Telehealth CBT assists breast cancer survivors with memory problems

Specialized cognitive behavioral therapy delivered via telehealth reduced memory problems and anxiety for breast cancer survivors living in Maine in a new study published online May 2.

The small-scale study published in Cancer, the peer-reviewed journal of the American Cancer Society, is the first randomized controlled trial to use telecommunications technology to evaluate the treatment of chemotherapy-related cognitive dysfunction with an active control condition.

And it shows promise in supporting large cancer center survivorship programs as the number of people living with a cancer diagnosis in the U.S. continues to increase.

While the study had only 47 participants, about 75 percent reported that they would have declined seeking treatment for their cognitive problems because of the travel required to get to their cancer center, said lead author Robert J. Ferguson, Ph.D., who conducted the research while a clinical health psychologist at the Eastern Maine Medical Center and Lafayette Family Cancer Center in Bangor, Maine.

He joined the University of Pittsburgh Cancer Institute Biobehavioral Oncology Program as an assistant professor of medicine in mid-April.

“One of the problems with survivorship programs in large cancer centers like what we have at the University of Pittsburgh is getting survivors to come back,” Ferguson said.

“When you ask further, one of the comments that kept coming up and up is ‘Well I missed so much work while I was getting active cancer treatment’ in addition to the distance of driving. So driving time and missed work for a psychologist appointment, it’s unrealistic to expect cancer survivors to take that time again.”

Trouble remembering recent conversations, forgetting why one walked into a room or driving past a destination might not be apparent when a patient isn’t working full time and has help fulfilling family obligations.

But mild cognitive impairments can diminish a patient’s quality of life after they return to their pre-cancer roles and the stress of daily life.

An estimated 40 to 50 percent of cancer patients who receive chemotherapy experience long-term effects with verbal working memory and processing speed similar to those associated with a mild traumatic brain injury, Ferguson said.

The study used 12 sites at medical centers spanning the 300 miles between Saco in southern Maine and Presque Isle in the state’s northernmost Aroostook County.

Participants received eight weekly visits to a site where they used a private room to speak with either Ferguson or another clinician for 30 to 45 minutes over a videoconference system. Participants received either Memory and Attention Adaptation Training (MAAT) – a CBT designed by Ferguson – or the control condition supportive therapy (ST).

MAAT focuses on increasing awareness of daily life situations where memory problems arise and learning and building coping skills to prevent or compensate for them. ST, offering empathy and active listening without behavior training, was used as a “behavioral placebo,” Ferguson said.

Participants were all white women with an average age of 54.6 years who were at least four years post-chemotherapy treatment for a diagnosis of Stage I, II, or IIIA breast cancer.

Those with a history of substance abuse, learning disability, neurological disorder, brain injury or surgery involving the central nervous system were excluded from the study.

Participants rated their memory problems and anxiety associated with them on questionnaires and received over the phone neuropsychological tests to measure verbal memory and how well they could perform relatively easy cognitive tasks.

Participants were evaluated at baseline, after the eight MAAT or ST visits and then again two months later.

The MAAT participants reported significantly fewer memory problems and improved processing speed after the eight visits than the ST participants. Additionally, MAAT participants reported less anxiety about their post-treatment memory functioning at the two-month mark after the end of their clinical interaction. However, the study noted the difference in general anxiety and fatigue levels between the two groups was not statistically significant.

Ferguson acknowledged the limitations of small, homogeneous sample size of his study, which was supported by a grant from the National Institutes of Health Office of Research on Women’s Health administered by the National Cancer Institute.

He is pursuing funding for additional MAAT research that will expand the scope of study to include more diverse populations in terms of sex, ethnicity and cancer type.

“Right now we have evidence of efficacy, but our clinical trials aren’t big enough because we haven’t used multiple clinicians and we haven’t used multiple sites,” he said.

Ferguson was also working on securing a publisher for MAAT treatment manuals and workbooks to guide clinicians and survivors through their eight visits.

Research has shown no difference in efficacy between remote delivery of psychological services and in-person therapy sessions.

“I grew up in a town of 150 people in western Maine so I know what it’s like to travel for health care,” said Ferguson.