 years, SD = 13.8
• MALES (%): Not reported  
• FEMALES (%): Not reported
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer undergoing paclitaxel therapy
• OTHER KEY SAMPLE CHARACTERISTICS: Body mass index (BMI) mean score = 22.4

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Kyoto University Hospital, Japan

PHASE OF CARE: Active antitumor treatment

Controlled clinical trial where patients served as their own controls

Symptoms were assessed before chemotherapy at baseline and before each subsequent cycle. Semmes-Weinstein monofilament test (PN, tactile disturbance), thermal simulator to measure thermosensory disturbance (objective symptoms), tuning form to measure vibration perception (objective symptoms), manipulative dexterity to measure performance speed (objective symptom), PROs (Japanese version of the PNQ a validated measure of neuropathy and activities of daily living), cryotherapy tolerability (ad hoc questions), electrophysiological signs (conduction velocity and action potential amplitude of the median nerve), and PKs36

No patients dropped out due to cold intolerance. Pain was reported in 8.2%, and feeling cold was reported in 4.2%. The primary endpoint was tactile deterioration, which was clinically and statistically significantly lower for the intervention side (hand = 27.8% versus 80.6%, OR = 20, p < 0.001; foot = 25% versus 63.9%, OR = infinite, p < 0.001). For secondary endpoints, CIPN occurred faster on the control side than on the intervention side (hand HR = 0.13; foot HR = 0.13). Additional secondary endpoints also reported.

Cryotherapy appears to have efficacy for the prevention of CIPN. In this study, the development of subjective CIPN symptoms was almost completely prevented at a cumulative dose of 960 mg/m².

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: No information on gender or smoking history. No information was provided about the manufacturer of the gloves or socks and the cost. Unknown cost and workflow implications for patients and staff/institution.

Cryotherapy is a promising intervention to prevent CIPN. Additional studies are needed to determine the long-term effects of this therapy on the development of CIPN symptoms in patients treated with paclitaxel.

STUDY PURPOSE: To evaluate status of research on pharmacologic interventions for CIPN

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Medline, Embase, and China National Knowledge Internet

YEARS INCLUDED: (Overall for all databases) Information for dates of search not provided, articles included were from 1995 to 2014

INCLUSION CRITERIA: The study (a) assessed CIPN in patients with cancer, (b) compared two or more drugs or placebo, (c) provided sufficient data to assess differences, and (c) assessed incidence or severity of CIPN

EXCLUSION CRITERIA: None listed

TOTAL REFERENCES RETRIEVED: 1,839

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No description of quality evaluation

FINAL NUMBER STUDIES INCLUDED: 23

TOTAL PATIENTS INCLUDED IN REVIEW: 2,298

SAMPLE RANGE ACROSS STUDIES: 20-732

KEY SAMPLE CHARACTERISTICS: All but one of the studies focused on patients getting platinum-based chemotherapy and 12 of 23 only included people with colorectal cancer.

PHASE OF CARE: Active antitumor treatment

Contrary to the title, this article does not include any commonly prescribed prescription drugs, including gabapentin, pregabalin, or duloxetine. This review included studies of amifostine, Vitamin E, calcium and magnesium infusions, and glutathione. Eighteen studies had a placebo control group and had no control group. Neither blinding nor control were needed for inclusion. Findings indicate that Vitamin E and amifostine reduce incidence of CIPN, while glutathione and amifostine reduced severity of CIPN. There was one study (n = 20) included that had patients getting amifostine who all had cervical cancer and were receiving cisplatin with radiation therapy. The authors of this original study (Gallardo et al., 1999) found no statistically significant difference in neurotoxicity between those getting amifostine and those who did not. It is therefore unclear how the authors of the meta-analysis found otherwise. There was also only a single study of glutathione versus placebo versus calcium/magnesium (n = 93, 33 of whom received glutathione) included. The original study (Dong et al., 2010) showed no significant differences in CIPN incidence or severity between the three groups. Four studies of Vitamin E, two which were placebo controlled and two with no control group.

The limitations, including lack of quality control, small sample sizes, focus on platinum use, and GI malignancies, limit the generalizability of the findings from this meta-analysis.

• Limited search
• Limited number of studies included
• No quality evaluation
• Low sample sizes

Findings from this study suggest that amifostine, glutathione, and Vitamin E may be helpful for CIPN but no recommendations for practice can be made at this time due to limitations of this meta-analysis.

To assess the impact of a brief, individualized, psychoeducational intervention on the self-management of cancer-related cognitive dysfunction (CRCD) for survivors of breast cancer. Primary endpoint: memory contentment; secondary endpoints: knowledge, attitudes, and behaviors related to CRCD.

Participants received a one-hour individualized psychoeducational intervention delivered by a clinical neuropsychologist that was tailored specifically to their level of knowledge and specific complaints related to CRCD. Content included information on CRCD, strategies to reduce frustration and normalize the experience, as well as specific strategies to improve memory. Strategies were not practiced during the session; however, participants selected one or two specific goals to regularly practice between assessment timepoints.

• N = 100   
• AGE: 18 or older, mean age = 52.19 (range = 35-79)
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy, radiation, combination radiation and chemotherapy, immunotherapy, and other
• KEY DISEASE CHARACTERISTICS: Female patients diagnosed with breast cancer, not restricted by stage of disease, previous or current treatment. The majority had stage I or II disease and had completed chemotherapy and/or radiation. Half were currently receiving endocrine therapy. 
• OTHER KEY SAMPLE CHARACTERISTICS: The majority were well educated at the college level or above and were currently employed.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Princess Margaret Cancer Center

PHASE OF CARE: Multiple phases of care

Single-arm, prospective, longitudinal study

• Multifactorial Memory Questionnaire (MMQ)--contentment subscale
• Researcher-developed instrument to measure CRCD knowledge (2 items), symptom distress (2 items), self-efficacy for CRCD management (3 items), satisfaction with the intervention (2 items), and effectiveness of compensatory strategies (3 items)

Memory contentment improved from T1 to T2 (p < 0.001, Cohen’s d = 0.58) and T1 to T3 (p < 0.001, d = 0.77). 

Reliable Change Index (RCI) indicated statistically reliable change for 32% following the intervention. Reliable change was durable at six weeks postintervention for 38%. 

Participants’ statistically significant improvement in memory contentment after the intervention remained lower than published norms at six weeks follow-up (p < 0.001, d = -0.93). 

Lower baseline memory contentment predicted increased improvement postintervention (T1-T2: b = -0.18, p = 0.004; T1-T3: b = -0.18, p = -0.023). Change in memory contentment from baseline to six weeks postintervention was positively associated with compensatory strategy effectiveness (b = 3.73, p = 0.011).

The researchers concluded that the brief one-hour, individualized psychoeducational intervention appeared to be effective and durable in relieving distress from CRCD and improving memory contentment and self-efficacy for managing CRCD. They also concluded that the results supported generalizability of the intervention effectiveness to survivors currently on treatment.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Subjective measures only

Individually tailored psychoeducational interventions for CRCD may be efficacious for facilitating self-efficacy in coping strategies and improvement of memory contentment for survivors of breast cancer. Future study with a randomized controlled design is needed for further validation and investigation of the intervention.

STUDY PURPOSE: To determine the effectiveness of exercise for minimizing cognitive impairment related to cancer and/or cancer-treatment.

TYPE OF STUDY: Systematic integrative review

DATABASES USED: PsycINFO, PubMed, CINAHL

YEARS INCLUDED: (Overall for all databases) though January 2016

INCLUSION CRITERIA: Quantitative studies evaluating effectiveness of exercise for maintaining cognitive functioning in adult patients with cancer with objective and/or subjective assessments 

EXCLUSION CRITERIA: Studies published in a language other than English.

TOTAL REFERENCES RETRIEVED: 232 citations screened, but only 26 met study eligibility criteria.

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The Grading of Recommendations Assessment, Development and Evaluating tool was used to appraise the quality of evidence for study outcomes.

FINAL NUMBER STUDIES INCLUDED: 26

TOTAL PATIENTS INCLUDED IN REVIEW: 2,145 

SAMPLE RANGE ACROSS STUDIES: 4 to 658 participants.

KEY SAMPLE CHARACTERISTICS: 85% of studies included breast cancer survivors, 77% of all participants received chemotherapy and 31% received radiation therapy.

PHASE OF CARE: Late effects and survivorship

Twenty-six studies evaluated the effectiveness of exercise on improving various cognitive functions (CF) (i.e., memory [M], attention/concentration [AC], executive function [EF], information processing speed [IPS], language [L]) or perceived cognitive function (PCF). Forty-two percent of the studies were randomized controlled trials (n = 11), 42% were quasiexperimental (n = 11), 11.5% were observational (n = 3), and one case study. Interventions included aerobic exercise (n = 4), resistance exercise (n = 3), combination of aerobic and resistance exercise (n = 7), aerobic exercise with another modality (e.g., methylphenidate, psycho-education, behavioral intervention) (n = 4), and mindfulness-based exercise (i.e., yoga, Tai chi, Qigong) (n = 8). Of note, 15% of studies did not have an intervention but, rather, relied on patient self-report regarding exercise.  

Eighty-one percent of studies used subjective measures, but only 35% included objective measures of CF. In addition, there was a great deal of variability between instruments used as well the frequency or timing of evaluation. Eighty-eight percent of studies were longitudinal and assessed patients at baseline until less than three months (26%), three months (52%), or six months (22%). While some studies found significant improvements in PCF and/or various cognitive domains (e.g., IPS, AC, EF, L, M), these results were not consistent across studies.

Findings from this study revealed that there is insufficient good quality evidence to determine whether exercise may improve cognitive functioning in cancer survivors.  Although exercise may be beneficial in improving cognitive functioning, there is insufficient evidence to determine the type of exercise, including duration and frequency, that would be recommended. Additional research, including multi-site studies with large sample sizes and higher quality evidence, are needed to determine the effectiveness that specific types of exercise might have a role in alleviating cognitive impairment.

• Limited search
• Mostly low quality/high risk of bias studies

Study findings do not support recommending exercise for improving cognitive impairment in cancer survivors. However additional research using these interventions are recommended to further determine their effectiveness.

Explore whether meditative movement improves cognitive function, quality of life, physical activity, and body mass index (BMI) in postmenopausal women with breast cancer who report clinically significant fatigue.

The intervention included two groups: meditative movement (consisting of Qigong and Tai Chi Easy movements) versus sham Qigong (consisting of similar movements without meditative components), both of which were referred to as rejuvenating movement to blind participants. Participants completed 14 one-hour sessions over 12 weeks with interventionists and were asked to complete 30-minute DVD-guided sessions at home five days per week. Study assessments were done before groups began, at the end of the groups (i.e., 12 weeks post-baseline), and three months after the groups ended.

• N = 87   
• AGE: mean = 58.8 years (SD = 8.94)
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Initial diagnosis of nonmetastatic, invasive breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: 91% White, 59% completed some college, stage 0-III, no recurrence or other cancers, 69% on endocrine therapy, completed adjuvant chemotherapy and/or radiation therapy six months to five years before enrollment, currently reporting clinically significant fatigue; excluded for moderately severe or greater depressive symptoms, BMI > 32, comorbidities and medications affecting fatigue and sleep, smoking/excessive alcohol consumption, and routine mind-body practices.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Arizona

PHASE OF CARE: Late effects and survivorship

Double-blind randomized controlled trial of meditative movement versus sham control with repeated measures

• Cognitive impairment: Functional Assessment of Cancer Therapy-Cognitive Function (subjective); Digit Span and Letter-Number Sequencing (attention and working memory)
• Other measures: SF-36 for quality of life, Brief Physical Activity Questionnaire

Feasibility: 86% completed the study, adherence to intervention sessions and home practice not reported; no adverse events

Cognitive impairment: No group differences at baseline. Both groups improved in self-reported cognitive function and attention/working memory tests (time effects, p < 0.05), but no differences were found between the groups (no group by time effect).

Other outcomes: No group differences at baseline. BMI decreased in the meditative movement group but increased in the sham control group (p = 0.0048).  All other outcomes showed similar pattern to cognitive impairment (i.e., significant time effects for both groups, but no group by time effects).

This exploratory pilot study suggests that meditative movement does not improve cognitive function more than gentle movement without mindfulness. Although both types of movement may improve cognitive impairment, it is unclear if improvement was due simply to participating in groups.

• Small sample (< 100)
• Measurement validity/reliability questionable 
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: This secondary analysis used data from a larger study not designed to evaluate cognitive function comprehensively. The neuropsychological tests used did not capture all domains of cognitive function. The participants reported very few cognitive problems at baseline (potential floor effect). In addition, the sample size was determined based on primary outcome of fatigue, so whether there was sufficient statistical power to detect differences in cognitive outcomes is unclear. Therefore, definitive conclusions cannot be drawn about cognitive impairment. This single-site pilot study is not generalizable to all postmenopausal women with breast cancer.

Study findings do not support suggesting meditative movement exercises such as Qigong or Tai Chi over other types of gentle physical activity to improve cognitive impairment reported by postmenopausal women with breast cancer. The findings do support future well-powered studies using these types of interventions.

The purpose was to compare results of a cognitive rehabilitation program to standard care in patients reporting cognitive symptoms.

All subjects participated in a 30-minute telephone consultation outlining cognitive compensatory strategies prior to study group assignment. Patients were randomly assigned to intervention and control groups. The intervention was a computerized neurocognitive program targeting visual precision, divided attention, working memory, and visual processing speed, which was provided as a CD. Patients were to use training for four 40-minute sessions per week for 15 weeks. The program had an automated measure of compliance. Study assessments were completed by patients at baseline, after 15 weeks, and 6 months later.

• N = 242 in ITT analysis   
• AGE: Range 23-74 years, median 53
• MALES: 5%  
• FEMALES: 95%
• KEY DISEASE CHARACTERISTICS: Solid tumors; had completed definitive treatment within a mean of 27 months reporting quite a bit of changes or greater in concentration or memory on the EORTC QLC–C30 cognitive function scale. The majority had breast cancer. About 70% were on hormone therapy.

• SITE: Multisite   
• SETTING TYPE: Outpatient    
• LOCATION: Australia

PHASE OF CARE: Late effects and survivorship

Longitudinal randomized clinical trial

• FACT-COG questionnaire
• Cogstate computerized testing
• General Health Questionnaire (for anxiety and depression)
• FACT-General 
• FACT-Fatigue 
• Perceived Stress Scale

Only 86% of those in the intervention group used the program. Average total training time was 25 hours of the recommended 40 hours. Patients in the intervention group had better outcomes on the FACT-Cog compared to controls at 15 weeks on all subscales with better perceived cognitive abilities (p < 0.001), less perceived cognitive impairment (p < 0.001) with less impact on quality of life (p = 0.02), and less comments from others regarding cognitive functioning (p = 0.04). However, these differences were sustained at six months only for perceived cognitive impairment (p = 0.001) and perceived cognitive abilities (p < 0.001) but not for the other subscales. Similarly, those in the intervention group had less anxiety and depression (p = 0.02), fatigue (p = 0.03), and perceived stress (p = 0.03) at 15 months. Differences remained only for perceived stress (p = 0.01) at six months. There were no differences between groups in Cogstate measures of neuropsychological function. There was no evidence of dose response for training time and patient outcomes.

The computerized cognitive rehabilitation program tested here showed benefit in terms of patient-reported outcomes of cognitive function but no effect on objective measures of neuropsychological function. There were short-term improvements in anxiety, depression, and fatigue with the intervention that were not sustained.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Single-scale scores were used for measurement of anxiety and depression outcomes. 14% of the intervention group never used the program, raising the question of overall usefulness for a variety of patients. There were varied numbers of patients lost to follow-up at various time points with different measures and it is not clear which participants and results were included in ITT analysis.

Findings suggest that computerized cognitive rehabilitation may improve patient perceptions of cognitive functioning; however, these findings were not consistent with objective measures. Actual benefit of computerized cognitive training for cancer treatment-related cognitive impairment remains unclear.

The purpose was to evaluate the efficacy of a cognitive rehabilitation intervention on self-report of cognitive dysfunction, performance on neuropsychological tests, and brain functioning.

Five weekly, manualized, two-hour sessions included two difficulty levels of in-class cognitive training and three levels of homework exercises that were designed to build skills in the targeted areas of attention, executive function, and memory. Participants were encouraged to do four 20-minute sessions of homework exercises per week. Participants received a training manual workbook, auditory exercises CDs, answer keys, and a stopwatch. In-class education also included instruction on coping strategies to minimize anxiety (e.g., deep breathing, relaxation, pacing, countering negative thoughts). Goal attainment was discussed during the group sessions to facilitate setting individual short-term and long-term goals. These specific intervention details were published in 2013 with the results of the single-arm pilot study and not iterated in the 2015 article. Neurocognitive testing, self-report instruments, and qEEG (substudy) were administered at baseline (T0), within one week (T1), and two (T2) and four (T3) months from completing the intervention.

• N = 48; 29 in EEG substudy   
• AGE: mean = 53.8 years, SD = 8.2
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors within 18 months to 5 years after initial treatment completion who reported persistent cognitive complaints that interfered with daily activities and scored at least one item on the memory scale of the PAOFI as moderately severe. Ongoing endocrine therapy was allowed. Inclusion requirements were within 21-75 years of age and stage 0-III breast cancer. 
• OTHER KEY SAMPLE CHARACTERISTICS: Participants primarily were Caucasian (90%), married (79%), well educated (54% had postcollege degrees), status postchemotherapy (77%) and radiation therapy (75%), and were currently receiving endocrine therapy (71%). Exclusion criteria included uncontrolled depression, current psychiatric disorder, chronic concurrent use of psychoactive medications, central nervous system (CNS) disorders, previous intrathecal chemotherapy or cranial radiation, previous head trauma, seizures, or learning disability, or substance abuse disorder.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: UCLA, Los Angeles, CA

PHASE OF CARE: Late effects and survivorship

Randomized, wait-list controlled, interventional study. Powered on previous single-arm pilot study. Used block randomization (2:1). Intent-to-treat analyses

CNS vital signs computerized testing platform

•     Finger tapping dominant, finger tapping nondominant
•     Shifting attention test
•     Stroop reaction time
•     Continuous performance test
•     Symbol digit test

Rey Auditory Verbal Learning Test (RAVLT) 

Brief Visuospatial Memory Test, Revised

Verbal fluency test

Trail Making Tests A and B

Paced Auditory Serial Addition Test

Wechsler Test of Adult Reading (WTAR)

Patient’s Assessment of Own Functioning Inventory (PAOFI)

Beck Depression Inventory, 2nd edition (BDI-II)

Awake and resting state quantitative electroencephalography (qEEG)

Improvement in PAOFI total scores and memory scale scores were significant for the intervention group (p = 0.01, Effect size (ES) 0.90 and 1.10 respectively). The intervention group improved on RAVLT total scores (trials I-V, p = 0.02, ES = 0.57) and delayed recall (p = 0.007, ES = 0.29). Both groups improved on BDI-II scores at T2 and T3 without significant group differences. The qEEG substudy demonstrated intervention group changes (T1 to T2) for global absolute delta power (p = 0.02) and absolute alpha power (AP, p = 0.04). Decreased delta power did not predict PAOFI improvement at T2 (p = 0.971), nor did increased AP (p = 0.137). However, increased AP predicted improved self-report of cognitive dysfunction at T3 (p = 0.012), even controlling for age and IQ (p = 0.011).

The intervention was associated with improved self-report of cognitive function and neuropsychological test performance sustained up to two months. The qEEG substudy demonstrated preliminary evidence of an overall decrease in delta power and increase in AP for the intervention group, suggesting qEEG may serve as a biomarker of intervention efficacy.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable

Study findings provided further evidence that cognitive rehabilitation is beneficial to improving perceived and actual cognitive function in breast cancer survivors. qEEG may be promising as an early biomarker of intervention effectiveness.

STUDY PURPOSE: To determine the effectiveness of nonpharmacologic interventions for minimizing chemotherapy-induced cognitive impairment in adult patients with breast cancer.

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE, Embase, PubMed, CINAHL, PsycINFO, and CENTRAL (Cochrane Centre Register of Controlled Trials) 

YEARS INCLUDED: (Overall for all databases) 1980 through September 29, 2015

INCLUSION CRITERIA: Randomized controlled trials evaluating the effectiveness of nonpharmacologic interventions on maintaining or improving cognitive function in cancer survivors who completed chemotherapy (including those currently on hormonal therapy)  

EXCLUSION CRITERIA: Studies involving participants with primary or metastatic central nervous system (CNS) disease, nonmelanoma skin cancer, and/or patients in nursing home or residential care settings

TOTAL REFERENCES RETRIEVED: 255 screened (plus 47 additional records), but 40 assessed for study eligibility 

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias tool was utilized to evaluate study quality.

FINAL NUMBER STUDIES INCLUDED: 5

TOTAL PATIENTS INCLUDED IN REVIEW: 235

SAMPLE RANGE ACROSS STUDIES: 100% female; all patients received chemotherapy and/or hormonal therapy 

KEY SAMPLE CHARACTERISTICS: Breast cancer survivors

PHASE OF CARE: Transition phase after active treatment

Five randomized clinical trials compared an intervention with wait-list controls to improve various cognitive functions (i.e., memory, information processing speed [IPS], executive functioning [EF]). Nonpharmacologic interventions included cognitive behavioral therapy (n = 1), cognitive training (n = 2), meditation through Tibetan sound therapy (n = 1), and aerobic exercise (n = 1).

• Cognitive behavioral therapy significantly improved verbal memory (p < 0.05), but not IPS or patients' perceived cognitive functioning.  
• Two trials evaluated cognitive training. The first study compared cognitive training in IPS or memory to controls and found improved immediate and delayed memory (p < 0.01) in the IPS group as well as better immediate (p = 0.036) and delayed memory (p = 0.013) in the memory group. In addition, both intervention groups found improved subjective cognitive functioning (p < 0.05). The second study used computerized cognitive training and found significant improvements in IPS (p = 0.009) as well as some measures of EF (p = 0.008; p = 0.003).  
• Tibetan sound therapy resulted in no differences for either objective or subjective measures of cognitive function.
• Similarly, no differences were observed between intervention and control groups evaluating aerobic exercise.  

Although cognitive training and cognitive behavioral therapy may be beneficial in improving cognitive functioning, there is insufficient evidence for exercise and meditation. The overall quality of the evidence was determined to be low for all studies included.

Findings from this study revealed that there is insufficient good-quality evidence to determine whether cognitive training, cognitive behavioral interventions, exercise, or meditation may improve cognitive functioning in breast cancer survivors who have received chemotherapy with or without hormonal therapy. However, cognitive training and cognitive behavioral interventions were associated with improvements in objective and subjective measures of cognitive function, so further research including multisite studies with large sample sizes and higher-quality evidence may confirm their effectiveness. Further studies are needed to determine whether exercise and/or meditation might have a role in alleviating cognitive impairment.

Limited number of studies included

Mostly low quality/high risk of bias studies

Study findings do not support recommending cognitive training, cognitive behavioral interventions, exercise, or meditation for improving cognitive impairment in breast cancer survivors. However, additional research using these interventions are recommended to further determine their effectiveness.

The purpose of this study was to test the effects of a yoga program to determine impact on perceived stress, sleep, diurnal cortisol, and natural killer cell counts in patients with metastatic cancer compared to education and supportive therapy sessions.

Patients with advanced metastatic breast cancer were recruited from a comprehensive cancer center in the medical and radiation outpatient clinics. Consenting patients were randomized to yoga or supportive therapy groups. Providers of oncology care were blinded to group assignment. The yoga program intervention included two sessions a week for 12 weeks. Each session started with a lecture and yoga for 10 minutes followed by 20 minutes of low-impact yoga postures, breathing, and pranayama and relaxation. Then, subjects completed 30 minutes of guided yoga practice by one of two trained instructors. Practicing was encouraged between sessions with instructions and booklets documented in diary logs. The control group completed supportive care sessions, including education and reinforcing social support. Introductory sessions were 60 minutes before starting treatment and during each treatment visit for 15 minutes. Participants could contact counselors at any time with issues or questions. Diary logs were also completed.

• N = 91   
• AGE: Mean 49.6 years
• FEMALES: 100%
• CURRENT TREATMENT: Combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Diagnosed with stage IV breast cancer within six months of enrollment with no brain involvement 
• OTHER KEY SAMPLE CHARACTERISTICS: No active steroids, unable to perform exercise, psychiatric, neurological, autoimmune disorder. No pregnancy or lactating mothers.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Comprehensive cancer center, India

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS:  Palliative care

Two-arm, prospective randomized control trial

The Pittsburgh Insomnia Rating Scale was used to measure distress related to sleep, sleep parameters, and sleep-related quality of life. Salivary cortisol was measured using oral swab on three consecutive days at three time points. Natural killer cells were collected at baseline and at the end of the study using serum samples to determine immune response. A daily diary was used to document yoga practice in the intervention group and control group.

Of the 91 baseline participants, complete data were analyzed on 66. Reasons for high dropout were listed. No demographic group differences were noted at baseline. Within-group findings included significant decreased distress scores (p = 0.004), decreased sleep distress scores (p = 0.01), improved sleep quality-of-life scores (p = 0.006), improved sleep total distress scores (p = 0.002), decrease in cortisol (p = 0.03), and natural killer cells (p < 0.01) in the yoga group alone. Intervention adherence was 80% attending 24 supervised sessions. Attending more than 20 sessions showed the decreased 9 am cortisol level in the yoga intervention group.

There was evidence to support that yoga could be impacting sleep distress, sleep outcomes, and sleep quality of life, as well as neuroendocrine immune changes providing mechanistic information regarding the benefits of yoga on sleep. Additional research is needed to generalize findings to a wider cancer population.

• Small sample (< 100)
• Risk of bias (no blinding)
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Inequality of intervention contact duration between groups

When recommending yoga as an intervention for sleep, there is a potential impact on subjective sleep outcomes, quality of life, and neuroendocrine responses such as immune function and cortisol levels.