Cancer-related cognitive decline (CRCD) is a significant problem. Up to 75% of patients receiving active cancer treatment experience CRCD, which may manifest as difficulties in attention, processing speed, executive function, and memory [1-3]. In addition to CRCD, older adults with cancer (aged ≥65 years) also experience age-related cognitive decline, further compromising their cognitive health [4-8]. For instance, half of older adult women receiving adjuvant chemotherapy for breast cancer report worsening of cognition, and 25% have measurable declines on neuropsychological testing 6 months after chemotherapy [9,10]. CRCD can also compromise the functional independence of older adults, such as the ability to remain independent with managing medications or finances (eg, activities of daily living) [11]. Thus, addressing the cognitive needs of older adults with cancer is essential to promote independence, enhance their well-being, and promote healthy aging. However, CRCD interventions tailored to them do not exist [12].

Memory and Attention Adaptation Training (MAAT) is a cognitive behavioral therapy (CBT)–based intervention for CRCD that focuses on an individual’s psychological response to injury as compared to the biological events triggering CRCD [13]. MAAT has 8 manualized workshops supplemented by a participant workbook and is individually delivered by a psychologist via videoconferencing. Together, the workshops and workbook provide instruction and practice with adaptive behavioral coping skills, stress management techniques, and compensation strategies to manage CRCD symptoms [14]. Although MAAT has been associated with greater scores on perceived cognition functioning, verbal memory, and processing speed in 3 separate studies, these populations were primarily middle-aged survivors of breast cancer who completed treatment months before enrolling in the intervention [13-15]. Thus, additional research is necessary to examine the effectiveness of MAAT in other populations, such as older adults with cancer. However, adapting the intervention to their specific needs and resources is essential to increase their usability and potential benefits.

Older adults are more likely to be diagnosed at later cancer stages [16] that may require extended treatments. Furthermore, due to the increased risk of age-related cognitive decline and CRCD, adapting MAAT to intervene earlier (eg, concurrent with cancer therapy) has the potential to improve outcomes in this vulnerable population. Thus, the goals of this study were to (1) adapt MAAT to the unique needs of older adults with breast cancer (eg, develop Memory and Attention Adaptation Training–Geriatrics [MAAT-G]) and (2) evaluate the acceptance and usability of MAAT-G in a sample of older adults with breast cancer receiving systemic therapy.

We adapted a CBT-based intervention to address CRCD symptoms among older adults with cancer undergoing systemic therapy and examined its usability and acceptability. MAAT-G engages participants in a 1:1 telehealth setting to explore and learn coping skills, stress management techniques, and methods to target episodes of CRCD [1]. We strove to promote universal usability and acceptance using telehealth and early and meaningful involvement of patient advocates throughout the intervention adaptation process.

Although several studies have evaluated behavioral interventions to address CRCD symptoms, their scope is limited [30]. Similar to MAAT-G’s parent intervention (MAAT) [13-15], most existing interventions focus on younger survivors of cancer and individuals who have completed treatment months to years before enrollment. For instance, Cherrier et al [31] studied the effect of a 7-week workshop among middle-aged (mean age 58.9 years) people with breast, bladder, prostate, colon, and uterine cancer with an average of 4.84 years after treatment completion. Similarly, ReCog, a group cognitive rehabilitation intervention, improved perceived cognitive functioning in survivors of cancer with an average of 3 years since treatment completion [32]. Our findings expand the current literature by providing a CRCD intervention for older adults undergoing treatment and showing preliminary evidence of its usability.

MAAT-G was designed as a telehealth delivery model given that older patients in active cancer treatment often have frequent in-person appointments. Thus, having additional in-person study visits may create accessibility barriers for those no longer driving independently. This design was based on other studies demonstrating that telehealth provides participants with the flexibility and comfort of completing all study-related tasks from home [14]. Additionally, a one-on-one intervention delivery model such as that of MAAT-G was preferred due to its scheduling flexibility, which allows sessions to be coordinated around existing clinic and therapy appointments.

Previous studies have demonstrated that the inclusion of patient advocates as research collaborators has significant benefit in clinical trials [33,34]. For this study, we collaborated with the Cancer and Aging Research Group (CARing) SCOREboard, a patient advocate advisory board supported by the Cancer and Aging Research Group. CARing SCOREboard members provided critical insights about study design, aspects related to intervention adaptation, and guidance on technology support. The inclusion of the patient perspective throughout the study design and intervention adaptation led to more patient-focused study procedures and design, which contributed to the favorable usability of the resulting intervention and, ultimately, advocated for and prioritized the study participants’ needs.

The foundation of the MAAT-G intervention was developed using the CCMSC model [17], which has been previously used in other CBT adaptation studies for older adult populations. For example, Trevino et al [35] used the CCMSC framework to develop the Managing Anxiety From Cancer (MAC) intervention, which addresses anxiety symptoms among older adults with cancer. Both the MAC and MAAT-G adaptations emphasize the cohort component of the CCMSC model, which highlights ideas such as membership and beliefs about and attitudes toward the problems. As such, MAC minimized the psychological language and developed examples with situations that older participants with cancer may experience. Similarly, MAAT-G revised the language of the intervention materials and created examples based on real-life experiences of older adults receiving cancer therapy. Despite this, the 2 interventions differed in some CCMSC components, particularly the specific challenge and maturity components. For example, MAAT-G accounted for the technological challenges of telehealth intervention delivery by adjusting the font size of the materials, developing a tablet manual, and screening for hearing loss, among others. Regarding the maturity components, MAC decreased the total number of sessions to minimize the participants’ time commitment. In contrast, MAAT-G increased the number of sessions to reduce the quantity of information delivered during each session.

This study had multiple strengths, such as the comprehensive, evidence-based adaptation approach; the intensive patient advocate involvement; and the patient usability and engagement rates. Allowing patients to provide direct input on their experience helped the research team prioritize intervention components and delivery factors and overall tailor the intervention based on input from the targeted population. Furthermore, the technological support manual allowed older adults to feel more comfortable with the technological components of the intervention over time. Thus, our findings highlight activities that can promote technological engagement among older adults, which have the potential to improve the representation of this population group in future technology-based clinical trials.

A limitation of this study is the small sample size of the usability phase. However, our sample size is congruent with those of other usability studies in the field [36]. Furthermore, there was low variability in the clinical and demographic characteristics of the participants (all were recruited from a single cancer center, identified as non-Hispanic White individuals, and were older women undergoing systemic treatment for breast cancer but healthy enough to complete the intervention, and most of them also reported high educational levels), so generalizability to other populations of older adults, particularly those most often affected by CRCD and digital barriers, is limited, and further adaptations of the intervention might be required for those populations. Finally, capacity for study participation was confirmed by the patients’ treating oncologists; future studies could consider a more standardized method for capacity assessment for participation.

In summary, we developed MAAT-G, a CBT-based intervention to address CRCD symptoms among older adults receiving active treatment for breast cancer and showed its preliminary usability and acceptability in a small cohort. A comprehensive, evidence-based, and patient-informed approach was followed, which improved accessibility, usability, and engagement. The feasibility and preliminary efficacy of MAAT-G are currently being evaluated in a pilot randomized clinical trial testing its effects on CRCD symptoms among older adults undergoing systemic breast cancer treatment.