Original ArticleLong-Term Cognitive Functioning and Psychological Well-Being in Surgically Treated Patients with Low-Grade Glioma
Introduction
A great challenge in neurosurgery is the preservation of patients' brain functions and quality of life. Over the past 15 years, the neuro-oncology and neurosurgery literature has shown a growing interest in low-grade gliomas (LGG),1, 2, 3, 4 which are slow-growing infiltrative brain tumors affecting younger individuals and often located close to or infiltrating eloquent brain areas (e.g., language). LGG patients typically do not show cognitive deficits for many years and the presence of the lesion is mostly revealed by the onset of seizures.5, 6 In these tumors, survival is associated with the maximal extent of resection (EOR),5, 7 which, on the other hand, may affect neurologic/cognitive functioning and, consequently, patients' quality of life (QoL). In contrast, high-grade gliomas (HGG) are fast-growing, very aggressive, and destructive tumors affecting older people6 and associated with reduced cognitive abilities.8, 9 They have a poorer prognosis, overall survival, cognitive functioning, and QoL with respect to LGG.
After surgical resection, patients with HGG have to immediately undergo adjuvant therapies (chemotherapy and radiotherapy) and their clinical picture is likely to change significantly in just a few months after diagnosis. Regarding QoL, in patients with HGG, poorer QoL was found to be linked to worse cognitive functioning, mood, and higher World Health Organization grading.10 Also for patients with LGG, past studies tended to report a reduced QoL, with lower cognitive functioning (with respect to the healthy population), especially in patients receiving radiotherapy.3, 11 However, most studies have considered only general QoL measures3, 11 or, when deeper psychological aspects are considered, the studies tend to be more qualitative and descriptive,12, 13, 14 often considering HGG and LGG together.15, 16, 17, 18, 19 These studies seem to suggest that existential distress (i.e., the feeling of threat to one's own conception of meaning, purpose, and satisfaction with life) is common at different stages of illness progression,17 with greater existential distress being linked to depression and poorer QoL.20
As a consequence, a comprehensive quantitative assessment of psychological functioning and well-being in patients with LGG seems particularly important, given that these patients may have a longer survival but the tumors may be potentially harmful for patients' cognitive and affective functioning and, more generally, for their well-being and QoL.
This study aims to provide an in-depth, comprehensive, and quantitative investigation of long-term cognitive and affective functioning and psychological well-being of surgically treated patients with LGG. This investigation is carried out by assessing patients' cognitive functioning with a series of neuropsychological cognitive tests, and their emotional state (including anxiety and depression) and psychological well-being with standardized quantitative measures.21, 22 This approach allows progression beyond the mere ascertainment of the absence of negative signs and symptoms, which is traditional in standard clinical practice.23
To this aim, all the cognitive and psychological well-being variables we measured were evaluated in relation to comparable segments of the healthy population by using standardized clinical, psychological, and neuropsychological measures and referring to the existing psychometric norms. In addition, because self-report measures are prone to potential self-presentation biases,24, 25 close relatives were also involved in the study to obtain an external point of view on the patients' functioning and experience.
Section snippets
Participants
A consecutive series of 50 surgically treated patients with LGG, operated on at least 1 year previously (average, 3.35 years), participated in the study between May 2013 and June 2014 (further details on inclusion criteria are given in the Supplementary Material). Only patients showing radiologically stable LGG appearance at the time of evaluation were included (i.e., in a stable state of their illness). The study was approved by the local ethical committee and all patients gave written consent.
Cognitive Status
Patients' overall cognitive status was satisfactory. At an average of 3.5 years from surgery, 84% (42/50) were either free (n = 25) or with 1 (n = 17) detectable cognitive deficit (over 18 measures).
Discussion
The present study provides a quantitative and comprehensive investigation of the long-term consequences of surgically treated patients with LGG, with an in-depth characterization of their cognitive and affective functioning and well-being.
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Conflict of interest statement: F.C. was supported by a postdoctoral research fellowship from A.O.U.S. Maria della Misericordia “Regional basic and clinical research project for the use of High Field Magnetic Resonance Tomograph (3 Tesla)” and F.F. was supported by a grant from Fondazione Cassa di Risparmio di Udine e Pordenone (CRUP).
Supplementary digital content available online.