Accelerated Neuromodulation to Alleviate Cognitive Deficits Due to Cancer Therapy

Study Overview
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Brief Summary
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This project is aimed at the discovery of neuro-modulation techniques that may alleviate chemotherapy induced cognitive deficits (CICD), especially in executive (higher-order) cognitive function (EF).

Detailed Description
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The specific aim for this study is to use magnetic resonance spectroscopy (MRS), self-report, and neuropsychological testing to identify changes in brain metabolite concentrations/ratios and changes in EF deficits associated with chemotherapy, before and after accelerated theta-burst transcranial stimulation (iTBS). The secondary aim is to assess for any association of changes in executive function with brain metabolite concentrations.

Official Title
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Repetitive Intermittent Accelerated Theta-burst Transcranial Stimulation(iTBS) as a Potential Intervention for Chemotherapy Induced Cognitive Deficits (CICD)- a Pilot Clinical Trial to Explore Feasibility and Efficacy

Conditions
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Cancer

Intervention / Treatment
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* Other: Accelerated repetitive intermittent theta-burst transcranial stimulation (iTBS)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Women or men with a history of non-metastatic cancer who have completed definitive curative cancer therapy Received cytotoxic chemotherapy as a part of their therapy for cancer and at least one month has passed since the final cytotoxic chemotherapy treatment ≥ 18 years of age at time of cancer diagnosis and receipt of chemotherapy Patients must report subjective symptoms of chemo-brain (memory loss, difficulty with concentration, word-finding difficulties) with a FACT-Cog perceived cognitive impairment score < 60 Ability to sign informed consent and comply with study procedures Exclusion Criteria: Patients with a recurrence of cancer or those with current metastatic disease Patients with a history or current diagnosis of brain metastasis Patients with a history or current diagnosis of a primary brain tumor Patients with a history of brain surgery or brain radiation Patients receiving maintenance systemic therapy for cancer, other than endocrine therapy Patients who cannot produce or request adequate medical record documentation to ensure they meet inclusion and exclusion criteria Women who are currently pregnant History of childhood cancer or receipt of chemotherapy in childhood (<age 18). Developmental insult to the PFC, can be associated with long-term, durable and sometime debilitating cognitive deficits. Hence, we avoid any cognitive confounds that maybe related to this issue. Patients with a weight over 250 lbs., as these patients would not fit in the MRI scanner used in the protocol Patients who require benzodiazepines for MRI due to claustrophobic anxiety Patients with chest wall tissue expanders or other retained 7 Tesla MRI-incompatible metal. Any other specific contraindication to TMS or MRI not already listed above, including: (a) any implanted device in the head, neck or upper body (e.g. cochlear implant, cranial or other electrodes, pacemaker or defibrillator, medication pump, stent, aneurysm clip, etc.) (b) personal history of seizures or epilepsy, personal history of multiple concussions or unexplained loss of consciousness. This will be determined by physician judgement History of adverse reaction to previous TMS or MRI exposure Active substance use disorder in the past 6 months, excluding tobacco use disorder, as diagnosed by study physicians

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 99 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Accelerated repetitive intermittent theta-burst transcranial stimulation (iTBS) or sham<br>Patients will participate in the prospective longitudinal research protocol over a period of 1.5 months. Treatment will include 8 visits of either accelerated repetitive intermittent theta-burst transcranial stimulation (iTBS) or iTBS sham stimulation. Patients will be informed that iTBS sham stimulations will be part of the protocol (but will be blind to when treatment/sham will be administered). | Other: Accelerated repetitive intermittent theta-burst transcranial stimulation (iTBS)<br>* Accelerated iTBS will be used to stimulate the regions of interest of mPFC and L-DLPFC nodes in cancer survivors or patients. Accelerated iTBS will be administered in a single half-day period to allow for a 50minutes interval between any two treatments to minimize interference effects between treatments. Thus, there will be  10 minute sessions of stimulation x 2 applications per node x 2 nodes (L-DLPFC, mPFC) = 40 total minutes of daily stimulation - each session delivers 1800 pulses in a 5 Hz triplet burst frequency, 2 second trains with intertrain interval of 8 seconds; triplets occur with 50 Hz frequency, as per standard iTBS protocols for depression treatment. The treatment will be offered for five consecutive days.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mean changes in executive cognitive function between pre and post application of iTBS treatment protocol | Executive cognitive function will be quantified using technician administered Color Word Interference Test, Category Fluency, Tower of Hanoi, Card Sort and Strategy Application Task (Shallice &Burgess) tests, and the self-report Functional Assessment of Cancer Therapy - Cognitive Scale (FACT-COG) (Dyk et al.). Executive Function (EF) is measured by utilizing standardized test scores adapted from the Delis-Kaplan Executive Function Scales (D-KEFS battery) (Homack et al.). FACT-COG, Category Fluency and Strategy Application Task use raw scores. All EF measures used in this battery form a part of a normative database created and maintained by the principle investigator of this study. An overall score of EF is computed by averaging the Z scores of each test. Higher score on each test represents better performance. | 1.5 months | 
| Mean changes in brain metabolite concentrations between pre and post application of iTBS treatment protocol | Proton Magnetic Resonance Spectroscopy will be used to quantify brain metabolite concentrations in parts per million. Brain metabolites under evaluation include: glutamine, glutamate, N-acetyl aspartate, choline, and creatine. | 1.5 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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neuromodulation, chemo-brain