As we embrace 2021 with fresh hope and positivity, it is my great honor to represent ASNO and serve as Executive Editor of Neuro-Oncology Practice. I am deeply humbled to receive the baton from Prof Rakesh Jalali and will continue in his footsteps of dedication and strong commitment—striving to improve the journey of patients, families, and carers from every corner of the world. I feel privileged for the opportunity to serve with a distinguished Editorial team under the strong leadership of Prof Martin Taphoorn, together with Dr Terri Armstrong and Dr Patrick Roth.
In this issue of Neuro-Oncology Practice, the articles delve into themes reaching across the entire spectrum of care for our brain tumor patients.
Salmi, Mansouri, and Taylor (p. 233) start off with a timely editorial in view of a new US federal rule implemented on April 5, 2021, mandating that patients will be able to access their medical information and electronic clinical notes without delay. As there is no specific guidance on open notes, they offer succinct suggestions for this cultural change, based on personal experience and insights—for clinical note documentation adjustments to help patients benefit from reading their neuro-oncology notes.
The ability to secure gainful employment, live independently within society, and enjoy an intimate relationship are goal posts we seek to achieve in brain tumor survivorship. In a cross-sectional study, Remes and colleagues (p. 266) determine the extent of neurocognitive impairment for radiotherapy treated adult survivors of childhood brain tumors, linked with employment, social situation, and difficulties therein. Their findings confirm that survivors are at risk especially for impaired executive function, processing speed, and attention, associated with lower employment rate and social status. Further studies on early interventions and rehabilitation to prevent late adverse effects are crucial.
Adolescent and young adult (AYA) neuro-oncology is an area of unmet need with a paucity of clinical trials, AYA-specific publications, and resources. Yeo and colleagues (p. 236) present a timely and much welcomed comprehensive review of this discipline encompassing all the nuances ranging from; comprehensive genetic testing, different molecular profiling, underrepresentation in trials, to psychosocial considerations including oncofertility and reproductive health. This heightens our awareness of not only the importance of AYA-focused neuro-oncology clinical research but access to quality AYA cancer programs to ensure best practice.
Targeted therapies and immuno-oncology have revolutionized cancer treatment, bringing with them unique new frontiers. In a retrospective analysis of 282 patients with resected brain metastases, Bander and colleagues (p. 278) explore the effect of timing of adjuvant stereotactic radiosurgery (SRS) on durable 5-year local control. They identified that delay in initiation of postoperative SRS can decrease efficacy, with significant improvement in local control rates when SRS was delivered within approximately 1 month of surgery. Gatson and colleagues (p. 247) report the first case series dedicated to the review of neuroradiological changes secondary to immune checkpoint inhibitors (ICIs) in cancer patients. As neurological immune-related adverse events are a diagnosis of exclusion, the pivotal decision to continue or discontinue ICIs in this setting is a real challenge, demanding robust multidisciplinary team input. This case series highlights how misdiagnosis can impact patient outcomes, particularly due to the variation in time to onset of symptoms. Further research is necessary to understand the most accurate neuroimaging algorithms. Chimeric antigen receptor (CAR) T-cell therapy is at the forefront of adoptive cell therapies. In a practical review, Gonzales Castro and Dietrich (p. 259) provide key insights into the clinical presentation, evaluation, management, prognosis, and long-term follow-up for CAR T-cell-associated neurotoxicity. As newer techniques and novel therapies are introduced into care, familiarity with management principles of neurotoxicity will be essential for practice.
Quantifying health-related quality of life (HRQoL) in primary brain tumor patients has several dimensions. Exercise oncology is an evolving field—in particular, the role of prescriptive exercise rehabilitation. Dulfikar and colleagues (p. 290) report a preliminary descriptive study on physical functional capacity of grade II, III, and IV glioma patients prior to undergoing adjuvant radiation with or without chemotherapy. They document aerobic endurance and lower limb strength were below the criterion cutoff recommended to maintain independent living. Further research into supervised, tailored exercise interventions is awaited. Spirituality has been associated with better HRQoL in patients with cancer. In a retrospective cross-sectional study of 606 patients with a primary brain tumor, Randazzo and colleagues (p. 299) demonstrate that greater Spiritual Well Being (SWB) was associated with better self-reported HRQoL. The authors recommend a longitudinal prospective study to measure how spirituality changes over time throughout the disease trajectory in the primary brain tumor population.
Molecular testing (MT) albeit with a selection of different panels and a variety of commercial platforms, has become standard of care for most solid tumors. In a survey distributed to SNO members, Fortin Ensign and colleagues (p. 310) assessed the attitudes, practice patterns, and utility toward MT in clinical application and decision making. Overall, MT results were beneficial for clinical decision making, and 95% of clinicians shared MT results with patients. Their results also captured that the greatest unmet need for more widespread use of MT was established guidelines and rigorous scientific interpretation of MT results. Low survey response rate was one of the limitations of the results.
The development of distant metastases from glioma is extremely rare, and genomic alterations remain incompletely understood. In this issue, two separate case series report on biopsy confirmed distant metastases and their available mutational data, adding on to our current knowledge. In the first nationwide study from the Netherlands, den Hartog and colleagues (p. 317) describe 25 cases of biopsy-proven distant metastases originating not only from glioblastoma but also lower-grade glioma. Bone/bone marrow and lymph nodes were the most frequent site of metastases. In a study from the Memorial Sloan Kettering Cancer Center, Noch and colleagues (p. 325) document that genomic analysis of primary and metastatic sites from 10 patients—9 glioblastoma and 1 gliosarcoma—reveal shared and private mutations. Further research with larger patient populations will enable a better understanding of the molecular landscape.
Brain tumor registries are an integral resource for population-based mass data collection not only for epidemiology but to investigate the genotype and phenotype of diverse populations. Through a comprehensive literature search, Mbi Feh and colleagues (p. 337) analyzed the frequency of CNS tumors in the entire African continent based on 26 studies available. Nigeria, Egypt, and Uganda report the highest number of cases but results may be underestimated due to limited health infrastructure in low-income countries. The authors underline the lack of a central brain tumor registry in Africa, critically needed to move the field forward.
Last but not least, in a poignant cross-sectional survey of 105 bereaved families from Kyoto University Hospital, Chikada and colleagues (p. 345) emphasize the importance of end-of-life discussions (EOLDs), timing, and extent of patient involvement. Although the majority of respondents felt early initiation of EOLDs with patients and families was appropriate, they found that patient goals and priorities were discussed in only 28% of EOLDs.
As we reflect on the entire spectrum of care for our brain tumor patients and their families, we continue as a community to provide innovative research toward improving best practice and comprehensive care.