Kim Edelstein

More than 60% of adult survivors of childhood cancer report medical financial hardship due to the cumulative costs of cancer-directed therapy and related chronic health conditions. Whether neurocognitive impairment as a late effect is associated with increased financial hardship is unknown. In a large national cohort of 3023 adult survivors of childhood cancer, we observed a dose-dependent relationship between neurocognitive impairment and financial hardship outcomes. Individuals with 4 impaired neurocognitive domains had over 3-fold increased odds of debt collection (odds ratio [OR] = 3.12, 95% confidence interval [CI] = 1.91 to 5.09) and bankruptcy (OR = 3.77, 95% CI = 2.01 to 7.07) compared to individuals with no impaired neurocognitive domains. After adjusting for education, employment, and household income, the independent association between neurocognitive impairment and financial hardship outcomes persisted suggesting that other mechanisms may be at play. Neurocognitive impairment is an important risk factor for medical financial hardship in this patient population and should be considered for targeted screening and intervention.

PURPOSE: To examine associations between special education, chronic health conditions (CHCs), and college graduation in survivors of childhood cancer and their siblings. METHODS: Childhood Cancer Survivor Study participants included 23,082 5-year survivors (53.7% male; median [IQR] age at diagnosis, 6 [3-13] years; age at evaluation, 31.0 [24-39] years; treated between 1970 and 1999) and 5,037 siblings (47.7% male; 36.0 [28-44] years at evaluation). Special education use, reasons for special education, CHCs, and college graduation were self-reported. Primary cancer diagnosis and treatment exposures were abstracted from medical records. Comparisons between survivors and siblings were made using chi-square statistics; demographic and treatment factors associated with outcomes were examined using modified Poisson regression models. RESULTS: More survivors reported special education use than siblings (26.5% v 8.6%; relative risk [RR], 2.55 [95% CI, 2.32 to 2.80]). Of those survivors and siblings who had special education services, use was highest between kindergarten and fifth grade (64.4% of survivors and 71.9% of siblings in kindergarten-fifth grade, 14.4% of survivors and 12.5% of siblings in sixth-eighth grade, and 9.2% of survivors and 9.0% of siblings in ninth-12th grade), and primarily attributable to learning and concentration problems. Despite receiving special education, survivors were less likely to graduate college compared with siblings requiring special education (RR, 0.76 [95% CI, 0.66 to 0.88]). Risk for not graduating college included history of CNS tumor (RR, 1.47 [95% CI, 1.40 to 1.55]), cranial irradiation (20-29 Gy, RR, 1.16 [95% CI, 1.09 to 1.25]; 30-49 Gy, RR, 1.37 [95% CI, 1.26 to 1.49]; ≥50 Gy, RR, 1.35 [95% CI, 1.28 to 1.42]), or the presence of a severe, disabling or life-threatening CHC (Common Terminology Criteria for Adverse Events grade 3-4, RR, 1.15 [95% CI, 1.07 to 1.24]). CONCLUSION: Cognitive problems and CHCs increase risk for not graduating college; these problems are not alleviated by special education.

Background: The distinct tumor histopathology, molecular features, and psychosocial needs among adolescents and young adults (AYA) with brain tumors pose challenges within traditional healthcare systems. Establishing a multidisciplinary AYA neuro-oncology clinic has been proposed to address these gaps in care. This is the first study to describe the framework and patient profile of a multidisciplinary AYA neuro-oncology clinic in a quaternary cancer center in Canada. Methods: Clinic framework was outlined and patients seen from December 2022 to June 2024 were included. Demographic profiles, tumor characteristics, treatment details, clinical trial enrollment, and allied health referrals were collected. Barriers encountered were summarized. Results: The clinic is composed of specialists in pediatric and adult neuro-oncology with seamless referrals to neurosurgery, radiation oncology, and allied health teams. A total of 100 patients (males 54%, females 46%) were seen with a median age of 24 years. Pediatric-type low-grade glioma (PLGG) was the leading diagnosis. BRAF alterations were the primary molecular drivers. Twenty-nine patients received active neuro-oncology management in the clinic. Overall, 77 patients underwent at least one surgery, 31 patients received radiotherapy, and 43 patients received chemotherapy. Trametinib was the primary targeted treatment prescribed. Three patients were eligible and enrolled in clinical trials. Barriers identified included a lack of peer support groups and a paucity of available clinical trials. Conclusions: This study provides insight into the clinical profile of patients seen in a multidisciplinary AYA neuro-oncology clinic in Canada. Multidisciplinary care is feasible and integral in addressing the multifaceted needs of AYAs with brain tumors.

This study investigates long-term changes in neurocognitive performance and psychological symptoms in meningioma survivors and associations with radiation dose to circumscribed brain regions. We undertook a retrospective study of meningioma survivors who underwent longitudinal clinical neurocognitive assessments. Change in neurocognitive performance or psychological symptoms was assessed using reliable change indices. Radiation dosimetry, if prescribed, was evaluated based on treatment-planning computerized tomography co-registered with contrast-enhanced 3D T1-weighted magnetic resonance imaging. Mixed effects analyses were used to explore whether incidental radiation to brain regions outside the tumor influences neurocognitive and psychological outcomes. Most (range = 41%–93%) survivors demonstrated stable—albeit often below average—neurocognitive and psychological trajectories, although some also exhibited improvements (range = 0%–31%) or declines (range = 0%–36%) over time. Higher radiation dose to the parietal-occipital region (partial R² = 0.462) and cerebellum (partial R² = 0.276) was independently associated with slower visuomotor processing speed. Higher dose to the hippocampi was associated with increases in depression (partial R² = 0.367) and trait anxiety (partial R² = 0.236). Meningioma survivors experience neurocognitive deficits and psychological symptoms many years after diagnosis, and a proportion of them decline over time. This study offers proof of concept that incidental radiation to brain regions beyond the tumor site may contribute to these sequelae. Future investigations should include radiation dosimetry when examining risk factors that contribute to the quality of survivorship in this growing population.

Background: In addition to poor survival rates, individuals with glioblastoma (GBM) are at risk of neurocognitive impairment due to multiple factors. This study aimed to characterize neurocognitive impairment, neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms in newly diagnosed GBM patients; and to examine whether neurobehavioral symptoms, fatigue, sleep, and depressive symptoms influence neurocognitive performance.Methods: This study was part of a prospective, inception cohort, single-arm exercise intervention in which GBM patients underwent a neuropsychological assessment shortly after diagnosis (median 4 weeks; ie, baseline) and 3, 6, 12, and 18 months later, or until tumor progression. Here, we present baseline data. Forty-five GBM patients (mean age = 55 years) completed objective neurocognitive tests, and self-report measures of neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms.Results: Compared to normative samples, GBM patients scored significantly lower on all neurocognitive tests, with 34 (76%) patients exhibiting neurocognitive impairment. Specifically, 53% exhibited impairment in memory retention, 51% in executive function, 42% in immediate recall, 41% in verbal fluency, and 24% in attention. There were high rates of clinically elevated sleep disturbance (70%), fatigue (57%), depressive symptoms (16%), and neurobehavioral symptoms (27%). A multivariate regression analysis revealed that depressive symptoms are significantly associated with neurocognitive impairment.Conclusions: GBM patients are vulnerable to adverse outcomes including neurocognitive impairment, neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms shortly after diagnosis, prior to completing chemoradiation. Those with increased depressive symptoms are more likely to demonstrate neurocognitive impairment, highlighting the need for early identification and treatment of depression in this population.

In most jurisdictions where medical assistance in dying (MAiD) is legal, patients must have decision-making capacity. Brain cancer often damages the cognitive networks required to maintain decision-making capacity. Using qualitative methodology guided by a relational ethics conceptual framework, this study explored neuro-oncology clinicians’ perspectives on access to and eligibility for MAiD for patients diagnosed with brain cancer. We interviewed 24 neuro-oncology clinicians from 6 countries. Participants described the unique challenges facing brain cancer patients, potentially resulting in their inequitable access to MAiD. The findings highlight the importance of early end-of-life conversations, advance care planning, and access to end-of-life treatment options.

Although radiation (RT) is standard treatment for many brain tumors, it may contribute to neurocognitive decline. The objective of this study was to investigate associations between RT dose to circumscribed brain regions and specific neurocognitive domains in patients with meningioma. We undertook a retrospective study of 40 patients with meningioma who received RT and underwent an in-depth clinical neurocognitive assessment. Radiation dosimetry characteristics were delineated based on treatment planning computerized tomography co-registered with contrast-enhanced 3D T1-weighted magnetic resonance imaging. Principal components analysis was applied to organize neurocognitive test scores into factors, and multivariate multiple linear regression models were undertaken to examine if RT dose to circumscribed brain regions is associated with specific neurocognitive outcomes. Radiation dose to brain regions was associated with neurocognitive functions across a number of domains. High dose to the parietal-occipital region was associated with slower visuomotor processing speed (mean dose, β = −1.100, P = .017; dose to 50% of the region [D50], β = −0.697, P = .049). In contrast, high dose to the dorsal frontal region was associated with faster visuomotor processing speed (mean dose, β = 0.001, P = .036). These findings suggest that RT delivered to brain regions (ie, parietal-occipital areas) may contribute to poor neurocognitive outcomes. Given that modern radiotherapy techniques allow for precise targeting of dose delivered to brain regions, prospective trials examining relations between dose and neurocognitive functions are warranted to confirm these preliminary results.

Knowledge regarding cognitive problems in metastatic non-small cell lung cancer (mNSCLC) is limited. Such problems may include both patient-reported cognitive concerns and demonstrable cognitive impairment. Greater understanding of these outcomes is needed to inform rehabilitation strategies for these difficulties. We aimed to identify the frequency of cognitive problems and associated factors in patients with mNSCLC. In this cross-sectional study, adults with mNSCLC completed validated neuropsychological tests and self-report questionnaires measuring cognitive concerns, neurobehavioral concerns, depression, demoralization, illness intrusiveness, self-esteem, and physical symptoms. Cognitive impairment (performance based) was defined according to International Cancer and Cognition Task Force criteria. Clinically significant cognitive concerns were defined by a score ≥1.5 SD below the normative mean on the Functional Assessment of Cancer Therapy-Cognitive Function Perceived Cognitive Impairment (FACT-Cog PCI). Univariate and multivariate logistic regression analyses were performed to identify associated factors. Of 238 patients approached, 77 participated (median age: 62 years; range: 37-82). Brain metastases were present in 41 patients (53%), and 23 (29%) received cranial irradiation. Cognitive impairment and cognitive concerns were present in 31 (40%) and 20 patients (26%), respectively. Cognitive impairment and cognitive concerns co-occurred in 10 patients (13%), but their severity was unrelated. Cognitive impairment was associated with cranial irradiation (odds ratio [OR] = 2.89; P = .04), whereas cognitive concerns were associated with greater illness intrusiveness (OR = 1.04; P = .03) and lower self-esteem (OR = 0.86; P = .03). Cognitive impairment and cognitive concerns are both common in patients with mNSCLC but are not necessarily related, and their risk factors differ. The association of illness intrusiveness and self-esteem with cognitive concerns can inform therapeutic interventions in this population.