CHICAGO — Patients suffering from depression at the time of malignant brain astrocytoma surgery had significantly reduced survival compared with nondepressed patients in a retrospective analysis of 1,052 patients.
Although no causative association can be inferred because of the study's retrospective design, recognizing and treating preoperative depression could maximize survival in patients with malignant brain tumors, Dr. Alfredo Quiñones-Hinojosa said at the annual meeting of the American Association of Neurological Surgeons.
Currently, patient age, tumor grade, and functional status are known preoperative prognostic indicators of survival. Identification of any reversible comorbidity would be important, as malignant astrocytoma, also known as glioma or glioblastoma multiforme, typically results in death in about 1 year, even with the latest, most effective therapies.
Researchers at Johns Hopkins University in Baltimore, led by Dr. Matthew J. McGirt, analyzed the outcomes of 1,052 patients with malignant astrocytoma who underwent surgery from 1995 to 2006.
Of these patients, 605 underwent primary resection, 410 underwent secondary resection, and 37 had a biopsy only. Excluding the biopsies, 213 tumors were World Health Organization grade III and 802 tumors were grade IV.
A total of 204 patients received subtotal resection, 274 received adjuvant therapy, and 136 required subsequent resection.
Only 49 patients (5%) who were found to be taking antidepressant medication for clinical depression at the time they underwent surgery met the study's definition of having depression. All demographic and clinical characteristics were similar between the two groups, said Dr. Quiñones-Hinojosa. Their mean age was 51 years and median preoperative Karnofsky Performance Scale (KPS) score was 80. Among survivors, the median follow-up was 12 months (range 3–18 months).
In a Kaplan Meier analysis, patients with depression had more than a 40% increase in the relative risk of mortality compared with nondepressed patients (relative risk 1.41), regardless of KPS, WHO tumor grade, patient age, or clinical presentation. This association was independent of extent of resection and postoperative treatment with either adjuvant temozolomide chemotherapy or Gliadel wafer use, Dr. Quiñones-Hinojosa said.
Median survival was 7 months among patients with depression, vs. 11 months in those without depression.
At 2 years post surgery, 5% of patients with depression were alive, compared with 23% of nondepressed patients. The difference was significant, he said.
Dr. Quiñones-Hinojosa acknowledged that the investigators could not be certain that the patients' depression was not a response to the recent diagnosis of a terminal disease. In addition, many patients with clinical depression may have been undiagnosed and unmedicated, lowering the sensitivity of the classification scheme.
Discussant Stephen B. Tatter, a neurosurgery professor at Wake Forest University, Winston-Salem, N.C., said treating depression in this patient population is important as it might influence a variety of patient decisions, particularly when to stop treatment. “We don't want just to prolong life but to provide quality that is acceptable to patients,” Dr. Tatter said.