151
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Abstract
Neurotoxicity from radiation can range widely and produce effects that may include (1) small absolute increases in cancer risks, (2) subtle effects on higher level functioning in some individuals, (3) severe cognitive impairment in some individuals, (4) severe focal injury tat may include necrosis or irreversible loss of function, and (5) overwhelming and rapidly fatal diffuse injury associated with high-dose, whole-body exposures. An understanding of the implications of nervous system exposure to radiation can guide efforts in radiation protection and aid in the optimization of the medical uses of radiation.
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Affiliation(s)
- L Cameron Pimperl
- Department of Radiation Oncology, Wilford Hall Medical Center, Lackland Air Force Base, Suite 1/MMCN, 2200 Bergquist Drive, TX 78236, USA.
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152
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Papagikos MA, Shaw EG, Stieber VW. Lessons learned from randomised clinical trials in adult low grade glioma. Lancet Oncol 2005; 6:240-4. [PMID: 15811619 DOI: 10.1016/s1470-2045(05)70095-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
"Lesson" is a Middle English word that has been defined as "a passage from sacred writings read in a service of worship" as well as "something learned by study or experience". The term is quite appropriate in assessment of what has been learned from randomised trials in adult low-grade gliomas, since the treatment of these tumours has traditionally been guided as much by belief as by fact. Therefore, when assessing these trials we can apply the principles of hermeneutics. Thus, the first meaning of "lesson" given here can be described as literal, whereas the second may be seen as figurative. Since hermeneutics may also refer to an in-depth analysis of a particular text, the investigators will present their interpretation of data from randomised trials. The goal is to show that the lessons learned are not necessarily literal or dogmatic but can be much more allegorical in nature.
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Affiliation(s)
- Michael A Papagikos
- Department of Radiation Oncology, Comprehensive Cancer Center, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA
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153
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Abstract
Radiotherapy (RT) is a proven curative and palliative therapeutic tool in the treatment of a wide variety of primary and metastatic brain tumors in adults. Recent advances in multimodality therapy have led to improvement in survival for many cancer patients. As survival has improved, more attention has been directed toward long-term treatment-related morbidity. Specifically, the effect of RT on the long-term cognitive performance of these patients is a major concern. This article reviews the neurocognitive effects of cranial RT on adult patients with brain tumors. Analyses of neurocognitive function are confounded by factors such as surgery, chemotherapy, tumor characteristics, tumor progression, concurrent medical illnesses, neurologic comorbidity, and medications that can contribute to neurocognitive deficits. Risk of deficits after cranial RT is associated with high RT dose, large fraction size, larger field size, and extremes of age at time of treatment. Using modern techniques with moderate total doses (50 to 54 Gy), conformal RT, conventional fractionation, and advanced planning imaging and software, the risks of neurocognitive deficits are quite small and greatly overshadowed by deficits caused by the tumor itself. Further studies need to be undertaken to elucidate the degree and cause of cognitive decline in adult patients undergoing multimodality therapy for cranial tumors.
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Affiliation(s)
- Nadia N Laack
- Division of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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154
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Shaw EG, Tatter SB, Lesser GJ, Ellis TL, Stanton CA, Stieber VW. Current controversies in the radiotherapeutic management of adult low-grade glioma. Semin Oncol 2004; 31:653-8. [PMID: 15497118 DOI: 10.1053/j.seminoncol.2004.07.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Over the last decade, the results of four prospective clinical trials of supratentorial low-grade glioma (LGG) in adults have been published. The data from the nearly 1,000 patients treated on these studies are summarized in this presentation, addressing the following three current controversies in the radiotherapeutic management of these patients: (1) optimum timing of radiation therapy (RT); (2) optimum RT dose; and (3) addition of chemotherapy to RT. The 5-year overall survival (OS) and progression-free survival (PFS) rates in these four studies ranged from 58% to 72% and from 37% to 55%, respectively. Significant prognostic factors included extent of surgical resection, histology, tumor size, and age. The European Organization for Research and Treatment of Cancer (EORTC) study 22845 randomized 311 adults to postoperative observation or RT. There was no difference in the 5-year OS rate between the two arms, but the irradiated patients had a significantly improved 5-year PFS rate. EORTC study 22844 randomized 379 adults to low- versus high-dose RT. Similarly, an intergroup study conducted by the North Central Cancer Treatment Group (NCCTG), Radiation Therapy Oncology Group (RTOG), and Eastern Cooperative Group (ECOG) randomized 211 adults to low- versus high-dose RT. There was no difference in the 5-year OS or PFS rates between the two dose groups in either study. A Southwest Oncology Group (SWOG) study randomized 60 adults with incompletely resected LGG to RT alone or RT plus lomustine (CCNU) chemotherapy. There was no difference in outcome between the two treatment arms. Further prospective clinical trials are needed to define the optimal management strategy for adults with supratentorial LGG. The schemata from recently completed and ongoing LGG studies will be presented.
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Affiliation(s)
- Edward G Shaw
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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155
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Armstrong CL, Gyato K, Awadalla AW, Lustig R, Tochner ZA. A critical review of the clinical effects of therapeutic irradiation damage to the brain: the roots of controversy. Neuropsychol Rev 2004; 14:65-86. [PMID: 15260139 DOI: 10.1023/b:nerv.0000026649.68781.8e] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We critically examined the damaging affects of therapeutic irradiation by comparing results from cross-disciplinary studies of early- and late-delayed radiotherapy effects. Focus is attained by concentrating on clinical treatment issues (volume of brain, dose, timing of effects, age, modality types, and stereotactic treatment techniques), rather than on methodological means or problems, which is necessary to understand the mechanisms and characteristics of radiotherapy-induced behavioral dysfunction including cognition. We make observations and hypotheses about the actual risks from radiotherapy that could be informative in the treatment decision process, and which may lessen the concerns of some patients and their families about the risks they take when receiving radiation. Conditions that predispose to radiation injury are reviewed: (1) higher doses even to part of the brain versus lower doses to the whole brain, (2) combined treatment modalities, (3) malignancy itself, (4) radiation early during postnatal brain development, and (5) late-delayed effects (more than 3 years posttreatment). Current neurocognitive frameworks for understanding cognitive change over time in children and adults are summarized, along with the literature on effects of brain tumors and treatment on depression. No studies have as yet identified candidate brain regions that are more sensitive to radiotherapy. Two studies have provided early, preliminary evidence for a specific vulnerability of visual attention/memory to the early stage of late radiation damage. Furthermore, radiation effects appear severe only in a minority of patients. Risk is related to direct and indirect effects of cancer type, concurrent clinical factors, and premorbid risk factors.
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Affiliation(s)
- Carol L Armstrong
- Department of Neurology, University of Pennsylvania Medical School, Philadelphia, Pennsylvania 19104, USA.
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156
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Iconomou G, Mega V, Koutras A, Iconomou AV, Kalofonos HP. Prospective assessment of emotional distress, cognitive function, and quality of life in patients with cancer treated with chemotherapy. Cancer 2004; 101:404-11. [PMID: 15241840 DOI: 10.1002/cncr.20385] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The current study sought to delineate prospectively the rates and clinical course of emotional distress, cognitive impairment, and quality of life (QOL) in chemotherapy-naive patients with cancer and to consider the determinants of global QOL. METHODS Patients who consented to participate were administered the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, the Mini-Mental State Examination (MMSE), and the Hospital Anxiety and Depression Scale before and at the end of treatment (EOT). RESULTS Of the 102 patients initially assessed, 80 (78.4%) completed the study. Most aspects of QOL did not change considerably over time. At EOT, patients reported only significant increases in fatigue and significant decreases in sleep disturbance. Although no significant changes emerged in the rates of anxiety or depression throughout chemotherapy, nearly one-third of the patients experienced severe emotional distress at both points in time. In addition, the authors observed neither significant alteration in the cognitive performance over time nor reliable associations between scores on the MMSE and subjective cognitive function, emotional distress, or QOL. Finally, depression proved to be the leading predictor of global QOL at baseline and at EOT. CONCLUSIONS The results indicated that a significant proportion of Greek patients with cancer experienced intense anxiety and depression throughout chemotherapy and confirmed the importance of depression as a strong predictor of global QOL. Routine screening of emotional distress across all phases of cancer is mandatory because it will contribute to the identification of patients who are in need of pharmaceutical and/or psychologic intervention.
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Affiliation(s)
- Gregoris Iconomou
- Division of Oncology, Department of Medicine, University of Patras Medical School, University Hospital, Rion, Greece
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157
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Affiliation(s)
- I R Whittle
- Department of Clinical Neuroscience, Western General Hospital, Edinburgh, UK.
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158
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159
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Lebrun C, Fontaine D, Vandenbos F, Chanalet S, Bourg V, Frénay M, Alchaar H, Bleuse A, Bondiau PY, Brunetto JL, Chatel M, Courdi A, Darcourt J, Fauchon F, Guibert F, Grellier P, Lanteri-Minet M, Lonjon M, Michiels JF, Paquis P, Paquis V, Ramaioli A, Rasendrarijao D. Chimiothérapie néoadjuvante dans les astrocytomes fibrillaires de grade II symptomatiques non opérables de l’adulte. Rev Neurol (Paris) 2004; 160:533-7. [PMID: 15269670 DOI: 10.1016/s0035-3787(04)70982-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We collected 6 case-reports of symptomatric non removable low grade fibrillary astrocytoma of adults treated with a procarbazine-CCNU-vincristine chemotherapy regimen. All patients had drug-resistant epilepsy but brain imaging was stable. Total gross resection was rejected because of Volume or tumor location. After 4 to 7 cycles of chemotherapy, 2 patients had partial response and one minor response on brain MRI. All of them were seizure-free. Progression free survival was not reached at 5 Years. Up-front chemotherapy for low-grade astrocytomas may be useful and has to be prospectively evaluated.
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Affiliation(s)
- C Lebrun
- Service de Neurologie, Hôpital Pasteur, Nice, France.
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160
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Abstract
Cognitive function, with survival and response on brain imaging, is increasingly regarded as an important outcome measure in patients with brain tumours. This measure provides us with information on a patient's clinical situation and adverse treatment effects. Radiotherapy has been regarded as the main cause of cognitive decline in these patients, because children with brain tumours can develop intellectual deterioration caused by radiotherapy. In long-term surviving patients, radiotherapy may indeed lead to cognitive deficits, or even dementia. Recent studies, however, have made clear that focal radiotherapy in patients with glioma is not the main reason for cognitive deficits. The tumour itself and other medical treatments contribute largely to the cognitive deficits. Cognitive function is now also recognised as an independent prognostic factor in the survival of glioma patients. Additionally, cognitive deterioration can be the first indicator of progressive disease after treatment.
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161
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Klein M, Heimans JJ. The Measurement of Cognitive Functioning in Low-Grade Glioma Patients After Radiotherapy. J Clin Oncol 2004; 22:966-7; author reply 967-8. [PMID: 14990661 DOI: 10.1200/jco.2004.99.290] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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162
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163
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Rugo HS, Ahles T. The impact of adjuvant therapy for breast cancer on cognitive function: current evidence and directions for research. Semin Oncol 2003; 30:749-62. [PMID: 14663776 DOI: 10.1053/j.seminoncol.2003.09.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Available evidence supports the hypothesis that adjuvant chemotherapy for breast cancer can produce cognitive deficits, and that these deficits may have a significant impact on patients' quality of life. Studies have generally compared the results of a variety of cognitive measures performed following treatment to standardized population-based norms or to cancer patients who received local therapy, rather than to the individual's baseline level of functioning. Several longitudinal studies are in progress or in the planning stages to better quantify and understand the incidence and impact of cognitive effects of adjuvant chemotherapy, and to identify possible susceptibility factors in subgroups. Although the neurocognitive changes appear to be subtle, there may be enough data to consider discussing the possibility of cognitive dysfunction as an adverse effect when assessing the risks and benefits of adjuvant chemotherapy. Likewise, as the aromatase inhibitors are increasingly given to larger numbers of women in the adjuvant setting, it will be important to understand the cognitive impact of estrogen deprivation. Finally, there is interest in examining supportive pharmacologic or behavioral measures that might prevent or decrease cognitive effects in this setting. Herein, the data on cognitive changes associated with chemotherapy for breast cancer, current and future research directions, as well as possible treatments are reviewed.
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Affiliation(s)
- Hope S Rugo
- Department of Medicine, University of California Comprehensive Cancer Center, San Francisco 94115, USA
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164
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Meyers CA, Wefel JS. The use of the mini-mental state examination to assess cognitive functioning in cancer trials: no ifs, ands, buts, or sensitivity. J Clin Oncol 2003; 21:3557-8. [PMID: 12913103 DOI: 10.1200/jco.2003.07.080] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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165
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Méndez-Meneses KJ, Rebolledo García ML, Díaz Chacón S, Rodríguez Vázquez LA, Acosta Maldonado BL, Mantilla-Maya B, González-Rodríguez E, Aguilar Ponce JL, Galindo Vázquez O, Rivera-Fong L. Validación de la Escala de Ansiedad Preoperatoria y de Información Ámsterdam (APAIS) en mujeres latinoamericanas con cáncer de mama: Estudio México - Costa Rica. PSICOONCOLOGIA 1970. [DOI: 10.5209/psic.63649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
El tratamiento más frecuente contra el cáncer es la cirugía; sin embargo es un procedimiento invasivo que se ha asociado con la presencia de sintomatología psicológica hasta en el 76% de los pacientes. El estudio de la ansiedad ante la cirugía requiere de herramientas específicas adaptadas a las peculiaridades del constructo; entre ellas se encuentra la Escala de Ansiedad Preoperatoria y de Información Ámsterdam (APAIS) que ha sido validada en pacientes sometidos a diversas cirugías en múltiples países; mostrando consistentemente propiedades psicométricas adecuadas. Objetivo: Obtener la confiabilidad y validez de la APAIS en población oncológica para población latinoamericana. Método: Estudio transversal, no experimental, de análisis psicométrico que incluyó una muestra no probabilística de 117 mujeres con edades entre 25 y 75 años, todas diagnosticadas con cáncer de mama y programadas para cirugía en un hospital público de México (57 mujeres) o Costa Rica (63 mujeres). Resultados: Los seis reactivos de la Escala APAIS mostraron adecuada distribución de las contestaciones de las participantes entre las opciones de respuestas, tener capacidad de discriminación entre grupos extremos y contribuyeron a la consistencia interna del instrumento. El análisis factorial de máxima verosimilitud con rotación varimax mostró una estructura que explicó el 58,58% de la varianza con dos factores, la cual fue confirmada por análisis factorial confirmatorio; la escala total mostró una consistencia interna de α=0,816. Dicha escala mostró adecuada sensibilidad y especificidad con un punto de corte de 14 puntos. Conclusiones: La escala APAIS muestra propiedades psicométricas adecuadas para considerarla válida y confiable para evaluar ansiedad prequirúrgica en mujeres con cáncer de mama.
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