With advanced treatments improving survival outcomes for patients with low-grade gliomas, clinicians and researchers at UC San Francisco’s Brain Tumor Center are working to enhance the cognitive improvement of these individuals as well.
Knowing that as patients are living longer they also want to live well with a high quality of life, UCSF providers are intensifying their study of the cognitive impairments that can result from a brain tumor and/or its treatment. They are researching and implementing therapies typically recommended for patients with a longer life expectancy, such as those those recovering from stroke or traumatic brain injury (TBI).
“Many, if not most, individuals with brain tumors struggle with lingering cognitive changes after treatment – from distractibility and forgetfulness to slowed thinking, aphasia, fatigue and difficulty with executive functioning,” said Christina Weyer-Jamora, PhD, RN, clinical associate professor and director of Neurocognitive Care Services (NCCS) at UCSF’s Brain Tumor Center. “They are often in the prime of their life, and these problems can negatively impact important areas of their life such as continuing to work and caring for their families and relationships. That is where cognitive rehabilitation can come in.”
Many factors conspire to impair cognitive ability or prevent its recovery. “The brain tumor itself can disrupt networks that lead to impairments,” said Jennie Taylor, MD, MPH, a neuro-oncologist and associate professor of Neurology and Neurological Surgery at UCSF. “In addition, the treatments known to improve outcomes, such as surgery to resect the tumor, radiation and chemotherapy used to treat residual disease, and medications to manage symptoms such as steroids and seizure medications, can have delayed and progressive impacts on cognition.”
Tailored therapy brings new hope
Clinically, the NCCS providers focus on the unique cognitive needs of each patient. Their tailored interventions improve patients’ understanding of their cognitive strengths and vulnerabilities and harness this information to improve day-to-day life. The work typically focuses on a combination of computerized retraining, which involves repeatedly practicing cognitive tasks, and compensatory strategy training, where patients hone strategies to modify their environment or approach to tasks. NCCS also provides advocacy and support for workplace and school accommodations, resource linkages, and caregiver training to help patients solidify their gains.
Conceived as a cognitive “boot camp,” the regimen is scheduled over a few months, with booster sessions as needed. The treatment normally starts three to six months after surgery or completion of active tumor-directed therapy, to optimize neuroplastic recovery.
Need for continued research; clinical trial underway
In a recent article in Neuro-Oncology Practice, researchers with UCSF’s Brain Tumor Center reviewed the cognitive domains impacted by lower-grade gliomas and provided an overview of existing cognitive rehabilitation approaches that appear promising for use with individuals with brain tumors. The authors also offered guidelines for implementing such efforts, and noted that further investigation is needed.
“It’s an area of research that has not yet received much attention,” said Weyer-Jamora, lead author of the report. “But given patients’ longer survivability and likelihood of success similar to what we’ve seen with treatment for stroke and TBI patients, it behooves us to utilize what we already know and continue to learn more to help these individuals live healthier and more productive lives.”
“One of our limitations is the small number of studies featuring lower-grade glioma patients alone,” said Taylor, the senior and corresponding author of the article. To address that, the UCSF team is currently enrolling patients in a clinical trial exploring novel interventions to help patients with lower-grade gliomas who feel their cognitive impairments are impacting their daily life [NCT03948490].
UCSF physicians interested in referring Brain Tumor Center patients for evaluation or possible inclusion in the clinical trial should contact Jane Rabbit, RN, research manager with the UCSF Brain Tumor Center’s Neuro-Oncology Clinic, at jane.rabbitt@ucsf.edu.
Case study: Young man reaps benefits from cognitive rehabilitation to thrive in the workplace
A 27-year-old man was diagnosed with a left frontal grade II astrocytoma. In the process of returning to work in sales, he noted difficulty finding words, as well as fatigue, slowed thinking and distractibility. He worried these changes were adversely affecting his work and relationships, as a supervisor had told him his performance was suffering.
In the beginning of cognitive rehabilitation treatment at NCCS, providers focused on helping the patient to learn more about his cognitive strengths and vulnerabilities, and how to manage his fatigue and problem-solve ways to improve his day-to-day functioning. Next, his team completed a job task analysis and identified practical strategies to address his cognitive difficulties. These strategies included breaking down information into smaller parts, pre-planning to reduce load given his slowed thinking and tracking his energy so he could pace himself more effectively.
The patient’s cognitive treatment course taught him practical skills required for success in the workplace –relying on notes in meetings, rehearsing potential conversations and preparing in advance for visits with new clients. These interventions were rehearsed in sessions, with immediate feedback to help him gain mastery. The patient was able not only to incorporate the strategies at work, reducing instances where he lost his train of thought and veered from his performance improvement plan, but also to adapt them for less structured tasks in his daily life. Today, his tumor remains stable, and he is working 40 hours a week in sales, continuing to use the strategies he learned and doing well.
The UCSF Brain Tumor Center is part of the UCSF Weill Institute for Neurosciences. UCSF Medical Center is ranked No. 1 in the nation for neurology and neurosurgery by U.S. News & World Report’s 2021-2022 Best Hospitals survey.
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