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He said another focus of sleep research should be to clarify the underlying biological mechanisms by which chemotherapy and other cancer treatments might interfere with the structural organization of sleep i. He also emphasized the need to adapt effective interventions for more widespread dissemination and implementation.

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For example, he said cognitive behavioral therapy is effective and could be disseminated further through Web-based approaches. Lastly, Jacobsen stated that the implications of a symptom cluster concept, such as the co-occurrence of fatigue and sleep problems, should be considered because they might have a common underlying mechanism, or the treatment of one symptom could have a cascade effect on the other.

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Compared with posttreatment fatigue and sleep disorders, much less is known about cognitive problems following cancer treatment, said Jacobsen. Patient reports and concerns that may suggest problems in executive functioning have prompted the research community to focus on this problem.

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Neuropsychological tests, standard tests of major domains of cognitive functioning e. Functional imaging studies, such as magnetic resonance imaging and positron emission tomography PET Wefel et al. Qualitative electroencephalography often used in combination with other measures to more directly assess brain function Hunter et al. Jacobsen said PROs and neuropsychological tests are only modestly correlated in many studies, and that some researchers speculate that self-reported measures might be more sensitive. He said that risk factors for posttreatment cognitive problems include older age Ahles et al.

The direct neurotoxic effect of treatment is one mechanism implicated in posttreatment cognitive problems, Jacobsen said Bray et al. Animal models suggest that cancer drugs may cross the blood—brain barrier in very small amounts, leading to both gray and white matter volume loss, reduced white matter integrity, and altered neurochemistry and metabolism.

Cytokine deregulation and treatment-induced hormonal changes have also been implicated, he said Bray et al.