NCCN Guidelines® Insights: Survivorship, Version 1.2023

Featured Updates to the NCCN Guidelines

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Tara Sanft Yale Cancer Center/Smilow Cancer Hospital

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Andrew Day UT Southwestern Simmons Comprehensive Cancer Center

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Shannon Ansbaugh Patient Advocate

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Saro Armenian City of Hope National Medical Center

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K. Scott Baker Fred Hutchinson Cancer Center

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Tara Ballinger Indiana University Melvin and Bren Simon Comprehensive Cancer Center

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Wendy Demark-Wahnefried O’Neal Comprehensive Cancer Center at UAB

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Kristin Dickinson Fred & Pamela Buffett Cancer Center

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Nathan Paul Fairman UC Davis Comprehensive Cancer Center

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Josephine Felciano The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

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Tessa Faye Flores Roswell Park Comprehensive Cancer Center

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Debra L. Friedman Vanderbilt-Ingram Cancer Center

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Nicolette M. Gabel University of Michigan Rogel Cancer Center

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Mindy Goldman UCSF Helen Diller Family Comprehensive Cancer Center

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Norah Lynn Henry University of Michigan Rogel Cancer Center

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Christine Hill-Kayser Abramson Cancer Center at the University of Pennsylvania

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Melissa Hudson St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center

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Divya Koura UC San Diego Moores Cancer Center

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Kimberly Lee Moffitt Cancer Center

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Allison L. McDonough Massachusetts General Hospital Cancer Center

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Michelle Melisko UCSF Helen Diller Family Comprehensive Cancer Center

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Kathi Mooney Huntsman Cancer Institute at the University of Utah

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Halle C.F. Moore Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

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Natalie Moryl Memorial Sloan Kettering Cancer Center

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Heather Neuman University of Wisconsin Carbone Cancer Center

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Tracey O’Connor Roswell Park Comprehensive Cancer Center

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Linda Overholser University of Colorado Cancer Center

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Electra D. Paskett The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

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Chirayu Patel Massachusetts General Hospital Cancer Center

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Lindsay Peterson Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

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William Pirl Dana-Farber/Brigham and Women’s Cancer Center

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Andrea Porpiglia Fox Chase Cancer Center

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M. Alma Rodriguez The University of Texas MD Anderson Cancer Center

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Lidia Schapira Stanford Cancer Institute

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Anna L. Schwartz Fred & Pamela Buffett Cancer Center

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Sophia Smith Duke Cancer Institute

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Amye Tevaarwerk Mayo Clinic Comprehensive Cancer Center

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Eric Yang UCLA Jonsson Comprehensive Cancer Center

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Phyllis Zee Robert H. Lurie Comprehensive Cancer Center of Northwestern University

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Nicole R. McMillian National Comprehensive Cancer Network

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Deborah A. Freedman-Cass National Comprehensive Cancer Network

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The NCCN Guidelines for Survivorship are intended to help healthcare professionals address the complex and varied needs of cancer survivors. The NCCN Guidelines provide screening, evaluation, and treatment recommendations for psychosocial and physical problems resulting from adult-onset cancer and its treatment; recommendations to help promote healthy behaviors and immunizations in survivors; and a framework for care coordination. These NCCN Guidelines Insights summarize recent guideline updates and panel discussions pertaining to sleep disorders, fatigue, and cognitive function in cancer survivors.

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  • 1.

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  • 2.

    Miller KD, Nogueira L, Devasia T, et al. Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin 2022;72:409436.

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    Beckjord EB, Reynolds KA, van Londen GJ, et al. Population-level trends in posttreatment cancer survivors’ concerns and associated receipt of care: results from the 2006 and 2010 LIVESTRONG surveys. J Psychosoc Oncol 2014;32:125151.

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    Burg MA, Adorno G, Lopez ED, et al. Current unmet needs of cancer survivors: analysis of open-ended responses to the American Cancer Society Study of Cancer Survivors II. Cancer 2015;121:623630.

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    Weaver KE, Forsythe LP, Reeve BB, et al. Mental and physical health- related quality of life among U.S. cancer survivors: population estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2012;21:21082117.

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  • 6.

    Emery J, Butow P, Lai-Kwon J, et al. Management of common clinical problems experienced by survivors of cancer. Lancet 2022;399:15371550.

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    Xu S, Thompson W, Ancoli-Israel S, et al. Cognition, quality-of-life, and symptom clusters in breast cancer: using Bayesian networks to elucidate complex relationships. Psychooncology 2018;27:802809.

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    St Fleur RG, St George SM, Ream M, et al. A latent profile analysis to assess physical, cognitive and emotional symptom clusters in women with breast cancer. Psychol Health 2022;37:12531269.

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  • 9.

    de Ligt KM, de Rooij BH, Walraven I, et al. Varying severities of symptoms underline the relevance of personalized follow-up care in breast cancer survivors: latent class cluster analyses in a cross-sectional cohort. Support Care Cancer 2022;30:78737883.

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  • 10.

    Behringer K, Goergen H, Müller H, et al. Cancer-related fatigue in patients with and survivors of Hodgkin lymphoma: the impact on treatment outcome and social reintegration. J Clin Oncol 2016;34:43294337.

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  • 11.

    Von Ah D, Storey S, Tallman E, et al. Cancer, cognitive impairment, and work-related outcomes: an integrative review. Oncol Nurs Forum 2016;43:602616.

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    Alanazi MT, Alanazi NT, Alfadeel MA, et al. Sleep deprivation and quality of life among uterine cancer survivors: systematic review. Support Care Cancer 2022;30:28912900.

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  • 13.

    Berger AM, Mitchell SA. Modifying cancer-related fatigue by optimizing sleep quality. J Natl Compr Canc Netw 2008;6:313.

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    Slade AN, Waters MR, Serrano NA. Long-term sleep disturbance and prescription sleep aid use among cancer survivors in the United States. Support Care Cancer 2020;28:551560.

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  • 15.

    Palesh O, Aldridge-Gerry A, Ulusakarya A, et al. Sleep disruption in breast cancer patients and survivors. J Natl Compr Canc Netw 2013;11:15231530.

  • 16.

    Loh KP, Zittel J, Kadambi S, et al. Elucidating the associations between sleep disturbance and depression, fatigue, and pain in older adults with cancer. J Geriatr Oncol 2018;9:464468.

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  • 17.

    Berrett-Abebe J, Cadet T, Pirl W, et al. Exploring the relationship between fear of cancer recurrence and sleep quality in cancer survivors. J Psychosoc Oncol 2015;33:297309.

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  • 18.

    Ahmedani BK, Peterson EL, Hu Y, et al. Major physical health conditions and risk of suicide. Am J Prev Med 2017;53:308315.

  • 19.

    Dirksen SR, Epstein DR. Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors. J Adv Nurs 2008;61:664675.

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  • 20.

    Palesh O, Aldridge-Gerry A, Zeitzer JM, et al. Actigraphy-measured sleep disruption as a predictor of survival among women with advanced breast cancer. Sleep 2014;37:837842.

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  • 21.

    Lee S, Ma C, Shi Q, et al. Sleep and cancer recurrence and survival in patients with resected stage III colon cancer: findings from CALGB/SWOG 80702 (Alliance). Br J Cancer. Published online May 13, 2023. doi:10.1038/s41416-023-02290-2

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  • 22.

    Zhou ES, Partridge AH, Syrjala KL, et al. Evaluation and treatment of insomnia in adult cancer survivorship programs. J Cancer Surviv 2017;11:7479.

  • 23.

    Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 2016;27:2028.

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  • 24.

    Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021;17:255262.

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  • 25.

    Kline CE, Sui X, Hall MH, et al. Dose-response effects of exercise training on the subjective sleep quality of postmenopausal women: exploratory analyses of a randomised controlled trial. BMJ Open 2012;2:e001044.

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  • 26.

    Rubio-Arias , Marín-Cascales E, Ramos-Campo DJ, et al. Effect of exercise on sleep quality and insomnia in middle-aged women: a systematic review and meta-analysis of randomized controlled trials. Maturitas 2017;100:4956.

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  • 27.

    Yang PY, Ho KH, Chen HC, et al. Exercise training improves sleep quality in middle-aged and older adults with sleep problems: a systematic review. J Physiother 2012;58:157163.

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  • 28.

    Li L, Wang L, Sun Q, et al. Effect of two interventions on sleep quality for adolescent and young adult cancer survivors: a pilot randomized controlled trial. Cancer Nurs 2022;45:E560572.

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  • 29.

    Cheville AL, Kollasch J, Vandenberg J, et al. A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung and colorectal cancer: a randomized controlled trial. J Pain Symptom Manage 2013;45:811821.

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  • 30.

    Mishra SI, Scherer RW, Geigle PM, et al. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev 2012;2012:CD007566.

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  • 31.

    Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol 2013;31:32333241.

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  • 32.

    Rogers LQ, Fogleman A, Trammell R, et al. Effects of a physical activity behavior change intervention on inflammation and related health outcomes in breast cancer survivors: pilot randomized trial. Integr Cancer Ther 2013;12:323335.

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  • 33.

    Van Gerpen RE, Becker BJ. Development of an evidence-based exercise and education cancer recovery program. Clin J Oncol Nurs 2013;17:539543.

  • 34.

    Mustian KM. Yoga as treatment of insomnia among cancer patients and survivors: a systematic review. Eur Med J Oncol 2013;1:106115.

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    Rogers LQ, Courneya KS, Oster RA, et al. Physical activity and sleep quality in breast cancer survivors: a randomized trial. Med Sci Sports Exerc 2017;49:20092015.

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  • 36.

    Kim SW, Shin IS, Kim JM, et al. Effectiveness of mirtazapine for nausea and insomnia in cancer patients with depression. Psychiatry Clin Neurosci 2008;62:7583.

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  • 37.

    Chen WY, Giobbie-Hurder A, Gantman K, et al. A randomized, placebo-controlled trial of melatonin on breast cancer survivors: impact on sleep, mood, and hot flashes. Breast Cancer Res Treat 2014;145:381388.

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  • 38.

    Blume C, Garbazza C, Spitschan M. Effects of light on human circadian rhythms, sleep and mood. Somnologie (Berl) 2019;23:147156.

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    Brown TM, Brainard GC, Cajochen C, et al. Recommendations for daytime, evening, and nighttime indoor light exposure to best support physiology, sleep, and wakefulness in healthy adults. PLoS Biol 2022;20:e3001571.

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    Fleming L, Randell K, Harvey CJ, et al. Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients? Psychooncology 2014;23:679684.

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  • 41.

    Heckler CE, Garland SN, Peoples AR, et al. Cognitive behavioral therapy for insomnia, but not armodafinil, improves fatigue in cancer survivors with insomnia: a randomized placebo-controlled trial. Support Care Cancer 2016;24:20592066.

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  • 42.

    Rios P, Cardoso R, Morra D, et al. Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews. Syst Rev 2019;8:281.

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  • 44.

    Thong MS, van Noorden CJ, Steindorf K, et al. Cancer-related fatigue: causes and current treatment options. Curr Treat Options Oncol 2020;21:17.

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    Sleight AG, Crowder SL, Skarbinski J, et al. A new approach to understanding cancer-related fatigue: leveraging the 3P model to facilitate risk prediction and clinical care. Cancers (Basel) 2022;14:1982.

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    Schroder J, Mackenzie L. Outcomes related to activity performance and participation of non-pharmacological cancer-related fatigue interventions. OTJR (Thorofare, NJ) 2022;42:5064.

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  • 47.

    Savina S, Zaydiner B. Cancer-related fatigue: some clinical aspects. Asia Pac J Oncol Nurs 2019;6:79.

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    Vannorsdall TD, Straub E, Saba C, et al. Interventions for multidimensional aspects of breast cancer-related fatigue: a meta-analytic review. Support Care Cancer 2021;29:17531764.

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    Mustian KM, Alfano CM, Heckler C, et al. Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: a meta-analysis. JAMA Oncol 2017;3:961968.

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  • 52.

    Yuan Y, Lin L, Xie C, et al. Effectiveness comparisons of various psychosocial therapies for cancer-related fatigue: a Bayesian network meta-analysis. J Affect Disord 2022;309:471481.

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  • 53.

    Hilfiker R, Meichtry A, Eicher M, et al. Exercise and other non- pharmaceutical interventions for cancer-related fatigue in patients during or after cancer treatment: a systematic review incorporating an indirect-comparisons meta-analysis. Br J Sports Med 2018;52:651658.

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  • 54.

    Barsevick AM, Dudley W, Beck S, et al. A randomized clinical trial of energy conservation for patients with cancer-related fatigue. Cancer 2004;100:13021310.

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  • 55.

    de Raaf PJ, de Klerk C, Timman R, et al. Systematic monitoring and treatment of physical symptoms to alleviate fatigue in patients with advanced cancer: a randomized controlled trial. J Clin Oncol 2013;31:716723.

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  • 56.

    Hanna A, Sledge G, Mayer ML, et al. A phase II study of methylphenidate for the treatment of fatigue. Support Care Cancer 2006;14:210215.

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    Gong S, Sheng P, Jin H, et al. Effect of methylphenidate in patients with cancer-related fatigue: a systematic review and meta-analysis. PLoS One 2014;9:e84391.

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  • 58.

    Qu D, Zhang Z, Yu X, et al. Psychotropic drugs for the management of cancer-related fatigue: a systematic review and meta-analysis. Eur J Cancer Care (Engl) 2016;25:970979.

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  • 59.

    Mücke M, Mochamat M, Cuhls H, et al. Pharmacological treatments for fatigue associated with palliative care. Cochrane Database Syst Rev 2015;2015:CD006788.

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    Xiao P, Ding S, Duan Y, et al. Effect of light therapy on cancer-related fatigue: a systematic review and meta-analysis. J Pain Symptom Manage 2022;63:e188202.

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  • 61.

    Barton DL, Liu H, Dakhil SR, et al. Wisconsin ginseng (Panax quinquefolius) to improve cancer-related fatigue: a randomized, double-blind trial, N07C2. J Natl Cancer Inst 2013;105:12301238.

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    Mandelblatt JS, Small BJ, Luta G, et al. Cancer-related cognitive outcomes among older breast cancer survivors in the thinking and living with cancer study. J Clin Oncol 2018;36:JCO1800140.

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  • 65.

    Janelsins MC, Heckler CE, Peppone LJ, et al. Longitudinal trajectory and characterization of cancer-related cognitive impairment in a nationwide cohort study. J Clin Oncol 2018;36:JCO2018786624.

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    Wagner LI, Gray RJ, Sparano JA, et al. Patient-reported cognitive impairment among women with early breast cancer randomly assigned to endocrine therapy alone versus chemoendocrine therapy: results from TAILORx. J Clin Oncol 2020;38:18751886.

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  • 67.

    Schmidt JE, Beckjord E, Bovbjerg DH, et al. Prevalence of perceived cognitive dysfunction in survivors of a wide range of cancers: results from the 2010 LIVESTRONG survey. J Cancer Surviv 2016;10:302311.

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  • 68.

    Wefel JS, Schagen SB. Chemotherapy-related cognitive dysfunction. Curr Neurol Neurosci Rep 2012;12:267275.

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    Janelsins MC, Heckler CE, Peppone LJ, et al. Cognitive complaints in survivors of breast cancer after chemotherapy compared with age-matched controls: an analysis from a nationwide, multicenter, prospective longitudinal study. J Clin Oncol 2017;35:506514.

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  • 70.

    Carroll JE, Nakamura ZM, Small BJ, et al. Elevated C-reactive protein and subsequent patient-reported cognitive problems in older breast cancer survivors: the Thinking and Living With Cancer study. J Clin Oncol 2023;41:295306.

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  • 71.

    Schroyen G, Vissers J, Smeets A, et al. Blood and neuroimaging biomarkers of cognitive sequelae in breast cancer patients throughout chemotherapy: a systematic review. Transl Oncol 2022;16:101297.

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    Li M, Caeyenberghs K. Longitudinal assessment of chemotherapy- induced changes in brain and cognitive functioning: a systematic review. Neurosci Biobehav Rev 2018;92:304317.

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    Liou KT, Ahles TA, Garland SN, et al. The relationship between insomnia and cognitive impairment in breast cancer survivors. JNCI Cancer Spectr 2019;3:pkz041.

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    Schagen SB, Das E, Vermeulen I. Information about chemotherapy- associated cognitive problems contributes to cognitive problems in cancer patients. Psychooncology 2012;21:11321135.

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    Crouch A, Champion VL, Von Ah D. Comorbidity, cognitive dysfunction, physical functioning, and quality of life in older breast cancer survivors. Support Care Cancer 2022;30:359366.

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    Fernandes HA, Richard NM, Edelstein K. Cognitive rehabilitation for cancer-related cognitive dysfunction: a systematic review. Support Care Cancer 2019;27:32533279.

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    Von Ah D, Crouch A. Cognitive rehabilitation for cognitive dysfunction after cancer and cancer treatment: implications for nursing practice. Semin Oncol Nurs 2020;36:150977.

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  • 78.

    Huang X, Zhao X, Li B, et al. Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: a systematic review and network meta-analysis. J Sport Health Sci 2022;11:212223.

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  • 79.

    Akbari PS, Hassan Y, Archibald L, et al. Effect of physical activity during chemotherapy on cognitive function in cancer survivors: a systematic review and meta-analysis. Physiother Can 2023;75:1221.

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  • 80.

    Campbell KL, Zadravec K, Bland KA, et al. The effect of exercise on cancer-related cognitive impairment and applications for physical therapy: systematic review of randomized controlled trials. Phys Ther 2020;100:523542.

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  • 81.

    Miladi N, Dossa R, Dogba MJ, et al. Psychostimulants for cancer-related cognitive impairment in adult cancer survivors: a systematic review and meta-analysis. Support Care Cancer 2019;27:37173727.

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  • 82.

    Lawrence JA, Griffin L, Balcueva EP, et al. A study of donepezil in female breast cancer survivors with self-reported cognitive dysfunction 1 to 5 years following adjuvant chemotherapy. J Cancer Surviv 2016;10:176184.

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  • 83.

    van der Linden SD, Gehring K, De Baene W, et al. Assessment of executive functioning in patients with meningioma and low-grade glioma: a comparison of self-report, proxy-report, and test performance. J Int Neuropsychol Soc 2020;26:187196.

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