Clinical articleCase seriesLongitudinal Impact of Yoga on Chemotherapy-Related Cognitive Impairment and Quality of Life in Women with Early Stage Breast Cancer: A Case Series
Introduction
Chemotherapy-related cognitive impairment (CRCI) or “chemobrain” as it is referred to in the lay literature, is of significant concern to patients with cancer and estimates of frequency range from 17%-75%.1 Over the last decade, several studies have investigated whether standard dose chemotherapy treatment for breast cancer survivors (BCS) affects cognitive function.2, 3, 4 These findings are consistent with a developing body of translational animal research demonstrating both acute and delayed structural brain changes, as well as functional changes associated with common chemotherapeutic agents. The potential mechanisms that cause this disruption remain largely unknown, although contributing factors could include vascular injury and oxidative damage, inflammation, direct injury to neurons, autoimmune responses, chemotherapy-induced anemia, and the presence of the apolipoprotein E epsilon4 gene.5, 6
There is evidence that psychological and health factors may increase vulnerability to cognitive dysfunction after chemotherapy for BCS.7, 8 Current research indicates the cognitive domains that may be most impacted by chemotherapeutic agents are visual and verbal memory, attention, and psychomotor functioning.5, 9 Changes in brain structure and function have been identified through neuroimaging and neurophysiologic studies.10, 11 From a clinical perspective, the degree of impairment determined on the basis of the individual-based methodologies could have a major impact on quality of life (QOL) for those affected.12
Interventions to help mitigate the symptoms of cognitive changes could include nonpharmacologic treatment such as antioxidants and cognitive-behavioral therapy. In addition, individuals may benefit from pharmacologic treatment such as recombinant human erythropoietin and psychostimulant drugs such as methylphenidate.5 Although these pharmacologic treatments may offer some neurocognitive enhancement, extensive use has been associated with various side effects.13 Additionally, many BCS prefer not to take medications continuously in order to manage daily symptoms.14, 15
Complementary therapy usage among BCS is quite common.16, 17 Yoga is widely available in the community and specifically has improved patient reported QOL in diverse patient groups of breast cancer survivors.18, 19, 20, 21, 22, 23 However, existing literature is very limited in understanding the specific effect of yoga on cognitive outcomes. A detailed understanding of the mechanisms that cause cognitive changes, as well as an understanding of affected specific cognitive domains, is crucial in developing more specific treatments to improve BCS' cognitive functioning and overall QOL.
Yoga is a gentle exercise that focuses on breathing, flexibility, and relaxation. Yoga and its related components (postures, breathing, and meditation) have been effectively used in various studies to alleviate or decrease stress management in other cancer populations.24 In terms of cognition, one or more of these components has been proven to aid in improved memory scores, attentive state of mind, increased concentration, decreased confusion, or improvement in overall cognitive performance in other populations.25, 26 Additionally, one or more of these components of yoga has been proven to aid in decreased fatigue or improved perceptions of vitality.20
Previous trials of yoga for BCS, although improving QOL, lack sufficient objective measures of cognition. In order to determine the effects of yoga on CRCI, we proposed a case series to explore the potential impact of yoga on cognition for BCS. The specific aims of this study were to determine the impact of yoga on CRCI through longitudinal measures using CogState, a computerized measure, with a yoga intervention and explore the effects of yoga on function and QOL.
Section snippets
Study Patient Population
We recruited eligible patients from cancer centers in southern New Jersey with appropriate investigational review board approval at Richard Stockton College of New Jersey, Atlanticare Regional Medical Center and Cooper University Hospital Cancer Center. Potential BCS were screened first by telephone, and then by one outpatient visit. Participants of this study included women ages 18 and older who had been diagnosed with stage I, II, or III breast cancer, and received active treatment with
Cognition
CogState computerized tests provide rapid, sensitive, and valid measurement of distinct cognitive functions (www.cogstate.com). CogState comprises a customizable range of computerized cognitive tasks able to measure baseline and change in all cognitive domains. Specialized tasks can assess attention, memory, executive function, as well as language and social-emotional cognition if required. The tests use novel visual and verbal stimuli to ensure assessment is culture-neutral, is not limited by
Results
Challenges in recruiting precluded us from completing the study as we had initially planned. Instead, we opted to present the specific cases of four women who were representative in different ways of the sample of BCS who participated in this program. Four Caucasian women, with a mean age of 54.75 ranging from 44-65, are included in this case series. Excel was used to generate descriptive statistics for cognition, psychometric, and physiologic outcome measures over the five time periods.
Conclusion
This case series provides insight into cognitive, physiological, and QOL findings with an Iyengar-inspired intervention for women undergoing adjuvant chemotherapy. Further study examining potential underlying mechanisms and future possible clinical applications in the prevention and treatment of CRCI is necessary. These issues are of clinical importance given the prevalence of breast cancer, the use of chemotherapy as adjuvant therapy, the increasing administration of more aggressive dosing
Acknowledgments
The authors thank Louise Baca, RN, Linnea Brown, MS, and Beverly Wilson, RN, from Atlanticare Regional Medical Center and Generosa Grana, MD, and Dee Wolf, RN, for subject recruitment, Sonia Gonsalves and Will Albert from the Richard Stockton College of New Jersey for statistical assistance, and the women who participated in this research.
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This study was funded by the New Jersey Cancer Consortium for Research (2007-2009).