Elsevier

World Neurosurgery

Volume 103, July 2017, Pages 799-808.e9
World Neurosurgery

Original Article
Long-Term Cognitive Functioning and Psychological Well-Being in Surgically Treated Patients with Low-Grade Glioma

https://doi.org/10.1016/j.wneu.2017.04.006Get rights and content

Objective

The aim of this work is to provide an in-depth investigation of the impact of low-grade gliomas (LGG) and their surgery on patients' cognitive and emotional functioning and well-being, carried out via a comprehensive and multiple-measure psychological and neuropsychological assessment.

Patients and Methods

Fifty surgically treated patients with LGG were evaluated 40 months after surgery on their functioning over 6 different cognitive domains, 3 core affective/emotional aspects, and 3 different psychological well-being measures to obtain a clearer picture of the long-term impact of illness and surgery on their psychological and relational world. Close relatives were also involved to obtain an independent measure of the psychological dimensions investigated.

Results

Cognitive status was satisfactory, with only mild short-term memory difficulties. The affective and well-being profile was characterized by mild signs of depression, good satisfaction with life and psychological well-being, and good personality development, with patients perceiving themselves as stronger and better persons after illness. However, patients showed higher emotional reactivity, and psychological well-being measures were negatively affected by epileptic burden. Well-being was related to positive affective/emotional functioning and unrelated to cognitive functioning. Good agreement between patients and relatives was found.

Conclusions

In the long-term, patients operated on for LGG showed good cognitive functioning, with no significant long-term cognitive sequelae for the extensive surgical approach. Psychologically, patients appear to experience a deep psychological change and maturation, closely resembling that of so-called posttraumatic growth, which, to our knowledge, is for the first time described and quantified in patients with LGG.

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.

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