The Chessable Research Awards for the Summer 2023 cycle had four winners, undergraduate student Michael Martins and graduate students Jordan von Hippel, Jérôme Genzling, and Jane Zhang.
In this guest blog post, Jane Zhang reviews research literature relevant to her pilot study’s hypothesis. That hypothesis is that a chess curriculum, developed in collaboration with Chess.com, for female breast cancer patients undergoing chemotherapy treatment might combat cancer-related cognitive impairment. Her pilot study is now recruiting patients at Pluta Cancer Center of the University of Rochester.
Testing a Chess-based Training Tool on Patients with Cancer-related Cognitive Impairment
by Jane Zhang
Cancer is a broad categorization for a large spectrum of diseases revolving around uncontrolled cell growth. It can occur in many forms and affect many different parts of the body, and its overall impact on our population is undeniable: the National Center for Health Statistics projects almost 2 million new cancer cases and more than 600,000 cancer-related deaths to occur in 2023 in the United States alone (Siegel et al., 2023).
Although novel developments in cancer therapeutics, including chemotherapy, radiation, hormone therapy, and immunotherapy, have increased available options for targeting various cancers and subsequently improved survival rates, these treatments have been known to have a wide range of side effects. One such consequence, particularly in association with chemotherapy, is neurocognitive impairment. This can manifest in different ways, from decreased processing speed and concentration to loss of executive function and memory, which is reflected in both patient cognitive self-assessments and standardized neuropsychological testing. These changes can be seen in imaging studies of the brain, both structurally (Apple et al., 2017) and on fMRI (Chen et al., 2020), a measure of cerebral blood flow and by extension, brain activity. In addition, the pathophysiology of cancer itself can cause neurocognitive changes. Collectively, these effects are known as cancer-related cognitive impairments (CRCI) and can significantly impact patients’ ability to work and function and decrease their quality of life.
Unfortunately, CRCI is also not uncommon: a recent longitudinal nationwide study that followed over 500 breast cancer patients found that over 40% of them reported a subjective decline in cognitive function after chemotherapy treatment (Janelsins et al., 2017). These symptoms may present prior to, during, or even months after therapy is completed and can persist for years.
Studies have shown that early intervention can prevent worsening of CRCI. However, there is currently no standardized treatment for CRCI. Some pharmacological agents have been repurposed to target CRCI but more extensive research needs to be conducted to determine their efficacy. Other non-pharmacological management options include changes in diet, exercise regimens, cognitive behavioral therapy, and cognitive training. Of note, studies have shown that cognitive training can improve neuron survival and that an increased level of training difficulty is correlated with higher neuron survival rates (Lv et al., 2020).
Various trials have been conducted to assess the efficacy of computer-based cognitive training on CRCI. One Australian randomized control study followed over 200 solid tumor patients and implemented a 40-hour web-based learning program over the course of 15 weeks. This program targeted information processing and divided attention among other domains and was found to improve patients’ self-reported cognitive function even 6 months post-intervention (Bray et al., 2017). Similarly, another randomized control pilot study conducted in 2020 tested a web-based internet video game intervention, also showing improvements in patients’ self-assessment of cognition as well as visual memory and reaction speed (Bellens et al., 2020). However, programs such as these can be expensive and difficult to access. Even if beneficial, socioeconomic barriers could prevent many patients from being able to utilize these modalities.
As healthcare providers and researchers, our goal was to create a tool that can both target CRCI and be accessible to a large patient population. Perhaps unsurprising to many readers on this platform, chess, a well-known game that requires the utilization of many higher cognitive functions, fits this description well. Because chess is available for free online, it is more attainable than other computer-based games which may require additional software or have language barriers. As a popular game, it also may have potential to increase study involvement and compliance compared to other programs. Furthermore, we anticipate that the complexities and different neuro-modalities involved in playing chess, such as memory, spatial reasoning, and executive function, will contribute to improved neuron survival rates and cognitive function.
In fact, research has already been conducted looking at how chess can be used both as a protective factor to prevent the onset of Alzheimer’s disease and dementia as well as a tool to treat it once it has already been diagnosed, due to its ability to enhance cognitive reserve (Lillo-Crespo et al., 2019). Preliminary data has been promising, but more work needs to be done to determine causal relationships.
Our project is a pilot study of a chess-based training tool for female breast cancer patients undergoing chemotherapy treatment at the Pluta Cancer Center of the University of Rochester. This study is IRB approved and currently underway. We plan to continue recruiting patients into our study until we have a total of forty patients enrolled, with ages ranging between eighteen to eighty years. Our study patients are undergoing a two-month chess training curriculum developed in collaboration with Chess.com. The patients we are enrolling have at least a mild-moderate level of CRCI, with difficulties in the areas of memory, attention span, and multitasking ability. They also have had no previous chess experience.
At the beginning of the two-month intervention, each patient undergoes objective neurocognitive testing via Cambridge Cognition. Through a series of iPad-based exercises, they will be evaluated on several modalities including baseline reaction time, attention and visual searching ability, executive function, spatial planning, working memory, verbal memory, visual pattern recognition memory, manipulation of visuospatial information, and ability to encode and retrieve information. They will also complete a FACT-Cog test, which is a standardized subjective assessment of cognitive function.
Participants will then engage in twenty minutes a day of a chess curriculum. They will be provided with a premium Chess.com membership and begin with eight introductory lessons on how to move pieces. This is followed by forty-two other lessons on how to play the game, opening principles, how to win the game, capturing pieces, finding checkmate, and introductory openings. Once basic lessons are completed and patients are at least able to play the game, they will practice playing against the Chess.com AIs, starting from the easiest level, and moving up once they are able to win. Following completion of all lessons, they will also begin puzzle training, with 10 puzzles every day. Over the intervention period, patients will be able to access all necessary materials via the Chess.com platform using a computer or smartphone device. After the completion of the curriculum, each patient will once again undergo both objective and subjective neurocognitive testing. We will then assess for any changes in cognitive function pre- and post-intervention.
As discussed above, our pilot study is currently in the recruitment process. Several patients are enrolled and already starting the curriculum. We are hopeful that our program will contribute to potential improvements in CRCI and that with participant feedback and modifications to our intervention, we can continue to improve this tool and perform more extensive studies with the goal of developing an accessible and efficacious therapy option for CRCI.
References
Apple, A., Ryals A., & Alpert, A., et al. (2017) Subtle hippocampal deformities in breast cancer survivors with reduced episodic memory and self-reported cognitive concerns. Neuroimage Clin., 14, 685-691.
Bellens, A., Roelant, E., & Sabbe, B., et al. (2020).A video-game based cognitive training for breast cancer survivors with cognitive impairment: A prospective randomized pilot trial. Breast, 53, 23-32.
Bray V.J., Dhillon, H.M., & Bell, M.L., et al. (2017). Evaluation of a web-based cognitive rehabilitation program in cancer survivors reporting cognitive symptoms after chemotherapy. J Clin Oncol., 35 (2), 217-225.
Chen, V.C-H., Lin, K.Y., & Tsai, Y.H., et al. (2020). Connectome analysis of brain functional network alterations in breast cancer survivors with and without chemotherapy. PLoS ONE 15(5), e0232548. https://doi.org/10.1371/journal.pone.0232548
Janelsins, M.C., Kesler, S., & Ahles, T., et al. (2014). Prevalence, mechanisms, and management of cancer-related cognitive impairment. Int Rev Psychiatry, 26 (1), 102-113.
Janelsins, M.C., Heckler, C.E., & Peppone, L.J., et al. (2017). 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., 35(5), 506-514.
Janelsins, M.C., Heckler, C.E., & Peppone, L.J., et al. (2018). Longitudinal trajectory and characterization of cancer-related cognitive impairment in a nationwide cohort study. J Clin Oncol., 36 (32), 3231-3239.
Lange, M., Joly, F., & Vardy, J., et al. (2019). Cancer-related cognitive impairment: an update on state of the art, detection, and management strategies in cancer survivors. Ann Oncol., 30 (12), 1925-1940.
Lillo-Crespo, M., Forner-Ruiz, M., & Riquelme-Galindo,J., et al. (2019). Chess practice as a protective factor in dementia. Int J Environ Res Public Health, 16(12), 2116.
Lv, L., Mao, S., Dong, H., Hu, P., & Dong, R. (2020). Pathogenesis, assessments, and management of chemotherapy-related cognitive impairment (CRCI): An updated literature review. Journal of oncology, 3942439. https://doi.org/10.1155/2020/3942439
Siegel, R. L., Miller, K. D., Wagle, N. S., & Jemal, A. (2023). Cancer statistics, 2023. CA Cancer J Clin., 73(1), 17-48. doi:10.3322/caac.21763
Interested in research?
The Chessable Research Awards are for undergraduate and graduate students conducting university-level chess research. Chess-themed topics may be submitted for consideration and ongoing or new chess research is eligible. Each student must have a faculty research sponsor. For more information, please visit this link.
