Brain tumor surgery, depression and survival

Depression is one of the most common psychiatric disorders in the world today. It is estimated that in any given year, 5 to 9 percent of the US population is clinically depressed. Studies have shown that depression negatively affects the immunological system, alters the body's response to malignancy, and may influence behavioral factors that impact recovery from disease.

Psychiatric symptoms, including depression, often occur in patients with malignant brain tumors. Research has linked these psychiatric symptoms to tumor location and extent of the disease. In the past decade, studies have suggested that there is a relationship between depression and poor outcome in patients undergoing craniotomy for brain lesions as a whole. This association has also been reported after surgical therapy of non-neurological disease.

Malignant brain astrocytoma, also known as glioma or glioblastoma multiforme (GBM), is the most commonly diagnosed primary brain tumor. Glioma is a devastating brain cancer that typically results in death in about one year. The most effective therapies introduced over the past three decades have improved median survival by an average of only three months. Thus, identification of any reversible morbidity factors, which could potentially improve survival rates, such as depression, is of paramount importance.

Researchers at Johns Hopkins School of Medical in Baltimore analyzed the outcome of 1,052 patients who underwent surgical resection and radiotherapy for glioma over a 10-year period. The results of this study, Association of Preoperative Depression and Survival after Resection of Malignant Brain Astrocytoma, will be presented by Matthew J. McGirt, MD, 4:01 to 4:15 p.m. on Monday, April 28, 2008, during the 76th Annual Meeting of the American Association of Neurological Surgeons in Chicago. Co-authors are Frank J. Attenello, MS, Henry Brem, MD, Kaisorn L. Chaichana, BS, Muraya Gathinji, MS, Alessando Olivi, MD, Alfredo Quinones-Hinojosa, MD, Khoi Than, MD, and Jon D. Weingart, MD.

Currently, patient age, tumor grade, and functional status remain the known preoperative prognostic indicators of survival. "The goal of this research was to determine whether malignant glioma patients with a preoperative diagnosis of depression have a lower survival rate irrespective of treatment modality or degree of disability," stated Dr. McGirt. The research encompassed the following methodology:

• The surgical management of 1,052 consecutive patients with malignant astrocytomas (WHO grade 3 or 4) performed at a single institution from 1995 to 2006 were reviewed.
• Of these 1,052 surgical procedures, 605 (58 percent) were for primary resection, 410 (39 percent) were for secondary resection, and 37 (3.5 percent) were for biopsy.
• For the purpose of this study, only patients taking anti-depressant medication for clinical depression at the time of surgery were classified as having "depression." This equated to 49 patients (5 percent) of the total cases.

"Interestingly, all demographic and clinical characteristics did not differ between depressed and non-depressed patients. However, patients already depressed at diagnosis had a significantly reduced survival compared to non-depressed patients," stated Dr. McGirt. This was most notable in survival rates beyond 12 months, suggesting that depression may be most detrimental for long-term survival." Detailed findings included the following:

• Regardless of patient functional status prior to surgery (KPS score), WHO Grade III vs. Grade IV tumor, patient age, or clinical presentation, those with depression had more than a 40 percent increase in the relative risk of mortality versus non-depressed patients. This association was independent of degree of resection or postoperative treatment modality.
• At 12 months post surgery, 41 percent of non-depressed patients were alive, while only 15 percent of depressed patients were alive.
• At 20 months post surgery, there were no depressed patients still alive, while 21 percent of non-depressed patients were still alive.

Although patients classified as depressed were diagnosed prior to neurosurgical evaluation in most cases, it is uncertain that their depression was not a response to the recent diagnosis of a terminal disease. Many patients with clinical depression may have been undiagnosed and off medication, lowering the sensitivity of the classification scheme and resulting in inclusion of clinically depressed patients in the non-depressed cohort. Further research investigating the survival of patients with non-medicated versus medicated depression is warranted to address these variables.

"In conclusion, this study does indicate strong evidence that there is a connection between the existence of depression and survival rates in patients with malignant brain glioma. Recognizing and treating depression preoperatively should be looked at more closely as a means to maximize survival in the treatment of malignant brain tumors," remarked Dr. McGirt.

Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 7,200 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system, including the spinal column, spinal cord, brain and peripheral nerves.