Quality of life in adults with brain tumors: current knowledge and future directions

Sleep-wake disturbance in patients with brain tumors

Sleep-wake disturbances are defined as perceived or actual alterations in sleep that result in impaired daytime functioning. Unlike other cancers, there is limited information about sleep-wake disturbances in adults with primary brain tumors throughout the illness trajectory. Sleep-wake disturbance is among the most severe and common symptoms reported by primary brain-tumor patients, particularly those undergoing radiation therapy. As with other cancers and neurologic illness, sleep-wake disturbance may also be clustered or related to other symptoms such as fatigue, depression, and cognitive impairment. There is increasing evidence for a genetic basis of normal sleep and sleep regulation in healthy adults. Specific mutations and single nucleotide variants have been reported to be associated with both fatigue and sleep-wake disorders, and both inflammation and alterations in circadian rhythms have been postulated to have a potential role. Guidelines for assessment and interventions have been developed, with cognitive behavioral therapy, exercise, and sleep hygiene demonstrating benefit in patients with other solid tumors. Further research is needed to identify risk and appropriate treatment in the brain-tumor patient population.

Assessing patient and caregiver needs and challenges in information and symptom management: a study of primary brain tumors

Brain cancer is a devastating diagnosis characterized by significant challenges and uncertainties for patients and their caregivers. Although mobile health and patient-facing technologies have been successfully implemented in many patient populations, tools and technologies to support these users are lacking. We conducted semi-structured interviews with 13 patients and caregivers, investigating experiences, challenges, interests, and preferences for managing symptoms and health information. We found that although current technology use in health-related activities was minimal, participants reported being highly willing to use such technologies to capture and manage information, provided they were designed according to the needs, interests, and abilities of these users. Participants felt that such tools could benefit patient care activities, and help to address information challenges for both current and future patients and caregivers. We present findings surrounding these challenges, behaviors, and motivations, and discuss considerations for the design of systems to support current and future patients and caregivers.

Is there a response shift in generic health-related quality of life 6 months after glioma surgery?

Background

Patients may recalibrate internal standards when faced with a serious diagnosis or neurological deficits. This so-called response shift is important to understand in longitudinal health-related quality of life (HRQoL) data, but this is not quantitatively assessed in glioma patients.

Methods

Patients with gliomas were eligible for this HRQoL study. We used EuroQol-5D 3 L to assess generic HRQoL with assessment preoperatively and at 6 months postoperatively. At time of follow-up, patients scored how they considered their baseline HRQoL in retrospect using the same questionnaire (“then-test”).

Results

Seventy-three patients were enrolled between January 2013 and September 2015. With the then-test approach, the mean EQ-5D 3 L index was similar compared to baseline (0.77, mean difference 0.01, 95% CI −0.57 to 0.07, p = 0.82). Also, then-test and baseline VAS score were similar (mean difference 0, 95% CI −7 to 7, p = 0.97). However, a 0.10–0.13 difference from baseline was observed in patients that improved or deteriorated in HRQoL at follow-up according to the then-test EQ-5D 3 L index value. The direction of change as observed from the then-test was similar to the direction of clinical change, reducing the impact of any HRQoL change from baseline to follow-up.

Conclusions

On average, we observed no response shift using EQ-5D 3 L in the selection of glioma patients able to participate at 6 months after surgery. However, following change in HRQoL at follow-up, response shift seems to reduce the effects of HRQoL changes by lowering of internal standards in patients that deteriorate and raising the standards in patients that improve.

The Process of Translation and Linguistic Validation of the Functional Assessment of Cancer Therapy-Brain Quality of Life Instrument from English to Malayalam: The Challenges Faced

AIM

Both brain tumors and their treatments have a major negative impact on the quality of life (QoL). EORTC BN20 and Functional Assessment of Cancer Therapy-Brain (FACT-BR) are the most commonly used tools to assess QoL. The FACT-BR is a 23-item questionnaire, especially about the psychosocial aspects of QoL. This paper describes the challenges we faced during the process of translation and validation of the FACT-BR into Malayalam.

METHODS

We first screened the patients to ensure their mental status was satisfactory and that they could communicate well in both languages. According to the Functional Assessment of Chronic Illness Therapy methodology, there were two forward translations from English to Malayalam by two independent translators, a reconciliation of the two forward translations, a back-translation into English, a review/finalization by a fifth translator, proofreading, and then testing on a small cohort of patients.

RESULTS

The whole process of translation was fraught with small and large hurdles - from small technical issues to the gaps in sociocultural norms. The sub item BR 7, due to the lack of an exact equivalent word, had issues that persisted up to the validation phase. The postquestionnaire debriefing interviews confirmed that the translations were well understood and conceptually equivalent to the original English one.

CONCLUSIONS

Translation of the FACT-BR into Malayalam nearly completely reproduced the concepts of the original English questionnaire, as proved in the subsequent validation process.

Investigating the impact of headaches on the quality of life of patients with glioblastoma multiforme: a qualitative study

OBJECTIVES

Headaches and facial pain have been identified as the most prevalent form of pain among patients with glioblastoma multiforme, the most common malignant primary brain tumour. Despite this, minimal research has been undertaken investigating the direct and indirect impact these headaches have on their quality of life. Therefore, in this study, we aimed at gaining a personal insight into the importance and impact that these headaches have on the quality of life of patients with glioblastoma multiforme.

DESIGN

Exploratory study using face-to-face semistructured interviews. Interviews were audio-recorded, transcribed verbatim and then qualitatively analysed using thematic analysis.

SETTING

Participants recruited from a tertiary referral hospital in Birmingham, UK.

PARTICIPANTS

Purposive sampling of 14 registered outpatients recently diagnosed with glioblastoma multiforme.

RESULTS

3 themes were identified: (1) an underlying attitude of determination and positivity; (2) impact of headache unpredictability on social interaction; (3) headaches found to act as a springboard onto thoughts regarding their disease and future.

CONCLUSIONS

While the quality of life of patients with glioblastoma multiforme is clearly multifactorial, headaches do indeed play a part for some. However, it is not the direct pain of the headache as one might expect that impacts on the quality of life of these patients, but the indirect effect of headaches through limiting patients' social lives and by serving as a painful psychological reminder of having a life-threatening illness. In clinical practice, using headache diaries for these patients may help provide a more comprehensive assessment and further aid management plans. Alongside acting as an important reminder of the potential secondary implications of this disease, suggestions for future research include quantitatively investigating whether headaches can act as a prognostic indicator for quality of life within this patient demographic and determining whether these conclusions also hold true for a wider spectrum of patients with brain tumour.

TPX2 promotes glioma cell proliferation and invasion via activation of the AKT signaling pathway

Glioblastoma multiforme (GBM) is the most common and most malignant type of primary adult brain cancer. The most common phenotype associated with GBM is cellular invasion; however, the molecular mechanisms governing this process are poorly understood. Targeting protein for Xenopus kinesin-like protein 2 (TPX2) is a nuclear protein with roles in cellular proliferation and mitotic spindle assembly. TPX2 is overexpressed in various malignancies, including human malignant astrocytoma. Despite this finding, the exact role of TPX2 in human glioma is not well defined. The present study reports the elevated expression of TPX2 in a number of glioma cell lines. TPX2 overexpression promoted cellular proliferation, decreased the percentage of cells in G0/G1 phase, and increased invasion of both U251 and U87 cells. Overexpression of TPX2 also significantly enhanced the phosphorylation of AKT, decreased the expression of p21, and increased the expression of cyclin D1 and matrix metallopeptidase (MMP)-9. In both U251 and U87 cells, knockdown of TPX2 resulted in phenotypes that are in direct contrast to those observed following TPX2 overexpression. Specifically, TPX2 knockdown inhibited cell proliferation, increased the percentage of cells in G0/G1 phase, inhibited invasion, decreased AKT phosphorylation, decreased the expression of MMP-9 and cyclin D1, and increased p21 expression. The AKT inhibitor IV in large part phenocopied the effect of TPX2 knockdown. The present data suggest that TPX2 promotes glioma cell proliferation and invasion via AKT signaling.

The Impact of Hope and Resilience on Multiple Factors in Neurosurgical Patients

The purpose of the present article is to outline and review the impact of stable psychological characteristics on the emotional and functional outcomes of neurosurgical patients. Neurosurgical patients face adversity as inherent to their diagnoses and, consequently, experience emotional distress. Despite commonalities in diagnoses, diverse outcomes are seen post-neurosurgery, which are influenced by psychological factors. Therefore, an understanding of neurosurgical patients’ behavior, thoughts, and feelings surrounding their diagnoses, informed by psychological concepts, is important for both neuropsychology and neurosurgery.

Psychosocial distress and its effects on the health-related quality of life of primary brain tumor patients

All cancer patients experience distress from the diagnosis, the effects of the disease or the treatment. Clinically significant distress decreases overall quality of life and the recognition of distress with prompt intervention is essential. The National Comprehensive Cancer Network distress thermometer (NCCN-DT) is a validated measuring tool that has been utilized in the primary brain tumor population to detect psychologic distress thereby provoking a referral process to the appropriate support system. Brain tumor patients commonly reported emotional and physical distress encompassing: fatigue, fears, memory and concentration and worry. More research is needed to identify the stressors of all primary brain tumor patients and their caretakers and integrate appropriate interventions to improve health-related quality of life in both groups.

A clinical care pathway to improve the acute care of patients with glioma

BACKGROUND

Patients with glioma are at increased risk for tumor-related and treatment-related complications. Few guidelines exist to manage complications through supportive care. Our prior work suggests that a clinical care pathway can improve the care of patients with glioma.

METHODS

We designed a quality improvement (QI) project to address the acute care needs of patients with gliomas. We formed a multidisciplinary team and selected 20 best-practice measures from the literature. Using a plan-do-study-act framework, we brainstormed and implemented various improvement strategies starting in October 2013. Statistical process control charts were used to assess progress.

RESULTS

Retrospective data were available for 12 best practice measures. The baseline population consisted of 98 patients with glioma. Record review suggested wide variation in performance, with compliance ranging from 30% to 100%. The team hypothesized that lack of process standardization may contribute to less-than-ideal performance. After implementing improvement strategies, we reviewed the records of 63 consecutive patients with glioma. The proportion of patients meeting criteria for 12 practice measures modestly improved (65% pre-QI; 76% post-QI, P > .1). Unexpectedly, a higher proportion of patients were readmitted within 30 days of hospital discharge (pre-QI: 10%; post-QI: 17%, P > .1). Barriers to pathway development included difficulties with transforming manual measures into electronic data sets.

CONCLUSIONS

Creating evidence-based clinical care pathways for addressing the acute care needs of patients with glioma is feasible and important. There are many challenges, however, to developing sustainable systems for measuring and reporting performance outcomes overtime.

Quantitative Perfusion and Permeability Biomarkers in Brain Cancer from Tomographic CT and MR Images

Dynamic contrast-enhanced perfusion and permeability imaging, using computed tomography and magnetic resonance systems, are important techniques for assessing the vascular supply and hemodynamics of healthy brain parenchyma and tumors. These techniques can measure blood flow, blood volume, and blood-brain barrier permeability surface area product and, thus, may provide information complementary to clinical and pathological assessments. These have been used as biomarkers to enhance the treatment planning process, to optimize treatment decision-making, and to enable monitoring of the treatment noninvasively. In this review, the principles of magnetic resonance and computed tomography dynamic contrast-enhanced perfusion and permeability imaging are described (with an emphasis on their commonalities), and the potential values of these techniques for differentiating high-grade gliomas from other brain lesions, distinguishing true progression from posttreatment effects, and predicting survival after radiotherapy, chemotherapy, and antiangiogenic treatments are presented.

Incidence, Characteristics, and Implications of Seizures in Patients With Glioblastoma

BACKGROUND

Seizures in patients with glioblastoma are associated with worse quality of life. However, their incidence, clinical characteristics, and prognostic implications are less well characterized.

OBJECTIVE

This study was undertaken to provide a contemporary experience along with benchmark data relevant to the above in patients with glioblastoma. It also sought to reexplore improved survival with seizures, as observed by others.

METHODS

In this single-institution study, patients with glioblastoma from 2010 through 2014 had their medical records reviewed in detail.

RESULTS

Among 122 patients, 58 (48%) had a seizure history. Of these, 67% had more than 1, 41% had generalized seizures, and most received antiseizure medication (most commonly levetiracetam). The median survival for patients with seizures was 1.66 years and 0.87 years for those without (hazard ratio for risk of death with seizures: 0.72; 95% confidence interval: 0.43, 1.21; P = .22 by the log-rank test).

CONCLUSION

Seizures are common in patients with glioblastoma and, in contrast to earlier reports, are not associated with a statistically significant improvement in survival.

Overexpression of interleukin-33 is associated with poor prognosis of patients with glioma

Interleukin-33 (IL-33) has shown diagnostic and prognostic values in multiple human cancers. However, there is little knowledge on the role of IL-33 in human gliomas and its association with disease prognosis. This study aimed to evaluate the value of IL-33 in the prognosis of glioma patients. The expression of IL-33 was determined and compared in surgical specimens from 86 glioma patients and 16 normal brain tissues. The associations of IL-33 expression with the clinicopathological features and prognosis of glioma patients were assessed. qRT-PCR assay showed higher IL-33 mRNA expression in glioma tissues than in normal brain tissue ( p < 0.001), and significantly higher IL-33 mRNA expression was detected in both low- and high-grade glioma tissues relative to normal brain tissues ( p < 0.001). Western blotting revealed elevated IL-33 protein levels in glioma tissues compared to those in normal brain tissues, and immunohistochemical staining showed higher IL-33 protein expression in glioma tissues than in normal brain tissues. IL-33 expression correlated with the glioma grade ( p < 0.001) and Karnofsky performance status score ( p = 0.024), and the glioma patients with high IL-33 expression had a shorter progression-free survival ( p < 0.001) and overall survival ( p < 0.001) than those with low IL-33 expression. The univariate and multivariate analyses showed that IL-33 overexpression and the glioma grade were independent factors of a poor prognosis in glioma patients. Therefore, IL-33 may be a promising biomarker for the detection of gliomas, and IL-33 expression is useful for predicting the prognosis of the disease.

Trends in cognitive dysfunction following surgery for intracranial tumors

Background:

This study was conducted to prospectively assess the cognitive function of patients with intracranial tumors.

Methods:

The cognitive status of patients with intracranial tumors were prospectively studied before surgery, and later at 1 and 6 months following surgery, on purposive sampling, using validated post graduate institute (PGI) battery for brain dysfunction (score 0–30) with a higher dysfunction rating score indicating poor cognitive status.

Results:

Out of 23 patients enrolled, 20 could complete the study. They had substantial cognitive dysfunction before surgery (score 17.1 ± 9.4). Though there was no significant improvement (16.9 ± 9.0) at 1 month, the score improved significantly (10.3 ± 9.2) at 6 months following surgery (P = 0.008). The improvement was relatively subdued in intra-axial, malignant, and radiated tumors. Overall, there was a significant improvement in mental balance (P = 0.048), verbal retention of dissimilar pairs (P = 0.01), and recognition (P = 0.01), while dysfunction persisted in the domains of memory, verbal retention to similar pairs, and visual retention.

Conclusion:

Patients with intracranial tumors have substantial cognitive dysfunction, which tend to show significant improvement beyond 6 months following surgery, especially among tumors, which were extra-axial, benign, and nonirradiated.

Fatigue among patients with brain tumors

Fatigue is a ubiquitous and an extremely distressing symptom among patients with brain tumors (BT), particularly those with high-grade gliomas. The pathophysiology of cancer-related fatigue (CRF) in the context of patients with BT is multifactorial and complex, involving biological, behavioral, medical and social factors. The etiology of CRF in the general oncology population is pointing to the role of inflammatory cytokines as a key factor in the genesis of CRF, but this research is currently limited in the setting of BT. CRF should be screened, assessed and managed according to clinical practice guidelines. Fatigue has recently emerged as a strong, independent prognostic factor for survival that provides incremental prognostic value to the traditional markers of prognosis in recurrent high-grade gliomas. Therefore, strategies to treat fatigue warrant investigation, not only to improve the QOL of a group of patients with often limited life expectancy, but also possibly to optimize survival.

Validation of the National Institutes of Health Patient-Reported Outcomes Measurement Information System Survey as a Quality-of-Life Instrument for Patients with Malignant Brain Tumors and Their Caregivers

At present there is a lack of well-validated surveys used to measure quality of life in patients with malignant brain tumors and their caregivers. The main objective of this pilot study was to validate the National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH PROMIS) survey for use as a quality-of-life measure in this population. This article presents the rationale for using the NIH PROMIS instrument as a quality-of-life measure for patients with malignant brain tumors and their caregivers.

Introduction of Questionnaires for Quality of Life of Patients with Malignant Tumors of the Central Nervous System into Neurosurgical Practice in the Republic of Kazakhstan

BACKGROUND

Studies of quality of life (QoL) of oncological patients is carried out using questionnaires approved in many international clinical studies. The European Organization for Research and Treatment of Cancer EORTC QLQ-C30 (Quality of Life Questionnary-Core 30) and its special brain cancer module EORTC QLQ-BN20 are widely used in the world neurooncologic practice. They are available in more than 80 official versions of 30 languages of the world. Previously we used the official versions in Russian, which often causes difficulty in understanding for native Kazakh language speakers, who comprise more than 60% of our respondents. This was the reason for creating a version of Kazakh language. Therefore, in 2014 for the first time the process of adaptation of questionnaires to the Kazakh language was initiated.

MATERIALS AND METHODS

The translation process of questionnaires to Kazakh language was held in accordance with the requirements of the European Organization for Research and Treatment of Cancer EORTC on QoL and consisted of the following stages: preparation - translation - pilot testing - approval. The official permission of authors and "Guideline on translation" was obtained which was developed by the working group of the EORTC on QoL. The pilot testing of EORTC QLQ-C30 and QLQ-BN20 questionnaires was conducted on the basis of the Department of Central Nervous System Pathology of the "National Centre for Neurosurgery" in patients with malignant tumors of the central nervous system.

RESULTS

The official versions of the EORTC QLQ-C30 and QLQ-BN20 questionnaires in Kazakh language were introduced and adapted in practical neurosurgical operations in Kazakhstan.

CONCLUSIONS

The approved versions of the questionnaires in Kazakh language are now available for mainstream use on the official website EORTC.com. The versions of these questionnaires can be used in domestic cohort studies and clinical practice in the Republic of Kazakhstan. The use of these tools for assessing QoL will help professionals in the planning of individual treatment strategies and selection of the necessary therapy.

Palliative care at the end-of-life in glioma patients

The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.

Health-related quality of life and psychological functioning in patients with primary malignant brain tumors: a systematic review of clinical, demographic and mental health factors

Background

The impact of primary malignant brain tumors on patient quality of life and psychological functioning is poorly understood, limiting the development of an evidence base for supportive interventions. We conducted a thorough systematic review and quality appraisal of the relevant literature to identify correlates of health-related quality of life (HRQoL) and psychological functioning (depression, anxiety and distress) in adults with primary malignant brain tumors.

Method

Twenty-three articles met predefined inclusion criteria from a pool of peer-reviewed literature published between January 1984 and July 2015 (N = 2407). Methodological quality of included studies was assessed using an adapted version of the Newcastle-Ottawa Scale.

Results

The overall methodological quality of the literature was moderate. Factors relating consistently with HRQoL and/or psychological functioning were cognitive impairment, corticosteroid use, current or previous mental health difficulties, fatigue, functional impairment, performance status and motor impairment.

Conclusions

Practitioners should remain alert to the presence of these factors as they may indicate patients at greater risk of poor HRQoL and psychological functioning. Attention should be directed towards improving patients' psychological functioning and maximizing functional independence to promote HRQoL. We outline several areas of future research with emphasis on improved methodological rigor.

[Attention system functions and their relationship with self-reported health in patients with brain damage due to tumor]

AIM

To compare parameters of attention in healthy people and patients with neoplasms in different regions of the cerebral cortex and to evaluate quality of life (QoL) indices with regard to impairment of different attention systems.

MATERIAL AND METHODS

Twenty patients with oncological lesions of the brain (mean age 56.5±8.8 years) who did not undergo surgery were studied. Tumor localization was confirmed using contrast-enhanced computed tomography, the tumor type was histologically verified. A control group included 18 healthy people matched for age, sex and education level. To determine attention system functions, we developed a computed version of the Attention Network Test. Error rate and reaction time for correct responses to the target stimulus, displayed along with neutral, congruent and incongruent signals, were the indicators of the efficacy of selective processes. QoL indices were assessed using SF-36 health survey questionnaire.

RESULTS AND CONCLUSION

The readiness to respond to incoming stimuli was mostly impaired in patients with brain tumors. Efficacy of executive attention, assessed as the increase in the number of errors in selection of visual stimuli, was decreased while temporary parameters of the functions of this system were not changed in patients compared to controls. The SF-36 total score was stable in patients with marked reduction in scores on the Role and Emotional Functioning scales. The most severe health impairment measured on the SF-36 scales of role/social emotional functioning and viability was recorded in patients with the lesions of frontal cortical areas compared to temporal/parietal areas. The relationship between SF-36 Health self-rating and attention systems was found. This finding puts the question of the importance of attention characteristics and QoL for survival prognosis of patients with brain tumors.

The impact of epilepsy on the quality of life of patients with meningioma: A systematic review

Quality of life (QoL) is regarded as an important outcome measure in meningioma, and studies have investigated the role of various clinical and demographic factors. Epilepsy is known to impair quality of life but the impact of epilepsy on quality of life in a meningioma population is not well defined. The aim of this systematic review is to identify and summarise the current literature on meningioma, epilepsy and quality of life. A PubMed search was performed that identified 162 articles. Only 4 articles relevant to meningioma, epilepsy and QoL were found and each were analysed in terms of design, data, findings and conclusions. Each article was different in terms of study population, aims and outcome measure, but all suggest that epilepsy has an impact on quality of life. Anti-epileptic drugs, uncontrolled seizures and cognitive dysfunction may be particularly significant. The identified articles were weakened by small sample size, short follow-up, a lack of recorded epilepsy variables and the use of quality of life measures that are either too specific or not validated. Future studies are warranted to improve understanding in this topic, aid clinical decisions and improve QoL in these patients.

Case-Based Review: newly diagnosed glioblastoma

Glioblastoma (WHO grade IV astrocytoma) is the most common and most aggressive primary brain tumor in adults. Optimal treatment of a patient with glioblastoma requires collaborative care across numerous specialties. The diagnosis of glioblastoma may be suggested by the symptomatic presentation and imaging, but it must be pathologically confirmed via surgery, which can have dual diagnostic and therapeutic roles. Standard of care postsurgical treatment for newly diagnosed patients involves radiation therapy and oral temozolomide chemotherapy. Despite numerous recent trials of novel therapeutic approaches, this standard of care has not changed in over a decade. Treatment options under active investigation include molecularly targeted therapies, immunotherapeutic approaches, and the use of alternating electrical field to disrupt tumor cell division. These trials may be aided by new insights into glioblastoma heterogeneity, allowing for focused evaluation of new treatments in the patient subpopulations most likely to benefit from them. Because glioblastoma is incurable by current therapies, frequent clinical and radiographic assessment is needed after initial treatment to allow for early intervention upon progressive tumor when it occurs.

Perioperative quality of life in functionally dependent glioblastoma patients: A prospective study

OBJECTIVE

Functionally dependent patients with glioblastoma have a poor prognosis which may in part be due to a negative treatment selection. Prospective data on patient-reported quality of life (QoL) following surgery, together with an updated survival analysis, are lacking with regard to functionally dependent glioblastoma patients.

MATERIALS AND METHODS

Adult patients (≥ 18 years) with a histologically confirmed primary glioblastoma with preoperative Karnofsky Performance Status (KPS) ≤ 60, who were treated between January 1, 2007 and March 30, 2014, were eligible for inclusion. EuroQol 5D (EQ-5D) was scored before surgery and at 4-6 weeks postoperatively. A control group of 20 independent (i.e., KPS ≥ 70) adult primary glioblastoma patients was constructed.

RESULTS

Among the 27 patients included, only 22 patients were willing to participate in QoL research, with complete QoL follow-up data obtained for 16. There were 22 resections and 5 biopsies. In resection cases, the median extent of resection was 93% (IQR 78-99), with gross-total resection achieved in 24%. In the 16 patients with complete QoL data, the EQ-5D index score increased from 0.34 ± 0.38 preoperatively to 0.45 ± 0.32 postoperatively (p = 0.30), with 3 patients that deteriorated in QoL following surgery. Median survival was 7.3 months (95%, CI: 4.6-9.9, n = 27), and the perioperative mortality was 7%. Treatment characteristics between dependent and independent patients were similar, as were the unfavorable outcomes defined as QoL reduction, QoL drop-out, and dead before QoL assessment (41% vs. 45%, p = 0.79). However, a difference was seen in 6-month survival (42% vs. 15%, p = 0.05).

CONCLUSION

In most functionally dependent patients with glioblastoma, cytoreductive surgery is possible, and improved or unchanged postoperative QoL may be seen in approximately half of the cases. This must be weighed against the risk of complications and the modest effect of cytoreductive surgery.

Impairment of medical decisional capacity in relation to Karnofsky Performance Status in adults with malignant brain tumor

BACKGROUND

We aimed to investigate the relationship between medical decisional capacity (MDC) and Karnofsky Performance Status (KPS) in adults with malignant brain tumors.

METHODS

Participants were 71 adults with primary (n = 26) or metastatic (n = 45) brain tumors. Testing to determine KPS scores and MDC was performed as close together as possible for each patient. Participants were administered a standardized measure of medical decision-making capacity (Capacity to Consent to Treatment Instrument [CCTI]) to assess 3 treatment consent abilities (ie, appreciation, reasoning, and understanding). Capacity classifications (ie, capable, marginally capable, and incapable) were established using cut scores previously derived from healthy control CCTI performance.

RESULTS

The majority of participants had KPS scores of 90-100 (n = 39), with the remainder divided between KPS scores of 70-80 (n = 26) and 50-60 (n = 6). Comparisons between persons with KPS scores of 90-100 or 70-80 revealed significant differences on the CCTI consent standards of understanding and appreciation. Participants with KPS ratings of 90-100 achieved 46% capable classifications across all CCTI standards, in contrast with 23% of participants with KPS ratings of 70-80, and 0% of participants with KPS ratings of 50-60.

CONCLUSIONS

A substantial portion of brain-tumor patients with KPS scores reflecting only minimal disability nonetheless demonstrated impairments on standardized measures of MDC. Clinicians working with this adult population should carefully screen for capacity to make clinical treatment decisions regardless of functional/performance status.

Cellular and molecular mechanisms of radiation-induced brain injury: can peripheral markers be detected?

Investigation of the mechanisms of radiation-induced brain injury is a relevant fundamental objective of radiobiology and neuroradiology. Damage to the healthy brain tissue is the key factor limiting the application of radiation therapy in patients with nervous systems neoplasms. Furthermore, postradiation brain injury can be clinically indiscernible from continued tumor growth and requires differential diagnosis. Thus, there exists high demand for biomarkers of radiation effects on the brain in neurosurgery and radiobiology. These markers could be used for better understanding and quantifying the effects of ionizing radiation on brain tissues, as well as for elaborating personalized therapy. Despite the high demand, biomarkers of radiation-induced brain injury have not been identified thus far. The cellular and molecular mechanisms of the effect of ionizing radiation on the brain were analyzed in this review in order to identify potential biomarkers of radiation-induced injury to nervous tissue.

Palliative care and quality of life in neuro-oncology

Health-related quality of life has become an important end point in modern day clinical practice in patients with primary or secondary brain tumors. Patients have unique symptoms and problems from diagnosis till death, which require interventions that are multidisciplinary in nature. Here, we review and summarize the various key issues in palliative care, quality of life and end of life in patients with brain tumors, with the focus on primary gliomas.

Management of low-grade gliomas: a review of patient-perceived quality of life and neurocognitive outcome

Low-grade glioma (LGG) comprises nearly 20% of all central nervous system glial tumors, with approximately 2000-3000 patients diagnosed annually in the United States. Because of their infiltrative ability and aggressive nature, the average 10-year survival is 30% when <90% of the tumor is resected. Since the 1970s, prognosis for LGGs has improved significantly. This improvement is primarily attributable to earlier diagnoses via magnetic resonance imaging scanning, increased awareness of the more favorable oligo component, technical advances in intraoperative neurosurgery, and stratification for young age. Using a number of prognostic factors, LGGs have been classified into low-risk and high-risk subgroups. Optimal therapy for patients with low-risk, supratentorial grade II glioma remains a highly controversial issue in the neuro-oncology community. The concerns regarding the toxicity of therapy often outweigh the benefits of delaying tumor progression. The recommendation for observation is made without full prospective understanding of the impact of radiologic tumor progression on the quality of life (QOL), neurocognitive function (NCF), seizure control, and functional status of these patients. We present a review of the current knowledge of the management of LGG with emphasis upon patient-reported outcomes of QOL, NCF, and seizure control. We also discuss current clinical trials with proposals to evaluate QOL, NCF, and seizure control in patients undergoing observation alone after newly diagnosed low-risk LGG or treatment options for those patients in the high-risk group.

Predictors of health-related quality of life in neurosurgical brain tumor patients: focus on patient-centered perspective

BACKGROUND

In brain tumor (BT) patients, the association between health-related quality of life (HRQoL) and psychological characteristics remains largely unknown. We evaluated the association of personality traits, clinical factors, psychological distress symptoms, and cognitive state with HRQoL in BT patients.

METHODS

On admission for BT surgery, 200 patients (69 % women; age 55.8 ± 14.5 years) were evaluated for HRQoL (SF-36 scale), Big-Five personality traits (Ten-Item Personality Inventory), psychological distress symptoms (Hospital Anxiety and Depression Scale or HADS), cognitive function (Mini-Mental State Examination or MMSE) and clinical characteristics, including functional status (Barthel index or BI). The most common BT diagnoses were meningioma (39 %) and high-grade glioma (18 %).

RESULTS

Only factors significantly associated with SF-36 domains in univariable regression analyses were included in their respective multivariable models and predicted from 6 %-49 % of the total variance of SF-36 scores. Greater TIPI emotional stability score was independently associated with greater SF-36 emotional well-being (β = 0.23, p < 0.001) and general health (β = 0.18, p = 0.01) scores, and greater TIPI consciousness score, with greater SF-36 emotional well-being score (β = 0.13, p = 0.02). HADS-anxiety and HADS-depression scores were the strongest independent determinants of all, except physical functioning, SF-36 scores (β-values range from 0.14 to 0.56; p values ≤ 0.03). BI score was the strongest independent determinant of SF-36 physical functioning score (β = 0.36, p < 0.001). MMSE score was associated with all but emotional well-being and social functioning SF-36 scores.

CONCLUSIONS

Consciousness and emotional stability should be considered important personality-related determinants of HRQoL in BT patients. Psychological distress, functional disability, and cognitive impairment are also important predictors of HRQoL.

Together and apart: providing psychosocial support for patients and families living with brain tumors

PURPOSE

Brain tumors are associated with neurological sequelae and poor survival, contributing to distress in patients and their families. Our institution has conducted separate support groups for brain tumor patients and caregivers since 1999. This retrospective cohort study aimed to identify characteristics of brain tumor group participants in relation to attendance frequency, and compare themes of discussion in patient and caregiver groups.

METHODS

Demographic and medical characteristics were obtained from patient and caregiver group registration sheets and medical chart review. We quantified discussion topics recorded by group facilitators between 1999 and 2006, extracted themes, and examined similarities and differences in the way these themes were expressed.

RESULTS

A total of 137 patients and 238 caregivers attended the groups; about half attended more than one session. The chart review of a randomly selected subset of patient participants revealed that 57.5 % were married, 58.8 % had high-grade gliomas, and 55 % attended their first group within 3 months of diagnosis or at tumor progression. Both groups discussed physical and cognitive consequences, emotional reactions, relationships, coping, end of life, and practical issues. Caregivers discussed difficulties achieving self-care and caregiver burden.

CONCLUSIONS

Brain tumor support group facilitators can expect to encounter a range of medical and psychosocial issues in accommodating patients' and caregivers' diverse concerns. Separate brain tumor patient and caregiver groups may allow participants to explore those concerns without worrying about effects on their friends or family. It remains to be seen whether the groups meet the needs of attendees, and whether those who do not attend the groups have unmet needs.

Radiation-induced cognitive impairment--from bench to bedside

Approximately 100,000 patients per year in the United States with primary and metastatic brain tumor survive long enough (>6 months) to develop radiation-induced brain injury. Before 1970, the human brain was thought to be radioresistant; the acute central nervous system (CNS) syndrome occurs after single doses of ≥ 30 Gy, and white matter necrosis can occur at fractionated doses of ≥ 60 Gy. Although white matter necrosis is uncommon with modern radiation therapy techniques, functional deficits, including progressive impairments in memory, attention, and executive function have become increasingly important, having profound effects on quality of life. Preclinical studies have provided valuable insights into the pathogenic mechanisms involved in radiation-induced cognitive impairment. Although reductions in hippocampal neurogenesis and hippocampal-dependent cognitive function have been observed in rodent models, it is important to recognize that other brain regions are affected; non-hippocampal-dependent reductions in cognitive function occur. Neuroinflammation is viewed as playing a major role in radiation-induced cognitive impairment. During the past 5 years, several preclinical studies have demonstrated that interventional therapies aimed at modulating neuroinflammation can prevent/ameliorate radiation-induced cognitive impairment independent of changes in neurogenesis. Translating these exciting preclinical findings to the clinic offers the promise of improving the quality of life in patients with brain tumors who receive radiation therapy.

Molecular pathways: radiation-induced cognitive impairment

Each year, approximately 200,000 patients in the United States will receive partial- or whole-brain irradiation for the treatment of primary or metastatic brain cancer. Early and delayed radiation effects are transient and reversible with modern therapeutic standards; yet, late radiation effects (≥6 months postirradiation) remain a significant risk, resulting in progressive cognitive impairment. These risks include functional deficits in memory, attention, and executive function that severely affect the patient's quality of life. The mechanisms underlying radiation-induced cognitive impairment remain ill defined. Classically, radiation-induced alterations in vascular and neuroinflammatory glial cell clonogenic populations were hypothesized to be responsible for radiation-induced brain injury. Recently, preclinical studies have focused on the hippocampus, one of two sites of adult neurogenesis within the brain, which plays an important role in learning and memory. Radiation ablates hippocampal neurogenesis, alters neuronal function, and induces neuroinflammation. Neuronal stem cells implanted into the hippocampus prevent the decrease in neurogenesis and improve cognition after irradiation. Clinically prescribed drugs, including PPARα and PPARγ agonists, as well as RAS blockers, prevent radiation-induced neuroinflammation and cognitive impairment independent of improved neurogenesis. Translating these exciting findings to the clinic offers the promise of improving the quality of life of brain tumor patients who receive radiotherapy.

Low grade gliomas in eloquent locations - implications for surgical strategy, survival and long term quality of life

Background

Surgical management of suspected LGG remains controversial. A key factor when deciding a surgical strategy is often the tumors’ perceived relationship to eloquent brain regions

Objective

To study the association between tumor location, survival and long-term health related quality of life (HRQL) in patients with supratentorial low-grade gliomas (LGG).

Methods

Adults (≥18 years) operated due to newly diagnosed LGG from 1998 through 2009 included from two Norwegian university hospitals. After review of initial histopathology, 153 adults with supratentorial WHO grade II LGG were included in the study. Tumors’ anatomical location and the relationship to eloquent regions were graded. Survival analysis was adjusted for known prognostic factors and the initial surgical procedure (biopsy or resection). In long-term survivors, HRQL was assessed with disease specific questionnaires (EORTC QLQ-C30 and BN20) as well as a generic questionnaire (EuroQol 5D).

Results

There was a significant association between eloquence and survival (log-rank, p<0.001). The estimated 5-year survival was 77% in non-eloquent tumors, 71% in intermediate located tumors and 54% in eloquent tumors. In the adjusted analysis the hazard ratio of increasing eloquence was 1.5 (95% CI 1.1–2.0, p = 0.022). There were no differences in HRQL between patients with eloquent and non-eloquent tumors. The most frequent self-reported symptoms were related to fatigue, cognition, and future uncertainty.

Conclusion

Eloquently located LGGs are associated with impaired survival compared to non-eloquently located LGG, but in long-term survivors HRQL is similar. Although causal inference from observational data should be done with caution, the findings illuminate the delicate balance in surgical decision making in LGGs, and add support to the probable survival benefits of aggressive surgical strategies, perhaps also in eloquent locations.

The effects of radiotherapy on psychosocial and cognitive functioning in adults with a primary brain tumor: a prospective evaluation

A paucity of studies have evaluated the biopsychosocial factors contributing to quality of life (QoL) in adults with a primary brain tumor (BT). Our objective was to investigate (i) the effects of radiotherapy on the psychosocial (ie, posttraumatic stress symptoms [PTSS]) and cognitive functioning of adults with a primary BT, assessed preradiotherapy [T1] and postradiotherapy [T2], and (ii) predictors of PTSS and QoL postradiotherapy. Seventy adults with a BT were assessed at T1, and 67 patients were reassessed 3.5 months postradiotherapy. At each assessment, participants completed measures of PTSS, mood, QoL, and quality of social support and neurocognitive tests focusing on memory and executive functioning. Minimal differences in functioning were found between patients according to BT type (benign [n = 45] vs malignant [n = 25]) and tumor laterality (left vs right hemisphere), with 2 exceptions. Individuals with a left hemisphere benign BT experienced greater distress at T1, which declined at T2, whereas individuals with a left hemisphere malignant BT reported poorer social support at T2. The full sample performed poorly on tests of executive functioning, and 17% reported clinically elevated PTSS at T1, which reduced to 13% at T2. Younger age (<65 y), reduced QoL, and elevated anger symptoms at T1 predicted PTSS at T2, whilst having a benign BT, low PTSS, and depressive symptoms at T1 were predictive of improved QoL at T2. Findings highlight the importance of screening for psychosocial and cognitive disturbances in BT patients undergoing treatment to identify those at risk for acute and more prolonged problems.

Changes in neurocognitive functioning and quality of life in adult patients with brain tumors treated with radiotherapy

This review aims to summarize what is currently known about neurocognitive outcome and quality of life in patients with brain tumors treated with radiotherapy. Whether potential tumor-controlling benefits of radiotherapy outweigh its potential toxicity in the natural history of brain tumors is a matter of debate. This review focuses on some of the adult main brain tumors, for which the issue of neurocognitive decline has been thoroughly studied: low-grade gliomas, brain metastases, and primary central nervous system lymphomas. The aims of this review are: (1) the analysis of existing data regarding the relationship between radiotherapy and neurocognitive outcome; (2) the identification of strategies to minimize radiotherapy-related neurotoxicity by reducing the dose or the volume; (3) the evidence-based data concerning radiotherapy withdrawal; and (4) the definition of patients subgroups that could benefit from immediate radiotherapy. For high grade gliomas, the main findings from literature are summarized and some strategies to reduce the neurotoxicity of the treatment are presented. Although further prospective studies with adequate neuropsychological follow-up are needed, this article suggests that cognitive deficits in patients with brain tumor have a multifactorial genesis: radiotherapy may contribute to the neurocognitive deterioration, but the causes of this decline include the tumor itself, disease progression, other treatment modalities and comorbidities. Treatment variables, such as total and fractional dose, target volume, and irradiation technique can dramatically affect the safety of radiotherapy: optimizing radiation parameters could be an excellent approach to improve outcome and to reduce neurotoxicity. At the same time, delayed radiotherapy could be a valid option for highly selected patients.

Changes in neurocognitive functioning and quality of life in adult patients with brain tumors treated with radiotherapy

This review aims to summarize what is currently known about neurocognitive outcome and quality of life in patients with brain tumors treated with radiotherapy. Whether potential tumor-controlling benefits of radiotherapy outweigh its potential toxicity in the natural history of brain tumors is a matter of debate. This review focuses on some of the adult main brain tumors, for which the issue of neurocognitive decline has been thoroughly studied: low-grade gliomas, brain metastases, and primary central nervous system lymphomas. The aims of this review are: (1) the analysis of existing data regarding the relationship between radiotherapy and neurocognitive outcome; (2) the identification of strategies to minimize radiotherapy-related neurotoxicity by reducing the dose or the volume; (3) the evidence-based data concerning radiotherapy withdrawal; and (4) the definition of patients subgroups that could benefit from immediate radiotherapy. For high grade gliomas, the main findings from literature are summarized and some strategies to reduce the neurotoxicity of the treatment are presented. Although further prospective studies with adequate neuropsychological follow-up are needed, this article suggests that cognitive deficits in patients with brain tumor have a multifactorial genesis: radiotherapy may contribute to the neurocognitive deterioration, but the causes of this decline include the tumor itself, disease progression, other treatment modalities and comorbidities. Treatment variables, such as total and fractional dose, target volume, and irradiation technique can dramatically affect the safety of radiotherapy: optimizing radiation parameters could be an excellent approach to improve outcome and to reduce neurotoxicity. At the same time, delayed radiotherapy could be a valid option for highly selected patients.

Quality of life in patients with intracranial gliomas: the impact of modern image-guided surgery

Object

Outcome following brain tumor operations is often assessed by health professionals using various gross function scales. However, surprisingly little is known about how modern glioma surgery affects quality of life (QOL) as reported by the patients themselves. In the present study the authors aimed to assess changes in QOL after glioma surgery, to explore the relationship between QOL and traditional outcome parameters, and to examine possible predictors of change in QOL.

Methods

Eighty-eight patients with glioma were recruited from among those 16 years or older who had been admitted to the authors' department for brain tumor surgery in the period between January 2007 and December 2009. A 3D ultrasonography–based navigation system was utilized in nearly all operations and functional MR imaging data on eloquent lesions were incorporated into the neuronavigation system. Preoperative scores for QOL (EuroQol 5D [EQ-5D]) and functional status (Karnofsky Performance Scale [KPS]) were obtained. The EQ-5D and KPS scores were subsequently recorded 6 weeks postoperatively, as were responses to a structured interview about new deficits and possible complications.

Results

There was no change in the median EQ-5D indexes following surgery, 0.76 versus 0.75 (p = 0.419). The EQ-5D index value was significantly correlated with the KPS score (p < 0.001; rho = 0.769). The EQ-5D index values and KPS scores improved in 35.2% and 24.1% of cases, were equal in 20.5% and 47.2% of cases, and deteriorated in 44.3% and 28.7%, respectively. Thus, both improvement and deterioration were underestimated by the KPS score as compared with the patient-reported QOL assessment. New motor deficits (p = 0.003), new language deficits (p = 0.035), new unsteadiness and/or ataxia (p = 0.001), occipital lesions (p = 0.019), and no use of ultrasonography for resection control (p = 0.021) were independent predictors of worsening QOL in a multivariate model.

Conclusions

The surgical procedures per se may not significantly alter QOL in the average patient with glioma; however, new deficits have a major undesirable effect on QOL. It seems that the active use of intraoperative ultrasonography may be associated with a preservation of QOL. The EQ-5D seems like a good outcome measure with a strong correlation to traditional variables while offering a more detailed description of outcome.

High β-catenin/Tcf-4 activity confers glioma progression via direct regulation of AKT2 gene expression

Recent data suggest that the β-catenin/Tcf-4 signaling pathway plays an important role in human cancer tumorigenesis. However, the mechanism of β-catenin/Tcf-4 signaling in tumorigenesis is poorly understood. In this study, we show that Tcf-4 protein levels were significantly elevated in high-grade gliomas in comparison with low-grade gliomas and that Tcf-4 levels correlated with levels of AKT2. Reduction of β-catenin/Tcf-4 activity inhibited glioma cell proliferation and invasion in vitro and tumor growth in vivo. This effect of β-catenin/Tcf-4 activity was mediated by AKT2, and in vivo binding of β-catenin/Tcf-4 to the AKT2 promoter was validated using the chromatin immunoprecipitation assay and luciferase reporter assays. Taken together, we have demonstrated that Tcf-4 is associated with glioma progression and that AKT2 is a new member of the genes that are regulated by β-catenin/Tcf-4.