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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 119-120

“My cancer is cured, but I do not feel normal”: A commentary on neuropsychological outcomes of pediatric acute lymphocytic leukemia in India

1 Department of Palliative Care and Psycho-Oncology, Tata Medical Centre, Kolkata, West Bengal, India; MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
2 Department of Palliative Care and Psycho-Oncology, Tata Medical Centre, Kolkata, West Bengal, India

Date of Submission24-Feb-2021
Date of Decision01-Mar-2021
Date of Acceptance02-Mar-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Soumitra Shankar Datta
Department of Palliative Care and Psycho-Oncology, Tata Medical Center, Main Arterial Road, Newtown, Kolkata - 700 160, West Bengal

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_49_21

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How to cite this article:
Datta SS, Mukherjee A. “My cancer is cured, but I do not feel normal”: A commentary on neuropsychological outcomes of pediatric acute lymphocytic leukemia in India. Cancer Res Stat Treat 2021;4:119-20

How to cite this URL:
Datta SS, Mukherjee A. “My cancer is cured, but I do not feel normal”: A commentary on neuropsychological outcomes of pediatric acute lymphocytic leukemia in India. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Dec 4];4:119-20. Available from: https://www.crstonline.com/text.asp?2021/4/1/119/312108

In the year 2020, there were a total of 4,74,519 newly diagnosed cases of leukemia globally.[1] The outcomes for acute lymphocytic leukemia (ALL) have improved significantly over the past three decades, and long-term survival is not at all uncommon. Cancer-related cognitive changes along with other problems, such as emotional issues, body image issues, fertility issues, skin and eye changes, endocrine abnormalities, and more serious outcomes like the diagnosis of a second cancer, may significantly impact the personal as well as professional lives of cancer survivors. There have been attempts to quantify and provide appropriate individualized interventions for cancer-related cognitive symptoms in adolescent and adult cancer survivors.[2],[3]

In the current issue of the journal, Abraham et al.[4] have reported on the long-term neuropsychological functioning of 51 pediatric ALL survivors from a single center in South India. Their study cohort included both adolescent and adult survivors with a wide age range. Authors in this study used separate sets of psychological instruments specific to the different age groups. Two of the most important findings reported by the authors were: (1) increased impairment of focused attention and verbal memory in patients who had been diagnosed with ALL before 8 years of age and (2) long-term survival of more than 9 years being associated with better neuropsychological outcomes. In addition, the authors have adequately discussed about the limitations of their study and emphasize the need for future prospective studies with larger sample sizes.

There are several controversies around the topic of neuropsychological assessment of patients with cancer. A recent review has pointed out that there is a lack of consensus regarding the best possible ways to assess cognitive functioning in cancer survivors, and Olson et al. concluded that none of the tools were suitable to be included in clinical practice.[3] There is often a lack of agreement between objective deficits, as measured by the neuropsychological tests, and subjective reports of impairment.[5] A subset of childhood cancer survivors may have good intellectual functioning as measured by standardized instruments, but may also have new-onset domain-specific difficulties that emerge several years after the cancer treatment.[2] However, most experts believe that cancer-related cognitive changes need to be reviewed in the late-effects clinics.

There is a paucity of data from India on the objective measure of cognitive deficits among ALL survivors, and Abraham et al.'s study makes a sincere attempt to fill this gap. However, as the study population was heterogeneous, the participants had to be administered the test in a language that they could read, write, and comprehend. In the absence of standardized and validated translations of the assessment tools in each of the four languages used in this study, there may have been issues related to the comparability of the instructions given to the participants as well as the test findings. Moreover, having a measure of adaptive functioning to compare the objective assessment of cognitive functioning with the subjective views on adaptive functioning as reported by the participants could have added more value to the study. The neuropsychological functioning is reported using the categorical outcomes of “deficit” versus “no deficit” that were defined according to specific norms. For a heterogeneous study sample with a wide age range, a continuous score with statistical transformation (for non-normally distributed scores) could provide a more robust description of the data. We agree that for a study with a small sample size, it would probably be difficult to perform a multivariate analysis. However, future studies need to be planned to accommodate the need for such analyses. In our opinion, a longitudinal study with more detailed baseline data correlating with the neuro-imaging findings must be planned. Subjective cognitive decline can have confounding effects on the objective neuropsychological test scores and implications on the overall functioning.[5] In Abraham et al.'s study, the survivors who were tested after 9 years or later performed better; these findings are consistent with the earlier findings that cognitive effects of chemotherapy reduce over a period of time.[6]

We wish to congratulate the authors for their tenacity to conduct a study on such an important topic involving a cohort that is difficult to consistently follow-up for more than 8 years in any country, especially in India, where the majority of cancer treatment happens in the non-governmental cancer centers. The findings of neuropsychological deficits in childhood cancer survivors who were diagnosed before 8 years of age have important implications in planning their rehabilitation once they are back in school. There is also an urgent need to develop a consensus statement between various centers in India for acceptable neuropsychological measurement protocols that can be utilized by cancer centers around the country.

  References Top

World Health Organisation. Data Visualization Tools for Exploring the Global Cancer Burden in 2020. Lyon, International Agency for Research on Cancer; 2020. Available from: https://gco.iarc.fr/today/home. [Last accessed on 2021 Feb 24].  Back to cited text no. 1
Siegwart V, Benzing V, Spitzhuettl J, Schmidt M, Grotzer M, Steinlin M, et al. Cognition, psychosocial functioning, and health-related quality of life among childhood cancer survivors. Neuropsychol Rehabil 2020;(Ahead of Print):1-24.  Back to cited text no. 2
Olson K, Hewit J, Slater LG, Chambers T, Hicks D, Farmer A, et al. Assessing cognitive function in adults during or following chemotherapy: A scoping review. Support Care Cancer 2016;24:3223-34.  Back to cited text no. 3
Abraham J, Veeraiah S, Radhakrishnan V. Neuropsychological functioning in long-term survivors of pediatric acute lymphoblastic leukemia: A prospective cross-sectional study. Cancer Res Stat Treat 2021;4:19-28.  Back to cited text no. 4
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Hutchinson AD, Hosking JR, Kichenadasse G, Mattiske JK, Wilson C. Objective and subjective cognitive impairment following chemotherapy for cancer: A systematic review. Cancer Treat Rev 2012;38:926-34.  Back to cited text no. 5
Schagen SB, Muller MJ, Boogerd W, Rosenbrand RM, van Rhijn D, Rodenhuis S, et al. Late effects of adjuvant chemotherapy on cognitive function: A follow-up study in breast cancer patients. Ann Oncol 2002;13:1387-97.  Back to cited text no. 6


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