Validating self-report and proxy reports of the Dexamethasone Symptom Questionnaire -Chronic for the evaluation of longer-term corticosteroid toxicity

Acetazolamide versus placebo for cerebral oedema requiring dexamethasone in recurrent and/or progressive high-grade glioma: phase II randomised placebo-controlled double-blind study

OBJECTIVES

Symptoms of raised intracranial pressure (ICP) in recurrent high-grade glioma (HGG) generally require corticosteroid treatment, often causing toxicity with variable effects on ICP symptoms. Acetazolamide reduces ICP when used in other clinical non-cancer settings. The aim of the study was to explore whether the addition of oral acetazolamide enables safe dexamethasone dose reduction in management of raised ICP in recurrent HGG.

METHODS

Participants had recurrent HGG with any of dexamethasone recommencement, dose increase or dependency; prior/current bevacizumab was an exclusion. Eligible participants were randomised 1:1 to acetazolamide or placebo for 8 weeks. Standardised protocols were used for dexamethasone dosing, with planned dose decrease from day 5 once ICP symptoms were stable. The primary endpoint was a composite of dexamethasone dose reduction and stable Karnofsky Performance Status Secondary endpoints included toxicity and feasibility.

RESULTS

Thirty participants (15 per group) were enrolled (mean age 58 years) from seven Australian sites. The mean baseline dexamethasone dose was 6.2 mg. Mean duration on study treatment was 38 days (placebo group) and 31 days (acetazolamide group) with nine participants (30%) completing all study treatments (six placebo, three acetazolamide). Study withdrawal was due to adverse events (n=6; one placebo, five acetazolamide) and disease progression (n=6 (three per arm)). Four participants (13%) (two per arm) were stable responders. Ten participants experienced a total of 13 serious adverse events (acetazolamide arm: five participants (33%), six events, two related).

CONCLUSIONS

The study closed early due to poor accrual and increasing availability of bevacizumab. The addition of acetazolamide did not facilitate dexamethasone reduction.

TRIAL REGISTRATION NUMBER

ACTRN12615001072505.

A Practice Pilot Survey on the Current Use of Corticosteroid Therapy in Brain Tumor Patients

BACKGROUND

This pilot survey aims to provide an insight into the variations of corticosteroid prescription among health care professionals across the Indian subcontinent and serve as a prerequisite for the future development of corticosteroid therapy guidelines in brain tumor patients.

MATERIALS AND METHODS

Participants of this anonymized online questionnaire-based survey included health care professionals involved in treating brain tumor patients. Unique links were electronically mailed to health care professionals from a database populated from professional associations. Descriptive statistical analysis, Chi-square test, and/or exact test were used for data analysis.

RESULTS

Seventy-three percent of the respondents were radiation oncologists followed by neurosurgeons (23%), medical oncologists (2%), and other specialties (2%). Raised intracranial pressure (90%) was the commonest indication for prescribing corticosteroids. Fifty percent of neurosurgeons preferred corticosteroids to be given routinely for all patients undergoing surgery for brain tumors while 64% of the radiation oncologists would prescribe based on imaging findings and/or on appearance of neurologic symptoms. Most of the respondents (90%) used a flat dosage pattern for determining the starting dose of corticosteroids. Emerging data about the long-term use of corticosteroids having a negative impact on the survival of brain tumor patients were not known by 52% of the respondents. The majority of the practitioners (94%) agreed regarding the formulation of evidence-based guidelines for prescribing corticosteroids in brain tumor patients.

CONCLUSION

In view of the wide variations of corticosteroid therapy practices among health care professionals across various parts of the world, our pilot survey provides significant information which can act as a suitable benchmark to form uniform practice guidelines.

Melatonin Receptor Agonists for the Prevention of Delirium: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Although a previous review illustrated the efficacy of melatonin receptor agonists (MRAs) in preventing delirium, some recent randomized controlled trials (RCTs) did not confirm these effects.

OBJECTIVES

This study systematically reviewed the efficacy, acceptability, and tolerability of MRAs for delirium prevention.

MATERIALS AND METHODS

We searched electronic databases, including Scopus, PubMed, CINAHL, and Controlled Trials Register, from their inception to February 20, 2022. The primary efficacy outcome was delirium incidence rate after MRA administration; relative risks (RRs), overall discontinuation, and discontinuation due to adverse events are also presented.

RESULTS

The overall pooled incidence rates of delirium in MRA-treated and placebo-treated groups were significantly different with RR (95% CI)=0.66(0.52, 0.84, ), I2=59%. Similarly, the incidence rate was significantly lower in the melatonin-treated group than in the placebo-treated group [RR (95% CI) =0.65 (0.49, 0.88), I2=65%]. Unfortunately, incidence rates were not significantly different between ramelteon-treated and placebo-treated groups [RR (95% CI) =0.67 (0.42, 1.08), I2=50%]. The pooled incidence rate of delirium in either melatonin or ramelteon-treated groups was not significantly different from the placebo-treated group in elderly patients. The pooled incidence rate of delirium was significantly lower in the melatonin-treated group than in the benzodiazepinetreated group.

CONCLUSION

Based on this review, melatonin could prevent delirium with a small effect size. However, ramelteon did not show efficacy in preventing delirium. Additionally, neither melatonin nor ramelteon individually showed effectiveness in preventing delirium in elderly patients. Therefore, using MRAs to prevent delirium in clinical practice should be cautious. However, future welldefined and large sample size studies could verify these findings.

Subjective executive dysfunction in patients with primary brain tumors and their informants: relationships with neurocognitive, psychological, and daily functioning

OBJECTIVE

We assessed agreement between patient- and informant-report on the Behavior Rating Inventory of Executive Function - Adult (BRIEF-A) in patients with primary brain tumors (PBT) and differences on BRIEF-A in neurocognitive (intact v. impaired), psychological (asymptomatic v. distressed), and functional (independent v. dependent) categories using both patient- and informant-report.

METHOD

PBT patients (n = 102) completed neuropsychological evaluations including the BRIEF-A, clinical interview, neurocognitive tests, and mood questionnaires. Correlations between the BRIEF-A and Informant (n = 39) were conducted. Differences in patient and informant BRIEF-A indices were investigated across five classifications: neurocognitive functioning, psychological functioning, medication management, appointment management, and finance management.

RESULTS

Patient and informant BRIEF were correlated. There was no difference on BRIEF-A or Informant indices for intact v. impaired neurocognitive status. Higher BRIEF-A and Informant indices were observed among psychologically distressed v. asymptomatic patients. Results showed higher BRIEF indices among those requiring assistance with medication, appointments, and finances.

CONCLUSIONS

Patients and informants agreed in their reports of executive function (EF). These reports, while not different in neurocognitive classification, were different in psychological functioning and in those needing assistance with instrumental activities of daily living (IADL). Patient- and informant-reported EF may provide important data regarding psychological and IADL functioning in this population.

Working memory training for adult glioma patients: a proof-of-concept study

BACKGROUND

CogMed Working Memory Training (CWMT) is a computer-based program shown to improve working memory (WM) among those with cognitive impairments. No study to date has investigated its feasibility, acceptability, and satisfaction in adult patients with glioma, despite the well-documented incidence of WM impairment in this population.

METHODS

Twenty patients with glioma and objective and/or perceived WM deficits enrolled in the study: 52% high-grade, 60% female, Mage = 47 (range = 21-72 years). Adverse events were monitored to determine safety. Feasibility and acceptability were assessed based on established metrics. Satisfaction was explored by exit-interviews. Neurocognitive tests and psychological symptoms were analyzed at baseline and post-CWMT to estimate effect sizes.

RESULTS

Of 20 enrolled patients, 16 completed the intervention (80% retention rate). Reasons for withdrawal included time burden (n = 2); tumor-related fatigue (n = 1) or loss to follow-up (n = 1). No adverse events were determined to be study-related. Adherence was 69% with reasons for nonadherence similar to those for study withdrawal. The perceived degree of benefit was only moderate. Baseline to post-CWMT assessments showed medium to large effects on neurocognitive tasks. Psychological symptoms remained stable throughout the study period.

CONCLUSIONS

CWMT was found to be safe and acceptable in adult patients with glioma. Enrollment, retention rates, and treatment adherence were all adequate and comparable to studies recruiting similar populations. Only moderate perceived benefit was reported despite demonstrated improvements in objectively-assessed WM. This may indicate that the time commitment and intervention intensity (5 weeks of 50-min training sessions on 5 days/week) outweighed the perceived benefits of the program. (Trial Registration Number: NCT03323450 registered on 10/27/2017).

Sleep disturbance in people with brain tumours and caregivers: a survey of healthcare professionals' views and current practice

PURPOSE

Sleep disturbance is easily overlooked in subspecialty consultations and may remain untreated during and after initial treatment of malignant brain tumours (BT). This study aimed to explore perceptions of healthcare professionals (HCPs) actively engaged in neuro-oncology care towards sleep disturbance in adults with primary or secondary BT and to identify facilitators and barriers to assessment and management of sleep disturbance.

METHODS

A survey was conducted to explore HCPs' perceptions about their knowledge, skills, and confidence in managing sleep disturbance in people with BT. The survey also explored their beliefs, motivation, and perceived role in managing sleep disturbance, and views on contributing external factors that impacted management.

RESULTS

Seventy-three interdisciplinary HCPs with average of 9.3 years of clinical experience in neuro-oncology participated. Fifty-five percent of participants were medical or radiation oncologists. Participants reported a high observed prevalence of sleep disturbance, especially in inpatient settings, during initial treatment, and after tumour progression or recurrence. Only 20% of participants reported routinely reviewing sleep-related symptoms during consultations. General symptom screening questions were perceived as helpful to identify sleep disturbance. Almost all respondents (92%) viewed corticosteroids as the most relevant risk factor, followed by psychological distress. The most frequent clinical responses were offering verbal advice and prescribing medication. The lack of time, resources, and training for managing sleep issues were commonly reported barriers.

CONCLUSIONS

Overall, participants perceived sleep disturbance as highly prevalent in neuro-oncology and positively viewed the importance of managing this symptom. Practical barriers to management were reported that future interventions can target.

Assessment of Executive Functioning in Patients with Meningioma and Low-Grade Glioma: A Comparison of Self-Report, Proxy-Report, and Test Performance

OBJECTIVE

This study aimed to examine: (1) patient-proxy agreement on executive functioning (EF) of patients with primary brain tumors, (2) the relationships between patient- and proxy-report with performance-based measures of EF, and (3) the potential influence of performance-based measures on the level of agreement.

METHODS

Meningioma and low-grade glioma patients and their informal caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF-A) 3 months after surgery. The two index scores of the BRIEF-A, Behavioral Regulation and Metacognition, were evaluated. Mean scores of patients and proxies were compared with normative values and with each other. Patient-proxy agreement was evaluated with Lin's concordance correlation coefficients (CCCs) and Bland-Altman plots. Pearson correlation coefficients between reported EF and performance-based measures of EF were calculated. Multiple regression analysis was used to evaluate the potential influence of test performance on differences in dyadic reports.

RESULTS

A total of 47 dyads were included. Patients reported significantly more problems on the Metacognition Index compared to norms, and also in comparison with their proxies. Effect sizes indicated small differences. Moderate to substantial agreement was observed between patients and proxies, with CCCs of 0.57 and 0.61 for Metacognition and Behavioral Regulation, respectively. Correlations between reported EF and test performance ranged between -0.37 and 0.10. Dyadic agreement was not significantly influenced by test performance.

CONCLUSIONS

Patient-proxy agreement was found to be moderate. No clear associations were found between reported EF and test performance. Future studies should further explore the existing and new methods to assess everyday EF in brain tumor patients.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Steroids in the Treatment of Adults With Metastatic Brain Tumors

QUESTION

Do steroids improve neurological symptoms and/or quality of life in patients with metastatic brain tumors compared to supportive care only or other treatment options? If steroids are given, what dose should be used?

TARGET POPULATION

These recommendations apply to adults diagnosed with brain metastases.

RECOMMENDATIONS

STEROID THERAPY VERSUS NO STEROID THERAPYAsymptomatic brain metastases patients without mass effectInsufficient evidence exists to make a treatment recommendation for this clinical scenario.Brain metastases patients with mild symptoms related to mass effect Level 3: Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. It is recommended for patients who are symptomatic from metastatic disease to the brain that a starting dose of 4 to 8 mg/d of dexamethasone be considered.Brain metastases patients with moderate to severe symptoms related to mass effect Level 3: Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. If patients exhibit severe symptoms consistent with increased intracranial pressure, it is recommended that higher doses such as 16 mg/d or more be considered.

CHOICE OF STEROID

Level 3: If corticosteroids are given, dexamethasone is the best drug choice given the available evidence.Duration of Corticosteroid Administration Level 3: Corticosteroids, if given, should be tapered as rapidly as possible but no faster than clinically tolerated, based upon an individualized treatment regimen and a full understanding of the long-term sequelae of corticosteroid therapy.Given the very limited number of studies (2) which met the eligibility criteria for the systematic review, these are the only recommendations that can be offered based on this methodology.The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_7.

Corticosteroid use endpoints in neuro-oncology: Response Assessment in Neuro-Oncology Working Group

Background

Corticosteroids are the mainstay of treatment for peritumor edema but are often associated with significant side effects. Therapies that can reduce corticosteroid use would potentially be of significant benefit to patients. However, currently there are no standardized endpoints evaluating corticosteroid use in neuro-oncology clinical trials.

Methods

The Response Assessment in Neuro-Oncology (RANO) Working Group has developed consensus recommendations for endpoints evaluating corticosteroid use in clinical trials in both adults and children with brain tumors.

Results

Responders are defined as patients with a 50% reduction in total daily corticosteroid dose compared with baseline or reduction of the total daily dose to ≤2 mg of dexamethasone (or equivalent dose of other corticosteroid); baseline dose must be at least 4 mg of dexamethasone daily (or equivalent dose of other corticosteroids) for at least one week. Patients must have stable or improved Neurologic Assessment in Neuro-Oncology (NANO) score or Karnofsky performance status score or Eastern Cooperative Oncology Group (ECOG) (Lansky score for children age <16 y), and an improved score on a relevant clinical outcome assessment tool. These criteria must be sustained for at least 4 weeks after baseline assessment to be considered a response, and are confirmed 4 weeks after that (ie, 8 wk after baseline assessment) to be considered a sustained response.

Conclusions

This RANO proposal for corticosteroid use endpoints in neuro-oncology clinical trials may need to be refined and will require prospective validation in clinical studies.

Radiofrequency Electromagnetic Radiation and Memory Performance: Sources of Uncertainty in Epidemiological Cohort Studies

Uncertainty in experimental studies of exposure to radiation from mobile phones has in the past only been framed within the context of statistical variability. It is now becoming more apparent to researchers that epistemic or reducible uncertainties can also affect the total error in results. These uncertainties are derived from a wide range of sources including human error, such as data transcription, model structure, measurement and linguistic errors in communication. The issue of epistemic uncertainty is reviewed and interpreted in the context of the MoRPhEUS, ExPOSURE and HERMES cohort studies which investigate the effect of radiofrequency electromagnetic radiation from mobile phones on memory performance. Research into this field has found inconsistent results due to limitations from a range of epistemic sources. Potential analytic approaches are suggested based on quantification of epistemic error using Monte Carlo simulation. It is recommended that future studies investigating the relationship between radiofrequency electromagnetic radiation and memory performance pay more attention to treatment of epistemic uncertainties as well as further research into improving exposure assessment. Use of directed acyclic graphs is also encouraged to display the assumed covariate relationship.