Engaging carers in neuropsychological rehabilitation for brain cancer survivors: The "I'm aware: Patients And Carers Together" (ImPACT) program

BACKGROUND

Cognitive impairment is a common late effect in child and adult brain cancer survivors (BCS). Still, there is a dearth of research aimed at therapeutic interventions and no standard treatment options for most BCS.

OBJECTIVE

To describe 1) a novel neuropsychological rehabilitation program for BCS - the "I'm aware: Patients And Carers Together" (ImPACT) program, and 2) two studies that aim to assess the feasibility of the ImPACT program in child and adult BCS, respectively. The program adapts the holistic neuropsychological approach pioneered by Leonard Diller and Yehuda Ben-Yishay to an outpatient setting.

METHODS

Two feasibility studies are described: 1) A single-armed study with 15 child BCS (10-17 years) (ImPACT Child); and 2) a randomized waitlist-controlled trial with 26 adult BCS (>17 years) (ImPACT Adult). In both studies, patients will undergo an 8-week program together with a cohabiting carer. Primary outcomes (i.e., cognitive and neurobehavioral symptoms), and secondary outcomes (i.e., behavioral and psychological symptoms, e.g., quality of life, fatigue) will be assessed at four time points: pre-, mid-, and post intervention, and 8 weeks follow-up. Adult waitlist controls will be assessed at equivalent time points and will be included in the intervention group after all study assessments. Semi-structured interviews will be conducted at follow-up.

EXPECTED OUTCOMES

Results will provide feasibility data in support of future larger scale trials.

DISCUSSION

The findings could potentially improve the management of cognitive impairment in BCS and transform available services. The program can be delivered in-person or remotely and harnesses existing resources in patients' lives.

P09.02.B Engaging Parents in Neuropsychological Rehabilitation for Childhood Cancer Survivors: The I’M aware: Patients And Carers Together (ImPACT) Program

Background

Cognitive impairment is the most common late effect in childhood cancer survivors (CCS). A third are likely to experience impairments in skills such as attention, processing speed, memory, and executive function. Neurobehavioral impairments are also observed in CCS (e.g., apathy) and may underlie cognitive impairment. Although these problems can impair quality of life, scholastic achievement and long-term socioeconomic outcomes, there is a dearth of research on interventions to treat cognitive impairment in CCS. Cognitive rehabilitation studies in CCS have focused primarily on computerized cognitive training and meta-cognitive strategy training, but with limited effects and poor study designs. They have lacked four key elements: 1) transfer of learning to real-world functional outcomes; 2) awareness training to enhance compensatory strategy use, particularly since CCS may experience neurological unawareness preventing the optimal application of strategies; 3) inclusion of parents that could enhance transfer of learning to the home; and 4) recognition of the inter-related nature of cognitive, neurobehavioral, and psychological functions. A novel, context-sensitive neuropsychological rehabilitation program has been developed for CSS to address these missing elements - the “I’M aware: Patients and Carers Together (ImPACT)” program - based on an evidenced-based approach pioneered at NYU Hospital in the US. In this protocol, the feasibility, acceptability, and preliminary efficacy of the ImPACT program (8 x 1 hour sessions) will be evaluated.

Material and Methods

Phase One will consist of semi-structured interviews with 5 to 10 CCS and their parents in order to review and refine procedures for the ImPACT program. In Phase Two, twenty participants will be randomized to a wait-list control (WLC) or intervention group. WLCs will not receive the intervention immediately, but will serve as the control comparison group. Measures of self- and parent-reported cognition, neurobehavioral function, and global function will be administered pre- and post- intervention, and 9 weeks later (or equivalent time points for WLCs).

Results

Results of this project will provide vital data in support of a future large-scale trial.

Conclusion

Findings could have implications for the management of cognitive and neurobehavioral impairment in CCS that could transform the nature of services provided to CCS. The program can be delivered remotely or in-person and harnesses existing supports in the child’s life to promote real-world functioning.

Delineation atlas of the Circle of Willis and the large intracranial arteries for evaluation of doses to neurovascular structures in pediatric brain tumor patients treated with radiation therapy

BACKGROUND

Survivors of pediatric brain tumors are susceptible to neurovascular disease after radiotherapy, with dose to the chiasm or Circle of Willis (CW) as risk factors. The aims of this study were to develop a delineation atlas of neurovascular structures, to investigate the doses to these structures in relation to tumor location and to investigate potential dose surrogates for the CW dose.

MATERIAL AND METHODS

An atlas of the CW, the large intracranial arteries and the suprasellar cistern (SC) was developed and validated. Thirty proton plans from previously treated pediatric brain tumor patients were retrieved and grouped according to tumor site: 10 central, 10 lateralized, and 10 posterior fossa tumors. Based on the atlas, neurovascular structures were delineated and dose metrics (mean dose (D_mean) and maximal dose (D_max)) to these structures and the already delineated chiasm were evaluated. The agreement between dose metrics to the CW vs. chiasm/SC was investigated. The minimal Hausdorff distance (HD_min) between the target and SC was correlated with the SC D_mean.

RESULTS

The median D_mean/D_max to the CW were 53 Gy(RBE)/55 Gy(RBE) in the central tumors, 18 Gy(RBE)/25 Gy(RBE) in the lateralized tumors and 30 Gy(RBE)/49 Gy(RBE) in the posterior fossa tumors. There was a good agreement between the D_max/D_mean to the CW and the SC for all cases (R²=0.99), while in the posterior fossa group, the CW D_max was underestimated when using the chiasm as surrogate (R²=0.76). Across all patients, cases with HD_min < 10 mm between the target and the SC received the highest SC D_mean.

CONCLUSION

The pattern of dose to neurovascular structures varied with the tumor location. For all locations, SC doses could be used as a surrogate for CW doses. A minimal distance larger than 10 mm between the target and the SC indicated a potential for neurovascular dose sparing.

Associations between patient-reported outcomes and radiation dose in patients treated with radiation therapy for primary brain tumours

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Higher radiation doses to the brain may negatively affect quality of life.

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Higher radiation doses to the brain may negatively affect patient-reported cognition.

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Patients with fatigue had received higher dose to certain areas in the brain.

Aim

This study aimed to explore associations between radiation dose and patient-reported outcomes in patients with a primary non-glioblastoma brain tumour treated with radiation therapy (RT), with a focus on health-related quality-of-life (HRQoL) and self-reported cognitive function.

Methods

In this cross-sectional study, 78 patients who had received RT for a non-glioblastoma primary brain tumour, underwent neuropsychological testing and completed questionnaires on HRQoL, cognitive function, fatigue, depression, anxiety and perceived stress. The study explores the association between HRQoL scores, self-reported cognitive function and radiation doses to total brain, brainstem, hippocampus, thalamus, temporal lobes and frontal lobes. In addition, we examined correlations between neuropsychological test scores and self-reported cognitive function.

Results

The median time between RT and testing was 4.6 years (range 1–9 years). Patients who had received high mean radiation doses to the total brain had low HRQoL scores (Cohen’s d = 0.50, p = 0.04), brainstem (d = 0.65, p = 0.01) and hippocampus (d = 0.66, p = 0.01). High mean doses to the total brain were also associated with low scores on self-reported cognitive functioning (Cohen’s d = 0.64, p = 0.02), brainstem (d = 0.55, p = 0.03), hippocampus (d = 0.76, p < 0.01), temporal lobes (d = 0.70, p < 0.01) and thalamus (d = 0.64, p = 0.01). Self-reported cognitive function correlated well with neuropsychological test scores (correlation range 0.27–0.54.)

Conclusions

High radiation doses to specific brain structures may be associated with impaired HRQoL and self-reported cognitive function with potentially negative implications to patients’ daily lives. Patient-reported outcomes of treatment-related side-effects and their associations with radiation doses to the brain and its sub-structures may provide important information on radiation tolerance to the brain and sub-structures.