Assessment

It is becoming increasingly common to assess cognitive functioning and symptoms experienced by cancer patients in clinical trials of new anticancer therapies. As defined by a working group of members of the Food and Drug Administration, National Cancer Institute (NCI), and the NCI Division of Cancer Treatment Board of Scientific Counselors, net clinical benefit of cancer therapy includes: (i) survival benefit, (ii) time to treatment failure and disease-free survival, (iii) complete response rate, (iv) response rate, and (v) beneficial effects on disease-related symptoms and/or quality of life. Especially for regimens that differ only slightly with respect to response and survival, the rationale for selecting a particular therapy may be highly related to the impact of that treatment on cognitive function, symptoms, and quality of life.

As can be seen from the previous discussion, the specific causes of cognitive dysfunction is critically important to guide interventions because the type of intervention most helpful will be dramatically different depending on the etiology. The specific intervention plan not only takes into account the underlying cause of the complaint but also needs to be individualized for the person because the impact of a cognitive problem will be different for different people. A practical system to evaluate the impact of neurocognitive dysfunction was developed by the World Health Organization, which classifies the impact of an illness in three domains; impairment, disability, and handicap. Impairment is the deficit in function. In the case of neurocognitive symptoms, the deficit is in the function of the brain and manifested by neurologic, cognitive and emotional changes. Formal assessment of neuro-cognitive function can help determine the etiology of the complaints and the profile of the cognitive changes, and it can also help in the institution of appropriate intervention strategies. Disability is the impact of the deficit in the patient's ability to perform usual work and home activities. The degree of disability for an individual patient will be at least partially related to age, the type of work performed, and the amount of support that is available. Performance and functional status measures may help to define the disability and help determine the need for more comprehensive assessments. Handicap is the impact of the disability on the person's overall satisfaction and well-being. Handicap is generally what is referred to when discussing quality of life (QOL) and is often assessed by QOL questionnaires. Again, handicap is very individual. One person can be handicapped by a relatively minor disability, whereas another individual suffering from a severe impairment may experience little handicap. For example, an impairment in multitasking caused by a difficulty with sustained attention is a common problem for cancer patients. This may not be particularly handicapping to a person who is self-employed and can work at his or her own pace at home. However, it might cause a secretary in a busy office, who needs to answer the phone while word processing, to lose his or her job. Thus, all three levels of function (deficit, disability, and handicap) need to be assessed for appropriate management of the patient.

Many cancer patients have difficulty resuming their normal activities following diagnosis and treatment. Unfortunately, neurobehavioral functioning is often the least addressed aspect of a medical evaluation unless very severe behavioral changes are apparent. Multidisciplinary assessment of neurocognitive complaints can maximize patients' ability to function at the highest level of independence and productivity for the longest duration of time. As cancer treatment becomes more successful there will be increasing numbers of patients who live longer and expect to return to their preillness level of functioning. The risks of treatment and impact on the patient's ability to perform activities of daily living must be addressed more comprehensively. Many intervention strategies are available, including pharmacologic management, behavioral strategies, life-style alterations, formal rehabilitation, and counseling.

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