Cognitive Function in Older Adults With Cancer: Assessment, Management, and Research Opportunities

INTRODUCTION

Cancer is primarily a disease of aging, and the majority of new diagnoses of cancer occur in patients ≥ 65 years of age (herein referred to as older).¹ At the same time, cancer and its therapies are disease drivers of aging,² with studies of survivors showing accumulation of multimorbidity, sarcopenia, diminished physical function, and cognitive problems.³ Maintaining cognitive function and independence are important concerns for many patients, and loss of cognitive function is one of the most feared disease side effects.⁴

CONTEXT

• Key Objective

• What are the methods for assessing cognitive function and managing cancer-related cognitive decline (CRCD) in older adults?

• Knowledge Generated

• National guidelines recommend validated tools to assess cognitive function and screen older adults with cancer for cognitive problems, including self-report scales, performance-based measures, or a combination of both. Risk factors for the development of CRCD in older adults include low cognitive reserve, comorbidities, and frailty, and a growing body of literature suggests benefit for CRCD interventions, including cognitive rehabilitation approaches and physical activity, but further evidence in the older adult population is needed.

• Relevance

• Cognitive function is critical for an older patient's ability to conduct daily activities and maintain independence. Evaluating cognitive function may help inform older patients and their oncologists about the risks of CRCD, provide monitoring for early detection of CRCD, and allow an opportunity to intervene to optimize cognitive function.

Cancer-related cognitive decline (CRCD) is the term that describes subjective and objective changes in cognitive function that occur after a diagnosis of cancer and/or its treatment.^5,6 CRCD includes problems with memory, attention, executive function, and speed of processing information.^6,7 These symptoms can negatively affect patients' function and quality of life, although are generally more subtle than those that occur in other neurodegenerative disorders of the CNS (eg, dementia and mild cognitive impairment [MCI]).⁸ CRCD rates vary from 10%-50% depending on the setting, population, measurement, cancer type, and therapy (eg, chemotherapy, endocrine therapies, and radiation).^6,7,9-12

Although CRCD mechanisms are not fully understood, CRCD symptoms can be long-lasting, potentially extending for months to years after the completion of therapy for many patients.^13,14 Current clinical guidelines¹⁵ for older adults with cancer recommend assessment of cognitive function and risks for developing CRCD before initiating therapy to support treatment decision making. Just as the baseline functioning of other organ systems is assessed during an oncology evaluation (eg, renal and cardiac function), an understanding of cognitive function may help inform patients and oncologists about the risk of CRCD and provide an opportunity to monitor cognitive function over time and intervene to preserve cognitive functioning.

This article will highlight clinically relevant factors to consider in the evaluation of cognition when caring for older adults with cancer and discuss when to refer for additional assessment and possible intervention. Finally, we discuss knowledge gaps and future research directions.

EVALUATION OF COGNITIVE FUNCTION IN CLINICAL PRACTICE

Older individuals diagnosed with cancer often have many pre-existing conditions, including neurodegenerative diseases and dementia.^16,17 Pre-existing dementia is seen in 3.8%-7% of adults age 65+ years with cancer.¹⁸ In older adults without cancer, by 70 years of age, an estimated 13.9% have dementia¹⁶ and an additional 22.2% have MCI without overt dementia.¹⁷ Additionally, it is possible that cancer and cancer therapy may unmask or exacerbate underlying neurocognitive pathology.¹⁹ However, mild deficits are often not apparent in routine clinical encounters.²⁰ Hence, pre-treatment screening can be useful to detect these diseases and consider their impact on treatment decisions.²¹ Assessing cognitive function can also be useful to establish the patient's baseline before beginning therapy.

The evaluation of cognitive function and the risk for CRCD begins with a detailed patient history of risk factors. There are several known risk factors for the development of CRCD that can be routinely assessed during a clinical history, such as age, sociodemographic factors, comorbid medical conditions, psychologic factors, and host biology (Fig 1).^6,7,22 First, older chronologic age can predispose individuals to decline in cognitive function as part of the normative aging process and is a risk factor for the development of CRCD.^9,12,19,23 Cognitive aging is associated with gradual changes in memory, attention, and information processing speed with corresponding changes in brain structure and function (reduced gray matter volume and white matter connectivity).⁶ Cancer treatments mimic these changes, and measurable changes in these elements are observed in imaging studies of older adults with cancer undergoing treatment.²⁴

FIG 1.

This figure outlines risk factors for CRCD that should be assessed in older adults with cancer, including potentially modifiable risk factors, and associated conditions that can be related to cognitive function. Management considerations for CRCD in older adults with cancer, such as care coordination, referrals to services with cognitive expertise, and behavioral interventions (eg, cognitive rehabilitation and physical activity), are also outlined. ^aPotentially modifiable factors. APOE, apolipoprotein E; BOMC, Blessed Orientation-Memory-Concentration test; CRCD, cancer-related cognitive decline.

However, the relationship between age and CRCD is not straightforward because aging is heterogeneous and its effects are not fully reflected in chronologic age.²⁵

Cognitive reserve can buffer age-related losses in cognition in a broad array of disorders, and low cognitive reserve is a risk factor for CRCD.^11,12 Cognitive reserve refers to the individual differences in innate and acquired cognitive capacity that confers resilience to loss of cognitive function. Advanced education, occupations that require high cognitive challenges, participation in cognitively stimulating activities, and an active lifestyle contribute to higher cognitive reserve, and these factors can be ascertained during a routine personal and social history.²⁶

Other aging-related diseases and conditions (eg, diabetes, cardiovascular disease, and thyroid disease) and frailty are also considered risk factors for cognitive decline.^27,28 One study showed that in survivors of breast cancer ≥ 60 years of age, a higher comorbidity burden was associated with worse performance on neuropsychologic assessment pre-treatment.²⁹ Accumulation of comorbidities and functional limitations can lead to frailty, a clinically recognized state of limited reserve. Multiple studies have implicated the co-occurrence of frailty and cognitive decline,^9,30,31 which likely represents a patient's systemic loss of reserve and compensatory ability on a broader scale. Patients who are frail and pre-frail (vulnerable) before treatment appear most susceptible to cognitive decline with therapy.³⁰ Therefore, the presence of frailty may signify to the oncologist a limited overall reserve and a heightened risk for CRCD and other adverse outcomes.²⁹

Psychologic distress, anxiety, depression, and other psychologic conditions including those resulting from past trauma can also increase the risk for CRCD.^11,32,33 Additionally, symptom clusters including these psychologic conditions along with fatigue and sleep disturbance can contribute to CRCD.^34-36 Overall, risk factors for CRCD are routinely collected during a medical history and can help oncology specialists identify patients at risk for cognitive decline during and after therapy.

Host biology is also a risk for CRCD, but methods for assessing patients' biologic age remain investigational. Research markers to categorize older patients with increased risk of CRCD have been identified, and candidates with the potential for clinical utility include genotype testing, biomarkers of biologic age, markers of inflammation, and advanced neuroimaging. Most of the literature in this area thus far has reported preclinical research on the effects of chemotherapy on hippocampal neurogenesis, white matter damage, oxidative stress, vascular damage, inflammation, neuroinflammation, and mitochondrial dysfunction.³⁷ Few of these mechanisms have been studied in clinical research, and very few have been studied specifically in older adults, although the mechanisms underlying these research markers are of great relevance to this population.

Several single-nucleotide polymorphisms may affect vulnerability to CRCD including apolipoprotein E (APOE),^9,38 catechol-O-methyltransferase,³⁹ DNA methyltransferase 1,⁴⁰ and brain-derived neurotrophic factor.⁴¹ Two studies have identified that CRCD is associated with at least one allele of APOE4, the genetic risk factor for Alzheimer's disease.^9,38 One of these studies specifically investigated the role of APOE single-nucleotide polymorphisms in older adults with cancer receiving chemotherapy, showing that those with at least one copy of the E4 allele exhibited worse executive function.⁹ Further studies, involving multiple cohorts, are needed to validate these findings and test their clinical utility.

There is also growing interest to better characterize biologic age using markers like epigenetic DNA methylation status rather than by the use of chronologic age because these markers capture accumulation of damage and may better reflect biologic-level fitness. Although several studies have investigated epigenetic age on cancer incidence and mortality, this measure has not been thoroughly investigated in the context of CRCD. One study, however, did show that chemotherapy profoundly alters the epigenetic landscape in whole blood from pre- to post-chemotherapy and that methylation changes in epigenetic DNA were associated with perceived cognitive decline from pre- to post-chemotherapy in patients ≥ 50 years of age.⁴² Additionally, treatment may increase epigenetic age in patients with breast cancer,⁴³ and association between measures of biologic aging and objective measures of cognition has been observed in survivors of breast cancer.⁴⁴ Another biologic aging marker that has been recently studied is p16 (INK4a), which is a marker of cellular senescence; this has also been shown to be increased by chemotherapy suggestive of accelerated molecular aging.⁴⁵

Inflammation has long been proposed as a mechanism underlying CRCD. Several cohort and cross-sectional studies have revealed higher levels of inflammatory markers and associations with CRCD before, during, and after chemotherapy.^37,46,47 Of those, elevations in serum or plasma interleukin-6 and tumor necrosis factor-α, and tumor necrosis factor receptors are most consistently correlated with CRCD. High levels of inflammation are also seen with cancer itself and several common comorbidities like diabetes. Studies of inflammatory markers specifically in older adults are needed to assess their usefulness in predicting CRCD. Such information could help also inform interventions that target inflammation.

Brain structural and functional changes seen on magnetic resonance imaging scans are often correlated with worse performance on neuropsychologic assessment.⁴⁸ Data from a pilot neuroimaging study focusing on older adults with breast cancer demonstrated brain structural and cognitive changes including reductions in both temporal lobe volume and oral reading recognition scores among patients receiving a docetaxel and cyclophosphamide regimen.^49,50 Additionally, significant gray matter density reductions were observed in several specific brain regions in patients who received chemotherapy.²⁴ Furthermore, there were alterations in brain white matter microstructures showing significant increases in mean diffusivity and radial diffusivity values in the genu of the corpus callosum over time, indicating white matter injury.⁵⁰ These findings may potentially serve as neuroimaging biomarkers for identifying CRCD in older adults undergoing cancer treatment.

Screening to Evaluate Cognitive Function in Older Adults With Cancer

The ASCO Guideline for Geriatric Oncology recommends that all older adults with cancer receive a screening evaluation of cognitive function to help inform treatment decision making.¹⁵ Assessment of cognition with a screening measure is important, as cognitive issues are regularly under-reported and easily overlooked in an oncology setting.⁵¹ Brief screening tools such as the Mini-Cog,⁵² Montreal Cognitive Assessment,⁵³ or the Blessed Orientation-Memory-Concentration⁵⁴ are recommended to identify patients with cancer and decreased cognitive function who may need additional evaluation (Table 1).¹⁵ Many older adults (15%-48%) have an abnormal cognitive screen even before treatment.^55-58 Although these tools are not diagnostic, they can identify patients who may benefit from a referral for a more comprehensive evaluation of cognitive function. It is also important to note that these tools were developed to screen for dementia and may not identify those with more subtle cognitive changes seen in CRCD. Thus, patients who self-report cognitive problems should also be considered for evaluation.

TABLE 1.

Exemplar Measures for Cognitive Assessment in Older Adults With Cancer

Although these screening tools are used by some oncologists specializing in geriatrics, they are underutilized in routine oncology care because of lack of time and other resources.^21,66 If ancillary staff are available, they could be trained to administer the screening tools. When that is not possible, perceived cognitive functioning could be assessed by patient report using short questionnaires, such as the Functional Assessment of Cancer Therapy-Cognition,⁵⁹ the Patient-Reported Outcomes Measurement Information System–Cognitive Function,⁶¹ or the European Organization for Research and Treatment of Cancer Quality of Life questionnaire-Cognitive Function (EORTC-CF)⁶⁰ (Table 1). These tools have established thresholds that are suggested to indicate a need for further assessment before treatment decision making.^67-69 If there are concerns about cognitive function, the oncology clinician could refer to neuropsychology and other specialty services as further outlined in the Management Considerations section below.

Cognitive Effects During and After Cancer Therapy

It is important to monitor cognition during and after cancer therapy. Monitoring can be conducted using self-reported measures (eg, perceived cognition), performance-based measures (eg, objective cognition), or a combination of both. In this section, we review the cognitive effects of different classes of therapy.

Chemotherapy

Multiple studies have demonstrated the development of CRCD in 10% to more than 50% of patients following exposure to chemotherapy, with prevalence estimates varying based upon the population under study and the cognitive assessments used. In one of the largest studies to date, patients with breast cancer receiving chemotherapy were approximately four times more likely to report worsening of perceived cognition from pre-chemotherapy to post-chemotherapy as compared to noncancer controls.¹⁰ Although there was slight improvement in perceived cognition 6 months after completion of chemotherapy, patients were still almost three times more likely to report a clinically meaningful decline in perceived cognition (based on 0.5-standard deviation changes). Patients with cancer also demonstrated worse performance on objective measures in multiple cognitive domains, including memory, attention, and executive function up to 6 months post-chemotherapy as compared to noncancer controls.¹¹ In a subset analysis of older patients ≥ 50 years of age from this cohort, longitudinal worsening of cognition was associated with increased frailty.³¹

In the largest study of cognition in older adults with cancer to date, the Thinking and Living with Cancer study, patients with breast cancer of age 60 years and older who received chemotherapy experienced declines of approximately 0.3 standard deviation in performance-based measures of attention, processing speed, and executive function over 24 months, as compared to those on hormonal therapy or noncancer controls. Patients receiving endocrine therapy, however, also had reduced performance in learning and memory.⁹

Other smaller studies evaluating longitudinal change in cognition in patients with breast cancer and other cancer types have demonstrated similar findings, although older adults were less well represented on many of these reports.^6,13 Generally, the magnitude of decline in cognition is subtle in comparison to degenerative neurologic conditions. Despite this, these declines have negative effects on quality of life.⁸ The long-term effects of chemotherapy on cognition are less clear; some studies suggesting resolution of cognitive changes over time⁷⁰ and others demonstrate persistent changes several months to years after completion of therapy.^13,14

Nonchemotherapy agents

Multiple studies have been conducted on the cognitive effects of endocrine-based therapies commonly used for prostate cancer and breast cancer,⁷¹ malignancies commonly diagnosed in older adults. Several studies have been conducted on older patients with breast cancer receiving tamoxifen or aromatase inhibitor therapy demonstrating mixed results regarding their effects on cognition. Most studies have shown an effect of endocrine therapies on cognitive function in patients with breast cancer,^12,72 whereas others have not shown significant change.⁷³ For example, in a study of patients of age 60 years and older receiving aromatase inhibitors compared with age-matched controls, no significant declines in performance-based cognitive assessment were seen over the first 6 months of treatment.⁷³ However, in a separate cohort of postmenopausal women with breast cancer, patients receiving anastrozole (with or without prior chemotherapy) demonstrated worse executive function scores before treatment, as well as at multiple time points up to 18 months after initiation of therapy.⁷² Declines in working memory and concentration were also observed during the first 6 months of anastrozole therapy, with subsequent improvement; however, patients receiving anastrozole only (no prior chemotherapy) demonstrated later declines in working memory and concentration (up to 18 months after initiation of therapy).

Longitudinal studies of the effects of androgen deprivation therapy (ADT) for the treatment of prostate cancer on cognitive function have generated mixed results. A systematic review and meta-analysis of 14 studies demonstrated that patients treated with ADT performed worse than noncancer controls on performance-based visuomotor tasks, although no significant differences were noted in other cognitive domains.⁷⁴ Receipt of ADT is also associated with a 21% increase in dementia risk.⁷⁵

Newer cancer therapies such as immunotherapy with immune checkpoint inhibitors used as monotherapy or in combination with other treatments may also contribute to CRCD.^76,77 Other immunotherapy modalities, such as chimeric antigen receptor T-cell therapy targeting cancer-related cell-surface molecules, are frequently associated with cytokine release syndrome and neurotoxicity.^78,79 Neurotoxicity associated with chimeric antigen receptor T-cell therapy occurs in more than 40% of patients whose most frequent neurologic symptoms are cognitive disorders with and without language impairment.⁸⁰ However, it is important to note that the majority of studies evaluating the effects of immune-based therapies on cognition included mainly younger patients, and further research is needed in older adults.

MANAGEMENT CONSIDERATIONS

As the population ages, the number of older patients with cancer who are at risk for CRCD and/or those who have a pre-existing cognitive comorbidity such as MCI or dementia will increase.³ These demographic trends will drive the need for better integration of CRCD management into routine practice.

CRCD Management Issues for Treatment Decision Making

One obvious management issue related to CRCD and pre-existing cognitive problems is that decision-making capacity should be assessed for these patients, particularly for complex decisions about cancer treatment options.^81,82 Additionally, understanding of patients' cognitive status may also help to tailor their treatment approach and develop a more comprehensive plan for monitoring and support during treatment and survivorship care.^25,28 Studies have shown that worse performance on cognitive screening assessment is associated with adverse cancer-related outcomes, such as chemotherapy toxicity and overall survival.^57,83 For example, one such study of patients ≥ 70 years of age receiving chemotherapy demonstrated that a Mini-Mental Status Exam Score < 30 was independently associated with grade 3-5 nonhematologic chemotherapy toxicity.⁸³ In another study of patients ≥ 75 years of age with hematologic malignancies, an abnormal five-word delayed recall screening test was associated with worse overall survival.⁵⁷ Patients with cognitive impairment may have more difficulties understanding the complex instructions and schedules that are typical of cancer therapies, managing medications independently, and recognizing and reporting side effects and treatment complications in a timely manner.^25,84 Thus, ensuring adequate medical and social support for older patients with concurrent cancer and comorbid cognitive impairment is critical, and formal designation of a health care proxy and decisional support should be confirmed. Additionally, caregiver distress and burden are increased among those who care for patients with cognitive impairment, and monitoring of the caregiver's health and their ability to provide the necessary support is important as well.⁸⁵

For cognitive concerns that arise during and following exposure to therapy, published guidelines and resources for navigating cancer survivorship and managing CRCD exist.^15,28,86-88 These include referrals for neuropsychology evaluations, as well as cognitive rehabilitation and integrative oncology care services. These services can further help manage patients with CRCD or those at risk for CRCD. Accessibility of these resources can be variable, and oncologists should have knowledge of available resources in their community before treatment of high-risk patients. Because of the coronavirus pandemic, opportunities for remote neuropsychologic assessments are being explored and if successful, these may be options for research and clinical care in the future.⁸⁹

Survivorship Care Management and Interventions

More than 10 million older cancer survivors currently reside in the United States.⁹⁰ Given the prevalence of CRCD in cancer survivors, with up to 35% of patients reporting long-term cognitive symptoms,⁷ the development of treatments for CRCD is critical. Cancer survivors are very interested in receiving these therapies.⁹¹ Although no standard approach to managing CRCD symptoms exists, several interventions have been studied and can be considered.

Behavioral interventions

Behavioral interventions, such as cognitive rehabilitation approaches and physical activity, have been a primary area of investigation for the management of CRCD. Cognitive rehabilitation programs broadly include two treatment types—strategy or educational programs (typically a cognitive behavioral therapy–based approach) and computer-based cognitive training programs—or a combination of the two types. Table 2 highlights select published studies of cognitive rehabilitation interventions.^92-106 In a recent systematic review of cognitive rehabilitation programs for CRCD, including 19 studies with 1,124 participants, all studies observed improvements in at least one cognitive measure.¹⁰⁷ These studies included mainly younger cancer survivors and only two focused on older cancer survivors.^94,95 Of note, these were secondary analyses of outcomes of older cancer survivors included in larger studies of the general population. Additionally, nearly all studies were conducted months to years after cancer therapy was completed. For older adults who may be at greater risk for CRCD and potential subsequent loss of functional independence as a result of cognitive changes, intervening earlier, possibly along with cancer therapy, may help to mitigate the development of CRCD.

TABLE 2.

Cognitive Rehabilitation Interventions for CRCD

A growing body of evidence suggests that physical activity and exercise programs may also play a role in managing CRCD. A systematic review including 29 clinical trials with 3,440 participants evaluated the effect of physical activity and exercise on cognitive function in patients with cancer.¹⁰⁸ Overall, the majority of studies were designed to evaluate cognitive function as a secondary outcome. Only three studies evaluated the effect of exercise on CRCD as a primary outcome. Twelve studies observed improvement in perceived cognition, and three studies detected improvement in performance-based cognitive assessment. Again, the majority of patients included in these studies were younger, and less is known about the benefits of physical activity and exercise on cognition in older adults with cancer.

Pharmacologic interventions

There are no established pharmacologic interventions for CRCD. Research on pharmacologic interventions for CRCD has been limited, and results to date have not provided confirmatory results. Pharmacologic intervention studies addressing CRCD have not been conducted specifically on older adults.

Methylphenidate and modafinil are two stimulants that have been studied—both promote wakefulness at least in part by blocking dopamine transporters to increase dopamine levels. For methylphenidate, some trials have shown improvements in cognition, with others not showing any improvement.^109-111 Modafinil has been studied as part of a secondary analysis of a phase II randomized trial originally targeting fatigue and it reported improvements in memory and attention in breast cancer survivors.¹¹² A second randomized pilot study also showed improvements in attention and psychomotor speed in adults with advanced cancer.¹¹³

Donepezil is an acetylcholinesterase inhibitor that has shown cognitive benefits in patients with brain tumors.¹¹⁴ In a randomized pilot study of breast cancer survivors up to 5 years post-treatment, donepezil improved cognitive function both by both patient report and objective testing.¹¹⁵ However, further studies in older adults with cancer are needed before routine clinical use of donepezil in this setting.

Gaps in Knowledge to Guide Evidence-Based Cognitive Assessment and Care

Although considerable progress has been made in understanding the relationships between cancer, cognition, and aging, several questions remain unanswered. High-priority areas of research include increasing the representation of older adults into CRCD research, particularly those with pre-existing cognitive impairment, advancing cognitive assessment methods and cognitive screening for older adults with cancer, and developing CRCD interventions for older adults.

Older adults remain largely under-represented in CRCD studies, and nearly all studies exclude patients with diagnosed neurodegenerative conditions such as MCI or dementia. Little CRCD research has addressed this population in particular, and more knowledge is needed to better guide treatment decision making and supportive care strategies for this vulnerable group of patients. Additionally, as cancer therapy options evolve, a better understanding of the effects on cognition of targeted therapies and immune-based therapies is needed in older adults.

Cognitive assessment in routine clinical practice remains underutilized^21,66 despite national guidelines.¹⁵ Mechanisms for implementing cognitive screening tools into oncology care for older adults should be a priority area of research. In the research setting, the International Cognition and Cancer Task Force has recommended a core battery of neuropsychologic assessments for use,⁵ but it offers no specific considerations for the older adult population. Cognitive evaluation in older adults should include a functional component with measures of cognition, such as Instrumental Activities of Daily Living (eg, medication management). These would allow a better understanding of how cognitive changes influence day-to-day functioning for older adults with cancer and their ability to maintain independence.¹¹⁶ Assessments for more subtle cognitive effects, such as computerized neuroscience-based methods, are considered in detail elsewhere but could also be useful for the study of CRCD in older adults.¹¹⁷

Finally, identification of treatment options for CRCD is a high-priority area of research. Although interventions have been developed, most have been focused on younger patients. Given the unique considerations for CRCD in older adults as outlined above, tailored interventions for this population are needed. CRCD interventions in older adults should evaluate for possible benefit using traditional cognitive measures, but also using measures of functional cognition and independence. Most CRCD interventions have been evaluated in the survivorship setting (months to years after completion of therapy). Given the likelihood of decline in functional cognition and loss of independence in older adults, intervening earlier (eg, concurrent with cancer therapy) should be considered.

In conclusion, cognition, cancer, and aging are dynamically inter-related. A growing body of literature demonstrates that a subset of older patients with cancer will experience CRCD. Like other comorbidity and organ function assessments, cognitive evaluation should be incorporated as part of baseline oncology care to help inform discussions with patients about treatment risks and benefits and guide the development of supportive care strategies where needed. Risk factors for the development of CRCD have been identified. Several of these are highly relevant for the geriatric oncology population, such as cognitive reserve, comorbidities, and advanced age. Emerging data suggest that intervention strategies may be useful in the management of CRCD. However, further studies are needed in this area, particularly for the older adult population. Older patients value independence and cognitive function as well as optimizing cancer outcomes (eg, survival), and we should strive to maintain cognitive function and other aspects of quality of life while also providing goal-concordant cancer therapy individualized to each patient's preferences about treatment.

AUTHOR CONTRIBUTIONS

Conception and design: All authors

Collection and assembly of data: All authors

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Cognitive Function in Older Adults with Cancer: Assessment, Management, and Research Opportunities

The following represents disclosure information provided by the authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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