Cognitive Behavioral Cognitive Behavioral Management of Management of Chemotherapy Chemotherapy - - Related Related Cognitive Dysfunction Cognitive Dysfunction Robert J. Ferguson, Ph.D. Robert J. Ferguson, Ph.D. Eastern Maine Medical Center Eastern Maine Medical Center University of Maine Dept. of Psychology, University of Maine Dept. of Psychology, Dartmouth Medical School Dartmouth Medical School
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Cognitive Behavioral Cognitive Behavioral
Management of Management of
ChemotherapyChemotherapy--Related Related
Cognitive DysfunctionCognitive Dysfunction
Robert J. Ferguson, Ph.D.Robert J. Ferguson, Ph.D.
Eastern Maine Medical CenterEastern Maine Medical CenterUniversity of Maine Dept. of Psychology, University of Maine Dept. of Psychology,
Dartmouth Medical SchoolDartmouth Medical School
Janet Bayleran, PhDJanet Bayleran, PhD
Theresa White, CCRPTheresa White, CCRP
Sandra Sigmon, PhDSandra Sigmon, PhD
Sharon LaBrie, MSSharon LaBrie, MS
Merrill Garrett, MDMerrill Garrett, MD
Thomas Openshaw, MDThomas Openshaw, MD
Christine Fink, PhDChristine Fink, PhD
Shawn Ell, PhDShawn Ell, PhD
Tim Ahles, PhDTim Ahles, PhD
Paul Jacobsen, PhDPaul Jacobsen, PhD
Brenna McDonald, PsyD, Brenna McDonald, PsyD,
MBAMBA
••QuestionsQuestions
–– How to manage the problem?How to manage the problem?
––What are the proposed treatment What are the proposed treatment approaches?approaches?
processes to promote processes to promote repair of damaged repair of damaged circuitry or development circuitry or development
of new circuitry with of new circuitry with repetitive practicerepetitive practice
(Rohling, et al., 2010; (Rohling, et al., 2010; Roberston & Murre, Roberston & Murre, 1999)1999)
Pine Street Foundation, Pine Street Foundation, Becoming Your Own Advocate NewsletterBecoming Your Own Advocate Newsletter, 2005., 2005.
Adjusted ZAdjusted Z--transformed domain scores for transformed domain scores for
chemotherapy vs. local therapy groups.chemotherapy vs. local therapy groups.
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
0.4
VerbalAbility
VerbalLearning
VerbalMemory*
VisualMemory
Psycho-motor*
Motor Attention/Correct
Attention/RT
BlockDesign
Neuropsychological Domain
Local Therapy
Chemotherapy
Normal neuropsych testingNormal neuropsych testing
scores? scores?
What Impairment?!What Impairment?!
www.huricanevoices.orgwww.huricanevoices.org
Employment function Employment function TannockTannock & Vardy, 2007& Vardy, 2007
www.huricanevoices.orgwww.huricanevoices.org
Home function Home function TannockTannock & Vardy, 2007& Vardy, 2007
Diathesis Stress ModelDiathesis Stress ModelNon-cancer Twin-Twin B
Chemotherapy-treated Twin-Twin A
3-back>0-back2-back>0-back1-back>0-back
Memory and Attention Memory and Attention Adaptation Training Adaptation Training
(MAAT):(MAAT):A Brief Behavioral Skills Program A Brief Behavioral Skills Program
for Cancer Survivors with for Cancer Survivors with Attention and Memory Problems Attention and Memory Problems Associated with ChemotherapyAssociated with Chemotherapy
Robert J. Ferguson, Ph.D.*Robert J. Ferguson, Ph.D.*Behavioral Medicine Section Behavioral Medicine Section Dartmouth Medical SchoolDartmouth Medical SchoolRUNNING HEAD: Memory and Attention TrainingRUNNING HEAD: Memory and Attention Training**This is not a published document. Please do not reproduce or diThis is not a published document. Please do not reproduce or distribute stribute without permission of the author.without permission of the author.
CognitiveCognitive--Behavioral Approach to Behavioral Approach to
Management of Cognitive Management of Cognitive
ProblemsProblems
•• Education and Education and ““memory failure memory failure
reattributionreattribution””
•• SelfSelf--awareness trainingawareness training
•• SelfSelf--regulation and stress managementregulation and stress management
•• modafinil (Provigil)modafinil (Provigil)–– N = 68 Breast cancer survivors doubleN = 68 Breast cancer survivors double--blind placebo blind placebo controlcontrol
–– 22.8 months after chemotherapy22.8 months after chemotherapy
–– Improvements in speed of memory, continuity of Improvements in speed of memory, continuity of attention, and quality of episodic secondary memory attention, and quality of episodic secondary memory on computerized neurocognitive measure vs. placebo on computerized neurocognitive measure vs. placebo
–– (Cognitive Drug Research computerized assessment)(Cognitive Drug Research computerized assessment)
(Kohli, et al., 2007)(Kohli, et al., 2007)
““Levels of EvidenceLevels of Evidence”” and CBT and CBT
DevelopmentDevelopment
1.1. OneOne--group pilot studygroup pilot study
2.2. Waitlist Control Waitlist Control RCTRCT (absolute efficacy)(absolute efficacy)
-- (No longer recommended, Herbert, 2003)(No longer recommended, Herbert, 2003)
3.3. RCT with active control conditionRCT with active control condition
4.4. Component AnalysisComponent Analysis
CognitiveCognitive--Behavioral Treatment of ChemotherapyBehavioral Treatment of Chemotherapy--
Related Attention and Memory Problems Among Related Attention and Memory Problems Among
Breast Cancer Survivors: A Pilot StudyBreast Cancer Survivors: A Pilot StudyPI: Ferguson, R. J. CoPI: Ferguson, R. J. Co-- PI: PI: Ahles, T.A. Ahles, T.A.
•• N = 29, Stage I, II BCA, no CNS tx, intrathecal tx, or N = 29, Stage I, II BCA, no CNS tx, intrathecal tx, or psychiatric, substance abuse, neurologic psychiatric, substance abuse, neurologic
•• Mean Age = 56 (7.81), mean IQ, est: 112.82, 15 yrs eduMean Age = 56 (7.81), mean IQ, est: 112.82, 15 yrs edu
““Behavioral Management of Cognitive Behavioral Management of Cognitive Impairment Associated with Impairment Associated with ChemotherapyChemotherapy””
Lance Armstrong FoundationLance Armstrong FoundationR. Ferguson, PIR. Ferguson, PI
INCLUSIONINCLUSION
•• diagnosis of stage I and II breast cancer; diagnosis of stage I and II breast cancer;
•• at least 18 months postat least 18 months post--treatment currently disease free (not treatment currently disease free (not excluding individuals on hormonal therapies such as selective excluding individuals on hormonal therapies such as selective estrogen receptor modulators); estrogen receptor modulators);
•• treatment involved standard dose adjuvant chemotherapy; treatment involved standard dose adjuvant chemotherapy;
•• complaint of memory and attention following chemotherapy; complaint of memory and attention following chemotherapy;
•• able to speak read English;able to speak read English;
•• at least 18 years of age at diagnosis and able to provide informat least 18 years of age at diagnosis and able to provide informed ed written consent. written consent.
EXCLUSIONEXCLUSION
•• history of CNS disease; history of CNS disease;
•• history of CNS radiation, intrathecal therapy or CNShistory of CNS radiation, intrathecal therapy or CNS--involved involved surgery; surgery;
•• neuroneuro--behavioral risk factors such as traumatic brain injury, history behavioral risk factors such as traumatic brain injury, history of neurological disorder, learning disability or substance addicof neurological disorder, learning disability or substance addiction; tion;
•• current psychiatric disorder. current psychiatric disorder.
( 0 = not at all helpful; 8 = completely helpful) ( 0 = not at all helpful; 8 = completely helpful)
5 Top5 Top--rated strategies included:rated strategies included:0 = Not at all helpful; 4 = Completely helpful0 = Not at all helpful; 4 = Completely helpful
•• Increase MAAT Increase MAAT ““dosingdosing”” 8 visits8 visits
•• An active treatment RCT is needed with larger numbers and An active treatment RCT is needed with larger numbers and multiple cliniciansmultiple clinicians–– MAAT vs. Supportive Psychotherapy (Borkovec) or POSITMAAT vs. Supportive Psychotherapy (Borkovec) or POSIT--Science Science
•• FACTFACT--Cog (QOL impact), MIACog (QOL impact), MIA--A as the principal outcomesA as the principal outcomes–– This will also aid inclusion criteria This will also aid inclusion criteria
•• MAAT MAAT –– electronic? on line, Ielectronic? on line, I--phone based, Video conferencephone based, Video conference
•• Applied to Applied to –––– Other cancer treatments that contribute to cognitive impairmentOther cancer treatments that contribute to cognitive impairment