In Reply: Postacute Cognitive Rehabilitation for Adult Brain Tumor Patients

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To the Editor: We would like to thank Lavrador et al1 for their thoughtful response to Weyer-Jamora et al.2 We were excited to see a shared interest for enhancing rehabilitative services for brain tumor populations. It was particularly interesting to read about their integration of prehabilitation, for the goal of improving a patient's functional capacity before surgery to potentially offset postsurgical declines and enhance outcomes. We agree that providing rehabilitation before surgical intervention holds promise to help patients with brain tumor and their caregivers adapt earlier to the challenges they face during the disease trajectory. The multidisciplinary needs of brain tumor populations, along with their improving survival, argue for more of a chronic disease management approach which includes rehabilitation before surgery.3 Crucial prehabilitation elements include: (1) identifying and treating functional impairments that can be improved before surgery; (2) assessing and addressing patient/caregiver knowledge and resource gaps to improve self-management skills; and (3) enhancing communication between inpatient and outpatient teams for continuity of care to improve patient quality of life and reduce caregiver distress. This latter point is particularly aligned with the integrated transhabilitation model described by Lavrador et al.1 Furthermore, best practices in prehabilitation screening highlight the importance of orienting assessments and interventions to address treatable risk factors for poor postsurgical adjustment and functioning.4 This includes addressing emotional distress, substance misuse, physical strength, nutrition, psychosocial stressors, cognitive impairments, existential meaning and purpose, and other comorbidities. Prehabilitation concepts may also be applied across the brain tumor disease trajectory given the high risk of recurrence and possible need for more than one surgery. The unique approach by Lavrador et al1 to brain tumor care highlights the opportunities and gaps in our understanding for providing a chronic disease model of care in this population. We agree that the presurgical phase is a key teachable moment whereby individuals can be highly motivated to make behavioral changes4 and thus more open to learning key symptom management skills for improving their functional status to offset postsurgical decline. From a cognitive perspective, the UCSF cognitive rehabilitation model discussed by Weyer-Jamora et al,2 includes patients and caregivers in-treatment sessions to jointly enhance mastery and application of learned compensatory strategy skills to daily life. It would be interesting to investigate the potential attenuation of postsurgical cognitive decline based on application of cognitive prehabilitation care models in brain tumor populations. In addition, future research could focus on assessing feasibility and efficacy of crucial elements of prehabilitation treatment models to enhance quality of life of patients with brain tumor and their caregivers. This important research could help us to better define the relative importance of treatment timing and inform how to efficiently pace supportive care services at each phase of the disease to balance optimizing quality of life with practical application constraints.