Understanding the association between fatigue and neurocognitive functioning in patients with glioma: A cross-sectional multinational study

Background

Fatigue and neurocognitive impairment are highly prevalent in patients with glioma, significantly impacting health-related quality of life. Despite the presumed association between these two factors, evidence remains sparse. Therefore, we aimed to investigate this relationship using multinational data.

Methods

We analyzed data on self-reported fatigue and neurocognitive outcomes from postoperative patients with glioma from the University of California San Francisco (n = 100, UCSF) and Amsterdam University Medical Center (n = 127, Amsterdam UMC). We used multiple linear regression models to assess associations between fatigue and seven (sub)domains of neurocognitive functioning and latent profile analysis to identify distinct patterns of fatigue and neurocognitive functioning.

Results

UCSF patients were older (median age 49 vs. 43 years, P = .002), had a higher proportion of grade 4 tumors (32% vs. 18%, P = .03), and had more neurocognitive deficits (P = .01). While the number of clinically fatigued patients was similar between sites (64% vs. 58%, P = .12), fatigue and the number of impaired neurocognitive domains were not correlated (P = .16-.72). At UCSF, neurocognitive domains were not related to fatigue, and at Amsterdam UMC attention and semantic fluency explained only 4-7% of variance in fatigue. Across institutions, we identified four distinct patterns of neurocognitive functioning, which were not consistently associated with fatigue.

Conclusions

Although individual patients might experience both fatigue and neurocognitive impairment, the relationship between the two is weak. Consequently, both fatigue and neurocognitive functioning should be independently assessed and treated with targeted therapies.

Symptom networks in glioma patients: understanding the multidimensionality of symptoms and quality of life

PURPOSE

To comprehend the complex relationship between symptoms and health-related quality of life (HRQoL) in patients with diffuse glioma, we applied symptom network analysis to identify patterns of associations between depression, cognition, brain tumor-related symptoms, and HRQoL. Additionally, we aimed to compare global strength between symptom networks to understand if symptoms are more tightly connected in different subgroups of patients.

METHODS

We included 256 patients and stratified the sample based on disease status (preoperative vs. postoperative), tumor grade (grade II vs. III/IV), and fatigue status (non-fatigued vs. fatigued). For each subgroup of patients, we constructed a symptom network. In these six networks, each node represented a validated subscale of a questionnaire and an edge represented a partial correlation between two nodes. We statistically compared global strength between networks.

RESULTS

Across the six networks, nodes were highly correlated: fatigue severity, depression, and social functioning in particular. We found no differences in GS between the networks based on disease characteristics. However, global strength was lower in the non-fatigued network compared to the fatigued network (5.51 vs. 7.49, p < 0.001).

CONCLUSIONS

Symptoms and HRQoL are highly interrelated in patients with glioma. Interestingly, nodes in the network of fatigued patients were more tightly connected compared to non-fatigued patients.

IMPLICATIONS FOR CANCER SURVIVORS

We introduce symptom networks as a method to understand the multidimensionality of symptoms in glioma. We find a clear association between multiple symptoms and HRQoL, which underlines the need for integrative symptom management targeting fatigue in particular.

Cannabinoids to Improve Health-Related Quality of Life in Patients with Neurological or Oncological Disease: A Meta-Analysis

Background: Cannabinoids have been suggested to alleviate frequently experienced symptoms of reduced mental well-being such as anxiety and depression. Mental well-being is an important subdomain of health-related quality of life (HRQoL). Reducing symptoms and maintaining HRQoL are particularly important in malignant primary brain tumor patients, as treatment options are often noncurative and prognosis remains poor. These patients frequently report unprescribed cannabinoid use, presumably for symptom relieve. As studies on brain tumor patients specifically are lacking, we performed a meta-analysis of the current evidence on cannabinoid efficacy on HRQoL and mental well-being in oncological and neurological patients. Methods: We performed a systematic PubMed, PsychINFO, Embase, and Web of Science search according to PRISMA guidelines on August 2 and 3, 2021. We included randomized controlled trials (RCTs) that assessed the effects of tetrahydrocannabinol (THC) or cannabidiol (CBD) on general HRQoL and mental well-being. Pooled effect sizes were calculated using Hedges g. Risk of bias of included studies was assessed using Cochrane's Risk of Bias tool. Results: We included 17 studies: 4 in oncology and 13 in central nervous system (CNS) disease. Meta-analysis showed no effect of cannabinoids on general HRQoL (g=-0.02 confidence interval [95% CI -0.11 to 0.06]; p=0.57) or mental well-being (g=-0.02 [95% CI -0.16 to 0.13]; p=0.81). Conclusions: RCTs in patients with cancer or CNS disease showed no effect of cannabinoids on HRQoL or mental well-being. However, studies were clinically heterogeneous and since many glioma patients currently frequently use cannabinoids, future studies are necessary to evaluate its value in this specific population.

OS09.4.A Cognitive functioning of patients with diffuse glioma during stable disease

Background

Glioma patients often experience cognitive problems, which are associated with decreased functional independence and health-related quality of life. However, the prevalence and nature of cognitive impairment in these patients is relatively underreported, particularly during stable disease. In this study we determine the prevalence of cognitive deficits and explore distinct cognitive profiles of patients with diffuse glioma at least two months after tumor treatment.

Material and Methods

A total of 112 patients (mean age: 43 years) without clinical or radiological progression with a grade II-IV glioma were included in this observational cohort study. Cognitive functioning was assessed in five cognitive domains (attention, information processing speed, verbal memory, working memory, and executive functioning). Cognitive impairment was defined as a z-score of 1.5 SD below that of healthy controls. Hierarchical cluster analysis was used to examine cognitive profiles.

Results

In total, 46 patients (41%) had cognitive impairment. More than one domain was impaired in 25 of these patients (54%). The domains were affected in decreasing order of frequency: working memory in 31%, information processing speed in 22%, attention in 19%, verbal memory in 12%, and executive functioning in 11% of the patients. A clustered heatmap revealed three prominent cognitive clusters with an increasing number of cognitive domains impaired. The first cluster displayed patients with only working memory deficits, patients in the second cluster also had deficits in information processing speed, and the last cluster showed patients with impairments across all domains.

Conclusion

Cognitive impairment is highly prevalent in patients with diffuse glioma during stable disease. Working memory and information processing speed are most frequently affected. Importantly, our analyses show evidence for three subgroups in cognitively impaired glioma patients. Working memory seems an important driver in cognitive impairment given the involvement in all subgroups.

P01.03.B A quantitative comparison of cognitive performance and patient-reported symptoms in preoperative lower-grade glioma patients from two Dutch Hospitals

Background

Protocols for assessment of (neuro)psychological outcomes in lower-grade glioma patients vary between hospitals. This potentially complicates generalization of these outcomes. We compared standardized scores on tests of two frequently impaired cognitive domains (attention and executive functioning (EF)), and two relevant patient-reported outcomes (PROs; depression and fatigue) of two neuro-oncological hospitals that use different measurement instruments.

Material and Methods

Data were used from preoperative assessments of patients with (IDH-mut) WHO grade II/III glioma tested between 2007 and 2021 at Amsterdam UMC (AMS) or at Elisabeth-Tweesteden Hospital Tilburg (ETZ). AMS patients were referred for (neuro)psychological assessment based on physician and patient preference (paper and pencil tests), whereas all ETZ patients routinely undergo screening (computerized tests). To compare scores of the different attention and EF tests we converted patients’ performances to z-scores based on normative data. For cognitive performance, we compared scores of different cognitive flexibility tests (CST vs SAT), processing speed tests (SDC vs LDMT), and Stroop tests (Stroop I and Stroop III). PROs included the CES-D vs HADS-D and the CIS-fatigue vs MVI-general fatigue (AMS vs ETZ, resp.). Differences were tested using Fisher's, χ 2, and Mann-Whitney U tests.

Results

Assessments were done median 4 weeks (AMS, n=97, range 19-0 weeks) and 1 day (ETZ, n=106; range 14-0 days) preoperatively. Age, sex, tumor location and histology were comparable between cohorts (p&gt;0.05), but the AMS cohort showed significantly more grade III tumors (36% vs 16%) and more awake surgeries (84% vs 46%). Z-scores measuring attention and EF (n=94 and n=95, AMS vs ETZ) were not significantly different (CST vs SAT, percentage with a disorder (z &lt;-1.5SD) 15% vs 13%; SDC vs LDMT 13% vs 14%; Stroop I 11% vs 18%; Stroop III 13% vs 16% at AMS and ETZ, resp.). Percentages of patients with possible depression (CES-D≥16, n=88 and HADS-D≥8, n=106) did not differ significantly between hospitals (28% vs 26%), nor did percentages of patients with severe fatigue (CIS-fatigue≥35, n=88 and MVI-general fatigue (z &lt;-1.5SD), n=38, 42% vs 24% at AMS and ETZ, resp.).

Conclusion

Standardized scores of glioma patients on cognitive domains (attention and EF) and PROs (depression and fatigue) did not differ between two centers with slightly different samples using different testing protocols. This cautiously suggests that study findings on cognitive functioning and symptoms could be generalized. For research purposes, conjoint use of pooled populations for outcome evaluation could be explored with different samples from other centers using different instruments.

Toward unraveling the correlates of fatigue in glioma

BACKGROUND

Even though fatigue is one of the most prevalent and burdensome symptoms in patients with glioma, its etiology and determinants are still poorly understood. We aimed to identify which demographic, tumor- and treatment-related characteristics and patient-reported outcome measures (PROMs) are associated with or are predictors of fatigue in glioma.

METHODS

In this retrospective observational study, we included glioma patients with preoperative and postoperative assessments including PROMs on fatigue, depression, cognitive functioning, and health-related quality of life (HRQoL). Linear mixed models were used to identify which clinical factors and PROMs were associated with fatigue and linear multiple regression was used to detect predictors of postoperative fatigue.

RESULTS

In this study, 222 patients were included (78% grade II-III glioma, 22% grade IV). These patients had performed 333 assessments (193 preoperative and 116 one year postoperatively). Of all assessments, 39% was indicative of severe fatigue. Several HRQoL domains, depression, and right-sided tumors were significantly associated with fatigue (marginal R 2 = 0.63). Contrary to common expectations, tumor type, treatment-related factors, and timing of the assessment, were not associated with fatigue. In a subgroup of 70 patients with follow-up assessments, preoperative fatigue, and physical functioning were predictors of postoperative fatigue (adjusted R 2 = 0.31).

CONCLUSION

Fatigue is a complex symptom, which should not solely be attributed to the tumor or its treatment, but is instead related to different aspects of mood and HRQoL. These insights are important in understanding fatigue and could guide symptom management, especially in patients with lower-grade tumors.

P12.02 Symptoms of patients with diffuse glioma during stable disease as a potential target for treatment

BACKGROUND

Patients with diffuse glioma experience many tumor- and treatment-related symptoms, including fatigue, cognitive deficits, and anxiety. It remains unclear how the frequency and burden of these symptoms change over time and specifically which symptoms patients experience during the stable phase of the disease. We assessed the frequency and burden of common symptoms in glioma patients during stable disease and whether patients were willing to undergo treatment for those symptoms. We suggest a top five of potentially treatable symptoms.

METHODS

Patients with a diffuse glioma during stable disease completed a questionnaire on symptoms they experienced during the past two weeks, such as irritability, fatigue, stress, pain, depressive thoughts and relationship problems. They rated the frequency and burden of seventeen symptoms on a seven-point numeric scale ranging from ‘never’ to ‘continuously’ and from ‘no burden’ to ‘unbearable’, respectively. Also, they stated whether they were willing to undergo treatment for each symptom. Data was collected retrospectively. The median values of the frequency and burden dimension were calculated for each symptom. We composed a top five of most frequent and burdensome symptoms. We used Kendall’s Tau to correlate frequency, burden and willingness to undergo treatment per symptom.

RESULTS

Fifty-two patients were included, 77% had a KPS score of 90–100, 23% a KPS score of 70–80 and 40% had a glioblastoma. The top five most frequent and burdensome symptoms were fatigue, memory problems, reduced physical fitness, concentration problems and drowsiness. Fatigue had the highest median value on the frequency (median 4.5, IQR 2.5) and burden (median 4.0, IQR 3.00) dimension and 21% of the patients were willing to undergo treatment for fatigue. Overall 35% of the patients were willing to undergo treatment for at least one symptom. Frequency and burden of symptoms correlated well (median Kendall’s Tau of 0.84 with a range of correlations of 0.73–0.95). Frequency and willingness to undergo treatment correlated less (median Kendall’s Tau of 0.35, range 0.24–0.57), as well as burden and willingness to undergo treatment (median Kendall’s Tau, range 0.28–0.61).

CONCLUSION

The top five symptoms most often reported by patients with diffuse glioma during stable disease were: fatigue, memory problems, reduced physical fitness, concentration problems and drowsiness. These symptoms may serve as a roadmap for future research on treatment strategies to alleviate these symptoms.

SUPPORT/DISCLOSURE

This project is funded by The Anita Veldman Foundation (CCA-2019-2-21).

P11.01 Symptom networks in glioma: a novel approach to study multidimensional symptomatology in glioma patients

BACKGROUND

Glioma patients experience a high symptom burden contributing to poorer quality of life. Symptoms include depression, cognitive impairment, and fatigue and vary throughout the disease. These symptoms are rarely studied from a comprehensive perspective, while their interdependence may be relevant for their development, perpetuation, and ultimately successful treatment. The emerging field of symptom network analysis uncovers the multidimensional symptom space. Nodes are the symptoms, and edges are operationalized as the full conditional association, or partial correlation, between two symptom severity scores across patients. Highly connected nodes are considered central and may be particularly relevant targets for treatment as disruption of these central nodes impact the entire network. We visualized the overall glioma symptom network, compared multidimensional results to known literature, and statistically compared networks between relevant patient subgroups.

MATERIAL AND METHODS

A dataset comprised of 355 observations of 180 glioma patients at different disease phases was analysed. Cognitive testing and questionnaires regarding health-related and glioma-specific quality of life, fatigue, depression, and cognition resulted in the definition of 30 symptom nodes. Symptom clusters were visually explored in the resulting networks, as were node strength, betweenness, and closeness centrality measures for each node. Networks were statistically compared between preoperative patients and patients during stable disease, as well as patients with low versus high-grade gliomas. Networks of patients with normal versus severe levels of fatigue were also compared as cancer-/glioma-related fatigue has a strong impact on quality of life and can correlate with other common symptoms such as pain, depression, and/or sleep disturbance.

RESULTS

Symptom clusters existed between: 1) bodily pain, headache and physical functioning; 2) concentration and motivation; and 3) fatigue and drowsiness. Fatigue and mental health were the most central nodes in the networks. Furthermore, the overall connectivity between symptoms was significantly higher in the severely fatigued patients than in patients with normal fatigue. No network differences were found between low versus high-grade, and preoperative versus stable disease networks.

CONCLUSION

Fatigue is a central node in glioma patients’ burden of disease, and symptoms are more tightly intercorrelated in patients experiencing severe fatigue. From our data, we hypothesize that fatigue co-exists with or perpetuates other symptoms. Thus, although these results are preliminary, the network approach may innovate hypothesis generation in symptom management.

P12.07 The potential of cannabinoids to improve quality of life in glioma patients: A meta-analysis in patients with neurological and oncological disease

BACKGROUND

Gliomas are primary brain tumors with a dismal prognosis. Reducing symptoms and maintaining quality of life (QoL) are main treatment aims in glioma patients. Mental well-being is an important subdomain of QoL. Cannabinoids have been suggested to alleviate frequently experienced symptoms of reduced mental well-being such as anxiety or depression. Glioma patients frequently report unprescribed cannabinoid use for these reasons. We performed a meta-analysis of the current evidence on cannabinoid efficacy on QoL and mental well-being to identify its added value in treatment of glioma patients.

MATERIAL AND METHODS

We performed a systematic PubMed, Embase and Web of Science search according to the PRISMA guidelines on September 22nd and 23rd, 2020. The effects of any dose of tetrahydrocannabinol (THC) or cannabidiol (CBD) on both general QoL and mental well-being were evaluated. The intervention had to be given for at least a week to establish a steady-state concentration. Effect size was calculated using Hedges g. Risk of bias of included studies was assessed using Cochrane’s Risk of Bias tool 2.0.

RESULTS

We retrieved no publications on cannabinoids use and QoL in glioma and, therefore, we expanded the search to cannabinoid use in other cancer types and chronic central nervous system (CNS) diseases. Sixteen studies were identified: four in cancer and twelve in CNS disease. Meta-analysis showed no effect of cannabinoids on general QoL (twelve studies in 1,740 patients; g = -0.02, 95% CI -0.11 to 0.07, p = 0.65) and mental well-being (twelve studies in 1,587 patients; g = -0.00, 95% CI -0.15 to 0.14, p = 0.96). Risk of bias was low in five studies, raised some concern in one study and was high in ten studies, mainly due to possible unblinding of patients after psychoactive adverse effects.

CONCLUSION

No studies on the effects of cannabinoids on QoL in glioma patients have been reported. A pooled analysis of studies in oncological patients and patients with CNS disease showed no effect of cannabinoids on QoL or mental well-being. However, studies were clinically heterogeneous and only one small study investigated monotherapy CBD with undecided results. As many glioma patients currently use cannabinoids, and monotherapy CBD has not been sufficiently investigated, future studies are necessary to evaluate its value in this specific population.

SUPPORT/DISCLOSURE

This meta-analysis has been funded by The Anita Veldman Foundation (CCA-2019-2-21).

Determining a target SpO2 to maintain PaO2 within a physiological range

Objective

In the context of an ongoing debate on the potential risks of hypoxemia and hyperoxemia, it seems prudent to maintain the partial arterial oxygen pressure (PaO₂) in a physiological range during administration of supplemental oxygen. The PaO₂ and peripheral oxygen saturation (SpO₂) are closely related and both are used to monitor oxygenation status. However, SpO₂ values cannot be used as an exact substitute for PaO₂. The aim of this study in acutely ill and stable patients was to determine at which SpO₂ level PaO₂ is more or less certain to be in the physiological range.

Methods

This is an observational study prospectively collecting data pairs of PaO₂ and SpO₂ values in patients admitted to the emergency room or intensive care unit (Prospective Inpatient Acutely ill cohort; PIA cohort). A second cohort of retrospective data of patients who underwent pulmonary function testing was also included (Retrospective Outpatient Pulmonary cohort; ROP cohort). Arterial hypoxemia was defined as PaO₂ < 60 mmHg and hyperoxemia as PaO₂ > 125 mmHg. The SpO₂ cut-off values with the lowest risk of hypoxemia and hyperoxemia were determined as the 95th percentile of the observed SpO₂ values corresponding with the observed hypoxemic and hyperoxemic PaO₂ values.

Results

220 data pairs were collected in the PIA cohort. 95% of hypoxemic PaO₂ measurements occurred in patients with an SpO₂ below 94%, and 95% of hyperoxemic PaO₂ measurements occurred in patients with an SpO₂ above 96%. Additionally in the 1379 data pairs of the ROP cohort, 95% of hypoxemic PaO₂ measurements occurred in patients with an SpO₂ below 93%.

Conclusion

The SpO₂ level marking an increased risk of arterial hypoxemia is not substantially different in acutely ill versus stable patients. In acutely ill patients receiving supplemental oxygen an SpO₂ target of 95% maximizes the likelihood of maintaining PaO₂ in the physiological range.

[An unvaccinated man with a painful arm and jaw]

BACKGROUND

Clostridium tetani is a gram-positive spore-forming bacterium that produces toxins and grows under anaerobic conditions. Infections with this bacterium can lead to local or generalised forms of tetanus.

CASE DESCRIPTION

An 83-year-old man presented to the acute cardiac care unit with a painful left arm and jaw. Because the patient had a hypertonic left arm and was unable to open his mouth fully, the neurologist was consulted. The patient had been to the emergency department 9 days earlier for an infected wound after falling in the garden. He had not been actively or passively immunised against tetanus at that time. On inquiry, it appeared that the patient had also not been vaccinated as a child. We made a clinical diagnosis of tetanus. The patient was admitted and treated with tetanus immunoglobulin, metronidazole, diazepam and painkillers. He was also administered tetanus toxoid and the wound was cleaned. After 1 month and 7 months, the patient was again administered tetanus toxoid.

CONCLUSION

Patients with a wound that may have come into contact with road grime, dirt or manure, should always be asked for their vaccination status, especially people from high-risk groups, such as the elderly.