Assessment and Management of Cognitive Function in Patients with Prostate Cancer Treated with Second-Generation Androgen Receptor Pathway Inhibitors

Preservation of cognitive function is an important outcome in oncology. Optimal patient management requires an understanding of cognitive effects of the disease and its treatment and an efficacious approach to assessment and management of cognitive dysfunction, including selection of treatments to minimize the risk of cognitive impairment. Awareness is increasing of the potentially detrimental effects of cancer-related cognitive dysfunction on functional independence and quality of life. Prostate cancer occurs most often in older men, who are more likely to develop cognitive dysfunction than younger individuals; this population may be particularly vulnerable to treatment-related cognitive disorders. Prompt identification of treatment-induced cognitive dysfunction is a crucial aspect of effective cancer management. We review the potential etiologies of cognitive decline in patients with prostate cancer, including the potential role of androgen receptor pathway inhibitors; commonly used tools for assessing cognitive function validated in metastatic castration-resistant prostate cancer and adopted in non-metastatic castration-resistant prostate cancer trials; and strategies for management of cognitive symptoms. Many methods are currently used to assess cognitive function. The prevalence and severity of cognitive dysfunction vary according to the instruments and criteria applied. Consensus on the definition of cognitive dysfunction and on the most appropriate approaches to quantify its extent and progression in patients treated for prostate cancer is lacking. Evidence-based guidance on the appropriate tools and time to assess cognitive function in patients with prostate cancer is required. Plain Language Summary Men with prostate cancer are usually elderly and may have other health conditions. Old age, poor health, and some medications can all affect a person's ability to think clearly, make sound judgments, remember things, and learn new information. These mental difficulties can make it hard for people to do day-to-day tasks such as shopping or making a meal, looking after themselves, or taking medications correctly. People may also have problems with friendships and relationships. Therefore, before a man starts treatment for prostate cancer, he and his doctor must consider the likelihood that his mental ability might be affected by the treatment in order to choose the most suitable treatment option. Initially, the doctor can use short screening tests, such as asking the patient to remember and repeat numbers or words, draw objects, name things in a picture, or complete a survey. If these tests show that the patient might be having mental difficulties, he may be invited for additional tests with a specialist, called a neuropsychologist. A patient with, or at risk of, mental difficulties will be offered a care plan, which might include one or more of the following: selecting or switching treatments to avoid side effects; using memory aids; treatment for pain, difficulty sleeping, depression, or other problems that might affect mental function; sessions with a specialist to improve mental ability and develop techniques to adapt to worsening mental function; physical exercise; and getting help from others with household tasks, personal care, or taking medications.