Improve the management of cancer-related cognitive impairment in clinical settings: a European Delphi study

Purpose Cancer-related cognitive impairment (CRCI) is under-addressed by healthcare professionals owing to a lack of clinical management guidelines. This European Delphi study aims to propose recommendations to healthcare professionals for the management of CRCI in patients with non-central nervous system (non-CNS) cancers. Methods The survey included European professionals (psychologists, physicians, researchers) who are experts in CRCI. Twenty-two recommendations were developed based on a literature review and authors’ clinical experience, split into three categories: screening, cognitive assessment, intervention. The Delphi method was used. Experts assessed the clinical relevancy of recommendations on a 9-point Likert scale in three rounds. A recommendation was accepted if all votes were between 7 and 9. Results Eighteen


Introduction
Cancer-related cognitive impairment (CRCI) is one of the main symptoms experienced by patients with non-central nervous system (CNS) cancers and affecting their quality of life [1].It refers to cognitive di culties experienced by cancer survivors such as di culty remembering things and di culty focusing on tasks [2,3].
Subjective cognitive di culties, aka cognitive complaints, assessed by self-reported questionnaires are usually representative of di culties encountered in daily life.Cognitive complaints are often related with psychological factors (e.g., anxiety and depression), fatigue, pain and sleep di culties [4][5][6] but are not systematically related with objective cognitive impairment [7].Objective impairment is detected during neuropsychological evaluations by using cognitive tests.It mainly concerns attention, memory, executive functions and processing speed [8,9].Around 30% of patients experience an overall cognitive impairment before and after adjuvant treatment [5,10].CRCI can last for several years for some patients [11] and thus affects the resumption of daily life activities.For example, a large web-based survey conducted among 1610 cancer survivors found that CRCI had an impact on return to work for 76% of survivors who had cognitive complaints [12].Furthermore, 75% of cancer survivors reporting CRCI in that study would have liked to receive help such as cognitive training, psychological support and physical rehabilitation.CRCI has been recognized for over twenty years, with recommendations for screening and cognitive assessment established by expert societies such as the International Cancer and Cognition Task Force [13][14][15][16].Although used in research studies to harmonize ndings, these recommendations are rarely followed by healthcare professionals and are not always applicable in clinical settings.In clinical practice, a neuropsychological assessment theoretically allows a patient to be offered individualized management of cognitive di culties.Yet neuropsychological tests lack sensitivity to detect subtle cognitive di culties affecting a patient's daily routine and quality of life, which are better detected with self-report questionnaires.Neuropsychological tests are classically used to evaluate the e ciency of interventions, but the inclusion of patients in intervention groups relies on capturing cognitive complaints [17,18].Furthermore, the aim in research is to establish a standardized intervention rather than the most appropriate individualized intervention.Thus, clinical practice needs recommendations different than those used in research studies on interventions and structural framework to offer this type of supportive care to patients.
Over the past decade, the advent of research on interventions to improve CRCI has led to several systematic reviews and meta-analyses showing the e cacy of non-pharmacological interventions [19,20], whereas no evidence to date supports pharmacological interventions [21].Recent research has therefore focused mostly on non-pharmacological interventions and, until now, cognitive training, cognitive rehabilitation and physical activities seem the most effective [22][23][24][25][26].Although some local schemes offering non-pharmacological interventions for CRCI have been reported in European countries [27], they are scarce in clinical settings [28] because of the lack of nancial resources and trained health professionals.
To summarize, there is a lack of clinical recommendations and initiatives in Europe to detect and offer adapted interventions to patients with cognitive complaints, so health professionals and patients are at loss when they arise [2,29,30].A recent survey aiming to raise awareness among European public authorities about CRCI in patients with non-CNS cancers showed that CRCI is still insu ciently understood and considered by public authorities and healthcare professionals [27].Although CRCI is starting to be included in survivorship programs [31][32][33], numerous clinicians (e.g., oncologists, nurses, general practitioners) are not aware of the existence of these cognitive di culties [30].As a result, patients lack information about CRCI, which goes undetected and unmanaged.In the Europe's Beating Cancer plan [34], the current main framework for cancer control at the EU level, very little attention is given to survivorship rehabilitation programs and their content, such as CRCI.
Management of CRCI (screening, evaluation, intervention) is therefore a major challenge in clinical practice, and healthcare professionals require concrete answers and applications to be able to support patients, especially once their treatment has been completed.In 2021, a collaboration with the innovative Partnership for Action Against Cancer (iPAAC) Joint Action, a scheme was undertaken to create guidelines to help public authorities to deal with CRCI [27].Discussions with several stakeholders from public authorities, associations, medical and research structures in Europe highlighted the need to guide health professionals.As a result of this collaboration, a consultation on the subject was launched with European experts.Recommendations were drafted on the basis of a literature review and knowledge collected in clinical settings during the iPAAC project.Then, the Delphi method was used to establish a clinical consensus of experts on the issue of cancer and cognition for the management of CRCI.

Methods
The study used the Delphi methodology based on the RAND method [35].This is a series of iterative questionnaires determining the clinical relevancy of recommendations to be applied in clinical settings.The aim of this study was to propose expert-validated recommendations for health professionals to help them manage CRCI.

Initiation of the Delphi study
The authors of the recommendations (MD, GB, ML, JLF, IHL, CC, and FJ) were psychologists, oncologists and/or researchers, all studying CRCI.Each participated in a project under the iPAAC Joint Action to propose recommendations for public authorities to help them organize the management of CRCI.The project included a eld survey (interviews with public authorities, associations, expert societies) and a literature review of interventions for CRCI.Results were summarized and used to establish recommendations for public authorities.These were then debated during a workshop including authors, the stakeholders interviewed during the eld survey and the public authorities.The project highlighted the need to establish recommendations that clinicians could implement in clinical settings [27].The recommendations therefore focused on the entire care itinerary, from screening up to and including the intervention.

Establishment of recommendations
The recommendations were based on the data collected (scienti c literature review, non-scienti c review, interviews with health professionals) on CRCI management during summer 2021 by MD for the iPAAC project [27] and on the clinical experience of the authors (GB, ML, JLF, IHL, CC, FJ).The scienti c literature search was made on the Web of Science, Pubmed (MEDLINE), University of Montreal, Wiley, ScienceDirect databases and focused on interventions to manage CRCI in adults with non-CNS cancers (e.g.cognitive training, rehabilitation, physical activity, meditation, yoga, cognitive behavioral therapy).For details on data collection, see iPAAC guide [27].The non-scienti c review with a search engine and interviews with stakeholders during the iPAAC project covered patient management more broadly in ve topics [27]:

Participants
Experts were identi ed through the European iPAAC project, cancer associations (e.g.Ligue Contre le Cancer), studies conducted on CRCI management in Europe, and the authors' network of professional contacts.Participants were either healthcare professionals (e.g., clinical psychologists) involved in cancer survivorship care, physicians (e.g., oncologists) seeing cancer patients and aware of the issue of cognitive disorders, or researchers working in the eld of cancer and cognition.Their status could be multiple, i.e. both healthcare professional and/or physician and/or researcher.They received an e-mail explaining the aim and procedure of the Delphi method to be able to participate in the survey.
Participants who agreed to participate received the link to complete each survey online.
Characteristics of participants were reported: professional activity, country of professional activity, number of years involved in this eld, level of involvement in survivorship care, association or other membership, involvement in the drafting of guidelines dedicated to cancer and cognition.

Survey development
After validation by the ethics committee of the University Hospital of Caen, the software LimeSurvey, provided by the University of Caen Normandy, was used to create the questionnaires.Each recommendation or group of recommendations was preceded by a short state of the art and a short de nition of the intervention (see the section 'Creation of the recommendations').A 9-point Likert scale was used to rate the clinical relevance and feasibility, including "1-Not agree at all", "5-Undecided", and "9-Totally agree".Participants had to specify to what extent they thought the recommendation was clinically relevant (i.e., useful and necessary for patients) and to what extent the recommendation could be feasible in their institution or another establishment (to be speci ed in the comment box).If the participant rated the recommendation 6 or less, a mandatory text box appeared to justify his/her disagreement.An optional text box was also available so that participants agreeing with the recommendation could add further information concerning their clinical experience, references, and discuss the suggestions associated with the recommendation.A tick box "I am not able to respond" was also available for participants who considered that the recommendation was not in their area of expertise.

Analysis
Characteristics of participants, i.e. country of professional activity, professional status, and previous participation in iPAAC, were compared with Chi² tests between individuals who did or did not participate in the Delphi survey.

Round 1 -Survey
The rst round required participants to rate the clinical relevancy and the clinical feasibility of the recommendations, each on a 9-point Likert scale.Suggestions of applications in clinical settings, i.e., concrete examples, were associated with some recommendations to help participants to understand its applicability.Recommendations were accepted if all participants voted 7 or more.No consensus was expected for clinical feasibility, which depends on several factors from one country and clinical establishment to another.However, the suggestions of participants (mandatory and optional text boxes) concerning clinical relevancy and clinical feasibility were essential to discuss the recommendations and provide the appropriate suggestions in the discussion of this study.

Round 2 -Survey
The second round concerned the recommendations for which no consensus was obtained during the rst round.Only clinical relevancy was evaluated in this round, with the method previously described.
To assist participants in voting, a summary of the rst-round results including descriptive statistics and an anonymized summary of comments was presented before each recommendation.The summary allowed participants to become aware of the group opinion and thus to open up the discussion concerning the acceptance or not of an intention.Furthermore, each participant received a personalized e-mail with his/her previous vote.
Acceptance of recommendation was less strict in the second round as outliers could be excluded.According to the HAS (French High Health Authority) guidelines, when there are 15 to 30 participants, two outliers may be excluded if there are no missing values and 1 outlier may be excluded if 1 value is missing [36,37].In other cases, extreme values were not excluded.In other words, the extreme values (2 maximum) could be excluded to obtain a consensus.

Round 3 -Survey
In the third and last round, the recommendations for which no consensus was obtained in the second round were either deleted or modi ed on the basis of the participants' comments.After the authors (MD, GB, ML, JLF, IHL, CC, FJ) had validated the new (modi ed) recommendations, they went to a nal round of voting.As in the second round, only clinical relevancy was evaluated.
To help participants in voting, each one received a personalized e-mail with their previous vote and the summary (as previously described) of the second round to justify the deletions and modi cations of the remaining recommendations.

Results
Participants Thirty-nine experts were contacted and 18 accepted to participate (at least one round responded entirely) in the survey (participation rate 46%).No difference was observed concerning the category and country of residence between experts who accepted to participate and those who did not answer the invitation.Nevertheless, experts who participated in the iPAAC survey were signi cantly more likely to participate in this Delphi study than experts whom did not participate in the iPAAC survey (p < 0.001).The characteristics of the 18 participants are described in Table 1.More than 60% of participants had clinical experience and daily contact with patients, including expertise on the organization of clinical facilities.

Delphi survey
Table 2 summarizes the recommendations arising from the three rounds.
As this was the nal round, the two following recommendations that did not reach consensus were deleted: New recommendation 18: "Cognitive rehabilitation (psycho-education ± cognitive training) should be administered by a therapist trained in cognitive rehabilitation (e.g.occupational or speech therapist, nurse, medical doctor) preferably with training in psychology (e.g.

neuropsychologist)"
New recommendation 20: "Mindfulness/Meditation may be considered as a therapeutic option and offered to patients with CRCI, in combination with cognitive rehabilitation and according to their preferences, to improve their cognitive functioning and psychological status." The nal recommendations that reached consensus during the three rounds are listed in Table 3 Screening of cognitive complaints should be realized with simple questions from validated questionnaires RECOMMENDATION 3 If cognitive complaints have been screened, their severity and their impact on daily living should be assessed with a validated self-report questionnaire Cognitive assessment RECOMMENDATION 4 In the event of cognitive a objective cognitive evaluation should be performed RECOMMENDATION 5 If persistence of CRCI detected around 6 months post-treatment (such as chemotherapy), the patient should undergo a medical consultation to explore etiology of cognitive impairment.This consultation could be complemented by a neuropsychological assessment with a neuropsychologist.

RECOMMENDATION 6
To adapt the support to patients' needs, factors associated with cognitive impairment should be assessed i.e. mainly anxiety, depression, fatigue, sleep and pain RECOMMENDATION 7 In the event of signi cant cognitive complaints and/or objective cognitive impairment related to cancer and/or its treatments, non-pharmacological supervised supports should be offered to patients Whatever cognitive intervention already offered, physical activity should be offered to all cancer patients with CRCI, to improve cognitive performances and health status Meditative movement therapies RECOMMENDATION 21 Meditative movement therapies (i.e.gentle exercises combined with relaxation such as yoga) may be considered as a therapeutic option and offered to patients with CRCI, according to their preferences, to improve cognitive functioning and quality of life Multimodal interventions RECOMMENDATION 22 Multimodal interventions, i.e. cognitive intervention combined with other approaches chosen according to patients' preferences and needs (among physical activity and mind body therapies), are preferable to improve CRCI and associated symptoms

Discussion
In Europe, management of CRCI in patients with non-CNS cancers is a growing concern.Therefore, this Delphi study aimed to develop guidelines for supporting patients with CRCI based on scienti c evidence and expert knowledge.Eighteen experts in CRCI (psychologists, physicians and researchers) approved 15 out of 22 recommendations.In summary, experts recommended systematically screening for CRCI followed by a short objective cognitive assessment if cognitive complaints screened.A comprehensive evaluation (including a neuropsychological assessment and an evaluation of co-factors) should be performed if CRCI persists for more than six months post-treatment.Non-pharmacological supervised interventions should be offered, prioritizing cognitive rehabilitation (including psycho-education), physical activity, meditative movement therapies, or multimodal intervention.

Screening for CRCI
Patients should be systematically screened for cognitive impairment (Recommendation 1) with simple questions from validated questionnaires (Recommendation 2).For example, the Capital Region of Denmark's working group [38] and Regional Cancer Centers in Sweden [39] recommend using questionnaires with checkboxes such as the NCCN distress thermometer (listing a variety of symptoms including concentration/memory) to detect the need for rehabilitative care.Then if cognitive complaints are detected with simple questions (see suggestions Table 2), their severity and their impact on daily living should be assessed with a validated self-report questionnaire (Recommendation 3).The choice of the self-report questionnaire depends on the time available and the language involved.The panel mainly proposed the FACT-Cog [15] which has several advantages: available in several languages; evaluates the impact of cognitive di culties on quality of life; speci c to patients with cancer as it has Ideally, screening should be performed throughout the healthcare pathway of the patient, i.e., at the time of diagnosis, during adjuvant treatments, and at the end of adjuvant treatments (suggestions of Recommendation 1, see Table 2).If there are some initiatives in clinical settings to screen symptoms and supportive care needs, it is not yet generalized and cognitive di culties have not been well identi ed.Thus, regarding the resources available for now in clinical settings, the experts emphasized the need for evaluation in the months following the end of adjuvant treatments (radiotherapy and/or chemotherapy).The progressive introduction of digital tools in the follow-up of patients, such as app to assess cancer treatments side-effects, will be a lever to screen and follow more easily cognitive complaints.

Cognitive assessment
In the event of cognitive complaints attested by a self-report questionnaire (screening), it is recommended to perform a short objective cognitive evaluation (Recommendation 4) before the comprehensive neuropsychological evaluation.The choice of test will depend on several factors such as the age of the patient, the health professional available (e.g., trained nurse or neuropsychologist) and the time needed to perform the evaluation.
According to the literature and our experience of clinical settings, the following tests would be appropriate: the MOCA [41] or the combination of The Hopkins Verbal Learning Test-Revised [42], the Trail-Making Test [43], and the Controlled Oral Word Association [44] recommended by the ICCTF [14].
The MOCA can be administered by every trained and attested professional, whereas the other tests require a psychologist specialized in neuropsychology.
Then, according to the experts, if persistent CRCI is detected six months after treatments, whether or not an intervention has been performed, a medical check-up should be done.Thus, the etiology of cognitive di culties such as the use of psychotropic medications, biological disorders (e.g., anemia), or comorbidities, should be evaluated and a neuropsychological evaluation performed, if needed (new recommendation 5).The choice of cognitive tests should be made by the neuropsychologist who, if needed, can rely on the scienti c literature about CRCI [13].This consultation should include the evaluation of associated factors such as anxiety, depression, sleep disorders and fatigue (Recommendation 6).The arbitrary date of 6 months has been proposed based on the literature and expert comments.Obviously, it is not required to wait 6 months if an evaluation seems necessary, but it is recommended to avoid performing an evaluation in the weeks following the end of treatment because of the persistence of symptoms that are supposed to decrease progressively.CRCI is characterized by cognitive complaints not systematically related with neuropsychological assessment [7].Although neuropsychological evaluation is essential to the differential diagnosis and to determine the domains impaired, it should not be a prerequisite for having access to an intervention.

Interventions
As soon as a patient has cognitive complaints and irrespective of their con rmation by objective cognitive tests, a non-pharmacological supervised intervention should be offered (Recommendation 7).In the scienti c literature on non-pharmacological interventions, computerized cognitive training seems to be the most widely studied and bene cial type of intervention for improving CRCI [23,45].However, no consensus has been found on its use without the association with psycho-education.According to the comments of the rst and second rounds, the main reason of disagreement was that cognitive training alone is not effective in improving the di culties encountered on a daily basis and must be accompanied by psychoeducation.Moreover, the lack of standardization of training and the heterogeneity observed in clinical settings makes it di cult to reach a consensus on what cognitive training should comprise (e.g., duration and frequency of the sessions).Thus, the ve recommendations related to cognitive training "alone" were removed.On the other hand, the experts recommended offering at least one session of psycho-education for patients with cognitive complaints [46] (Recommendation 13).As de ned in the method section, this session is essential to reassuring patients by informing about "normal" cognitive functioning and CRCI but also offering some advices to reduce di culties encountered in daily life.
Cognitive rehabilitation, i.e., programs combining psycho-education with cognitive training [24] or with cognitive-behavioral therapy [47,48], seems effective to improve CRCI and was recommended by the experts (Recommendation 14).However, owing to the heterogeneity of studies, the choice of the frequency and duration of interventions is down to the healthcare professional's preference (Recommendation 15).On-site sessions combined with home-based exercises should be offered in rst instance to promote follow-up (Recommendation 16) with a minimum duration of 45min of combined psycho-education and cognitive training (Recommendation 17).No consensus was reached concerning the professional who should perform the cognitive rehabilitation (Recommendation 18, deleted).Indeed, depending on the health organizations and the countries, different professionals might possess the skills needed to administer cognitive rehabilitation.They should be chosen according to their specialty and the impairments observed.Psychologists specialized in neuropsychology and/or cognitive rehabilitation should be prioritized to administer cognitive rehabilitation.Speech therapists specialized in neuropsychology may also administer cognitive rehabilitation but should rather be recommended in the event of language impairments such as occupational therapists for motor impairments.The experts also suggested that psycho-education could be administered by oncologists, nurses, medical doctors, and therapists with a specialization (university diploma) in rehabilitation or neuropsychology.This is not an exclusive list and the healthcare professionals required could differ from one country to another.Physical activity (Recommendation 19) and "meditative movement therapies" (Recommendation 21) were recommended by the experts.Both interventions have been proven to reduce the cognitive complaints of patients with non-CNS cancers [49][50][51][52].In addition, exercises are already offered by some associations (e.g., Ligue Contre le Cancer in France) and cancer centers (adapted physical activity) and several public authorities or health organizations across Europe (e.g., France, Denmark, Norway, Sweden), including the World Health Organization, encourage cancer survivors to undertake physical activity [27,53].Thus, physical activity in general should be promoted and recommended/prescribed by physicians in the event of cognitive complaints.
Mindfulness/meditation therapy did not reach a consensus, owing to a lack of evidence concerning its e cacy (Recommendation 20, deleted).While few studies have demonstrated an improvement in objective cognitive functioning [54,55], meditation/mindfulness improves cognitive complaints and psychological outcomes [56-58].Thus, although not recommended for managing CRCI in the present survey, it might be proposed by patients' associations and cancer centers as an additional activity to be performed at home alone or in groups to improve patients' well-being.

Integration in clinical settings
Management of CRCI remains underdeveloped in clinical settings.Information to the patient and the professional is insu cient.Some initiatives are emerging at the local level thanks to patients' associations, hospitals and cancer centers trying to respond to patients' needs [2,30].However, there are several limitations: (a) no systematic offer to patients with cognitive complaints; (b) poor communication concerning management availability; (c) some interventions not free of charge; (d) when in hospital and cancer center: lack of desire of patients to return to their place of treatment; (e) few interventions for CRCI available in clinical settings; (f) limited in capacity and often prioritized for patients returning to work; (g) when on-site, especially available in large cities.These limitations re ect the social inequalities encountered in accessing CRCI management.In this study, the experts recommended physical activity and psycho-education which can be made readily available to patients (online access options [65, 66], reimbursement) and should be offered to patients as a priority if no cognitive training is available.Multimodal intervention was strongly recommended by experts during the iPAAC workshop [27].However, multimodal intervention is more di cult to implement in clinical settings owing to the requirements for coordination between different healthcare professionals and the need for greater patient participation.

Limitations
This Delphi study has some limitations including the low number of participants, without representation of all the European countries, and the lack of patients and some health professionals (e.g.nurses and general practitioners).As observed during the iPAAC project [27], there are few professionals who are experts in CRCI across Europe.The participation rate below 50% highlights the need to inform the health professionals involved in the care of cancer survivors.A choice was made to include only professionals who are expert in the domain of CRCI and its management, excluding de facto patients, whereas it would have been useful to have feedback from those primarily concerned to better re ne the recommendations.Furthermore, some points were not addressed in the vote owing to the lack of scienti c evidence, such as "should the intervention be performed individually or in a group" which is also patient-and establishment-dependent.

Conclusion
These recommendations are designed for healthcare professionals to guide them in the management of CRCI, from detection, through evaluation to intervention.The existence of evidence related to interventions to manage CRCI should guide decision-makers in the provision of resources for this type of supportive care.

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informing about CRCI; -screening CRCI and evaluating cognitive functioning; -organizing CRCI management (orienting, coordinating, offering interventions); -managing CRCI to allow the return to work; -identifying health professionals to be involved in CRCI management and training them.
authors' personal digital libraries on CRCI and data of health professionals' iPAAC interviews.Recommendations on interventions were based on the literature review (updated in 2022) and health professionals' interviews in the iPAAC survey.Types of interventions were selected according to scienti c evidence-based results, i.e., most studied interventions with evidence about their e cacy in improving cognitive complaints and/or cognitive functioning.They were de ned as follows: a) Cognitive training: improving cognitive di culties using repetitive and sustained exercises (frequently computerized) with incremental di culty based on the patient's performance.b) Psycho-education: education/information about cognitive functioning, how it might be affected by cancer and its treatments and how to deal with it.Psycho-education gives some advice and strategies to reduce cognitive di culties encountered in daily life and thus improve quality of life.c) Cognitive rehabilitation: interventions combining psycho-education, cognitive training, and/or cognitive behavioral therapy, in order to improve cognitive di culties observed in daily life.Cognitive behavioral therapy proposes new behaviors to adopt, to improve or compensate for a speci c function.d) Physical activity: physical exercises such as aerobic exercises and walking.e) Mindfulness / Meditation: breathing exercises, visualization and other techniques to develop attention, awareness, relaxation.f) Meditative movement therapy: gentle exercises combined with relaxation such as yoga.g) Multimodal interventions: combination of several approaches among those previously mentioned.

14 A
Psycho-education RECOMMENDATION At least one psycho-education session should be offered to all cancer patients with cognitive complaints Cognitive rehabilitation RECOMMENDATION cognitive rehabilitation program, i.e. combining psycho-education with cognitive training and/or cognitive behavioral therapy (for CRCI), should be offered to all cancer patients with CRCI, to improve complaints and cognitive functioning in daily life activities RECOMMENDATION 15 Frequency and duration of the sessions, and duration of the program should be adapted to the patient and the establishment where the intervention takes place RECOMMENDATION 16 On-site sessions and/or home-based exercises should be offered RECOMMENDATION 17 Duration of the session of cognitive rehabilitation (cognitive training + psycho-education) should be at least 45 min Physical RECOMMENDATION 19 been developed and validated by cancer patients.Another questionnaire validated in cancer patients and recommended by the Cancer Neuroscience Initiative Working group [16] is the Patient-Reported Outcome Measurement Information System Cognitive Function, short form [40].

Finally
, multimodal interventions are recommended (Recommendation 22).Although there have only been a few studies in non-CNS cancer patients [18, 59], a recent network meta-analysis found that each type of intervention speci cally improves some cognitive domains [60].For example, cognitive training is more effective to improve verbal memory and processing speed, whereas psycho-education is more effective on executive functioning, and meditation/mindfulness on attention.Thus, combining several approaches could be more e cient to improve global cognitive functioning.Moreover, a multimodal intervention could be more effective by acting on several factors that are putatively implicated in CRCI [61].Other therapies targeting associated factors might reduce cognitive complaints such as acupuncture for pain [62, 63], cognitive behavioral therapy for sleep [62] or fatigue [64].These interventions were not proposed in the recommendations owing to a lack of evidence concerning their e ciency on CRCI.

Table 1
a : oncologist, geriatrician, hematologist, psychiatrist, physical and rehabilitation medicine doctor; b : clinical psychologist, work psychologist, and neuropsychologist; c : post-doc researcher, associate professor and professor.AFSOS: French association of oncological support; ICCTF: International Cognition and Cancer Task Force; SNLF: Neuropsychological Society of French Language; IPAAC: International Partnership for Action Against Cancer.