Primary Brain Tumor Population Research Articles

Abstract 6305: Evaluating clinical and sociodemographic risk for symptom-related functional interference in the primary brain tumor population

Abstract Purpose: Primary brain tumors have a high propensity for causing physical and activity-related disabilities due to the location within the brain and use of targeted treatments resulting in significant symptom burden. In other cancers, physical function impacts mood, quality of life, and even mortality. This exploratory study aims to identify factors associated with activity-related functional interference in a cross-sectional cohort of 584 primary brain tumor patients enrolled in a natural history study (NCT03251989, PI: T.S. Armstrong). Methods: Sociodemographic (age, race, ethnicity, income, education, employment, body mass index [BMI]) and disease-related clinical data were collected at study entry. Activity-related interference (work, walking, and general activity) and health status were reported via the MD Anderson Symptom Inventory-Brain Tumor. Activity-related interference means ≥ 2 were categorized as moderate/severe. Logistic regression assessed univariate associations with moderate/severe interference, with sig. <0.05. Results: This sample had a median age of 49 years (range 18-85), and was mostly male (57%), with a high-grade tumor (grade 3/4) (74%), glioblastoma (39%), on active treatment (21%) and prior tumor recurrence (49%). Risk factors for moderate/severe activity-related interference included: ≥ 2 surgeries (OR = 1.55, 95% CI [1.11, 2.18], P = 0.011), ≥ 2 radiation treatments (OR = 2.87, 95% CI [1.59, 5.17], P < 0.001), currently on active treatment (OR = 1.47, 95% CI [0.97, 2.22], P = 0.066), disease progression (OR = 1.87, 95% CI [1.24, 2.84], P = 0.003), prior recurrence (OR = 1.57, 95% CI [1.13, 2.19], P = 0.007), and poor KPS (OR = 3.61, 95% CI [2.55, 5.12], P < 0.001), but not tumor grade (OR = 1.05, 95% CI [0.72, 1.54], P = 0.790). Sociodemographic risk factors for moderate/severe activity-related interference included: less than a high school education (OR = 2.03, 95% CI [1.18, 3.51], P = 0.011), on disability (OR = 3.20, 95% CI [1.79, 5.71], P < 0.001), or unemployed (OR = 3.81, 95% CI [2.34, 6.19], P < 0.001), an annual income less than $49,999 (OR = 2.62, 95% CI [1.28, 5.35], P = 0.008), or childhood in a rural area (OR = 1.87, 95% CI [1.24, 2.84], P = 0.003), but not BMI, smoking status, or past physical activity in the 10 years prior to report. Conclusion: As expected, activity-related interference is associated with disease and treatment associated clinical characteristics, with significant risk derived from sociodemographic factors such as education, childhood environment, employment, and household income. Future studies should further explore these associations longitudinally to identify individuals at the highest risk of activity-related interference due to their brain tumor as well as interventions designed for those who may be socioeconomically disadvantaged. Citation Format: Bennett Ann McIver, Tara S. Davis, Kimberly Reinhart, Elizabeth Vera, Anna Choi, Tricia Kunst, Morgan Johnson, Ewa Grajkowska, Hope Miller, Terri S. Armstrong, Michelle L. Wright. Evaluating clinical and sociodemographic risk for symptom-related functional interference in the primary brain tumor population [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6305.

The relationship between social determinants of health and neurocognitive and mood-related symptoms in the primary brain tumor population: A systematic review.

Social determinants of health (SDOH) impact cancer-related health outcomes, including survival, but their impact on symptoms is less understood among the primary brain tumor (PBT) population. We conducted a systematic review to examine the relationships between SDOH and neurocognitive and mood-related symptoms among the PBT population. PubMed, EMBASE, and CINAHL were searched using PROGRESS criteria (place of residence, race/ethnicity, occupation, gender/sex, religion, education, socioeconomic status, and social capital) on March 8th, 2022. Two individuals screened and assessed study quality using the NHLBI Assessment Tool for Observational Cohort and Cross-sectional Studies. Of 3006 abstracts identified, 150 full-text articles were assessed, and 48 were included for a total sample of 28 454 study participants. Twenty-two studies examined 1 SDOH; none examined all 8. Four studies measured place of residence, 2 race/ethnicity, 13 occupation, 42 gender, 1 religion, 18 education, 4 socioeconomic status, and 15 social capital. Fifteen studies assessed neurocognitive and 37 mood-related symptoms. While higher education was associated with less neurocognitive symptoms, and among individuals with meningioma sustained unemployment after surgery was associated with depressive symptoms, results were otherwise disparate among SDOH and symptoms. Most studies were descriptive or exploratory, lacking comprehensive inclusion of SDOH. Standardizing SDOH collection, reducing bias, and recruiting diverse samples are recommended in future interventions.

Evaluation of the key geriatric assessment constructs in primary brain tumor population - a descriptive study

IntroductionDespite an increasing aging population, older adults (≥ 65 years) with primary brain tumors (PBTs) are not routinely assessed for geriatric vulnerabilities. Recent reports of geriatric assessment (GA) in patients with glioblastomas demonstrated that GA may serve as a sensitive prognosticator of overall survival. Yet, current practice does not include routine evaluation of geriatric vulnerabilities and the relevance of GA has not been previously evaluated in broader cohorts of PBT patients. The objective of this descriptive study was to assess key GA constructs in adults with PBT dichotomized into older versus younger groups. Materials and MethodsA cross-sectional analysis of data collected from 579 participants with PBT recruited between 2016 and 2020, dichotomized into older (≥ 65 years, n = 92) and younger (≤ 64 years, n = 487) from an ongoing observational trial. GA constructs were evaluated using socio-demographic characteristics, Charlson Comorbidity Index (CCI), polypharmacy (>5 daily medications), Karnofsky Performance Status (KPS), Neurologic Function Score (NFS), and patient-reported outcome assessments including general health, functional status, symptom burden and interference, and mood. Descriptive statistics, t-tests, chi-square tests, and Pearson correlations were used to evaluate differences between age groups. ResultsOlder participants were more likely to have problems with mobility (58% vs. 44%), usual activities (64% vs 50%) and self-care (38% vs 26%) compared to the younger participants (odds ratios [ORs] = 1.3–1.4, ps < 0.05), while older participants were less likely to report feeling distressed (OR = 0.4, p < 0.05). Older participants also had higher CCI and were more likely to have polypharmacy (OR = 1.7, ps < 0.05). Increasing age strongly correlated with worse KPS score (r = −0.232, OR = 1.4, p < 0.001) and worse NFS (r = 0.210, OR = 1.5, p < 0.001). No differences were observed in overall symptom burden, symptom interference, and anxiety/depression scores. DiscussionWhile commonly used GA tools were not available, the study employed patient- and clinician-reported outcomes to identify potential future research directions for the use of GA in the broader neuro-oncology population. Findings illustrate missed opportunities in neuro-oncology practice and underscore the need for incorporation of GA into routine care of this population. Future studies are warranted to further evaluate the prognostic utility of GA and to better understand functional aging outcomes in this patient population.

Spiritual well-being and its association with health-related quality of life in primary brain tumor patients.

Spirituality can impact patients' attitudes and decisions about treatment and end-of-life care when coping with cancer. Previous studies documented health-related quality of life (HRQoL) and spiritual well-being (SWB) as positively correlated within a general cancer patient population, but little is known about their association in the primary brain tumor population. We sought to measure SWB in primary brain tumor patients and evaluate whether it was associated with HRQoL. Six-hundred and six patients treated at The Preston Robert Tisch Brain Tumor Center at Duke between December 16, 2013 and February 28, 2014 with data in the PRoGREss registry are included in this retrospective analysis. Each patient completed the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being 12 (FACIT-Sp-12) and -Fatigue (FACIT-F), and the Functional Assessment of Cancer Therapy-General and -Brain (FACT-G and FACT-Br). Mean age was 49.1 years (SD = 13.5 years), male (N = 328, 54.1%), married (N = 404, 66.7%), at least college-educated (N = 381, 62.9%), and diagnosed with a high-grade glioma (N = 412, 68.0%). Multiple regression analyses were performed on both the FACT-G and the FACT-Br using the FACIT-Sp-12 sub-scales of Meaning/Peace and Faith, FACIT-F, belief in God or a higher power, prayer, gender, tumor grade, and Karnofsky Performance Status (KPS) as predictors. We found that greater SWB (measured by FACIT-Sp-12) was associated with better HRQoL (measured by FACT-G and FACT-Br; p < .0001). The association between reported SWB and reported improved HRQoL emphasizes the importance of spirituality in primary brain tumor patients, suggesting SWB must be considered in strategies to improve HRQoL.

QOLP-29. MINDFULNESS MEDITATION PRACTICE IN MALIGNANT GLIOMA PATIENTS THROUGHOUT CONCOMITANT RADIATION AND TEMOZOLOMIDE: A FEASIBILITY STUDY

Abstract With a bleak prognosis for malignant glioma, maintaining quality of life (QoL) and decreasing distress of the patient are important in the clinical care of the patient. Mindfulness meditation is a mind-body therapy that has been recently investigated in the oncology field as a non-pharmacological strategy to ameliorate cancer symptoms and to improve QoL. This practice has not been studied in the primary brain tumor population. We initiated a pilot study among newly diagnosed brain tumor patients with the hypothesis that mindfulness meditation practice may benefit the patient by decreasing stress and anxiety and provide a means to cope with their new diagnosis. The specific aim of this pilot study is to determine the feasibility of a mindfulness meditation program to this population during standard of care chemoradiation and to determine whether it merits additional research in a subsequent trial. The intervention consists of six weekly one hour telephone-based mindfulness sessions followed by one in- person mindfulness session consisting of: mindfulness and healing, understanding stress, abiding in kindness, working with difficult emotions, finding peace, going forward and living fully. Subjects are provided with downloadable guided meditations. We plan to enroll fifteen newly diagnosed WHO grade III or IV malignant glioma subjects prior to their 6 week chemoradiation course. We will determine the percentage of subjects approached vs enrolled, number of sessions that each subject attends, completion of study questionnaires and satisfaction of the subjects. QoL surveys include: Functional Assessment of Cancer Therapy- Brain, Functional Assessment of Cancer Therapy- Cognitive Function, Pittsburgh Sleep Quality Index, Functional Assessment of Chronic Illness Therapy-Fatigue and the Five Facet Mindfulness Questionnaire – short form. 13 subjects have been approached and 8 signed consent over a two-month period. We will provide final study results at time of presentation.

Complementary and integrative health interventions and their association with health-related quality of life in the primary brain tumor population

Background and purposeLittle is known about complementary and integrative health intervention usage in the primary brain tumor population. We aimed to identify the percentage of patients using these practices and explore the impact on quality of life. Materials and methodsClinical records from patients seen in clinic between December 16, 2013 and February 28, 2014 were reviewed retrospectively. The questionnaires used were a modified version of the International Complementary and Alternative Medicine Questionnaire, the Functional Assessment of Cancer Therapy- Brain Cancer and the Functional Assessment of Chronic Illness Therapy- Fatigue. Results76% of patients utilized a complementary and integrative health modality. The most frequently reported modalities used were vitamins, massage, and spiritual healing, prayer, diet and meditation. ConclusionThese results confirm the usage of complementary and integrative health practices within the primary brain tumor population; however, there was no evidence of association between use and quality of life.

A cross sectional analysis from a single institution's experience of psychosocial distress and health-related quality of life in the primary brain tumor population.

Primary brain tumor patients experience high levels of distress. The purpose of this cross-sectional, retrospective study is to evaluate the level and different sources of psychosocial distress and how these pertain to health-related quality of life (HRQoL). The Primary and Recurrent Glioma registry at Duke's The Preston Robert Tisch Brain Tumor Center was queried retrospectively for demographic and clinical information on patients seen between December 2013 and February 2014. Data also included the National Comprehensive Cancer Network's Distress Thermometer (NCCN-DT), Functional Assessment of Cancer Therapy-Brain Cancer (FACT-Br), and Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT-F). 829 subjects completed questionnaires. 54% were male; 96% completed the NCCN-DT; 33.3% had a DT score ≥4 (moderate/severe distress). Women reported DT ≥ 4 more often than men (38.6 vs 29.0%; p = 0.005). Patients within 1year of diagnosis reported DT ≥ 4 more often than those 1+ years after diagnosis (38.8 vs 30.9%; p = 0.034). 73.0% reported physical problems; the most frequent being fatigue (43.2%) and memory/concentration (40.9%). 42.0% complained of emotional problems with worry (29.4%) and nervousness (22.4%) being the most common. Patients who reported at least one practical, family, emotional or physical problem had significantly lower HRQoL scores (p < 0.001). Primary brain tumor patients experience memory dysfunction, fatigue, nervousness, worry, and financial concerns, which have a negative effect on the patient's HRQoL. By identifying and addressing these stressors, it may be possible to improve patient HRQoL.

PS1 - 188 Rehabilitation Consultation: An Integrated Model for Addressing Rehabilitation Concerns in the Primary Brain Tumor Population

Individuals with primary brain tumors experience a range of physical, cognitive and psychosocial sequelae which impact their independence, safety and quality of life. These impairments may be addressed through rehabilitation intervention. Despite acknowledgement that timely rehabilitation services over the course of the disease process is of benefit, few outpatient neuro-oncology treatment teams include a rehabilitation professional. Purpose: The aims are: (1) to describe a rehabilitation consultation model of care integrated into outpatient neuro-oncology treatment for individuals with primary brain tumors; and (2) to describe the characteristics of individuals referred for rehabilitation services. Methods: This retrospective descriptive study examined data from 200 individuals that received rehabilitation consultation from January 2015 to March 2016 at Princess Margaret Hospital, Pencer Brain Tumor Centre. Information on patient demographics, referral characteristics, and number of patient care visits was collected. Descriptive statistics were calculated. Preliminary Results: Of all patients, (n=195), the most common diagnosis is glioblastoma, 39% (n=76), and 50% are 50-69 years of age (M=55, SD=15.0). The most common reason for initial referral was decline in physical functioning, strength and balance (41%). In 77% of cases, patients were seen immediately at the time of referral. In total, 540 consultations were completed (face-to-face=230, telephone=310) with 2.78 on average (SD=4.0) per patient. Conclusion: Given the range of symptoms that individuals with primary brain tumors experience coupled with changes in functional status as the disease progresses, integrated and timely rehabilitation consultation is feasible.

Psychosocial distress and its effects on the health-related quality of life of primary brain tumor patients.

All cancer patients experience distress from the diagnosis, the effects of the disease or the treatment. Clinically significant distress decreases overall quality of life and the recognition of distress with prompt intervention is essential. The National Comprehensive Cancer Network distress thermometer (NCCN-DT) is a validated measuring tool that has been utilized in the primary brain tumor population to detect psychologic distress thereby provoking a referral process to the appropriate support system. Brain tumor patients commonly reported emotional and physical distress encompassing: fatigue, fears, memory and concentration and worry. More research is needed to identify the stressors of all primary brain tumor patients and their caretakers and integrate appropriate interventions to improve health-related quality of life in both groups.

QOL-21DIET AND HEALTH-RELATED QUALITY OF LIFE (HRQoL) IN THE PRIMARY BRAIN TUMOR POPULATION

QOL-21. DIET AND HEALTH-RELATED QUALITY OF LIFE (HRQoL) IN THE PRIMARY BRAIN TUMOR POPULATION Dina M. Randazzo, Frances McSherry, James E. Herndon, II, Mary L. Affronti, Eric S. Lipp, Charlene Flahiff, Elizabeth Miller, Sarah Woodring, Maria Freeman, Patrick Healey, Janet Minchew, Susan Boulton, Annick Desjardins, Gordana Vlahovic, Henry S. Friedman, and Katherine B. Peters; Duke University Medical Center, Durham, NC, USA BACKGROUND: Many diets have been recommended for cancer patients, including ketogenic, vegetarian, alkaline, and calorie-restricted diets. Despite these recommendations, evidence is lacking. The goal of this study was to discern if patients with primary brain tumors used a diet and if it was associated with HRQoL. METHODS: Demographic and clinical data from the PRoGREss registry at the Preston Robert Tisch Brain Tumor Center at Duke, along with patient-outcome questionnaires, were queried retrospectively from December 16, 2013 to February 28, 2014. Kruskal-Wallis and Wilcoxon tests were performed to explore any associations between diet and HRQoL. RESULTS: 783 patients were identified with 81 (10%) using a special diet the last 12 months, 515 (66%) not using a special diet, and 297 (24%) with missing diet information. The majority of patients were male (n 1⁄4 423, 54%), married (n 1⁄4 463, 59%), college educated (N 1⁄4 438, 56%), had WHO grade III-IV tumors (N1⁄4 539, 69%), and the average age was 49.6 (13.6) years. Special diets reported by the 81 patients included: ketogenic (N 1⁄4 9, 11%), low carb (N 1⁄4 11, 14%), vegetarian/vegan (N 1⁄4 6, 7%), organic (N 1⁄4 8, 10%) and unspecified (27, 33%). Among those patients who used a special diet, 43% exercised ≥9 MET-hrs/wk; however, among patients who did not use a special diet, only 30% exercised ≥9 MET-hrs/wk. The HRQoL in patients using a special diet was better than the HRQoL in patients who did not use a special diet relative to the following outcomes: FACIT-Fatigue, FACT-G functional subscale, FACT-Br TOI, and the Brain cancer subscale. CONCLUSIONS: A small percentage of our primary brain tumor patients reported using a special diet. Given the general lack of evidence regarding diet and its potential effect on primary brain tumors, more research is needed in this area utilizing more accurate methods to identify and validate the diets used and to reduce missing data. Neuro-Oncology 17:v188–v194, 2015. doi:10.1093/neuonc/nov230.21 Published by Oxford University Press on behalf of the Society for Neuro-Oncology 2015.

The symptom burden of primary brain tumors: evidence for a core set of tumor- and treatment-related symptoms.

A set of symptoms common across cancers has been proposed to enhance quality of care and clinical research in solid tumor patients. Using data from several clinical studies, this study evaluated these symptoms in primary brain tumor patients. Symptom report data using the MD Anderson Symptom Instrument -Brain Tumor (MDASI-BT) from 621 patients enrolled in 8 clinical studies was used. The prevalence and severity of symptoms were reported as they relate to tumor grade, treatment stage and KPS. The sample was primarily white (82.5%) males (59%) with high-grade gliomas (75%). More than 50% of patients reported at least 10 concurrent symptoms, and 40% of patients reporting having at least 3 moderate-to-severe symptoms. Fatigue, drowsiness, difficulty remembering, disturbed sleep, and distress were the most severe symptoms reported by all tumor grades. Functional interference of symptoms with ability to work, perform activities, walk, and enjoy life was reported by more than 25% of patients. These results support a core set of symptoms, common in other solid tumor patients, that may impact clinical care and assessment of treatment benefit. Although only 5 of the Center for Medical Technology Policy list of proposed core symptoms met criteria for inclusion in this sample, 5 of the other proposed core symptoms were also reported in similar frequency as reported in the other cancer populations. This primary brain tumor population differed from other solid tumor patients in that other symptoms, which could be disease related, were more prevalent and thus should also be collected for these patients.

Complementary and Alternative Medicine in the Primary Brain Tumor Population and Its Association with Health-Reported Quality of Life (S18.007)

Complementary and Alternative Medicine in the Primary Brain Tumor Population and Its Association with Health-Reported Quality of Life (S18.007)

QL-21 * SPIRITUAL WELL-BEING AND ITS ASSOCIATION WITH HEALTH-RELATED QUALITY OF LIFE IN PRIMARY BRAIN TUMOR PATIENTS

Spirituality has been shown to impact patients' attitudes and decisions about treatment and end-of-life care when coping with chronic illnesses such as cancer. Previous studies have documented that health-related quality of life (HRQoL) and spiritual well-being are positively correlated, but little is known about the phenomenon in the primary brain tumor population. Therefore, we sought to measure spiritual well-being in primary brain tumor patients and evaluate whether it was associated with HRQoL. Data collected within the Preston Robert Tisch Brain Tumor Center at Duke as part of the PRoGREss registry between 12/16/2013 and 2/28/2014 were queried retrospectively. In addition to demographic and clinical information, data was obtained from patient reported outcome questionnaires including Functional Assessment of Cancer Therapy-Brain Cancer (FACT-Br) with a score range from 0-184 and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp12) with a score range from 0-48. Correlation analyses were performed with the Pearson correlation coefficient. For this study, 845 subjects were identified. Mean age was 49.8 (SD = 13.5) years and 54.6% were male, 56.8% married, and 34.1% college educated. Median score for FACT-Br Total was 135.9 with range from 40.8 to 184 and median score for FACIT-Sp12 was 38.0 with range from 8.0 to 48.0. A significant positive correlation existed between scores on FACT-Br and FACIT-Sp12 with r = 0.636 (p <0.0001). Similar results were seen for correlations between FACT-Br total score and FACIT-Sp12 subscales (Faith r = 0.338, p < 0.0001 and Meaning/Peace r = 0.712, p < 0.0001). These results highlight the relationship between spirituality and HRQoL in the brain tumor population and suggest that implementing strategies to measure and encourage spiritual well-being may be one avenue to improve HRQoL.

Norris Cotton Cancer Center (NCCC) neuro-oncology glioma tumor quality improvement project.

137 Background: Glioma patients represent 30% of the primary brain tumor population at NCCC, and often require surgical intervention prior to medical management. In order to ensure coordinated, comprehensive and timely care, reliable referral to the neuro-oncology program is needed. Earlier quality improvement efforts identified 10 best practices designed to facilitate referral into the neuro-oncology program, though over the years these practices lapsed. A manual record review of 2010 cases revealed 43 glioma patients, of which compliance with best practices ranged from 29% to 93%, and none of the patients had all best practices when indicated. Additionally, the percentage of 9 out of the 10 best practices (excluding post-operative order sets) completed for all consecutive patients from January 2010 to May 2011 was 63%. Methods: A project was chartered by leadership and a multidisciplinary team was convened twice a month from May to October 2011. The team was organized into three groups (entry into the system, surgical, and post-op care, and continuing care) and assigned a coach with instructions to flowchart the current processes and identify factors that contributed to poor performance. The three process maps were then combined to create one system map by which the team brainstormed improvement ideas to pilot. Results: Concurrent review of the individual case-level data during the project team meetings was helpful in identifying process weaknesses as changes were being piloted. Performance of best practices improved significantly when measured several months following completion of the project; furthermore, best practices completed for consecutive patients from June 2011-May 2012 was 87%. Conclusions: The team was challenged to identify changes in process that were not dependent upon individual providers/staff members and that took advantage of a newly implemented electronic medical record. Manual chart abstraction was replaced by electronic data abstraction. Sustained measurement and reporting of performance is essential and has been incorporated into the Neuro-Oncology Tumor Board meetings on a quarterly basis.

The impact of symptom interference using the MD Anderson Symptom Inventory‐Brain Tumor Module (MDASI‐BT) on prediction of recurrence in primary brain tumor patients

Tumor grade, age, extent of resection, and performance status are established prognostic factors for survival in primary brain tumor (PBT) patients. Development of disease-related symptoms is predictive of tumor recurrence in other cancers but has not been reported in the PBT population. A cross-sectional sample of 294 PBT patients participated. Progression was based on the radiologist report of the magnetic resonance imaging (MRI). The relation of clinical variables (age, extent of resection, tumor grade, and Karnofsky performance status [KPS]) and MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) mean symptom and interference subscales with progression was examined using logistic regression. The study enrolled more men (60%, n = 175); median age was 46 years. The majority had less than a gross total resection (n = 186, 64%), and a good KPS (KPS ≥ 90) (N = 208). The majority had a grade 3 or 4 tumor (n = 199) and 24% of patients had recurrence. Tumor grade and activity-related interference were significantly related to progression. Patients with tumor grade 4 were 2.4 times more likely to have recurrence (95% CI, 1.2-5.; P < .015). Patients with significant (ratings of ≥ 5) activity-related interference were 3.8 times more likely to have recurrence (95% CI, 2.14-6.80; P < .001). Mean activity-related score was 4.8 for those with progression on MRI and 2.2 for those with stable disease. Significant activity-related interference and tumor grade were associated with recurrence but not KPS, age, or extent of resection. These results provide preliminary support for the use of symptom interference in assessment of disease status. Because the authors used a cross-sectional sample, future studies evaluating change over time are needed.