Radiation Oncology/Supportive care/Neurologic symptoms

Radiation brain injury

For brain tumor patients after brain irradiation:

• Introduction
  • Radiation induced injury is manifested by fatigue, confusion, and cognitive impairment.
  • Imaging studies show demyelination, decreased cerebral perfusion, decreased cerebral metabolism, and decreased cerebral N-acetyl aspartate (ref: PMID 16549835)

• Wake Forest; 2007 PMID 17869448 -- "A Phase III, Double-Blind, Placebo-Controlled Prospective Randomized Clinical Trial of d-threo-methylphenidate HCl in Brain Tumor Patients Receiving Radiation Therapy." (Butler JM Jr, Int J Radiat Oncol Biol Phys. 2007 Sep 13; [Epub ahead of print])
  • Randomized. 68 patients with primary or metastatic brain tumors. Arm 1) prophylactic d-MPH 5mg BID -> 15mg BID vs. Arm 2) observation. Outcome measure QOL and cognitive function
  • Outcome: No difference in fatigue, QOL, or cognitive function
  • Conclusion: Prophylactic d-MPH not beneficial in brain tumor patients

• Donepezil (Aricept) - acetylcholinesterase inhibitor
  • Wake Forest, 2006 (2001-2003) - PMID 16549835 — "Phase II study of donepezil in irradiated brain tumor patients: effect on cognitive function, mood, and quality of life." Shaw EG et al. J Clin Oncol. 2006 Mar 20;24(9):1415-20.
    • Phase II. 5 mg/d x 6 weeks, then 10 mg/d x 18 weeks. Total of 24 weeks, followed by washout. Evaluated by multiple cognitive tests
    • 35 pts receiving partial or whole brain RT > 6 months before the study; KPS >= 70%; no evidence of tumor progression; steroids allowed but had to be stable or decreasing dose.
    • 24 of 35 pts remained on study for 24 weeks. Significant improvement from baseline to 24 weeks for attention/concentration, verbal memory, and figural memory and a trend for verbal fluency. Improvement in confused mood and a trend for fatigue and anger. Improved health-related QOL. 48% of pts chose to continue taking donepezil after the 24 weeks.

Driving impairment

Imposing driving restrictions on patients with brain tumors or neurologic symptoms from cancer

• See Official guidelines

• U.Wisconsin, 2011 PMID 20972603 -- "Current practices of driving restriction implementation for patients with brain tumors." (Thomas S, J Neurooncol. 2011 Jul;103(3):641-7.)
  • Survey of U.S. practitioners
  • "This survey highlights the lack of consensus regarding the responsibilities of physicians treating brain tumor patients in designing and enforcing driving restrictions. We propose that a panel of experts generate driving restriction guidelines to be used in conjunction with objective testing of motor and sensory impairment. These would aid practitioners in developing individualized driving restrictions for every brain tumor patient."

Review

• Wake Forest; 2006 PMID 17032563 -- "Managing the cognitive effects of brain tumor radiation therapy." (Butler JM, Curr Treat Options Oncol. 2006 Nov;7(6):517-23.)