Palliative Management of Glioblastoma

 

Summary

Patients with glioblastoma have a short life expectancy and an impaired quality of life. They should receive palliative care as soon as the diagnosis is announced. A quarter of patients over 65 can return home or nursing homes at the end of treatment by Recovery Groups. Home care must be encouraged by coordinating various disciplines such as physiotherapy and occupational therapy, medical and nursing care, and psychosocial support. Patients often present with behavior, mood, and personality disorders, impairing their rehabilitation capacities and social relationships. Isolation,

Introduction

Glioblastoma is the most aggressive and common main malignant brain tumor in adults. Its annual incidence is 3 to 5/100 000, with a slight predominance in humans. 1 The median age at diagnosis is 64 years. 2 The prognosis of patients with glioblastoma remains bleak with a median life expectancy of 15 to 17 months 1, 3 and a 5% survival rate at five years. 4

What Does Living With A Brain Tumor Mean To A Patient?

Intensity Of Treatment

The basic multidisciplinary approach for patients with glioblastoma involves surgical resection, as complete as possible, which clarifies the diagnosis and reduces the mass effect linked to the tumor. 3. The surgery is followed by concomitant daily radiochemotherapy for six weeks and an MRI four weeks later. Temozolomide is then prescribed at a dose of 150-200 mg / m 2 / day for five days every 28 days for a duration of six cycles. This protocol was established following a multicenter phase III study demonstrating that, compared to radiotherapy alone, radiochemotherapy improves median survival (14.6 vs. 12.1 months) and that at two years (26.5 vs. 10.4%). 5The period of radiation therapy requires daily travel or hospitalization for patients who are unable to travel. Maintenance chemotherapy is generally well tolerated and only requires monthly clinical follow-ups with radiological checks every two months, the wait for results, often generating a lot of concern.

In parallel, supportive care includes the management or prevention of seizures, thromboembolic events, intracranial hypertension, and possible infections, particularly bronchopneumonia in the context of swallowing disorders, and immunosuppressive treatment and hypervigilance. It is not uncommon for myopathy or blood sugar disorders to occur on steroids. Patients also benefit from rehabilitation measures (physiotherapy, speech therapy, occupational therapy), and psychological support. Communication with the patient and his family is essential and must include discussions around each person's expectations, given the disease's grim prognosis and the progressive loss of autonomy. 6

More Or Less Specific Symptoms And Their Psychosocial Consequences

Patients with glioblastoma may present with general symptoms such as headache, nausea, vomiting, disturbances in alertness, and asthenia. It is not uncommon for inaugural epileptic seizures to lead to suspect the diagnosis. Depending on the location, neurological motor, sensory, phasic, swallowing, or vision disorders can be observed. 7, 8

Feelings of exhaustion, anxiety, sadness, and distress are common when dealing with a grim prognosis exposing to adjustment disorders. 9 Up to 15% of patients with glioma present with depressive symptoms in the postoperative period, this proportion then varying between 22 and 93% depending on the study. 10, 11

Frequently described changes occur in behavior and personality (indifference, abulia, apathy, immaturity), emotional management (alexithymia), thought (hallucinations, psychotic episodes), executive functions, and image of oneself (loss of autonomy, mobility, physical change, anosognosia). The estimate of their real frequency remains uncertain because the studies carried out to date are essentially qualitative. 12 These neuro-cognitive-behavioral alterations can be a source of frustration, loss of meaning, incomprehension and can seriously interfere with family life. 9At present, the relationship between tumor location and psychopathological impact is not well understood. Three "frontal lobe syndromes" have been described in patients with brain tumors located in the prefrontal area. 13 Dorsolateral lesions are associated with executive disorders; the orbitofrontal can induce disinhibition and impulsivity, while the medial frontal induces apathy and abulia. 13, 14 Some apathy and executive dysfunction levels are also present when tumors are located outside the frontal lobes. 15It is likely that very complex interactions between cortical and subcortical lesions play a role in behavior. 15 When the paralimbic structures are involved, the mood disturbances are more marked, so it seems unlikely that the behavioral problems are only a direct consequence of the frontal lesions. 16 A study using anatomy-functional association mapping (Voxel-based Lesion Symptom Mapping) provides interesting evidence to understand neuropsychological effects depending on tumor location. 17The ability to discern the emotions and intentions of others is impaired with damage to the temporal lobe. More complex components of personality and behavior, such as alexithymia and the ability to recognize facial expressions, are affected by prefrontal, amygdala, and insula tumors. 17

The diagnosis of glioblastoma and cumbersome management greatly impacts the quality of life of patients and their families. 18 As in neurodegenerative diseases, the occurrence of glioblastoma exposes people to physical, emotional, and cognitive decline, with a risk of social stigma, and increases the burden on relatives who are unprepared for it. 19 - 21 The caregivers in charge of patients with glioblastoma deplore a lack of support and a poorer quality of life than their peers, this phenomenon being underestimated. 22, 23Many patients have limited awareness of their symptoms and the negative impact of their emotional, relationship, neurocognitive, and functional changes, which can have a major impact on the outcome of post-treatment rehabilitation. 24

When, Why, And How To Approach Palliative Care?

Focus On Quality Of Life

The main concerns of patients are their loved ones, the fear of not being themselves, the physical consequences of the disease, their finances, and their mental capacities. Patients cared for by their partner, suffering in their physical autonomy, with a low level of education, and experiencing financial difficulties, are most at risk of poor life quality. 25 Almost one in two patients who have just been revealed to have a brain tumor presents a severe deterioration in their quality of life with a high level of distress, this being more marked than with any other cancer diagnosis. 26

Whatever the therapeutic choice made, patients with a brain tumor should have access to palliative care from the moment of diagnosis to improve their own quality of life and that of their loved ones. As hospitalization affects the quality of life, home maintenance can be favored by oncological treatments when they are desired and possible. 27 Even in people over 65 years of age, whose average survival is five months, treatments reduce the risk of hospitalization for a quarter of the time remaining to live, with a respective adjusted Hazard Ratio of 0.31  for surgery.28

Patients and their loved ones have enormous, often unmet needs. 19, 29 Coordination of both ambulatory and hospital services, aids, and care is essential, basic palliative care being the responsibility and competence of everyone. Pursuing rehabilitation work is beneficial but requires organization, investment, and availability of professionals at home. 30 An Italian experiment demonstrated that interdisciplinary home monitoring made it possible to reduce the rehospitalization rate by half during the last two months of life, compared to standard monitoring. 31The frequent reasons for rehospitalization are immobility, acute clinical deterioration, and the occurrence of seizures, which must be addressed in advance. Relatives can benefit from support to alleviate the domestic, organizational, and financial burden and fight against exhaustion and isolation. The Ligue Contre le cancer, voluntary associations, are all resources to offer respite and concrete help. All patients should be referred to a palliative care team offering specialized home consultations and liaising with hospital neuro-oncology, emergency, and palliative medicine teams. The objective is to support/train relatives in their role of caregiver, to help them renegotiate relationships and responsibilities, to prevent/manage crises (behavioral disorders, epilepsy, degradations, etc.), and finally to know what to expect when the patient is living his last days and tackle the aftermath. The teams in charge must be able to offer both patients and their loved ones time for discussion to assess and integrate the situation by discussing the lived reality, the loss of autonomy, the preferences of each other, the alternatives, results, and prognosis.32Questions about hydration and nutrition at the end of life, the continuation or discontinuation of treatments, the place, and end-of-life care, crystallize a lot of discussions. Advance directives are rarely drawn up for fear of hastening the end, refusal to plan, and desire to live from day to day, due to existing cognitive alterations or team representations and strategies. These guidelines make it possible to collate the patient's wishes on the type and level of care he would like for himself and the choice of the person who could represent him and participate in the decisions. They often remain vague and not very applicable depending on the situation, which could rarely be foreseen, which does not favor decision-making processes. The teams are, therefore, responsible for getting patients to develop a care plan. Advance care planning, or anticipatory care project, aims to build a personalized frame of reference for making care-related decisions based on the patient's objectives. This also protects the patient in the event of incompetence to determine.

What Challenges At The Very end of life?

End Of Life Place

A study involving a cohort of 5,000 patients over the age of 65 with glioblastoma showed that 21% of them were hospitalized for more than 30 days, the duration sometimes extending up to three months. For patients who have been able to leave acute care hospital services, the stay continues in the rehabilitation service (33%), in a nursing home (14.6%), or a hospice (36.3%) more often than home (11.1%). 28During hospitalization or in an institution, maintaining the quality of life is a challenge that involves interdisciplinary care, promoting physical, intellectual, and spiritual occupational activities. In French-speaking Switzerland, the availability of places in palliative medicine units, in EMS or hospice being limited, the question arises of the place of care of patients with motor and behavioral disorders, incompatible with home care and that of funding of hospitalizations (in the context of the applicability of specific DRGs to acute palliative care) as well as long-term outpatient care.

Support Loved Ones in Understanding What is Part of The Dying Process

The last few weeks are marked by a decline in general health, frequent delirium, impaired vigilance, impaired communication, decreased appetite, the ability to hydrate, and incontinence. These manifestations must be explained early and repeatedly to relatives to better understand the situation and enlightened respect for the patient's new rhythm. The goal is to defend the patient from unnecessary or harmful initiatives to stimulate physical activity, diet, taking futile treatments or, on the contrary, stopping opiates in the hope of combating a certain lethargy. . The assessment of the patient's suffering and needs, as well as the answers to be given to questions from relatives, are priorities. Basic treatment requires the adaptation of analgesics and the continuation of parenteral antiepileptics. There is no consensus on the cure of agonic rales, occurring with the onset of lasting hypervigilance and the continuation of parenteral steroids.34 Disorders such as agitation, existential crisis, and epileptic seizures can prove complex to manage, become refractory, or even super-refractory, particularly to sedative agents such as midazolam and are an indication for early treatment. In a specialized palliative medicine unit. 35, 36

Conclusions and Perspectives

The challenges to improve the survival and quality of life of brain tumor patients and their families remain enormous. The major societal challenge is to guarantee, in the future, the availability and financing of long-term care structures.