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Objective: Cognitive assessment in individuals with cancer requires both measured performance on neuropsychological tests and self-report of effectiveness in functioning. Few instruments are available to assess the perceived impact of cognitive alterations on daily functioning in individuals treated for cancer. In this study, we investigated the psychometric properties of a theoretically based instrument, and the Attentional Function Index (AFI), designed to measure perceived effectiveness in common activities requiring attention and working memory, particularly the ability to formulate plans, carry out tasks, and function effectively in daily life.Methods: Women (N 5 172), ages 27-86 years, completed the questionnaire before primary treatment for early stage breast cancer. Construct validity was established using exploratory principal component factor analysis with varimax rotation.Results: A 13-item instrument emerged with 3 subscales, namely effective action, attentional lapses, and interpersonal effectiveness, which explained 74.69% of total variance. The internal consistency coefficients (Cronbach's a) were 0.92 for the total instrument, and ranged from 0.80 to 0.92 for the 3 subscales. Further examination of validity indicated that the scores on the AFI (1) showed expected correlations with established measures of ability to concentrate, cognitive failures, states of confusion, and mental fatigue, and (2) could distinguish differences in perceived cognitive functioning between younger and older age groups. AFI scores were not significantly associated with years of education or presence of comorbid conditions. Conclusion:The brief AFI has demonstrated usefulness for assessment of perceived cognitive functioning in populations with life-threatening and chronic illness, such as breast cancer.

Attentional fatigue usually follows intense use of mental effort and is manifested as a decreased capacity to concentrate, that is, to direct attention. The purpose of this study was to examine the capacity to direct attention in persons with cancer during the initial phase of illness. The sample consisted of 32 women without cognitive or affective disorders who underwent surgery for localized (Stage I or It) breast cancer. Subjects manifested attentional deficits of varying intensity on a battery of tests of directed attention on the day before discharge from the hospital, which was a mean of 3 days following mastectomy or breast conservation surgery. Unexpectedly, the two surgical groups did not differ significantly in attentional capacity and functioning. Attentional test scores were not significantly correlated with narcotic pain medication interval, mood state, or self-ratings of attentional functioning. However, as number of days postsurgery increased, attentional performance decreased. The theoretical basis for further examination of attentional fatigue in people with cancer or other life-threatening illnesses is discussed.

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Earlier research indicated that attentional fatigue with reduced capacity to direct attention in women treated for breast cancer may be ameliorated by a theoretically based intervention involving regular exposure to the natural environment. This study tested the efficacy of a natural environment intervention aimed at restoring attention in 157 women with newly diagnosed breast cancer. Capacity to direct attention was assessed with a brief battery of objective measures at two time points: approximately 17 days before surgery (time 1) and 19 days after surgery (time 2). A randomly assigned intervention protocol was initiated after the first assessment and before any treatment. The intervention comprised a home-based program involving 120 minutes of exposure to the natural environment per week. The intervention group (n = 83) showed greater recovery of capacity to direct attention from the pretreatment (time 1) to the preadjuvant therapy period (time 2), as compared with the nonintervention group (n = 74). A significant effect of the natural environment intervention was observed even after control was used for the effects of age, education, attention scores at time 1, other health problems, symptom distress, and extent of surgery. The findings suggest therapeutic benefits for capacity to direct attention from early intervention aimed at restoring attention in women with newly diagnosed breast cancer.

Women treated for breast cancer have shown cognitive deficits with reduced capacity to focus and concentrate or to direct attention. This study examined the relationship between cognitive function prior to any treatment for breast cancer and individual factors including age, education, menopausal status, chronic health problems, and distress. Women newly diagnosed with breast cancer (N=184), ages 27-86 years, were assessed with standardized attention tests, self-reports of effectiveness in cognitive functioning, and measures of distress at about 18 days before surgery. Measured performance on the cognitive tests was not significantly correlated to self-reports of effectiveness in cognitive functioning. Age, education, presence of a chronic health problem, and menopausal status, but not distress, were associated with performance on the cognitive tests. Only age and education, however, were significant (p<0.001) predictors of overall performance on the cognitive tests, when controlling covariates. In contrast, symptom and mood distress significantly (p<0.001) predicted perceptions of effectiveness in cognitive functioning. Thus, different factors were associated with measured performance versus self-reports of cognitive functioning. Individual factors that predispose to lowered effectiveness in cognitive functioning prior to treatment in women newly diagnosed with breast cancer are discussed.

Although the initial phase of illness is recognized as important in the overall process of adjustment after a diagnosis of breast cancer, little is known about pretreatment patterns of symptom distress. Seventy-four women ages 25 to 79 years and newly diagnosed with breast cancer were studied to determine physical, cognitive, and affective distress in the pretreatment period. Severity of distress was assessed about 11 days before primary surgery using the Symptom Distress Scale (SDS), Attentional Function Index (AFI), and Profile of Mood States (POMS). Higher levels of distress (SDS) were related to a triad of symptoms, insomnia, fatigue, and loss of concentration. Also, lowered effectiveness in cognitive function (AFI) and significant disturbances in mood state (POMS) were observed. Overall, a greater number of symptoms was associated with lowered cognitive function (r = -0.47; p < 0.01) and greater mood disturbance (r = 0.65; p < 0.01). Younger women younger than 55 years of age (n = 25) reported significantly (p = 0.02) greater overall symptom distress (SDS) than older women (n = 49). Interestingly, severity of distress did not differ in groups anticipating breast-conserving surgery (n = 35) instead of mastectomy (n = 39). The findings showed a discernible pattern of symptom distress before any treatment in women newly diagnosed with breast cancer, indicating a need for early intervention to promote the initial process of adjustment.

Compared with conventional care alone, the experimental intervention was effective among patients who entered the trial with higher levels of symptom severity. Age, sex, site or stage of cancer, and supportive medications did not modify the effect of this cognitive behavioral intervention on symptom severity.