Cognitive and Psychological Factors Associated With Early Post

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J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.
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J Psychosoc Oncol. 2009 ; 27(4): 415–434. doi:10.1080/07347330903183117.
Cognitive and Psychological Factors Associated with Early Post-

Treatment Functional Outcomes in Breast Cancer Survivors
Stephanie A. Reid-Arndt, PhD, ABPP

Department of Health Psychology University of Missouri One Hospital Drive, DC116.88 Columbia,
MO 65212 E-mail: reidarndts@health.missouri.edu
Albert Yee, PhD
Atascadero State Hospital 10333 El Camino Real Atascadero, CA 93423
Michael C. Perry, MD
Department of Internal Medicine Division of Hematology and Medical Oncology University of
Missouri One Hospital Drive Columbia, MO 65212
Catherine Hsieh, BA
Department of Educational, School, and Counseling Psychology 16 Hill Hall University of Missouri
Columbia, MO 65211
Abstract
Breast cancer survivors experience cognitive difficulties following chemotherapy, yet the effects of
these deficits on functional outcomes have not been systematically evaluated. This study assessed
the relationships between post-chemotherapy cognitive difficulties and functional outcomes. Forty-
six women with breast cancer were seen at 1-month post-chemotherapy; data were collected on
cognitive functioning, psychological variables, and physical symptoms. Wilcoxon Signed Rank
analyses revealed cognitive deficits in executive functioning and verbal fluency. Subsequent
regression analyses demonstrated that poorer executive functioning was associated with decreased
productivity, community involvement, and social role functioning. Poorer quality of life was
predicted by depression and reluctance to seek social support, but not cognitive functioning. These
findings indicate that executive functioning deficits are associated with important functional
outcomes among breast cancer survivors 1-month post-chemotherapy. Thus, treatment efforts should
focus on addressing cognitive, as well as psychological and physical, issues among cancer survivors.
Keywords
Breast cancer; Cognitive; Quality of life; Social support; Community integration
INTRODUCTION
Breast cancer is currently the most prevalent malignancy affecting women. Treatments have
improved over time, such that the current survival rate across stages is approximately 88%
(American Cancer Society, 2006). Coinciding with these improvements in mortality rates,
medical and behavioral health care providers alike are increasingly attuned to the experiences
women have following treatment completion. Research on quality of life after treatment for
cancer abounds (e.g., Carver, Smith, Petronis & Antoni, 2006; Helgeson & Tomich, 2005;
Correspondence concerning this article should be addressed to Stephanie A. Reid-Arndt, PhD, Department of Health Psychology,
University of Missouri-Columbia, One Hospital Drive, DC116.88, Columbia, MO, 65212. E-mail: reidarndts@health.missouri.edu..
Reid-Arndt et al. Page 2
Mols, Vingerhoets, Coebergh & van de Poll-Franse, 2005), with efforts underway to identify
factors that improve the quality of life experienced by cancer survivors, so that treatments to
enhance these factors can be developed.
Cognitive Deficits Following Cancer Treatment

Within the field of cancer survivorship research, one issue receiving increased attention in the
past 10 years is the impact of chemotherapy on cognitive functioning. A growing literature
suggests that chemotherapy is associated with a decline in cognitive functioning among a subset
of women treated for breast cancer (for reviews, see Rugo & Ahles, 2003; Tannock, Ahles,
Ganz, & Van Dam, 2004), with prevalence estimates ranging from 17-35% (Ahles & Saykin,
2001). Deficits have specifically been noted in memory (e.g., Ahles et al., 2002; Brezden,
Phillips, Abdolell, Bunston, & Tannock, 2000; Meyers, Byrne, & Komaki, 1995; Wienke &
Dienst, 1995), attention/concentration (Schagen et al., 1999; van Dam et al., 1998; Van
Oosterhout et al., 1996; Wienke & Dienst, 1995), psychomotor speed (Ahles et al., 2002;
Meyers et al., 1995; van Dam et al., 1998), and cognitive processing speed (Silberfarb,
Philibert, & Levine, 1980; van Dam et al., 1998; Van Oosterhout et al., 1996). Several meta-
analyses have revealed small to medium effect sizes across each of these cognitive domains
(Falleti, Sanfilippo, Maruff, Weih, & Phillips, 2005; Stewart, Bielajew, Collins, Parkinson, &
Tomiak, 2006), with the largest effects for executive functioning and verbal memory
(Anderson-Hanley, Sherman, Riggs, Agocha, & Compas, 2003). The etiology of these deficits
remains unclear, with several possibilities currently under consideration including: fatigue,
hormonal changes, direct neurotoxic effects, and genetic predispositions (for reviews, see Reid-
Arndt, 2006; Saykin, Ahles & McDonald, 2003).
While research documents cognitive changes post-chemotherapy, the duration of these

observed changes has not been clearly delineated. Some studies suggest these deficits may be
long-term, as continued reports of a decline in cognitive functioning (e.g., forgetfulness,
increased distractibility, problems concentrating) have been noted among breast cancer
survivors at 5-10 years after initial diagnosis (Ahles et al., 2002; Ganz et al., 2002). However,
other results from longitudinal and cross-sectional studies reveal that, for some women,
cognitive impairments may diminish over time. For example, one series of studies indicated
that initial cognitive impairments noted at 2 years post-treatment (Schagen et al., 1999; Van
Dam et al., 1998) were no longer present at 4 years post-treatment (Schagen et al., 2002).
Another study followed 18 women treated for breast cancer, collecting data pre-chemotherapy,
at 6-months post-chemotherapy, and at one year post-chemotherapy (Wefel, Lenzi, Theriault,
Davis, & Meyers, 2004). Deficits were documented in attention, processing speed and verbal
memory, particularly at 6-months post-chemotherapy; approximately 45% evidenced
improvements over time. Finally, one cross-sectional study compared individuals currently
undergoing chemotherapy with a group who had completed chemotherapy a median of 2 years
prior and a group of healthy controls (Brezden et al., 2000). A general cognitive screen revealed
deficits among all women with a history of chemotherapy; importantly, women with a prior
history of chemotherapy performed better than those currently undergoing chemotherapy,
while the healthy controls performed better than both chemotherapy groups. Together, these
data suggest that the decline in cognitive functioning post-chemotherapy may resolve over time
among a portion of affected individuals, while some will continue to demonstrate cognitive
deficits.
Factors Influencing Functional Outcomes among Breast Cancer Survivors

Although progress has been made in identifying and understanding cognitive deficits following
cancer treatment, what has yet to be considered is the functional significance of these deficits.
Specifically, while studies provide evidence of statistically significant cognitive weaknesses,
there is limited information regarding potential clinical significance (Reid-Arndt, 2006). For

example, although relative intra-individual cognitive weaknesses have been found, in general
women are performing in the normal range compared to age and education matched peers.
Additionally, to these authors' knowledge, there is a lack of research documenting the
relationship between cognitive functioning and measures of functional outcomes, despite calls
for this type of analysis (e.g., Ahles & Saykin, 2001).
While there is a dearth of information regarding the functional impact of cognitive deficits
among BCS, there exists a relatively extensive literature documenting the effects of other
variables on functional outcomes such as quality of life, vocational functioning, and social
functioning. For example, prior research has identified several psychological and interpersonal
factors that are associated with better quality of life, including greater degree of optimism
(Carver et al., 2005), strong social support (Friedman et al., 2006), and use of stress
management interventions (Antoni et al., 2006). Age also plays a part in predicting quality of
life after treatment, with younger survivors reporting poorer mental health outcome than older
patients (Wenzel et al., 1999).
Returning to work is both an indicator of recovery and an important contributor to quality of

life. In a qualitative study of cancer survivors, many individuals reported that “work brought
an added sense of meaning, challenge and accomplishment at a time when their cancer made
such meaning particularly important” (Main, Nowels, Cavender, Etschmaier, & Steiner,
2005, p. 1002). Unfortunately, some women experience changes in vocational functioning
associated with their diagnosis and treatment of cancer. For example, one study found that
approximately one-third of the cancer survivors who were employed prior to diagnosis were
no longer working 6 months after their diagnosis, and those who returned worked fewer hours
per week on average compared to before their diagnosis (Bradley, Neumark, Bednarek, &
Schenk, 2005). Moreover, individuals needed to accommodate treatment plans into their
vocational obligations in a variety of ways, including quitting their job or changing employers.
Social functioning is an important part of the multidimensional conceptualization of quality of

life, and women undergoing treatment for breast cancer express concerns about the impact of
their diagnosis and treatment on social and role functioning (Osoba et al., 2006). In a
longitudinal study, breast cancer survivors consistently reported lower social and role
functioning compared to a control group of healthy individuals both at the time of diagnosis
and up to one year after surgery (Schou, Ekeberg, Sandvik, Hjermstad, & Ruland, 2005). While
other domains of quality of life showed signs of improvement over time, social and cognitive
functioning were the slowest to recover. Several individual and situation factors have been
associated with poorer social role functioning outcomes, such as pessimism (Carver et al.,
2005), passive approach to decision-making about treatment plans (Hack, Degner, Watson, &
Sinha, 2006), and failure to disclose concerns (Figueiredo, Fries, & Ingram, 2004).
Together, these findings demonstrate the evident impact of cancer treatment on quality of life,
vocational functioning, and social functioning, as well as how individual factors may moderator
this effect. Interestingly, although there is evidence from other populations (e.g., TBI, multiple
sclerosis) that cognitive functioning is another individual variable that can impact functioning
in each of these domains (e.g., Girard et al., 1996; Hanks, Rapport, Millis, & Deshpande,
1999; Rao et al., 1991), the link between functional outcomes and cognitive deficits among
cancer survivors has yet to be clearly explicated.
The present study represents an initial effort to fill this knowledge gap. Women with Stages
1-3 breast cancer who completed adjuvant chemotherapy were seen at 1-month following
chemotherapy, at which time data were collected regarding cognitive, emotional, social, and
vocational functioning. The goal of this project was to demonstrate what effects changes in
cognitive functioning following chemotherapy for breast cancer may be having on quality of

life and functional outcomes in the early stages of survivorship. We predicted that cognitive
weaknesses, and particularly executive functioning deficits, would be associated with poorer
quality of life and social role functioning among women breast cancer patients one month
following completion of chemotherapy.
METHODS
Participants
Forty-six women receiving treatment for Stages I - III primary breast cancer participated in
this study. Demographic information for study participants is provided in Table 1. Almost one-
half of participants were diagnosed with Stage II breast cancer (47.4%), while 23.7% were
diagnosed with Stage I and 28.9% were diagnosed with Stage III. Participants underwent
mastectomy or lumpectomy and received adriamycincyclophosphamide with or without
paclitaxel or taxotere or a variant of that program; the average number of chemotherapy cycles
across all stages was 5.77 (SD = 1.93). Exclusion criteria were identified through a study-
specific intake screening questionnaire completed at the first appointment and included: prior
history of adjuvant chemotherapy for cancer, past or current neurological illness, and
significant psychopathology (e.g., psychosis).
Measures
Demographic data were obtained via a questionnaire created specifically for this study.
Information regarding medical variables (e.g., cancer stage, number of chemotherapy cycles,
and exposure to other adjuvant therapies including radiation and Tamoxifen) was obtained
from the participants' medical records, with their informed consent.
Neuropsychological measures were used to evaluate skills in five cognitive domains:

Immediate Memory, Delayed Memory, Attention, Executive Functioning, and Verbal Fluency.
Specific tests comprising each of 5 cognitive domains are listed in Table 2. Of note, while
verbal fluency is often considered a component of executive functioning because it can be
associated with frontal lobe lesions (e.g., Miceli, Caltagirone, Gainotti, Masullo, & Silveri,
1981;Stuss et al., 1998), an a priori decision was made to separate this from other executive
functioning measures based on clinical observations that word-finding deficits are one of the
most common complaints reported in the cancer treatment centers where this study occurred.
Finally, in line with neuropsychological theory and research (e.g., Griffin, Mindt, Rankin,
Ritchie, & Scott, 2002; Kareken, Gur, & Saykin, 1995; Lezak, 1995), the Wide Range
Achievement Test-3 (WRAT-3) Reading subtest (Wilkinson, 1993) was included as an
estimate of overall premorbid functioning. In general, this battery was designed to evaluate a
broad range of cognitive domains, and the specific selection of tests was based on
neuropsychological batteries used in prior research with cancer patients (e.g., Ahles et al.,
2002;Meyers et al., 1995;van Dam et al., 1998;). It included those tests determined to be most
sensitive to changes secondary to chemotherapy treatment for cancer.
Psychological variables were measured with the Hesitation Scale and the Profile of Mood
States - Short Form (POMS-SF). The Hesitation Scale is a 20-item measure of willingness to
seek social support. Previous research using this scale (Farmer, Clark & Sherman, 2003)
demonstrated that reluctance to seek social support was significantly related to perceptions of
lesser social support and lower quality of life. The POMS-SF, which is a 37-item version of
the original 65-item POMS, was developed by Shacham (1983) for use with cancer patients.
There are six subscales -- Depression, Vigor, Confusion, Tension, Anger, and Fatigue -- with
internal consistency reliabilities ranging from 0.78 to 0.91 (Baker, Denniston, Zabora, Polland,
& Dudley, 2002).

Social role functioning was measured with a questionnaire designed to assess individuals'
perceptions of their competency in fulfilling important social roles (Bettencourt & Sheldon,
2001; Sheldon & Bettencourt, 2002). This measure was developed as part of a body of research
examining the theory that successful social role involvement may promote authentic self-
expression while still enhancing group connectedness (Bettencourt & Sheldon, 2001; Sheldon
& Bettencourt, 2002). This measure has been found to predict subjective well-being
(Bettencourt & Sheldon, 2001) and depression among cancer survivors (Talley, Molix,
Schlegel & Bettencourt, in press). Subscales from this measure evaluate perceived competency
in social roles (internal reliabilities = .78-.80), providing an index of perceived functioning in
four possible roles: as a spouse/partner, a parent, an employee, and any other role identified
by each participant (e.g., volunteer, caregiver). Participants are asked to indicate their level of
agreement using a 6 point Likert scale in response to items such as: “I feel as if I am fully
functioning in my role as a spouse/partner.”
Community Integration Questionnaire (CIQ) was administered to measure general community

involvement as well as engagement in home activities, social activities, and work activities
(Willer, Rosenthal, Kreutzer, Gordon & Rempel, 1993). Research with other groups with
chronic medical conditions (e.g., TBI) has reported internal consistencies ranging from .79 to .
90 (Corrigan & Deming, 1995).
Functional Assessment of Cancer Therapy-Breast (FACT-B) is a commonly used measure of

quality of life in breast cancer survivors. The FACT-B includes items designed to assess quality
of life (QOL) in terms of patients' relationships with their physician(s) as well as physical,
emotional, social, functional well-being. This measure includes items from the FACT-General
as well as 9 additional items specifically selected to evaluate QOL issues in breast cancer
survivors. Per a validation study (Brady et al., 1997), the total score from this measure has
acceptable internal consistency (Chronbach's alpha=.90) and test-retest reliability (.85).
Construct validity was suggested by high correlations with other measures of QOL, such as
the Functional Living Index - Cancer (r=.87).
Procedure
Women who were receiving adjuvant chemotherapy treatment for breast cancer were recruited
at 3 sites in a Midwestern city (an academic hospital, a private hospital, and a private oncology
practice). They were informed of the study by a health care provider working with them
(typically their treating physician or nurse) prior to the completion of their last cycle of
chemotherapy. Those who expressed an interest in the study were contacted by a member of
the research team, either in person or via telephone, so that a description of the study could be
provided and any questions answered. All participants provided informed written consent in
accordance with the Institutional Review Board informed consent guidelines at each site.
Participants then completed a data collection session at 1-month following the completion of
their chemotherapy, which was an average of 5 months following the diagnosis of cancer for
study participants. Efforts were made to ensure that these appointments coincided with the
participants' follow-up appointments with health care providers at each site.
RESULTS
Wilcoxon Signed Rank tests were computed to assess for relative deficits for each cognitive
domain. Next, backwards selection regression analyses were conducted to determine what
variables predict the outcome measures of interest. For each regression model, possible
predictor variables included medical variables (i.e., number of chemotherapy treatments,
POMS-SF Fatigue subscale), psychological variables (i.e., POMS-SF Depression subscale,
Hesitation Scale), and cognitive variables (i.e., composite indices of Executive Functioning
and Verbal Fluency). Three composite indices (Immediate Memory, Delayed Memory,

Attention) were excluded from regression analyses based on findings from initial Wilcoxon
Signed Rank tests that revealed no evidence of deficits in these domains.
Cognitive functioning
First, composite variables were created for each cognitive domain of interest by converting
each individual's raw test scores to z-scores utilizing age, education, and gender based
normative data. Thereafter, an average of each person's z-scores for tests comprising each
domain was computed.
For the initial analyses, we were interested in determining whether participants may be
experiencing a decline in cognitive functioning compared to estimated premorbid abilities. As
noted above, in the absence of pre-treatment data, the WRAT-3 Reading test was used as a
proxy of premorbid functioning, a procedure that has support in both clinical literature (e.g.,
Lezak, 1995) and research literature (Johnstone, Hexum, & Ashkanazi, 1995). Thus, for these
analyses, a new variable was created reflecting the difference between each individual's
estimate of premorbid abilities (WRAT-3 Reading) and her composite score for each domain.
Wilcoxon Signed Rank tests were computed to determine if the mean change in composite test
scores was significantly different from zero. Results indicated that at 1-month post-
chemotherapy, participants were demonstrating significantly lower scores in Executive
Functioning (t = -2.71, p = .01) and Verbal Fluency (t = -4.54, p < .001) than would have been
expected based on premorbid estimates. Conversely, the mean Immediate Memory and
Delayed Memory scores were significantly higher than expected (Immediate Memory: t = 3.06,
p < .01; Delayed Memory: t = 4.08, p < .001). See Table 3 for mean scores. A review of the
distribution of difference scores revealed that 21.7% were performing >1 SD below premorbid
estimates in Executive Functioning, while 41.3% were performing >1 SD below premorbid
estimates in Verbal Fluency (see Figure 1).
Correlations between Outcome Variables

Pearson correlation analyses were performed to better understand the relationships between
the multiple measures of functional outcomes, which included FACT-B (Brady et al., 1997),
Community Integration Questionnaire (Willer et al., 1993) and the Social Roles Measure
(Bettencourt & Sheldon, 2001). As evidenced in Table 4, measures of social functioning
(FACT-B Social Well-Being, CIQ Social Integration, Social Roles) were significantly
correlated (all r's > .34, all p's < .05). Significant correlations were also observed among
measures of productivity (FACT-B Functional Well-Being, CIQ Productivity, CIQ Total: all
r's > .35, all p's < .05). Finally, consistent with prior research (Bettencourt & Sheldon, 2001;
Talley et al., in press), social role functioning was also correlated with emotional well being
(FACT-B Emotional Well-Being, r = .589, p < .01).
Predicting Functional Outcomes

Backwards selection regression analyses were conducted to evaluate the relationships between
functional outcomes of interest and several predictor variables. Based on a priori hypotheses
that they may impact participants' outcomes, predictors entered into the equation for each
model included medical variables (number of chemotherapy treatments, POMS Fatigue
subscale) and psychological variables (POMS Depression subscale, Hesitation scale).
Additionally, to evaluate the potential effects of cognitive decline on functional outcomes,
composite scores from domains where a relative decline in cognitive functioning was
evidenced in initial analyses -- Executive Functioning and Verbal Fluency -- were included.
Quality of life—Regression analyses were conducted to determine whether these predictor

variables were associated with reports of quality of life. As noted above, the FACT-B index

of quality of life is comprised of multiple subscales, each of which was evaluated separately.
The model for FACT-B Social Well-Being was significant, F(2, 38) = 8.93, p = .001,
accounting for 32% of the variance. Examination of the individual betas showed that higher
levels of depression and greater hesitation to seek support were associated with poorer social
well-being: POMS Depression was marginally significant at p = .079, while Hesitation was
significant at p = .017. Similarly, the model for FACT-B Emotional Well-Being was
significant, F(2, 38) = 21.29, accounting for 53% of the variance. A review of the individual
betas revealed that POMS Depression and Hesitation were again significant predictors in this
model (p = .017 and p < .001, respectively), revealing that higher levels of depression and a
greater reluctance to seek social support were also associated with poorer emotional well-being.
The model for FACT-B Functional Well-Being was significant, F(3, 37) = 12.11, p < .001,
accounting for 50% of the variance. A review of the individual beta weights revealed that
poorer functional well-being, an index of the ability to participate in important daily activities
(including work and leisure activities), was associated with greater reluctance to seek social
support (Hesitation: p = .001), more chemotherapy treatments (p = .061), and higher levels of
fatigue (POMS Fatigue: p = .001). The FACT-B includes a subscale seeking ratings on one's
Relationship with his/her Doctor, and this model was significant, F(1, 39) = 4.00, p = .052,
accounting for a modest 9% of the variance. A review of betas revealed that greater reluctance
to seek social support, indexed by the Hesitation scale, was associated with reports of less
satisfying relationships with doctors (p = .052). Finally, the model for the FACT-B Physical
Well-Being subscale was also significant, F(1, 39) = 5.162, p < .05, accounting for 12% of
variance. POMS Fatigue was the single variable that remained significant in this backwards
selection model (p = .029), indicating that increased fatigue was associated poorer physical
well-being.
Community involvement and productivity—Regression analyses were conducted to

determine what variables were associated with five measures of community involvement and
productivity included in this study. As noted above, the Community Integration Questionnaire
(CIQ) provides three subscale scores as well as a total score; regression analyses were computed
using each as an outcome measure. The model for CIQ Social Integration was significant, F
(1, 39) = 5.490, p < .05, with predictors accounting for 12% of the variance. A review of the
betas revealed that better executive functioning was associated with enhanced social integration
(Executive Functioning: p < .024). Executive functioning (p = .05) as well as depression
(POMS Depression: p = .05) were significant predictors accounting for 22% of the variance
in a model for CIQ Productivity (F(2, 38) = 5.26, p = .01), indicating that productivity was
lowered by poorer executive functioning and increased symptoms of depression. The model
for CIQ Home Integration did not reach significance. Finally, the model for the CIQ Total
Score was significant, F(2, 38) = 5.73, p < .01, accounting for 23% of the variance. A review
of the betas revealed that better executive functioning and less fatigue were associated with
enhanced overall community involvement (Executive Functioning: p = .10; POMS Fatigue:
p < .05).
Finally, the Social Roles questionnaire was also utilized as an index of participants' perceived
effectiveness in important social roles. The model for social roles functioning was significant,
F(2, 37) = 9.35, p < .001, accounting for 34% of the variance. A review of the betas revealed
that better executive functioning and less reluctance to seek social support were associated
with enhanced social role functioning (Executive Functioning: p = .01; Hesitation: p < .01).
DISCUSSION
The present study was undertaken to ultimately provide direction for improving the lives of
women breast cancer survivors by offering initial insight into how cognitive deficits relate to

functional outcomes in the early stages of recovery following chemotherapy. Although the
etiology remains unknown, research to date has suggested that a portion of women will
experience modest cognitive decline following chemotherapy (Ahles & Saykin, 2001), and the
present study supported this observation. Specifically, there was a significant decline in
executive functioning and verbal fluency skills compared to estimated premorbid abilities
among participants at 1-month following the completion of chemotherapy. These findings are
consistent with reports from other research, which suggest that these complex cognitive skills
may be most susceptible to adverse effects of chemotherapy (e.g., Ahles et al., 1998; Freeman
& Broshek, 2002; Schagen et al., 1999; van Dam et al., 1998; Wienke & Dienst, 1995;).
Subsequent analyses were conducted to clarify whether these cognitive deficits may be
impacting quality of life and daily functioning; findings provided mixed support for this
possibility. First, data did not support the hypothesis that the observed cognitive deficits were
having a significant impact on quality of life as measured by the FACT-B. Rather, consistent
with prior research on quality of life (Visser & Smets, 1998), symptoms of depression were
associated with social and emotional well-being among this group of cancer survivors. Also
consistent with a growing body of literature (e.g., Tchen et al., 2003) was the finding that
increased fatigue is associated with poorer quality of life among women following treatment
for breast cancer.
The present research revealed some novel findings regarding quality of life among cancer
survivors as well. Specifically, individuals who were more reluctant to seek social support, as
measured by the Hesitation Scale, were also more likely to report relatively poorer social and
emotional well-being, as well as poorer doctor-patient relationships. These findings are in line
with some of the literature on coping, which has suggested that social support seeking as a
coping style may have a significant impact on emotional well-being (Holland & Hollahan,
2003; Stanton & Snider, 1993).
While cognitive decline following treatment for breast cancer did not predict quality of life in
this study, there was evidence that deficits in executive functioning were adversely impacting
other functional outcomes. Specifically, women who were experiencing greater deficits in
executive functioning were less engaged in social and community activities, and they were
reporting greater difficulties functioning effectively in important social roles (e.g., spouse,
parent, employee, etc.). These findings validate breast cancer survivors' anecdotal reports that
difficulties with multi-tasking, particularly during treatment and in the early stages following
treatment completion, hinder their functioning at work and at home. They are also significant
because there may be long-term consequences of an initial decline in cognitive functioning
and functional abilities (e.g., women may be more inclined to quit a job or disengage from
other important responsibilities during this period). Moreover, while some of these women
may experience a recovery in cognitive functioning over time, prior research has indicated that
these deficits persist for a portion of those affected. Thus, this study points to the potential need
for interventions in the early stages of recovery following treatment for breast cancer.
Several limitations of the study are worth noting. First, although this procedure is consistent
with a majority of studies in this area (see Minisini et al., 2004), the absence of pre-
chemotherapy data restricts our ability to draw conclusions regarding the extent of cognitive
decline following treatment. However, it is also true that cognitive testing immediately prior
to starting chemotherapy may not provide the best indication of baseline functioning.
Specifically, it is well known that the time from diagnosis to the initiation of treatment is a
cognitively taxing and emotionally stressful period. Given the adverse impact that emotional
distress can have on cognitive functioning, it could be argued that testing during this period
may not provide a true index of premorbid abilities.

Second, multiple analyses were conducted on a dataset having a relatively large number of
variables and a modest sample size. Efforts were made to address this limitation in several
ways. For example, the number of variables in each model was minimized by creating
composites for the neuropsychological test scores, and the number of medical and
psychological variables was limited in each model. Moreover, all models were developed based
on a priori hypotheses, and efforts were made to uncover converging evidence to support
conclusions about relationships between the predictor and outcome variables. Despite this,
future projects can improve upon this work by relying on a larger sample size.
While deficits in executive functioning have been among the most consistently documented
following treatment for breast cancer (Anderson-Hanley et al., 2003), it is worth noting that
conceptually this domain of functioning encompasses a wide range of cognitive abilities. In
this study's test battery, two measures were utilized that are often described as indices of set
shifting (Trails B) and response inhibition (Stroop test). Research abounds indicating that
executive functioning is not a unitary construct, and that in fact different measures of executive
functioning rely on intact processing in a variety of neural regions (Posner & Peterson,
1990). Thus it would be informative to administer a broader range of executive functioning
measures to women following treatment for cancer. This could help to determine whether it is
appropriate to conclude that there are impairments in the broad range of skills typically
associated with executive functioning or whether the deficits are relatively more circumscribed.
With regards to understanding the cognitive changes experience with cancer treatment, it is
interesting to note that study participants performed better on immediate and delayed memory
tasks than would have been predicted based on WRAT-3 Reading test scores. This raises some
questions regarding the utility of this measure as an estimate of pre-morbid functioning with
this sample. While this test is commonly used in research and clinical work to estimate pre-
morbid abilities, research comparing IQ test scores with various estimates of pre-morbid
abilities has suggested that the WRAT-3 Reading test may underestimate abilities among
individuals with higher intellectual functioning (Johnstone, Callahan, Kapila, & Bouman,
1996; Weins, Bryan, & Crossen, 1993). As a group our participants had a high level of
education (33% had completed some college, and an additional 33% had college degrees or
higher), which is known to be correlated with higher intellectual abilities (Neisser et al.,
1996). If their intellectual functioning was in fact also above average, WRAT-3 Reading scores
may have underestimated their pre-morbid functioning, which could have implications for
analyses attempting to determine whether cognitive decline had occurred. However, it is noted
that the primary goal of this research was to examine relationships between cognitive deficits
and functional outcomes, and that regression analyses addressing this aim utilized cognitive
composite scores and did not rely on comparisons with estimated pre-morbid abilities.
IMPLICATIONS FOR CLINICAL PRACTICE

Literature on the experiences of cancer survivors has provided ample evidence of a decline in
cognitive functioning among a portion of women who have undergone treatment for breast
cancer. Data from the present study document this occurrence and further suggest that cognitive
difficulties after treatment can have significant implications for real world functioning.
Specifically, it appears that those women experiencing cognitive decline following treatment
may experience greater difficulties engaging in productive activities, such as being involved
in their communities and being effective in important social roles.
These observations provide support for the ongoing development of interventions for cognitive
deficits following chemotherapy, which has already received some attention to date. Potentially
useful treatments may include medications such as methylphenidate, which has demonstrated
positive effects (National Cancer Institute, 2005). Additionally, psychological interventions

focused on providing emotional support and training in metacognitive strategies, similar to

those being offered for other populations with mild cognitive decline (e.g., mild traumatic brain
injury) have promise and are currently being developed (Ferguson et al., 2007; Tannock et al.,
2003).
Given the improving survival rates, cancer is increasingly being viewed as a chronic illness,
with affected individuals benefiting from long-term follow-up and assistance in dealing with
physical and psychological sequelae. Findings from this research suggest that cognitive issues
may warrant similar attention in our efforts to understand and address factors that may affect
daily functioning and long-term outcomes among cancer survivors.
Acknowledgments
This research was supported by Grant R03 CA108340 from the National Cancer Institute.
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Figure 1.
Percentage of Participants with Relative Cognitive Weaknesses

Table 1
Demographic Information
Mean Age (years) 53.38 (9.61)

Marital Status
Married 64%
Single 36%
Ethnicity/Race
Caucasian 100%
Mean Education (years) 14.87 (2.56)
Employment Status
30+ hours/week 70.7%
10-30 hours/week 10.4%
Not employed 18.9%
n = 46

Table 2
Neuropsychological Measures
Cognitive Domain Measures
Immediate Memory WMS-III Logical Memory Ia
WMS-III Visual Reproduction Ia

Delayed Memory WMS-III Logical Memory IIa
WMS-III Visual Reproduction IIa
Rey AVLT Delayed Recallb

Attention Trail Making Test Ac
WAIS-III Digit Spand

Executive Functioning Trail Making Test Bc
Stroop Teste
Verbal Fluency COWATf
Category Fluencyg
[a]
(Wechsler, 1997a)
[b]
(Taylor, 1959)
[c]
(Reitan, 1955)
[d]
(Wechsler, 1997b)
[e]
(Golden, 1978)
[f]
(Benton & Hamsher, 1989)
[g]
(Spreen and Strauss, 1991)

Table 3
Group Mean z (difference) scores* for each Cognitive Domain

Cognitive Domain Mean z (difference) score
Immediate Memory .29 (.80)a
Delayed Memory .49 (.81)b

Attention -.04 (.84)
Executive Functioning -.44 (1.10)a
Verbal Fluency -.65 (.97)b
*
z(difference) score = (Domain composite z-score) - (WRAT-3 Reading z-score)
a
Wilcoxon Signed Rank test, p <. 05
b
Wilcoxon Signed Rank test, p < .001

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 4
Correlations between Outcome Measures
FACT/SWB Subscale FACT/RWD Subscale FACT/EWB Subscale FACT/FWB Subscale CIQ/Home Integration Score CIQ/Social Integration Score CIQ/Productivity Score CIQ/Total Score
FACT/RWD Subscale .316*

Reid-Arndt et al.
FACT/EWB Subscale .571** .121
FACT/FWB Subscale .713** .363* .674**

CIQ/Home Integration Score .024 -.085 .027 -.042
CIQ/Social Integration Score .506** .021 .413** .345* .390**
CIQ/Productivity Score .224 .157 .174 .358* -.104 .041
CIQ/Total Score .368* .079 .335* .306* .677** .699** .471**
Social Roles Average .573** .128 .589** .451** -.248 .341* .026 .066
*
Correlation is significant at the 0.05 level (2-tailed).
**
Correlation is significant at the 0.01 level (2-tailed).

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J Psychosoc Oncol. 2009 ; 27(4): 415–434. doi:10.1080/07347330903183117.

Cognitive and Psychological Factors Associated with Early Post-

Stephanie A. Reid-Arndt, PhD, ABPP

Cognitive Deficits Following Cancer Treatment

While research documents cognitive changes post-chemotherapy, the duration of these

Factors Influencing Functional Outcomes among Breast Cancer Survivors

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Returning to work is both an indicator of recovery and an important contributor to quality of

Social functioning is an important part of the multidimensional conceptualization of quality of

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

following completion of chemotherapy.

Neuropsychological measures were used to evaluate skills in five cognitive domains:

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Community Integration Questionnaire (CIQ) was administered to measure general community

Functional Assessment of Cancer Therapy-Breast (FACT-B) is a commonly used measure of

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Correlations between Outcome Variables

(FACT-B Emotional Well-Being, r = .589, p < .01).

Predicting Functional Outcomes

Quality of life—Regression analyses were conducted to determine whether these predictor

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Community involvement and productivity—Regression analyses were conducted to

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

IMPLICATIONS FOR CLINICAL PRACTICE

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

focused on providing emotional support and training in metacognitive strategies, similar to

493. [PubMed: 11786578]

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Corrigan JD, Deming R. Psychometric characteristics of the Community Integration Questionnaire:

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Micelli G, Caltagirone C, Gainotti G, Masullo C, Silveri MD. Neuropsychological correlated of localized

Quality of Life Research 2005;14:1813–1823. [PubMed: 16155769]

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Stewart A, Bielajew C, Collins B, Parkinson M, Tomiak E. A Meta-Analysis of the Neuropsychological

Chemotherapy for Breast Cancer. Psycho-Oncology 1995;41:61–66.

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Mean Age (years) 53.38 (9.61)

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Cognitive Domain Measures

Immediate Memory WMS-III Logical Memory Ia

WMS-III Visual Reproduction Ia

WMS-III Visual Reproduction IIa

Rey AVLT Delayed Recallb

WAIS-III Digit Spand

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

Group Mean z (difference) scores* for each Cognitive Domain

Cognitive Domain Mean z (difference) score

Immediate Memory .29 (.80)a

Delayed Memory .49 (.81)b

Executive Functioning -.44 (1.10)a

Verbal Fluency -.65 (.97)b

J Psychosoc Oncol. Author manuscript; available in PMC 2009 October 11.

FACT/RWD Subscale .316*

FACT/EWB Subscale .571** .121

FACT/FWB Subscale .713** .363* .674**

CIQ/Social Integration Score .506** .021 .413** .345* .390**

CIQ/Social Integration Score .506 .021 .413 .345* .390**

CIQ/Total Score .368* .079 .335* .306* .677 .699 .471**