Improved health-related quality of life after rehabilitation in patients with brain tumors is not affected by tumor type

BACKGROUND

The effect of rehabilitation therapy on health-related quality of life (HRQOL) among patients with brain tumors has not been fully investigated.

AIM

This study aimed to evaluate the effect of rehabilitation therapy on HRQOL among patients with brain tumors using the HRQOL index. We also examined factors that influenced changes in HRQOL, including differences in brain tumor type.

DESIGN

Prospective cohort study.

SETTING

University Medical and Dental Hospital.

POPULATION

Patients with brain tumors aged 20 years or older undergoing rehabilitation therapy were included. Patients with cognitive decline, aphasia, or poor general condition who had difficulty answering HRQOL questions were excluded.

METHODS

The EuroQol-5 Dimension 5-Level (EQ-5D-5L), EORTC Quality of Life Questionnaire Core 30 (QLQ-C30), and EORTC Quality of Life Questionnaire Brain Cancer Module (BN20) were used to assess HRQOL before and after rehabilitation treatment. Brain tumor type was classified into five groups: World Health Organization (WHO) grade 1, WHO grade 2/3, WHO grade 4, primary central nervous system lymphoma, and metastatic brain tumor. We compared EQ-5D-5L index scores and QLQ-C30 and BN20 scores before and at the end of rehabilitation. Multiple regression analysis was used to examine factors affecting changes in EQ-5D-5L index score (EQ-5D-5L gain).

RESULTS

In total, 112 patients participated in this study. The median EQ-5D-5L index score significantly improved from 0.698 before rehabilitation to 0.772 at the end of rehabilitation (P<0.001, r=0.46). QLQ-C30 and BN20 scores showed significant improvement in physical functioning, global health status, pain, and motor dysfunction (P<0.001, r>0.3). Multiple regression analysis revealed that recurrence (β=-0.191, P=0.037) and baseline EQ-5D-5L index score (β=-0.595, P<0.001) affected EQ-5D-5L gain, whereas differences in brain tumor type did not.

CONCLUSIONS

HRQOL among patients with brain tumors improved at the end of rehabilitation therapy compared with before therapy. Furthermore, the EQ-5D-5L index score gain was not affected by brain tumor type.

CLINICAL REHABILITATION IMPACT

These results suggest rehabilitation therapy may contribute to improved HRQOL irrespective of brain tumor type.

APPROACH: Analysis of Proton versus Photon Radiotherapy in Oligodendroglioma and Assessment of Cognitive Health - study protocol paper for a phase III multicentre, open-label randomised controlled trial

INTRODUCTION

Oligodendroglioma (ODG) is a rare type of brain tumour, typically diagnosed in younger adults and associated with prolonged survival following treatment. The current standard of care is maximal safe debulking surgery, radiotherapy (RT) and adjuvant procarbazine, lomustine and vincristine (PCV) chemotherapy. Patients may experience long-term treatment-related toxicities, with RT linked to impairments of neurocognitive function (NCF) and health-related quality of life (HRQoL). With proton beam therapy (PBT), radiation dose falls off sharply beyond the target with reduced normal brain tissue radiation doses compared with photon RT. Therefore, PBT might result in reduced radiation-induced toxicity compared with photon RT.

METHODS AND ANALYSIS

APPROACH is a multicentre open-label phase III randomised controlled trial of PBT versus photon RT in patients with ODG, investigating the impact of PBT on long-term NCF measured using the European Organisation for Research and Treatment of Cancer (EORTC) Core Clinical Trial Battery Composite (CTB COMP). The trial will randomise 246 participants from 18 to 25 UK RT sites, allocated 1:1 to receive PBT or photon RT, with PBT delivered at one of the two UK PBT centres. Participants with grade 2 and grade 3 ODG will receive 54 Gy in 30 fractions and 59.4 Gy in 33 fractions, respectively, followed by 6×6-weekly cycles of PCV chemotherapy. The trial contains staged analyses, with an internal pilot for feasibility of recruitment at 12 months, early assessment of efficacy at 2 years, futility assessment and final primary endpoint comparison of NCF between arms at 5 years. Secondary endpoints include additional NCF, treatment compliance, acute and late toxicities, endocrinopathies, HRQoL, tumour response, progression-free survival and overall survival.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Newcastle North Tyneside REC (reference 22/NE/0232). Final trial results will be published in peer-reviewed journals and adhere to International Committee of Medical Journal Editors (ICMJE) guidelines.

TRIAL REGISTRATION NUMBER

ISRCTN:13390479.

Longitudinal impact of intracerebral low-grade glioma disease on health-related quality of life

BACKGROUND

The aim of this study was to assess health-related quality of life (HRQOL) before and after treatment for intracerebral low-grade glioma.

METHODS

Patients with low-grade glioma who underwent surgical tumor removal between 2012 and 2018 were eligible for this study. All individuals and their closest relatives received thorough preoperative (

RESULTS

A total of 25 patients were referred for further analysis, after adjustment to the 2021 WHO classification for central nervous system tumors. Compared to the values of a healthy reference population, the patients expressed significant limitations in several SF36 items, both before and after treatment. Under treatment, there were no significant changes in the SF36 items, but the ALQI questionnaire indicated decreasing HRQOL over time. Data derived from relatives revealed a high degree of concordance with the rating results of the patients. Univariate analysis identified neurological deterioration and ongoing epileptic seizures as predictors for unfavorable HRQOL after one year.

CONCLUSIONS

Low-grade glioma disease has a significant impact on HRQOL and treatment might contribute to further deterioration. New-onset neurological deficits and ongoing epileptic seizures are predictors of limitations in quality of life. Since the results are based on a small cohort with limited follow-up time, the generalizability of these statements is limited and further studies are required.

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MESH Headings

• Humans
• Quality of Life/psychology
• Glioma/surgery
• Glioma/psychology
• Female
• Male
• Brain Neoplasms/surgery
• Brain Neoplasms/psychology
• Middle Aged
• Adult
• Longitudinal Studies
• Aged
• Surveys and Questionnaires
• Neuropsychological Tests

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Affiliation(s)

Laurèl Rauschenbach Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany - DKFZ Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Hospital of Essen, Essen, Germany - Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany -
Pauline Bartsch Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
Alejandro N Santos Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Anna Michel Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Hanah H Gull Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Pikria Ketelauri Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Marvin Darkwah Oppong Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Börge Schmidt Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
Celia Dobersalske DKFZ Division Translational Neurooncology at the West German Cancer Center (WTZ), DKTK Partner Site, University Hospital of Essen, Essen, Germany
Tobias Blau Institute for Neuropathology, University Hospital of Essen, Essen, Germany
Yahya Ahmadipour Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Ramazan Jabbarli Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Karsten H Wrede Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Ulrich Sure Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
Philipp Dammann Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany

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Health-related quality of life in 62 patients with diffuse low-grade glioma during a non-therapeutic and progression-free phase: a cross-sectional study

PURPOSE

Few studies have evaluated the health-related quality of life (HRQoL) of patients with diffuse low-grade glioma (LGG) during a clinical and radiological monitoring period. We report a cross sectional cohort study of HRQoL in patients with LGG and compare the results with normative population data. We then explore factors associated with HRQoL.

METHODS

We used the European Organisation for Research and Treatment of Cancer QLQ-C30, BN-20 and the Hospital Anxiety and Depression Scale (HADS) to evaluate HRQoL. Averaged QLQC30 and HADS scores were compared with scores of a normative population. A general linear model multivariate analysis of variance was used to investigate the association between HRQoL and independent factors.

RESULTS

A total of 62 patients with LGG completed HRQoL questionnaires. Compared with a normative population, LGG patients reported statistical and clinically significant lower cognitive, emotional, role and social functioning. Fatigue, anxiety, depression and sleep disturbances were frequently reported. Awake surgery and preserved high Karnofsky Performance Status were found to be independent prognostic factors for better global HRQoL, while radiotherapy was associated with worsened HRQoL.

CONCLUSION

Despite a non-therapeutic and progression free phase, LGG patients report noticeable limitations in several HRQoL subscales. Our study highlights the importance of HRQoL assessment not only at diagnosis or during active therapeutic stage. Further studies are needed to develop better adapted tools of HRQoL assessment.

Symptom management in isocitrate dehydrogenase mutant glioma

According to the 2021 World Health Organization classification of CNS tumors, gliomas harboring a mutation in isocitrate dehydrogenase (mIDH) are considered a distinct disease entity, typically presenting in adult patients before the age of 50 years. Given their multiyear survival, patients with mIDH glioma are affected by tumor and treatment-related symptoms that can have a large impact on the daily life of both patients and their caregivers for an extended period of time. Selective oral inhibitors of mIDH enzymes have recently joined existing anticancer treatments, including resection, radiotherapy, and chemotherapy, as an additional targeted treatment modality. With new treatments that improve progression-free and possibly overall survival, preventing and addressing daily symptoms becomes even more clinically relevant. In this review we discuss the management of the most prevalent symptoms, including tumor-related epilepsy, cognitive dysfunction, mood disorders, and fatigue, in patients with mIDH glioma, and issues regarding patient's health-related quality of life and caregiver needs in the era of mIDH inhibitors. We provide recommendations for practicing healthcare professionals caring for patients who are eligible for treatment with mIDH inhibitors.

Glioma resource outreach with support: A program to identify and initiate supportive care interventions for unmet needs among adult lower-grade glioma patients

Background

Lower-grade (WHO grades 2-3) gliomas typically affect young and middle-aged adults and exhibit isocitrate dehydrogenase (IDH) mutations. For such patients, symptoms related to the tumor and associated treatment contribute to morbidity and erode quality of life. With improved treatment, a better understanding of these effects over time is critically needed. Existing data characterizing unmet needs of lower-grade glioma patients is limited and little consensus exists on addressing these needs in clinical practice.

Methods

In order to better identify and address the unmet needs of lower-grade glioma patients, focus groups among patients and caregivers were initially conducted among patients treated at a single academic center. A semi-structured interview guide to comprehensively understand unmet needs was then developed. Each patient-defined unmet need was categorized into domains through qualitative content analysis. In parallel, a database of established local and regional community-based resources was established, and a dedicated resource specialist provided patient-specific referrals and follow-up.

Results

Eighty-five patients were interviewed. Median age was 41 years and the median time from tumor diagnosis was 63 months. Approximately 68% had a WHO grade 2 tumor and 60% were off therapy. Qualitative analysis of interview content identified 5 overarching domains of unmet need: Psychosocial; Neurologic/Cognitive; Lifestyle; Financial; and Other Medical. At least one unmet need was identified by 71% of participants and the most common domains were Psychosocial (40.7%) and Lifestyle (34.9%).

Conclusions

Our program begins to address frequently unmet survivorship needs of lower-grade glioma patients that spanned 5 major domains. Further research aimed to better define and address unmet needs among these patients is warranted.

Brain tumor-related epilepsy: an overview on neuropsychological, behavioral, and quality of life issues and assessment methodology

Brain tumor-related epilepsy (BTRE) is a rare disease in which brain tumor (BT) and epilepsy overlap simultaneously and can have a negative impact on a patient's neuropsychological, behavioral, and quality of life (QoL) spheres. In this review we (a) addressed the main neuropsychological, behavioral, and QoL issues that may occur in BTRE patients, (b) described how BT, BTRE, and their respective treatments can impact these domains, and (c) identified tools and standardized evaluation methodologies specific for BTRE patients. Neuropsychological disorders and behavioral issues can be direct consequences of BTRE and all related treatments, such as surgery, anti-cancer and anti-seizure medication, corticosteroids, etc., which can alter the structure of specific brain areas and networks, and by emotional aspects reactive to BTRE diagnosis, including the possible loss of autonomy, poor prognosis, and fear of death. Unfortunately, it seems there is a lack of uniformity in assessment methodologies, such as the administration of different batteries of neuropsychological tests, different times, frames, and purposes. Further research is needed to establish causality and deepen our understanding of the interplay between all these variables and our intervention in terms of diagnosis, treatment, psychosocial assessment, and their timing. We propose that the care of these patients to rely on the concepts of "BTRE-induced disability" and "biopsychosocial model" of BTRE, to prompt healthcare providers to handle and monitor BTRE-related psychological and social aspects, as to maintain the patient's best possible QoL.

Identifying and understanding how people living with a lower-grade glioma engage in self-management

PURPOSE

Lower-grade gliomas (LGG) are mostly diagnosed in working-aged adults and rarely cured. LGG patients may face chronic impairments (e.g. fatigue, cognitive deficits). Self-management can improve clinical and psychosocial outcomes, yet how LGG patients self-manage the consequences of their tumour and its treatment is not fully understood. This study, therefore, aimed to identify and understand how LGG patients engage in the self-management of their condition.

METHODS

A diverse group of 28 LGG patients (age range 22-69 years; male n = 16, female n = 12; mean time since diagnosis = 8.7 years) who had completed primary treatment, were recruited from across the United Kingdom. Semi-structured interviews were conducted. Informed by a self-management strategy framework developed in cancer, directed content analysis identified and categorised self-management types and strategies used by patients.

RESULTS

Overall, 20 self-management strategy types, comprising 123 self-management strategies were reported; each participant detailed extensive engagement in self-management. The most used strategy types were 'using support' (n = 28), 'creating a healthy environment' (n = 28), 'meaning making' (n = 27), and 'self-monitoring' (n = 27). The most used strategies were 'accepting the tumour and its consequences' (n = 26), 'receiving support from friends (n = 24) and family' (n = 24), and 'reinterpreting negative consequences' (n = 24).

CONCLUSIONS

This study provides a comprehensive understanding of the strategies used by LGG patients to self-manage their health and wellbeing, with a diverse, and substantial number of self-management strategies reported.

IMPLICATIONS FOR CANCER SURVIVORS

The findings will inform the development of a supported self-management intervention for LGG patients, which will be novel for this patient group.

Predictors of cognition after glioma surgery: connectotomy, structure-function phenotype, plasticity

Determining preoperatively the maximal extent of resection that would preserve cognitive functions is the core challenge of brain tumour surgery. Over the past decade, the methodological framework to achieve this goal has been thoroughly renewed: the population-level topographically-focused voxel-based lesion-symptom mapping has been progressively overshadowed by machine learning (ML) algorithmics, in which the problem is framed as predicting cognitive outcomes in a patient-specific manner from a typically large set of variables. However, the choice of these predictors is of utmost importance, as they should be both informative and parsimonious. In this perspective, we first introduce the concept of connectotomy: instead of parameterizing resection topography through the status (intact/resected) of a huge number of voxels (or parcels) paving the whole brain in the Cartesian 3D-space, the connectotomy models the resection in the connectivity space, by computing a handful number of networks disconnection indices, measuring how the structural connectivity sustaining each network of interest was hit by the resection. This connectivity-informed reduction of dimensionality is a necessary step for efficiently implementing ML tools, given the relatively small number of patient-examples in available training datasets. We further argue that two other major sources of interindividual variability must be considered to improve the accuracy with which outcomes are predicted: the underlying structure-function phenotype and neuroplasticity, for which we provide an in-depth review and propose new ways of determining relevant predictors. We finally discuss the benefits of our approach for precision surgery of glioma.

Global health status and fatigue score in isocitrate dehydrogenase-mutant diffuse glioma grades 2 and 3: A longitudinal population-based study from surgery to 12-month follow-up

Background

At the group level, health-related quality of life (HRQoL) in patients with IDH-mutant diffuse glioma grades 2 and 3 seems to remain stable over time. However, clinical experience indicates that there are patients with unfavorable outcomes on key HRQoL subdomains. The aim of this longitudinal population-based study, following patients over a period of 12 months from surgery, was to describe individual-level data on global health status and fatigue score and explore possible predictors of deterioration.

Methods

All patients undergoing surgery for presumed glioma grades 2 or 3 at the Sahlgrenska University Hospital during 2017-2022, were screened for the study. Patients were invited to complete the European Organization of Research and Treatment of Cancer core questionnaires and brain module at baseline, 3 and 12 months postoperatively. Data is reported with respect to minimal clinical important difference (MCID).

Results

We included 51 patients with IDH-mutant diffuse glioma grades 2 or 3. There was no difference in group-level data of either global health status or fatigue score from baseline to the 12-month follow-up (P-value > .05). Unfavorable individual changes (beyond MCID) in global health status and fatigue score were observed in 12 and in 17 patients, respectively (23.5% and 33.3%). A lower proportion of proton radiotherapy was found in patients with unfavorable changes in fatigue (10/15, 66.7%) compared to all other patients undergoing radiotherapy (22/23, 95.7%, P-value .03).

Conclusions

Deterioration beyond MCID was seen in approximately one-third of patients. Changes in global health status could not be predicted, but changes in fatigue may be influenced by tumor-targeted and symptomatic treatment.

Social cognition in adult survivors of brain tumors: studying the relationship between theory of mind and quality of life

OBJECTIVE

The present study is the first to examine theory of mind (ToM) sequelae in a sample of adult survivors of primary brain tumors, and to investigate the assumed relationship between ToM and health-related quality of life (HRQoL).

METHOD

Participants were 40 long-term adult survivors of primary brain tumors and 40 matched healthy controls. They completed ToM tests (Faux-Pas test and Advanced ToM task) and two questionnaires assessing HRQoL (36-Item Short-Form Health Survey and EORTC QLQ-C30/QLQ-BN20). Their relatives also completed an observer-rated version of the SF-36 questionnaire.

RESULTS

Survivors performed worse than controls only on the Advanced ToM task. Overall, patients and caregivers reported more problems than healthy controls and their relatives regarding both global HRQoL and its social/emotional aspects. No relationship was found between ToM and HRQoL scores.

CONCLUSION

Adult survivors of primary brain tumors may exhibit ToM deficits several years after treatment and report more problems on social/emotional HRQoL components. Our findings highlight the need to consider these late effects in survivors' long-term follow-up, even if the clinical involvement of ToM deficits still needs to be elucidated. The assessment of ToM deficits and their potential impact on survivors' everyday life is thoroughly discussed.

Longitudinal assessment of quality of life, neurocognition, and psychopathology in patients with low-grade glioma on first-line temozolomide: A feasibility study

Background

The treatment timing and choice after neurosurgical resection in patients with newly diagnosed diffuse low-grade glioma (DLGG) remain controversial. Indeed, the effect of such treatments must be balanced with the possible side effects. This study evaluated the feasibility of longitudinal exhaustive quality of life (QoL) and neuropsychological assessments in patients with DLGG receiving first-line temozolomide.

Methods

QoL, neurocognition, and psychological disorders were assessed prospectively until disease progression, using testing, clinician-reported, and self-reported questionnaires. The primary endpoint was the participation and adherence to this complete assessment at Baseline (before temozolomide initiation), months 6 and 12 of treatment, and month 6 post-treatment. The QoL and neuropsychological changes over time also were described.

Results

Twenty-six of the twenty-nine eligible patients were enrolled (participation rate: 89.7%, 95% CI: 72.6-97.8). The adherence rate was 95.7% (95% CI: 78.1-99.9; n = 23 because 3 patients progressed in the first 12 months of treatment). Up to month 6 post-treatment, QoL and fatigue remained stable (EORTC QLQC30 and BN20, MFI-20); some specific symptoms were transitory. Both subjective (FACT-Cog) and objective (Z-scores of neurocognitive tests) neurocognitive outcomes remained stable or tended to improve. The percentage of patients with severe depression (BDI-II), anxiety (STAI-Y), or anger (STAXI-II) was stable over time.

Conclusions

This prospective study demonstrated the feasibility of an exhaustive and longitudinal evaluation of QoL, neurocognition, and psychological disorders, with high acceptability by patients with DLGG undergoing chemotherapy. First-line temozolomide seems to have limited short-term effects on QoL and neurocognition. These findings must be confirmed in the long term and in a larger cohort.

Associations between Adult Primary Brain Tumor Survivors' Behavioral Executive Functions, Health Related Quality of Life and their Caregivers' Health Related Quality : A cross-sectional study

The present study focused on adult primary brain tumor (PBT) survivors' caregivers. The main objective was to study associations between PBT survivors' health-related quality of life (HRQOL), their behavioral executive functions (EF) and their caregivers' HRQOL. Forty PBT survivors of PBT and 37 caregivers (mostly patient's spouses 81.08%; n = 30) participated in the study. PBT survivors completed a cancer related Quality of Life (QOL) questionnaire. Caregivers completed informant rated HRQOL and behavioral EF reports relating to PBT survivors and a self-rated HRQOL questionnaire relating to themselves. Correlational and multiple regression analyses were conducted. No associations were found between caregivers' physical HRQOL and PBT survivors' HRQOL nor behavioral EF. Analyses yielded several significant correlations between caregivers' mental HRQOL and variables pertaining to PBT survivors' HRQOL and behavioral EF. Multiple regression analyses showed that caregivers' mental HRQOL is predicted by PBT survivors' mental HRQOL, global cancer-related QOL scores and global behavioral EF scores. This study provides evidence suggesting that during the survivorship phase, at an average of 3.67 (SD = 2.31) years following treatment for a PBT, caregivers mental HRQOL is linked to PBT survivors' long-term effects. These findings shed some light regarding post-cancer care for both PBT survivors and their caregivers.

Quality of life after surgery for lower grade gliomas

BACKGROUND

Few large studies have investigated quality of life (QOL) for adults diagnosed with lower grade glioma (LGG).

METHODS

QOL was assessed for 320 adults with LGG (World Health Organization grade 2/3) enrolled in the International Low Grade Glioma Registry by using the Medical Outcomes Study 36-Item Short Form health survey. Data on symptoms were also collected. QOL outcomes were examined by treatment group and also compared to those from a population-based case-control study of meningioma (the Meningioma Consortium), in which 1722 meningioma cases diagnosed among residents of Connecticut, Massachusetts, California, Texas, and North Carolina from May 1, 2006 through March 14, 2013 were enrolled and frequency matched to 1622 controls by age, sex, and geography.

RESULTS

The LGG sample average age is 45 years at the time of interview and 53.1% male. Almost 55% of patients had received radiation and chemotherapy (primarily temozolomide); 32.4% had received neither treatment. Two-thirds of participants with LGG report difficulty with speaking, memory, or thinking, and over one of three reports personality change or difficulty driving. After controlling for age and other comorbidities, individuals with LGG report levels of physical, emotional, and mental health functioning below those reported in a meningioma as well as a general healthy population.

CONCLUSIONS

Despite being relatively young, persons with LGG report significantly reduced QOL compared to persons with nonmalignant brain tumors and to a control population, which highlights the need to better acknowledge and manage these symptoms for this group of patients diagnosed in the prime of life.

Thirty years of progress in the management of low-grade gliomas

This paper reviews 30 years of developments in the area of low-grade gliomas. This includes the changes in diagnostics with the incorporation of 1p/19q and IDH mutations in the diagnostic classifier, the improved surgical techniques, improved delivery of radiotherapy and chemotherapy. More recently, the better understanding of the altered cellular processes has lead to the development of novel drugs that may alter completely alter the management of patients early in the course of their disease.

Health-related quality of life in adults with low-grade gliomas: a systematic review

PURPOSE

Low-grade glioma (LGG) patients may face health-related quality-of-life (HRQoL) impairments, due to the tumour, treatment and associated side-effects and prospects of progression. We systematically identified quantitative studies assessing HRQoL in adult LGG patients, for: aspects of HRQoL impacted; comparisons with non-cancer controls (NCC) and other groups; temporal trends; and factors associated with HRQoL.

METHODS

MEDLINE, CINAHL, Embase, PubMed, and PsycINFO were systematically searched from inception to 14th September 2021. Following independent screening of titles and abstracts and full-texts, population and study characteristics, and HRQoL findings were abstracted from eligible papers, and quality appraised. Narrative synthesis was conducted.

RESULTS

Twenty-nine papers reporting 22 studies (cross-sectional, n = 13; longitudinal, n = 9) were identified. Papers were largely good quality, though many excluded patients with cognitive and communication impairments. Comparators included high-grade gliomas (HGG) (n = 7); NCCs (n = 6) and other patient groups (n = 3). Nineteen factors, primarily treatment (n = 8), were examined for association with HRQoL. There was substantial heterogeneity in HRQoL instruments used, factors and aspects of HRQoL assessed and measurement timepoints. HRQoL, primarily cognitive functioning and fatigue, in adult LGG patients is poor, and worse than in NCCs, though better than in HGG patients. Over time, HRQoL remained low, but stable. Epilepsy/seizure burden was most consistently associated with worse HRQoL.

CONCLUSION

LGG patients experience wide-ranging HRQoL impairments. HRQoL in those with cognitive and communication impairments requires further investigation. These findings may help clinicians recognise current supportive care needs and inform types and timings of support needed, as well as inform future interventions.

The need to consider return to work as a main outcome in patients undergoing surgery for diffuse low-grade glioma: a systematic review

OBJECTIVE

For a long time, return to work (RTW) has been neglected in patients harboring a diffuse low-grade glioma (LGG). However, a majority of LGG patients worked at time of diagnosis. Moreover, these patients now live longer given current treatment paradigms, especially thanks to early maximal surgery.

METHODS

We systematically searched available medical databases for studies that reported data on RTW in patients who underwent resection for LGG.

RESULTS

A total of 30 studies were selected: 19 considered RTW (especially rate and timing) as an outcome and 11 used scales of health-related quality of life (HRQoL) which included work-related aspects. Series that considered RTW as a main endpoint were composed of 1014 patients, with postoperative RTW rates ranging from 31 to 97.1% (mean 73.1%). Timing to RTW ranged from 15 days to 22 months (mean 6.3 months). Factors related to an increased proportion of RTW were: younger age, better neurologic status, having a white-collar occupation, working pre-operatively, being the sole breadwinner, the use of awake surgery, and greater extent of resection. Female sex, older age, poor neurologic status, pre-operative history of work absences, slow lexical access speed, and postoperative seizures were negatively related to RTW. No studies that used HRQoL scales directly investigated RTW rate or timing.

CONCLUSIONS

RTW was scarcely analyzed in LGG patients who underwent resection. However, because they are usually young, with no or only mild functional deficits and have a longer life expectancy, postoperative RTW should be assessed more systematically and accurately as a main outcome. As majority (61.5-100%) of LGG patients were working at time of surgery, the responsibility of neurosurgeons is to bring these patients back to their previous activities according to his/her wishes. RTW might also be included as a critical endpoint for future prospective studies and randomized control trials on LGGs.

Long-term wellbeing and neurocognitive functioning of diffuse low-grade glioma patients and their caregivers: A longitudinal study spanning two decades

BACKGROUND

While patients with diffuse low-grade glioma (LGG) often survive for years, there is a risk of tumor progression which may impact patients' long-term health-related quality of life (HRQOL) and neurocognitive functioning (NCF). We present a follow-up of LGG patients and their informal caregivers (T3) who took part in our previous HRQOL investigations (T1, M = 7 and T2 M = 13 years after diagnosis).

METHODS

Participants completed HRQOL (short form-36 health survey [SF-36]; EORTC-BN20), fatigue (Checklist Individual Strength [CIS]), and depression (Center for Epidemiological Studies-Depression [CES-D]) questionnaires and underwent NCF assessments. T3 scores were compared with matched controls. Changes over time (T1-T2-T3) on group and participant level were assessed. Where available, histology of the initial tumor was revised and immunohistochemical staining for IDH1 R132H mutant protein was performed.

RESULTS

Thirty patients and nineteen caregivers participated. Of N = 11 with tissue available, 3 patients had confirmed diffuse LGG. At T3, patients (M = 26 years after diagnosis) had HRQOL and NCF similar to, or better than controls, yet 23.3% and 53.3% scored above the cut-off for depression (≥16 CES-D) and fatigue (≥35 CIS), respectively. Caregivers' HRQOL was similar to controls but reported high rates of fatigue (63.2%). Over time, patients' mental health improved (P < .05). Minimal detectable change in HRQOL over time was observed in individual patients (30% improvement; 23.3% decline; 20% both improvement and decline) with 23.3% remaining stable. NCF remained stable or improved in 82.8% of patients.

CONCLUSIONS

While HRQOL and NCF do not appear greatly impacted during long-term survivorship in LGG, depressive symptoms and fatigue are persistent.

Using machine learning to predict health-related quality of life outcomes in patients with low grade glioma, meningioma, and acoustic neuroma

Background

Predicting reduced health-related quality of life (HRQoL) after resection of a benign or low-grade brain tumour provides the opportunity for early intervention, and targeted expenditure of scarce supportive care resources. We aimed to develop, and evaluate the performance of, machine learning (ML) algorithms to predict HRQoL outcomes in this patient group.

Methods

Using a large prospective dataset of HRQoL outcomes in patients surgically treated for low grade glioma, acoustic neuroma and meningioma, we investigated the capability of ML to predict a) HRQoL-impacting symptoms persisting between 12 and 60 months from tumour resection and b) a decline in global HRQoL by more than the minimum clinically important difference below a normative population mean within 12 and 60 months after resection. Ten-fold cross-validation was used to measure the area under the receiver operating characteristic curve (AUC), area under the precision-recall curve (PR-AUC), sensitivity, and specificity of models. Six ML algorithms were explored per outcome: Random Forest Classifier, Decision Tree Classifier, Logistic Regression, K Neighbours Classifier, Support Vector Machine, and Gradient Boosting Machine.

Results

The final cohort included 262 patients. Outcome measures for which AUC>0.9 were Appetite loss, Constipation, Nausea and vomiting, Diarrhoea, Dyspnoea and Fatigue. AUC was between 0.8 and 0.9 for global HRQoL and Financial difficulty. Pain and Insomnia achieved AUCs below 0.8. PR-AUCs were similar overall to the AUC of each respective classifier.

Conclusions

ML algorithms based on routine demographic and perioperative data show promise in their ability to predict HRQoL outcomes in patients with low grade and benign brain tumours between 12 and 60 months after surgery.

The burden of a brain tumor: guiding patient centric care in neuro-oncology

PURPOSE

Brain tumor patients report an overwhelming sense of uncertainty when navigating the course of their terminal disease. Historically, organizational experts and/or treating physicians have established neuro-oncology programs. However, given the disease burden and incurable nature of current medical treatments, patient-centric care should be prioritized alongside institutional and academic objectives. Integrating patient perspectives into interdisciplinary programmatic development can improve comprehensive care and empower patients to advocate for their own quality healthcare needs.

METHODS

Data was derived from four focus groups with adult brain tumor patients (N = 15; M_age = 46 years, 53% female). A trained moderator led each 90-min group and posed semi-structured questions regarding patients' care needs throughout their neuro-oncological disease trajectory. Emphasis was placed on quality of life and psychological distress reduction for both patients and their loved ones. Common themes were identified via thematic content analysis using NVivo software. A high inter-rater reliability (M_kappa = 0.92, range= 0.85-0.93) was achieved.

RESULTS

Six distinct themes emerged, where the frequency of each theme ranged from 12.5 to 23.3%. Specifically, patients discussed relational concerns, navigation of interdisciplinary care, neurobehavioral impacts, emotional responses to stressors, existential concerns, and caregiver support. A discussion of themes follows.

CONCLUSIONS

It is imperative that we include the patient perspective in the development of neuro-oncology programs; considering the quality of survival in addition to quantity. Neuro-oncology quality care themes identified were relational concerns, navigating interdisciplinary care, neurobehavioral impact, emotional response to stressors, existential concerns, and caregiver support. A paramount concentration for comprehensive neuro-oncology programs must include patients' quality needs.

Relationships between executive functioning and health-related quality of life in adult survivors of brain tumor and matched healthy controls

INTRODUCTION

Few studies have considered health-related quality of life (HRQOL) as a primary outcome measure in adult survivors of primary brain tumor (PBT), and fewer still have studied the cognitive factors that may influence it. Research suggests that executive functions (EFs) are associated with HRQOL, but there is scant evidence to support this. The present study was conducted to (1) extend prior findings about HRQOL limitations in a sample of stable, long-term adult survivors of PBT, (2) investigate the associations between objective/reported EFs and HRQOL, and (3) identify the EFs that contribute most to HRQOL.

METHOD

We recruited 40 survivors of PBT (> 2 years post-treatment) and 40 matched healthy controls. Participants completed an objective EF assessment (inhibition, working memory, shifting, and rule detection) and two self-report questionnaires probing EFs (Behavior Rating Inventory of Executive Function-Adult) and HRQOL (Medical Outcomes Study Short-Form 36). Participants' relatives completed observer-rated versions of these questionnaires.

RESULTS

Patients' objective EF performances were relatively intact. However, patients and caregivers reported significantly more problems than healthy controls and their relatives, for both EFs and HRQOL. There were only negligible links between objective EFs and HRQOL, whereas numerous associations were found between reported EFs and HRQOL components. ANCOVA models revealed that specific reported EF processes contributed to both the physical and mental components of HRQOL, regardless of group.

CONCLUSIONS

From a clinical point of view, this study demonstrates that even several years after end of treatment, adult PBT survivors experience substantial problems across different HRQOL domains. HRQOL assessment should therefore be part of the long-term follow-up of PBT survivors, and clinicians should consider EF limitations when designing appropriate survivorship care plans. These findings indicate that cognitive interventions targeting EFs could improve HRQOL.

Sociocognitive Functioning and Psychosocial Burden in Patients with Brain Tumors

Simple Summary

After years of gauging the efficacy of tumor-directed therapies primarily by means of survival, a broader perspective on therapeutic outcome also focusses on patients’ everyday functional abilities. Besides neurocognition, a matter of high clinical relevance, “social cognition” may also affect well-being and quality of life (QoL) in brain tumor patients. Abilities that enable individuals to establish and maintain social relationships are summarized under the umbrella term “sociocognitive functioning”. These abilities encompass the understanding and sharing of emotional and mental states of other individuals as well as skills to detect and resolve interpersonal problems. These sociocognitive abilities may be challenged in highly demanding life situations such as brain tumor diagnosis and treatment. Therefore, we summarize the literature on psychosocial burden and sociocognitive functioning in adult brain tumor patients.

Abstract

Brain tumors may represent devastating diseases and neuro-oncological research in the past solely focused on development of better treatments to achieve disease control. The efficacy of tumor-directed treatment was evaluated by progression-free and overall survival. However, as neuro-oncological treatment became more effective, preservation and improvement of quality of life (QoL) was noticed to represent an important additional outcome measure. The need to balance between aggressive tumor-directed treatment and preservation of QoL was increasingly acknowledged in brain tumor patients. QoL is comprised by many determinants; one of those may have been rather neglected so far: social cognition. Since diagnosis and treatment of brain tumors represent demanding life situations, patients may experience increased psychosocial burden and the negative consequences of illness on well-being may be buffered by intact social relationships. These skills to build and maintain supportive social relationships essentially depend on the ability to empathize with others and to recognize and appropriately address social conflicts, i.e., “sociocognitive functioning”. Therefore, sociocognitive functions may influence QoL and treatment outcome. In this article, we review the literature on psychosocial burden and sociocognitive functioning in adult brain tumor patients.

Long-term impact of adult WHO grade II or III gliomas on health-related quality of life: A systematic review

Background

Glioma diagnosis can be devastating and result in a range of symptoms. Relatively little is known about the long-term health-related quality of life (HRQOL) challenges faced by these patients. Establishing the impact of diagnosis on HRQOL could help positively tailor clinical decision making regarding patient support and treatment. The aim of this review is to identify the long-term HRQOL issues reported at least 2 years following diagnosis of WHO grade II/III glioma.

Method

Systematic literature searches were carried out using Medline, EMBASE, CINAHL, PsycINFO, and Web of Science Core Collection. Searches were designed to identify patient self-reports on HRQOL aspects defined as physical, mental, or social issues. Quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Narrative synthesis was used to collate findings.

Results

The search returned 8923 articles. Two hundred seventy-eight titles remained after title and abstract screening, with 21 full-text articles included in the final analysis. The majority of studies used quantitative methods, with 3 articles reporting mixed methodology. Negative emotional/psychological/cognitive changes were the most commonly reported. Physical complaints included fatigue, seizures, and restricted daily activity. Social challenges included strained social relationships and financial problems. Patient coping strategies were suggested to influence patient’s survival quality.

Conclusion

The consequences of a glioma diagnosis and treatment can have substantial implications for patients’ long-term HRQOL and daily functioning. Findings from this review lay the groundwork for efforts to improve patient HRQOL in long-term survivorship.

Effects of brain radiotherapy on cognitive performance in adult low-grade glioma patients: A systematic review

Grade II gliomas are slow growing tumours that usually affect younger patients. The mainstream treatment modality at present is surgical. The role of radiation therapy in the management of grade II gliomas has been the subject of considerable debate. Radiation therapy has a proven potential to prolong progression free and overall survival in high-risk patients, but may also produce long-term cognitive deficits. Since grade II glioma patients are expected to live several years, retention of cognitive capacity and quality of life is an equally important endpoint as prolonging progression free survival. Our overarching goal is to critically review the available evidence on the possible neuropsychological effects of postoperative radiotherapy in adult grade II glioma patients. We performed a systematic literature search in Medline, Embase and Cochrane databases up to 1st of May 2020 for studies assessing the cognitive effects of radiation therapy on grade II glioma patients. Eleven studies meeting our inclusion criteria provide either negative or contradictory data regarding the cognitive domains affected, while major confounding variables remain incompletely addressed. The available evidence does not adequately support the notion that current radiation therapy protocols independently produce substantial cognitive decline in grade II glioma patients and therefore it would be premature to argue that radiation associated cognitive morbidity outweighs the benefit of prolonged survival. A large prospective study incorporating a full battery of neuropsychological testing, sufficiently long-term follow-up period and tight control of confounders is due to provide high quality data.

Life after surgical resection of a low-grade glioma: A prospective cross-sectional study evaluating health-related quality of life

Health related quality of life (HRQoL) has become an important consideration in LGG patients. We report the largest prospective, longitudinal, cross-sectional cohort study of HRQoL in LGG patients, aiming to identify actionable determinants of HRQoL. Post-operative LGG adults at a large tertiary center underwent HRQoL assessment using the EORTC QLQ-C30 questionnaire administered at follow-up visits and by mail. Scores at 12 month intervals were compared with those from a normative reference population. Spearman's Rho was used to evaluate correlation of subdomain and symptom scores with global HRQoL and change over time. There were 167 participants and 366 questionnaires analysed. Patients reported reduced global HRQoL at nearly every 12 month interval with significant impairments at 12, 72, 108, and 120+ months postoperative. They also reported a significant impairment in each functional subdomain at 12 months, which persisted to varying degrees over 120 months, as did significant fatigue and insomnia. Role, emotional, and social subdomains, as well as fatigue, were significantly associated with global HRQoL at the first 12 month interval. Overall, there was no significant correlation between time from surgery and global HRQoL or the subdomain functional or symptom sections of the QLQ-C30. LGG patients report considerable, sustained impairments in HRQoL after surgery, particularly in cognitive, emotional, and social function, as well as suffering significant fatigue and insomnia. These are strongly associated with global HRQoL and thus can be considered determinants of global HRQoL that with intervention, may improve HRQoL for our LGG patients. This is the largest prospective longitudinal study of HRQoL in postoperative LGG patients yet reported and is ongoing. It identifies several determinants of impaired HRQoL with available management options and interventions that have the potential to significantly improve HRQoL in these patients.

Pre-operative Neurocognitive Function Was More Susceptible to Decline in Isocitrate Dehydrogenase Wild-Type Subgroups of Lower-Grade Glioma Patients

Background: Neuropsychological deficits frequently occur in diffuse lower-grade glioma (DLGG) patients, but their relationship with molecular subgroups based on the 2016 World Health Organization (WHO) Classification of Tumors of the Central Nervous System (CNS) is unclear. Methods: All patients enrolled for this study were divided into different subgroups according to the molecular-integrated 2016 CNS WHO and morphology-centric 2007 CNS WHO to compare their neurocognitive function (NCF) dysfunction. Univariate and multivariate analyses were used to assess the independent factors for NCF decline. The performance of NCF changes for discrimination of IDH and 1p19q status was evaluated by receiver operating characteristic (ROC). Results: There was no significant difference in the clinical characteristics among the molecular and morphologic subgroups. In the molecular subgroups, significant differences in NCF alterations were found in terms of attention function, working memory and executive function in grade II glioma patients; in addition to these changes in NCF, memory function and abstract thinking were also significantly different in grade III glioma patients. The pairwise comparison further confirmed that patients with astrocytoma (A)/anaplastic astrocytoma (AA) with isocitrate dehydrogenase wild-type (IDHwt) glioma were more susceptible to severe cognitive decline in terms of the NCF performance described above. For the morphologic subgroups, only working memory was significantly different in grade III glioma patients. The distribution proportion was significantly different among each subgroup of DLGG (grade II, P = 0.001; grade III, P = 0.002). The proportion of extensive NCF decline (≥5 tests) was 4, 12, and 50% in the IDH mutant oligodendroglioma (IDHm-O), IDHm-A, and IDHwt-A subgroups, and this proportion was 33, 60, and 93% in the IDHm-AO, IDHm-AA, and IDHwt-AA subgroups, respectively. In multivariate regression analysis, molecular types were independent factors for NCF alterations after adjusted the factors of tumor and demographics (p < 0.05). ROC curves suggested combined NCF tests model showed an advantage in the differentiation of IDH status. Conclusions: NCF alteration is closely related to molecular-integrated subgroups with varying degrees and frequencies in DLGG. Patients with IDHwt gliomas are more susceptible to suffer from severe and extensive NCF decline than other subgroups.

Proton therapy for selected low grade glioma patients in the Netherlands

Proton therapy offers an attractive alternative to conventional photon-based radiotherapy in low grade glioma patients, delivering radiotherapy with equivalent efficacy to the tumour with less radiation exposure to the brain. In the Netherlands, patients with favourable prognosis based on tumour and patient characteristics can be offered proton therapy. Radiation-induced neurocognitive function decline is a major concern in these long surviving patients. Although level 1 evidence of superior clinical outcome with proton therapy is lacking, the Dutch National Health Care Institute concluded that there is scientific evidence to assume that proton therapy can have clinical benefit by reducing radiation-induced brain damage. Based on this decision, proton therapy is standard insured care for selected low grade glioma patients. Patients with other intracranial tumours can also qualify for proton therapy, based on the same criteria. In this paper, the evidence and considerations that led to this decision are summarised. Additionally, the eligibility criteria for proton therapy and the steps taken to obtain high-quality data on treatment outcome are discussed.

A basic review on systemic treatment options in WHO grade II-III gliomas

WHO grade II-III gliomas are rare primary brain tumors occurring at a median age of about 35-55 years. Median survival is longer in WHO grade II-III glioma compared with WHO grade IV glioblastoma as survival times of up to 10 years and longer can be observed. Maximal safe resection and adjuvant therapies including chemotherapy and radiotherapy are the mainstay of treatment. Clinical trials in WHO grade II-III tumors are challenging due to the rarity and the long follow up times. The 2016 WHO Classification of Central Nervous Tumours introduced a new diagnostic framework relying on molecular characteristics, providing the definition of prognostically more homogenous subgroups compared to the histopathological analysis. Most available evidence on the adjuvant treatment of WHO II-III gliomas was generated in the pre-molecular era, challenging the interpretation of study results. The present review therefore summarizes the available data from prospective trials on systemic treatment options in WHO grade II-III glioma, considering molecular markers, recently published results and future outlooks in the field.

Isocitrate Dehydrogenase, Patient-Reported Outcomes, and Cognitive Functioning of Glioma Patients: a Systematic Review

PURPOSE OF REVIEW

Isocitrate dehydrogenase (IDH) mutation status has important prognostic implications in glioma patients, with IDH wild-type (IDH-WT) gliomas being associated with worse prognosis and shorter survival when compared with IDH mutant (IDH-mut) gliomas. Optimization of quality of life is a priority in the management of glioma patients. The goal of this systematic review was to identify studies that explored the association of IDH mutation status with patient-reported outcomes (PROs) and cognitive functioning of glioma patients.

RECENT FINDINGS

Studies that evaluated the association of IDH mutation status with PROs and/or cognitive functioning of glioma patients were identified from the Pubmed/MEDLINE, Clarivate analytics, and Google Scholar databases. Eight studies (7 journal articles and 2 conference abstracts) with a total of 658 low-grade glioma and high-grade glioma patients investigated the association of cognitive functioning and/or QoL with IDH status. IDH-WT status was associated with greater cognitive impairment relative to IDH-Mut status in three studies, while one study did not find the association between IDH status and perioperative cognitive functioning. One study reported worse postoperative cognitive functioning patients with IDH-WT vs. IDH-mut gliomas. In one study, IDH-WT status was linked to greater impairment on physical and communication functioning after surgery. IDH-WT gliomas are associated with greater cognitive burden than IDH-Mut tumors. The association of IDH status with QoL remains less clear. Assessment of IDH status should be considered when evaluating QoL and cognitive complaints of glioma patients. Further studies linking glioma molecular phenotypes with PROs and cognitive functioning are encouraged.

Recent developments and future directions in adult lower-grade gliomas: Society for Neuro-Oncology (SNO) and European Association of Neuro-Oncology (EANO) consensus

The finding that most grades II and III gliomas harbor isocitrate dehydrogenase (IDH) mutations conveying a relatively favorable and fairly similar prognosis in both tumor grades highlights that these tumors represent a fundamentally different entity from IDH wild-type gliomas exemplified in most glioblastoma. Herein we review the most recent developments in molecular neuropathology leading to reclassification of these tumors based upon IDH and 1p/19q status, as well as the potential roles of methylation profiling and deletional analysis of cyclin-dependent kinase inhibitor 2A and 2B. We discuss the epidemiology, clinical manifestations, benefit of surgical resection, and neuroimaging features of lower-grade gliomas as they relate to molecular subtype, including advanced imaging techniques such as 2-hydroxyglutarate magnetic resonance spectroscopy and amino acid PET scanning. Recent, ongoing, and planned studies of radiation therapy and both cytotoxic and targeted chemotherapies are summarized, including both small molecule and immunotherapy approaches specifically targeting the mutant IDH protein.

Cognitive and brain structural changes in long-term oligodendroglial tumor survivors

BACKGROUND

We identify cognitive impairment and MRI structural brain changes in long-term oligodendroglial tumor survivors treated with radiation therapy (RT) alone (21%) or with chemotherapy (CT) (79%).

METHODS

Oligodendroglial tumor patients (based on the World Health Organization [WHO] 2007 classification) who completed RT ± CT at least 2 years before the study initiation, were classified into 3 groups according to the time treatment was completed: Group 1 = 2-5 years (n = 22), Group 2 = 6-10 years (n = 13), and Group 3 >10 years (n = 13). All patients had a cross-sectional neuropsychological evaluation (n = 48) and a longitudinal volumetric analysis (gray matter [GM; n = 34]) between postsurgical and last follow-up MRI. White matter (WM) changes on MRI were assessed using a qualitative scale.

RESULTS

There were no differences regarding tumor or treatment-related characteristics between groups. Six of 22 patients (27.3%) in Group 1; 5/13 (38.5%) in Group 2; and 9/13 (69.2%) in Group 3 had cognitive impairment that was considered severe in 3/22 patients (13.6%) in Group 1; 4/13 (30.8%) in Group 2; and 6/13 (46.2%) in Group 3. Patients in Groups 2 and 3 showed significant GM atrophy and more leukoencephalopathy than Group 1. Cognitive deficits were associated with brain atrophy and WM changes.

CONCLUSIONS

Long-term oligodendroglial tumor survivors who underwent standard RT ± CT treatment, mainly >5 years of its completion, present cognitive impairment, especially on memory and executive functions, associated with late GM and WM damage, thus highlighting the need of developing future strategies in patients with oligodendroglial tumor and long expected survival.

Research on cognitive and sociocognitive functions in patients with brain tumours: a bibliometric analysis and visualization of the scientific landscape

BACKGROUND

Many patients with brain tumours exhibit mild to severe (neuro)cognitive impairments at some point during the course of the disease. Social cognition, as an instance of higher-order cognitive functioning, specifically enables initiation and maintenance of appropriate social interactions. For individuals being confronted with the diagnosis of a brain tumour, impairment of social function represents an additional burden, since those patients deeply depend on support and empathy provided by family, friends and caregivers.

METHODS

The present study explores the scientific landscape on (socio)cognitive functioning in brain tumour patients by conducting a comprehensive bibliometric analysis using VOSviewer. The Web of Science Core Collection database was examined to identify relevant documents published between 1945 and 2019.

RESULTS

A total of 664 English titles on (socio)cognitive functions in patients with brain tumours was retrieved. Automated textual analysis revealed that the data available so far focus on three major topics in brain tumour patients: cognitive functions in general and in paediatric cases, as well as psychological factors and their influence on quality of life. The focus of research has gradually moved from clinical studies with cognitive functions as one of the outcome measures to investigations of interactions between cognitive functions and psychological constructs such as anxiety, depression or fatigue. Medical, neurological and neuropsychological journals, in particular neuro-oncological journals published most of the relevant articles authored by a relatively small network of well interconnected researchers in the field.

CONCLUSION

The bibliometric analysis highlights the necessity of more research on social cognition in brain tumour patients.

Impairment of sociocognitive functions in patients with brain tumours

The ability to decode mental states and to come up with effective solutions for interpersonal problems aids successful initiation and maintenance of social interactions and contributes to participation and mental health. Since these abilities of social cognition are challenged in highly demanding situations, such as diagnosis and treatment of a life-threatening illness, this article reviews the literature on emotion recognition, empathy, Theory of Mind and socially skilled behaviour in brain tumour patients. The data available suggest that patients are affected by a slight but consistent impairment of emotion recognition, empathy and Theory of Mind before and immediately after brain tumour treatment, with the degree of impairment being influenced by tumour histology and localization. Impairments mostly decrease a few months after surgery due to assumed neuroplasticity. Future research may address more complex sociocognitive functions, such as social problem solving, and may investigate to which degree sociocognitive difficulties act as risk factors for poor or failed reintegration into occupational and social life following successful brain tumour treatment.

Long-term neurocognitive and other side effects of radiotherapy, with or without chemotherapy, for glioma

BACKGROUND

Gliomas are brain tumours arising from glial cells with an annual incidence of 4 to 11 people per 100,000. In this review we focus on gliomas with low aggressive potential in the short term, i.e. low-grade gliomas. Most people with low-grade gliomas are treated with surgery and may receive radiotherapy thereafter. However, there is concern about the possible long-term effects of radiotherapy, especially on neurocognitive functioning.

OBJECTIVES

To evaluate the long-term neurocognitive and other side effects of radiotherapy (with or without chemotherapy) compared with no radiotherapy, or different types of radiotherapy, among people with glioma (where 'long-term' is defined as at least two years after diagnosis); and to write a brief economic commentary.

SEARCH METHODS

We searched the following databases on 16 February 2018 and updated the search on 14 November 2018: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11) in the Cochrane Library; MEDLINE via Ovid; and Embase via Ovid. We also searched clinical trial registries and relevant conference proceedings from 2014 to 2018 to identify ongoing and unpublished studies.

SELECTION CRITERIA

Randomised and non-randomised trials, and controlled before-and-after studies (CBAS). Participants were aged 16 years and older with cerebral glioma other than glioblastoma. We included studies where patients in at least one treatment arm received radiotherapy, with or without chemotherapy, and where neurocognitive outcomes were assessed two or more years after treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We assessed the certainty of findings using the GRADE approach.

MAIN RESULTS

The review includes nine studies: seven studies were of low-grade glioma and two were of grade 3 glioma. Altogether 2406 participants were involved but there was high sample attrition and outcome data were available for a minority of people at final study assessments. In seven of the nine studies, participants were recruited to randomised controlled trials (RCTs) in which longer-term follow-up was undertaken in a subset of people that had survived without disease progression. There was moderate to high risk of bias in studies due to lack of blinding and high attrition, and in two observational studies there was high risk of selection bias. Paucity of data and risk of bias meant that evidence was of low to very low certainty. We were unable to combine results in meta-analysis due to diversity in interventions and outcomes.The studies examined the following five comparisons.Radiotherapy versus no adjuvant treatmentTwo observational studies contributed data. At the 12-year follow-up in one study, the risk of cognitive impairment (defined as cognitive disability deficits in at least five of 18 neuropsychological tests) was greater in the radiotherapy group (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.02 to 3.71; n = 65); at five to six years the difference between groups did not reach statistical significance (RR 1.38, 95% CI 0.92 to 2.06; n = 195). In the other study, one subject in the radiotherapy group had cognitive impairment (defined as significant deterioration in eight of 12 neuropsychological tests) at two years compared with none in the control group (very low certainty evidence).With regard to neurocognitive scores, in one study the radiotherapy group was reported to have had significantly worse mean scores on some tests compared with no radiotherapy; however, the raw data were only given for significant findings. In the second study, there were no clear differences in any of the various cognitive outcomes at two years (n = 31) and four years (n = 15) (very low certainty evidence).Radiotherapy versus chemotherapyOne RCT contributed data on cognitive impairment at up to three years with no clear difference between arms (RR 1.43, 95% CI 0.36 to 5.70, n = 117) (low-certainty evidence).High-dose radiotherapy versus low-dose radiotherapyOnly one of two studies reporting this comparison contributed data, and at two and five years there were no clear differences between high- and low-dose radiotherapy arms (very low certainty evidence).Conventional radiotherapy versus stereotactic conformal radiotherapyOne study involving younger people contributed limited data from the subgroup aged 16 to 25 years. The numbers of participants with neurocognitive impairment at five years after treatment were two out of 12 in the conventional arm versus none out of 11 in the stereotactic conformal radiotherapy arm (RR 4.62, 95% CI 0.25 to 86.72; n = 23; low-certainty evidence).Chemoradiotherapy versus radiotherapyTwo RCTs tested for cognitive impairment. One defined cognitive impairment as a decline of more than 3 points in MMSE score compared with baseline and reported data from 2-year (110 participants), 3-year (91 participants), and 5-year (57 participants) follow-up with no clear difference between the two arms at any time point. A second study did not report raw data but measured MMSE scores over five years in 126 participants at two years, 110 at three years, 69 at four years and 53 at five years. Authors concluded that there was no difference in MMSE scores between the two study arms (P = 0.4752) (low-certainty evidence).Two RCTs reported quality of life (QoL) outcomes for this comparison. One reported no differences in Brain-QoL scores between study arms over a 5-year follow-up period (P = 0.2767; no raw data were given and denominators were not stated). The other trial reported that the long-term results of health-related QoL showed no difference between the arms but did not give the raw data for overall HRQoL scores (low-certainty evidence).We found no comparative data on endocrine dysfunction; we planned to develop a brief economic commentary but found no relevant economic studies for inclusion.

AUTHORS' CONCLUSIONS

Radiotherapy for gliomas with a good prognosis may increase the risk of neurocognitive side effects in the long term; however the magnitude of the risk is uncertain. Evidence on long-term neurocognitive side effects associated with chemoradiotherapy is also uncertain. Neurocognitive assessment should be an integral part of long-term follow-up in trials involving radiotherapy for lower-grade gliomas to improve the certainty of evidence regarding long-term neurocognitive effects. Such trials should also assess other potential long-term effects, including endocrine dysfunction, and evaluate costs and cost effectiveness.

Reflecting on survivorship outcomes to aid initial decision making in patients treated for IDH-mutated anaplastic glioma

BACKGROUND

Patients with anaplastic glioma (AG) harboring an isocitrate dehydrogenase mutation have potential durable survival after intensity-modulated radiotherapy (IMRT) and chemotherapy. Understanding long-term functioning, and the factors that have an impact on later effects, is important for decision making.

METHODS

Consecutive patients with AG who received IMRT were reviewed with regard to 6 survivorship domains, including Eastern Cooperative Oncology Group (ECOG) performance status, Medical Research Council (MRC) neurological status, late toxicity, comorbidity, functional status (employment/driving), and psychosocial events. Assessments were performed at baseline before RT; at month +6; and at years +1, +3, and +5 after RT. The primary endpoints were ECOG at year +3 and employment at year +3.

RESULTS

A total of 146 patients were included, with a median follow-up of 5.1 years. The 6-year overall survival rate was 78.7% (95% CI, 71.1%-87.0%). Baseline ECOG performance status was 0 to 1 in 82.2% of patients but improved at year +1 (95.7%) and year +3 (97.2%). Employment rates at year +3 and year +5 were 70.1% and 76.5%, respectively, compared with 61.6% at baseline. Worse ECOG performance status at year +3 was related to the anaplastic astrocytoma subtype (P = .001), delayed RT (P = .081), multiple craniotomies performed before RT (P = .002), worse ECOG performance status before RT (P < .001), worse MRC neurological status before RT (P < .001), seizures (P = .038), neurocognitive disturbance (P < .001), and the presence of recurrent disease (P = .004). Absent or impaired employment at year +3 was found to be related to older age (P = .007), delayed timing of RT (P = .023), multiple craniotomies prior to RT (P = .005), worse ECOG performance status before RT (P < .001), worse MRC neurological status before RT (P < .001), and neurocognitive disturbance (P < .001).

CONCLUSIONS

Patients with AG with an isocitrate dehydrogenase mutation have the potential for prolonged survival. Functional status appears to be good in patients who are free of disease progression at 3 to 5 years after IMRT, with >95% of patients having high ECOG performance status and >75% being employed.

Quality-adjusted life years in glioma patients: a systematic review on currently available data and the lack of evidence-based utilities

BACKGROUND

Cost-effectiveness studies gain importance in the context of rising health care expenses and treatment options. Especially in the neuro-oncological context, surgical therapy may increase overall survival, but restrain the patient by postoperative disability. Quality-adjusted life years, express treatment effects and are based on health utilities. In our study, we analyze the current evidence on health economic evaluations in glioma patients.

MATERIAL AND METHODS

We performed a systematic database search including Medline and Cochrane Library. Studies were critically appraised for statistical analyzes including glioma patients, health economic modeling and detailed health outcome. Study evidence was classified according to levels of evidence for therapeutic studies from the Centre for Evidence-Based Medicine (Oxford).

RESULTS

37 studies (1995-2018) were identified, 29 matched our inclusion criteria. Studies addressed surgical cost-efficiency and/or the standard treatment, postoperative chemotherapy (n = 6) and 5-ALA (n = 3). Only 16 studies used QALY as the outcome measure, most used overall survival or life years gained (LYG). Utilities were either based on one single study (Garside et al. in Health Technol Assess 11:iii-iv, ix-221) or derived from visual analogue scale (VAS). None assessed quality of life values for specific health statuses or utilities. Incremental cost-effectiveness ratios varied from 8325€ per QALY (5-ALA) to 518,342€ per LYG (tumor treating fields).

CONCLUSIONS

Only one study generated utility values to conduct cost-effectiveness analysis (CEA); most studies used indirect outcomes such as LYG or based their model on previously published data. Health economic evaluations lack specific utilities, further investigations are necessary to conduct reliable CEA in the neurosurgical context.

Impact of Radiation Target Volume on Health-Related Quality of Life in Patients With Low-Grade Glioma in the 2-Year Period Post Treatment: A Secondary Analysis of the EORTC 22033-26033

PURPOSE

It is currently unknown whether increasing radiation therapy (RT) volume has a negative impact on the health-related quality of life (HRQoL) of patients with low-grade glioma in the short term. The aim was to examine whether the size of the target volume is independently associated with HRQoL.

METHODS AND MATERIALS

We included patients who were treated with radiation therapy in the European Organisation for Research and Treatment of Cancer (EORTC) 22033-26033 study and who completed baseline HRQoL assessment. HRQoL was measured at baseline and every 3 months thereafter until progression, using the European Organisation for Research and Treatment of Cancer quality of life and brain cancer module questionnaires (QLQ-C30 and QLQ-BN20). We investigated whether there were associations between radiation volumes and (changes in) 4 preselected HRQoL scales (global health status, cognitive and social functioning, and fatigue). Also, we determined if radiation volumes were independently associated with a change in HRQoL over time.

RESULTS

We included 195 of 240 patients (81.3%) randomized to radiation therapy in this analysis. The brain volume receiving radiation therapy was not associated with (changes in) HRQoL during the first 24 months after radiation therapy. Over time, radiation volumes were also not independently associated with HRQoL. Notably, the occurrence of tumor progression was found to be associated with worse functioning and more fatigue.

CONCLUSIONS

The brain target volume receiving focal radiation therapy in fractions of 1.8 Gy to a total of 50.4 Gy did not appear to be independently associated with HRQoL in high-risk patients with low-grade glioma in the short term, as opposed to tumor progression. However, the impact of radiation volumes on long-term HRQoL, as well as neurocognitive functioning, remains to be investigated.

Primary health care decision making in pre-dialysis chronic kidney disease

OBJECTIVES

This qualitative descriptive study explored the primary health care decisions of a group of 12 Australians in Stages 3B to 5 with chronic kidney disease in the preservation of kidney health.

METHODS

Questioning within the qualitative interviews focused on gaining an understanding of the participants' perceptions of their kidney health and the decisions made as a consequence of their interaction within the Australian primary health care system.

RESULTS

Participants were dependent on their General Practitioner to recognise their symptoms, make the correct diagnosis and authorise the correct referral for specialist nephrology care. Three pathways in this process were identified: 'easy'; 'difficult' and 'protracted'. Clinician failure to correctly attribute symptoms to chronic kidney disease influenced the 'difficult' pathway, while failure to adequately communicate kidney health status influenced the 'protracted' pathway. Use of the language of 'recovery', 'stability' and 'protection' held meaning to the participants in gaining an understanding of their kidney health.

DISCUSSION

Identifying pathways to diagnosis and referral can raise awareness of the challenges kidney health consumers face in their participation within the primary health care arena. Using consumer meaningful language improves the capacity of these consumers to engage in their own primary health care agenda.

The Impacts of Tumor and Tumor Associated Epilepsy on Subcortical Brain Structures and Long Distance Connectivity in Patients With Low Grade Glioma

Low grade gliomas in cerebral cortex often cause symptoms related to higher cerebral functions such as attention, memory and executive function before treatment is initiated. Interestingly, focal tumors residing in one cortical region can lead to a diverse range of symptoms, indicating that the impact of a tumor is extended to multiple brain regions. We hypothesize that the presence of focal glioma in the cerebral cortex leads to alterations of distant subcortical areas and essential white matter tracts. In this study, we analyzed diffusion tensor imaging scans in glioma patients to study the effect of glioma on subcortical gray matter nuclei and long-distance connectivity. We found that the caudate nucleus, putamen and thalamus were affected by cortical glioma, displaying both volumetric and diffusion alterations. The cerebellar cortex contralateral to the tumor side also showed significant volume decrease. Additionally, tractography of the cortico-striatal and cortico-thalamic projections shows similar diffusion alterations. Tumor associated epilepsy might be an important contributing factor to the found alterations. Our findings indeed confirm concurrent structural and connectivity abrasions of brain areas distant from brain tumor, and provide insights into the pathogenesis of diverse neurological symptoms in glioma patients.

Antiepileptic and psychiatric medication in a nationwide cohort of patients with glioma WHO grade II-IV

INTRODUCTION

Glioma is the most common intracranial primary brain tumor. Patients with glioma often suffer from epilepsy, anxiety and depression. Aims of this study were to identify risk factors for drug-treated anxiety and depression, and to determine the use of psychiatric medication in a national glioma cohort.

METHODS

Data from the Cancer Registry of Norway on all persons diagnosed with glioma WHO grade II-IV 2004-2010 were linked with data from the Norwegian Prescription Database. Cox regression analysis was used to assess risk factors for drug-treated anxiety and depression. Standardized incidence ratios were calculated for psychiatric medication dispensed to glioma patients and compared to the general population.

RESULTS

The glioma cohort consisted of 1056 males and 772 females. Of the 1828 patients, 565 had glioma grade II-III, and 1263 had grade IV. The patients with glioma grade II-III who were treated with levetiracetam had an increased risk for drug-treated anxiety compared to patients without levetiracetam; hazard ratio 2.8 (95% confidence interval 1.7-4.9). Female gender increased the risk for drug-treated anxiety compared to males in patients with glioma grade IV; hazard ratio 1.5 (95% confidence interval 1.2-2.0). Antidepressants were less frequently dispensed to patients with glioma grade II-III and epilepsy than to the general population.

CONCLUSIONS

Patients with glioma grade II-III on levetiracetam had an increased risk for drug-treated anxiety. The subgroup of patients with glioma grade II-III and epilepsy received less antidepressants than the general population.

Procarbazine, CCNU and vincristine (PCV) versus temozolomide chemotherapy for patients with low-grade glioma: a systematic review

Low-grade gliomas (LGG) encompass a heterogeneous group of tumors that are clinically, histologically and molecularly diverse. Treatment decisions for patients with LGG are directed toward improving upon the natural history while limiting treatment-associated toxiceffects. Recent evidence has documented a utility for adjuvant chemotherapy with procarbazine, CCNU (lomustine), and vincristine (PCV) or temozolomide (TMZ). We sought to determine the comparative utility of PCV and TMZ for patients with LGG, particularly in context of molecular subtype. A literature search of PubMed was conducted to identify studies reporting patient response to PCV, TMZ, or a combination of chemotherapy and radiation therapy (RT). Eligibility criteria included patients 16 years of age and older, notation of LGG subtype, and report of progression-free survival (PFS), overall survival (OS), and treatment course. Level I, II, and III data were included. Adjuvant therapy with PCV resulted in prolonged PFS and OS in patients with newly diagnosed high-risk LGG. This benefit was accrued most significantly by patients with tumors harboring 1p/19q codeletion and IDH1 mutation. Adjuvant therapy with temozolomide was associated with lower toxicity than therapy with PCV. In patients with LGG with an unfavorable natural history, such as with intact 1p/19q and wild-type IDH1, RT/TMZ plus adjuvant TMZ may be the best option. Patients with biologically favorable high-risk LGG are likely to derive the most benefit from RT and adjuvant PCV.

Linking late cognitive outcome with glioma surgery location using resection cavity maps

Patients with a diffuse glioma may experience cognitive decline or improvement upon resective surgery. To examine the impact of glioma location, cognitive alteration after glioma surgery was quantified and related to voxel-based resection probability maps. A total of 59 consecutive patients (range 18-67 years of age) who had resective surgery between 2006 and 2011 for a supratentorial nonenhancing diffuse glioma (grade I-III, WHO 2007) were included in this observational cohort study. Standardized neuropsychological examination and MRI were obtained before and after surgery. Intraoperative stimulation mapping guided resections towards neurological functions (language, sensorimotor function, and visual fields). Maps of resected regions were constructed in standard space. These resection cavity maps were compared between patients with and without new cognitive deficits (z-score difference >1.5 SD between baseline and one year after resection), using a voxel-wise randomization test and calculation of false discovery rates. Brain regions significantly associated with cognitive decline were classified in standard cortical and subcortical anatomy. Cognitive improvement in any domain occurred in 10 (17%) patients, cognitive decline in any domain in 25 (42%), and decline in more than one domain in 10 (17%). The most frequently affected subdomains were attention in 10 (17%) patients and information processing speed in 9 (15%). Resection regions associated with decline in more than one domain were predominantly located in the right hemisphere. For attention decline, no specific region could be identified. For decline in information speed, several regions were found, including the frontal pole and the corpus callosum. Cognitive decline after resective surgery of diffuse glioma is prevalent, in particular, in patients with a tumor located in the right hemisphere without cognitive function mapping.

Survey on current practice within the European Low-Grade Glioma Network: where do we stand and what is the next step?

Diffuse low-grade glioma form a rare entity affecting young people. Despite advances in surgery, chemotherapy, and radiation therapy, diffuse low-grade glioma are still incurable. According to current guidelines, maximum safe resection, when feasible, is the first line of treatment. Apart from surgery, all other treatment modalities (temozolomide, procarbazine-CCNU-vincristine regimen, and radiation therapy) are handled very differently among different teams, and this in spite of recent results of several phase 3 studies. Based on a European survey, this paper aimed to get a picture of this heterogeneity in diffuse low-grade glioma management, to identify clinically relevant questions raised by this heterogeneity of practice, and to propose new methodological frameworks to address these questions.

Management of supratentorial recurrent low-grade glioma: A multidisciplinary experience in 35 adult patients

The management of recurrent diffuse low-grade gliomas (LGGs) is controversial. In the present study, the multidisciplinary management of 35 patients with recurrent LGGs was retrospectively analyzed. Tumor progression or recurrence was defined by clinical, radiological and/or metabolic pejorative evolution. All patients were regularly followed up by a multidisciplinary neuro-oncological group at Hôpital Erasme. Patients with histologically confirmed supratentorial LGGs (7 astrocytoma, 22 oligodendrogliomas and 6 oligoastrocytomas) who had undergone surgery between August 2004 and November 2010 were included. A total of 3 patients exhibited no tumor progression (median follow-up (FU), 81 months; range, 68-108 months). Tumor recurrence occurred in the 32 remaining patients [progression-free survival (PFS), 26 months; range, 2-104 months]. In addition, 25/29 (86%) patients who received surgery alone underwent reoperation at the time of tumor recurrence, and high-grade transformation occurred in 6 of these patients (24%). Furthermore, 4/29 (14%) patients were treated with adjuvant therapy alone (3 chemotherapy and 1 radiotherapy). In the 19 patients with no high-grade transformation at reintervention, 3 received adjuvant therapy and 16 were regularly followed up through multimodal imaging. The PFS time of the patients who underwent reoperation with close FU (n=16) and for the patients receiving adjuvant therapy with or without surgery (n=7) at first recurrence was 10 and 24 months (P=0.005), respectively. However, no significant difference was observed for overall survival (P=0.403). At the time of this study, 22 of the 35 patients included were alive following a median FU time of 109 months (range, 55-136). The results of the present study could change the multidisciplinary approach used into a more aggressive approach with adjuvant therapy, with or without surgery, for the treatment of a select subpopulation of patients with LGGs at the first instance of tumor recurrence.

Gamma Knife Radiosurgery for Low-Grade Gliomas: Clinical Results at Long-Term Follow-Up of Tumor Control and Patients' Quality of Life

OBJECTIVE

First-line therapy for low-grade gliomas (LGGs) is surgery, in some cases followed by radiotherapy and chemotherapy. Gamma Knife radiosurgery (GKRS) has gained more relevance in the management of these tumors. The aim of this study was to assess efficacy and safety of GKRS for treatment of LGGs.

METHODS

Between 2001 and 2014, 42 treatments were performed on 39 patients harboring LGGs; 48% of patients underwent previous surgery, and 20.5% underwent previous radiotherapy. Mean tumor volume was 2.7 cm³, and median margin dose was 15 Gy.

RESULTS

Mean follow-up was 60.5 months (range, 6-164 months). Actuarial progression-free survival was 74.9%, 52.8%, and 39.1% at 1 year, 5 years, and 10 years; actuarial overall survival was 97.4%, 94.6%, and 91.8% at 9 months, 1 year, and 5 years. Solid tumor control was achieved in 69.2% of patients, whereas cystic enlargement was recorded in 12.9% of cases. At last follow-up, volume reduction was recorded in 57.7% of cases, and median volume decreased by 33.3%. Clinical improvement was observed in 52.4% of patients. Karnofsky performance scale score was improved in 15 patients (45.5%), unchanged in 17 patients (51.5%), and worsened in 1 patient (3%). Mean posttreatment scores of 36-item short form health survey domains did not significantly differ from scores in a healthy Italian population.

CONCLUSIONS

This study confirms safety and effectiveness of GKRS for LGGs in controlling tumor growth, relevantly improving patients' overall and progression-free survival. GKRS improved patients' functional performance and quality of life, optimizing social functioning and minimizing disease-related psychological impact.