Female gender is not a proven risk factor for depression in glioma

Depression and Quality of Life in Patients with Gliomas: A Narrative Review

In patients with gliomas, depression is a common complication that may cause severe psychological barriers and deteriorate the patient’s quality of life (QoL). Currently, the Hospital Anxiety and Depression Scale (HADS) is the most commonly used tool to diagnose depression in patients with gliomas. Female sex, unmarried status, low education level, high tumor grade, and a history of mental illness may increase the risks of depression and depressive symptoms in patients with gliomas. The QoL of patients with gliomas can be directly reduced by depression. Therefore, the evaluation and intervention of mood disorders could improve the overall QoL of patients with gliomas. Antidepressant use has become a treatment strategy for patients with gliomas and comorbid depression. This narrative review summarizes the current issues related to depression in patients with gliomas, including the prevalence, risk factors, and diagnostic criteria of depression as well as changes in QoL caused by comorbid depression and antidepressant use. The purpose of this review is to guide clinicians to assess the psychological status of patients with gliomas and to provide clinicians and oncologists with a new treatment strategy to improve the prognosis of such patients.

Depression and tryptophan metabolism in patients with primary brain tumors: Clinical and molecular imaging correlates

Patients with brain tumors have an increased risk for depression, whose underlying pathomechanism may involve dysregulated tryptophan/kynurenine metabolism. In this study, we analyzed the relation of depressive symptoms to clinical and tumor characteristics as well as cerebral and systemic tryptophan metabolism in patients with primary brain tumors. Sixty patients with newly-diagnosed or recurrent primary brain tumor underwent testing with the Beck Depression Inventory-II (BDI-II), and 34 patients also had positron emission tomography (PET) imaging with alpha-[¹¹C]methyl-L-tryptophan (AMT). BDI-II scores were correlated with clinical and tumor-related variables, cerebral regional AMT metabolism measured in the non-tumoral hemisphere, and plasma tryptophan metabolite levels. Sixteen patients (27%) had BDI-II scores indicating depression, including 6 with moderate/severe depression. High BDI-II scores were independent of clinical and tumor-related variables except lower Karnofsky Performance Status scores. In patients with recurrent malignant gliomas, depression was associated with shorter survival (hazard ratio: 3.7; p = 0.048). High BDI-II total and somatic subscale scores were associated with higher frontal cortical and thalamic AMT metabolic values measured on PET. In contrast, plasma tryptophan and kynurenine metabolite levels did not correlate with the BDI-II scores. In conclusion, our results confirm previous data that depression affects more than ¼ of patients with primary brain tumors, it is largely independent of tumor characteristics and is associated with shorter survival in patients with recurrent malignant gliomas. On PET imaging, higher tryptophan metabolism in the frontal cortex and thalamus was found in those with brain tumor-associated depression and supports the role of dysregulated tryptophan/kynurenine metabolism in this condition.

Psychiatric co-morbidity, distress, and use of psycho-social services in adult glioma patients-a prospective study

BACKGROUND

Distress impacts the daily life of glioma patients. This study explored its course over time and the usage of psychosocial care.

METHODS

A consecutive sample of glioma patients completed the Hospital Anxiety and Depression Scale to assess distress levels at admission to the hospital (t1), before discharge (t2), after 3 months (t3), and after 6 months (t4). They were interviewed with the Structured Clinical Interview for DSM-IV to ascertain psychiatric disorders at t2. Psycho-oncological care in the hospital was determined with the Hospital Information System, and the use of outpatient treatment was evaluated with the Health Care Usage Questionnaire at t4. We compared the percentages of elevated distress, psychiatric co-morbidity, and care usage between men and women.

RESULTS

During the study period, 37 patients were enrolled. Nineteen percent of the patients were diagnosed with a psychiatric disorder. The percentages of patients with elevated distress were 56, 59, 39, and 40% at t1, t2, t3, and t4, respectively. Participants who did not survive the 6 months presented with higher levels of distress. In the hospital, 14% of those with elevated distress were visited by a psycho-oncologist. In the outpatient setting, 43% of those with elevated distress visited a neuro-psychiatrist, and 14% went to a psychotherapist. There was no evidence for an effect of gender on psychiatric co-morbidity, distress, or care use.

CONCLUSIONS

A significant proportion of glioma patients report elevated distress during the hospital stay and thereafter. Only a fraction of them receive mental health care.

Association between depression and brain tumor: a systematic review and meta-analysis

BACKGROUND

Patients with brain tumor are in risk of depression or depressive symptoms, but the estimated prevalence varies between studies. The aim of this study is to get a proper summarized estimate of depression prevalence in brain tumor patients.

METHODS

Literature search on Pubmed, PsycINFO, and Cochrane library from January 1981 through October 2016. The prevalence of depression or depressive symptoms in brain tumor patients was estimated by screening scales and analyzed using stratified meta-analysis and subgroup analysis. The prevalence of depression level or symptoms during the follow-up periods was detected by secondary analysis.

RESULTS

Among the 37 studies included in this meta-analysis, 25 used a cross-sectional design and 12 used longitudinal study. The pooled prevalence was 21.7% (971/4518 individuals, 95 % confidence interval (CI) 18.2%-25.2%) for overall sample. Lower prevalence was detected in studies with sample size ≥100 than <100, lower grade tumor than high grade tumor, studies using clinician-rated depression scales than self-rated or non-depression-specific ones, and in patients from UK, Germany and Italy than USA. After analyzing 6 longitudinal studies, prevalence of depression remained no change in the follow-up periods. No significant differences were observed between study designs and tumor types.

CONCLUSIONS

The estimated prevalence of depression or depressive symptoms among brain tumor patients was 21.7%, affected by depression assessment type, sample size, tumor grade and country. Diagnosis and treatment of co-morbid depression in brain tumor patients need to be addressed in future studies for better life quality and oncology management.

Factors associated with supportive care needs in glioma patients in the neuro-oncological outpatient setting

Objective of this study aimed at assessing glioma patients' supportive care needs in a neurosurgical outpatient setting and identifying factors that are associated with needs for support. In three neuro-oncological outpatient departments, glioma patients were assessed for their psychosocial needs using the Supportive Care Needs Survey short-form (SCNS-SF34-G). Associations between clinical, sociodemographic, treatment related factors as well as distress (measured with the distress thermometer) and supportive care needs were explored using multivariable general linear models. One-hundred and seventy three of 244 eligible glioma patients participated, most of them with primary diagnoses of a high-grade glioma (81%). Highest need for support was observed in 'psychological needs' (median 17.5, range 5-45) followed by 'physical and daily living needs' (median 12.5, range 0-25) and 'health system and information needs' (median 11.3, range 0-36). Needs in the psychological area were associated with distress (R² = 0.36) but not with age, sex, Karnofsky performance status (KPS), extend of resection, currently undergoing chemotherapy and whether guidance during assessment was offered. Regarding 'health system and information needs', we observed associations with distress, age, currently undergoing chemotherapy and guidance (R² = 0.31). In the domain 'physical and daily living needs' we found associations with KPS, residual tumor, as well as with distress (R² = 0.37). Glioma patients in neuro-oncological departments report unmet supportive care needs, especially in the psychological domain. Distress is the factor most consistently associated with unmet needs requiring support and could serve as indicator for clinical neuro-oncologists to initiate support.

Psycho-oncology

Psycho-oncologic care for glioma patients has two important aspects. First, clinical decision making regarding treatment of the tumor should reflect a sound balance between quality and quantity of life. Second, supportive care should be targeted at the symptoms that are most detrimental to perceived quality of life (QOL) of glioma patients, and of their informal caregivers. In this chapter we will first focus on the definition of QOL and the ways of measuring this adequately in clinical trials, and then discuss the impact of the disease itself, and of established and experimental treatment modalities on perceived QOL. Subsequently, we will discuss frequently occurring symptoms that have an impact on the perceived QOL of glioma patients and their caregivers. This will include what is known about the efficacy of symptomatic treatment and maintaining or improving QOL in both patients and caregivers, followed by recommendations for future directions of clinical care and research.

Are preoperative sex-related differences of affective symptoms in primary brain tumor patients associated with postoperative histopathological grading?

Our objective was to explore the impact of the histopathological tumor type on affective symptoms before surgery among male and female patients with supratentorial primary brain tumors. A total of 44 adult patients were included in the study. Depression and anxiety were measured using the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory. Additionally, clinical interviews, including the Hamilton Depression Rating Scale (HDRS), were conducted. The general function of patients was measured with the Karnofsky Performance Status scale (KPS). All measures were obtained before surgery and therefore before the final histopathological diagnosis. All self-rating questionnaires but not the HDRS, showed significantly higher scores in female patients. The functional status assessed with the KPS was lower in female patients and correlated to the somatic part of the BDI. We further found a tendency for higher HDRS scores in male patients with a WHO grade 4 tumor stage compared to female patients. This finding was supported by positive correlations between HDRS scores and WHO grade in male and negative correlations between HDRS scores and WHO grade in female patients. In conclusion the preoperative evaluation of affective symptoms with self-rating questionnaires in patients with brain tumors may be invalidated by the patient’s functional status. Depression should be explored with clinical interviews in these patients. Sex differences of affective symptoms in this patient group may also be related to the malignancy of the tumor, but further studies are needed to disentangle this relationship.

The frequency, longitudinal course, clinical associations, and causes of emotional distress during primary treatment of cerebral glioma

BACKGROUND

Relatively little is known about the frequency, longitudinal course, independent associations, and reported causes of emotional distress in adults with primary cerebral glioma. We aimed to describe these features in an observational study.

METHODS

This was a twin-center prospective cohort study. Eligible adults were those with a new histological diagnosis of glioma who were receiving active management. Distress was measured using the National Comprehensive Cancer Network Distress Thermometer and problem checklist. Subjects were sampled at 3 timepoints: T1 (shortly after starting chemo/radiotherapy), T2 (3 months later), and T3 (6 months later).

RESULTS

T1 n = 154; T2 n = 103; T3 n = 83. Significant distress was present in 36.4 ± 7.6% at T1, 35.9 ± 9.3% at T2, and 33.7 ± 10.2% at T3. Longitudinally, subjects with high distress at T1 (median Distress Thermometer score = 8; interquartile range [IQR] 7-9) remained highly distressed on follow-up (T2 median = 8, IQR 6-8; T3 median = 7, IQR 5-8) (Friedman test P = .304). Younger age, functional impairment, and concurrent major depressive disorder were independently associated with high distress (logistic regression χ(2) for model = 39.882, P < .001, R(2) = 0.312). The most frequently reported causes of distress were worry, fatigue, sleep difficulties, and sadness. Emotional difficulties were among the most common causes of distress at all 3 timepoints.

CONCLUSIONS

At each timepoint, one-third of patients reported significant emotional distress, which persisted during follow-up among those initially highly distressed. Young, functionally impaired, and depressed glioma patients may particularly benefit from increased support.

Association between epidermal growth factor +61 G/A polymorphism and glioma risk in a Chinese Han population

The association between the +61 G/A polymorphism of the epidermal growth factor (EGF) gene and glioma risk remains controversial and unclear. The objective of this study was to investigate the association between the EGF +61 G/A polymorphism and glioma risk in a Chinese Han population. Peripheral blood samples were extracted from 160 glioma patients and 320 control subjects. Genotyping was performed using a polymerase chain reaction-restriction fragment length polymorphism method. Glioma patients had a significantly higher frequency of the AA genotype (odds ratio [OR] 1.93, 95% confidence intervals [CI] 1.08, 3.44) than control subjects and the frequency of the AA genotype was significantly higher in glioblastoma patients than in patients with other gliomas (OR 2.19, 95% CI 1.05, 4.57). Patients with grade IV gliomas had a significantly higher frequency of the AA genotype (OR 2.25, 95% CI 1.08, 4.71) than patients with lower grade gliomas. This study demonstrated that the EGF +61 AA genotype is associated with an increased risk of glioma in a Chinese Han population.

Supportive care in neurooncology

PURPOSE OF REVIEW

Malignant brain tumors have a very poor prognosis and the natural history of disease is very short, usually less than 1 year. Brain tumor patients often present peculiar symptoms of disease that require appropriate supportive treatment, namely, peritumoral brain edema, venous thromboembolism, seizures and opportunistic infections. On the other hand, some important problems such as rehabilitation, depression, psychological support/communication and end-of-life issues/treatment decisions have been poorly investigated so far.

RECENT FINDINGS

This review focuses on the most recent findings for the management of the most relevant symptoms of brain tumor patients, also discussing the complexity of palliative measures that should be adopted in patients approaching the end of life.

SUMMARY

In recent years, there has been some progress in the medical management of brain tumor patients. Nevertheless, much still needs to be done for further improvement, especially focusing on the unmet need for education in supportive care and end-of-life issues.

Depression in cerebral glioma patients: a systematic review of observational studies

BACKGROUND

Depression is a common and important complication of primary cerebral glioma. However, observational studies of this relationship have not been systematically reviewed.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO for all English-language cross-sectional, case-control, and cohort studies of depression in adults with primary glioma published between January 1, 1980, and September 16, 2009. We identified 42 eligible studies that recruited 4089 individual glioma patients. We conducted a narrative review of these studies regarding the heterogeneity in diagnostic methods, the frequency of depression and its clinical associations, and the quality of study reporting.

RESULTS

Most studies of depression in adults with glioma were small, cross-sectional, or retrospective. Depression was most often measured using the Hospital Anxiety and Depression Scale (HADS; n = 10 studies). The Beck Depression Inventory, another frequently used screening instrument, returned a higher frequency of depression (median = 39%, range = 38%-42%) than the Hospital Anxiety and Depression Scale (median = 16%, range = 0%-21%). At clinical interview, the median frequency of depression in glioma was 15% (range = 6%-28%). Depression was consistently associated with reduced physical function, cognitive impairment, and reduced quality of life. It may be associated with reduced survival, although evidence for this association was modest. There was an absence of clear associations between depression and many tumor-related variables. Few observational studies examined the treatment of depression in glioma patients. Multivariable analyses were rare, and study reporting was of variable quality.

CONCLUSIONS

In glioma, mild to moderate depressive symptoms may only rarely be due to tumor-associated structural or functional disruption of neuronal emotional networks. Improved methodological reporting would help clinicians better evaluate future studies, and facilitate improved evidence-based care of depressed glioma patients.