69 Pre-Radiotherapy Cognitive Profiles in Patients with Brain Metastases cognitive performance.20 While subjective experience was not directly related to the objective cognitive performance, as in the majority of previous studies21, both measures did show differentiated profiles across the distinctive neurocognitive domains. Firstly, this indicates that patients are able to differentiate between their premorbid and their current cognitive performance using VAS. Secondly, our results suggest patients have domain-specific self-awareness of their cognitive functioning, similar to participants in a previous study.17 These findings demonstrate that utilizing domain-specific questions, particularly through the application of VAS, can offer valuable understanding of subjective experiences and serve as a practical tool for psycho-education. Neurocognitive functioning prior to radiotherapy was characterized by large intra-individual differences. Previous studies have reported 53-67% of BMs patients exhibit cognitive impairments on at least one cognitive test prior to radiotherapy.11,12,22,23 While we found 79% of patients had at least one cognitive impairment, this difference is likely due to the more comprehensive NCA performed in the current study, suggesting the reported numbers in the literature may be too low. On some tests patients with BMs, however, outperformed the norm scores, which should be interpreted in term of their motivation and effort to perform well.24 Stress appeared unrelated to their cognitive performance, pointing out that experienced stress cannot explain the differences with the norm population. While cognitive fatigue half-way through the NCA was related to overall slower information processing speed, it was unrelated to deficits within this domain. Using a data-driven, exploratory hierarchical cluster analysis we examined patterns of cognitive profiles in our BMs sample and found a four-cluster solution providing meaningful cognitive profiles. Separation between clusters was mainly based on the presence or absence of memory deficits. The group of patients with memory deficits (n=29) included a subgroup (n=11) with impairments across domains and worst overall cognitive performance. In the non-memory group, a substantial number of patients (n=21) had either no impairments or impairments restricted to processing speed or executive function. The discerned clusters can contribute to patient-centered care through development of psycho-education for patients and caregivers, thereby enhancing coping mechanisms and managing expectations in line with their profile. Moreover, knowledge of these clusters offers insights into cognitive support strategies for each specific cluster. For example, patients in Cluster III with relatively intact cognitive functions except for memory impairment may require different cognitive strategies (e.g. metacognitive training25) compared to Cluster IV patients with a wide range of cognitive impairments. While our sample 3
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