Improving Survivorship and Health-related Quality of Life in Patients With Primary Brain Tumours

Hypothesis Adult survivors of primary, non-pituitary brain tumours have an increased risk of hypopituitarism and experience impairments in HR-QOL and neuropsychological functioning. We hypothesise that diagnosis of these deficiencies and the subsequent active replacement of pituitary hormone deficits (as part of routine clinical care) will lead to an improvement in neuropsychological functioning and HR-QOL in adult survivors of primary brain tumours.

Objectives:

1. To examine the impact of radiotherapy on pituitary hormone function in adult survivors of primary, non-pituitary brain tumours.
2. To assess HR-QOL and neuropsychological functioning in adult survivors of primary, non-pituitary brain tumours.

3. To examine the impact of pituitary hormone replacement and optimisation (as part of routine clinical care) on HR-QOL and neuropsychological functioning in adult survivors of primary, non-pituitary brain tumours.

   Methods

   Study Design \& Setting:

   A cross-sectional study will be conducted in the RCSI clinical research centre, located on the Beaumont Hospital campus. The study will be conducted over three years from September 2023 to September 2025.

   Participants:

   The study population will consist of adults who have previously received cranial radiotherapy for a primary, non-pituitary brain tumour.

   Patient Recruitment:

   • Participants will be identified in Professor Clare Faul's, Dr David Fitzpatrick's and Dr Nazmi ElBeltagi's clinic in St Luke's Radiation Oncology Centre at Beaumont Hospital.
   • Patients will be approached by the research fellow during routine clinical consultations.
   • The nature, purpose, benefits and risks of the study will be discussed with potential participants. They will be given the opportunity ask questions about the study. The patients' medical history will be reviewed to ensure they meet the study inclusion criteria.
   • Patients will be given a patient information leaflet and asked to read this at home.
   • The research fellow will follow up with a phone call within 72 hours and offer patients the opportunity to participate in the study. A first research study visit will be arranged for those who agree to participate.

   Study Procedure

   Study Visit One:

   Consent:

   • Participants will be asked to attend study visit one in the RCSI Clinical Research Centre (CRC).
   • Participants will be given the opportunity to ask questions and to have any concerns addressed by the research team.
   • They will then be asked by the research fellow to provide their informed consent to (i) participate in the study and (ii) allow their data to be processed by the research team.

   Assessments:

   • Participants will be asked to fast from midnight the previous evening as per Beaumont Hospital protocol for dynamic testing of pituitary function.
   • They will be advised to take their usual medications with a small sip of water on the morning of the test.
   • The research fellow will assess the participants' blood pressure, height, weight and body composition (using the bioimpedance technique with the Tanita® BC-418 segmental body composition analyser).
   • Women of childbearing age will be questioned to ensure they are not pregnancy. If there is any uncertainty, they will be asked to take a pregnancy test.

   Baseline blood sampling:

   • A fasting 9am blood sample will be taken to assess pituitary function [ACTH, cortisol, FSH, LH, oestrogen (in females), testosterone (in males), sex hormone binding globulin, thyroid function tests, prolactin, IGF-1] and metabolic phenotype [full blood count, renal/ liver profile, cholesterol, HbA1c, homeostatic model assessment for insulin resistance (HOMA-IR)].

   Dynamic testing of pituitary function:

   • Patients will undergo dynamic testing of the ACTH and growth hormone axes using a glucagon stimulation test (GST).
   • The Beaumont Hospital GST protocol will be followed throughout.
   • A cannula will be inserted into the patient's forearm. Baseline serum samples for glucose, cortisol and growth hormone will be drawn from the cannula.
   • Glucagon will then be injected into the lateral aspect of the mid quadriceps (vastus lateralis) by the research nurse/ fellow. A glucagon dose of 1mg will be used in adults less than 90kg and 1.5mg in adults greater than 90kg.
   • Serum samples will be drawn from the cannula for glucose, cortisol and GH at 90, 120, 150 and 180 minutes.

   Neuropsychological assessment:

   • A battery of neuropsychological tests to assess for cognitive, memory, language and visuo-spatial dysfunction will be performed. These tests are fully validated and have been widely used in the research setting.
   • Cognitive dysfunction: Stroop colour-word test, phonemic verbal fluency, backward digital span
   • Language dysfunction: Boston naming test
   • Memory dysfunction: Logical memory, verbal paired associate and auditory delayed recognition task
   • Visuo-spatial dysfunction Rey-osterrieth complex figure test

   HR-QOL assessment:

   • Participants' HR-QOL will be measured using extensively validated assessment tools including the Short Form-36 (SF-36), Nottingham Health Profile and EQ-5D-5L.
   • The SF-36 is a widely used HR-QOL assessment tool consisting of 4 physical and 4 mental domains which are combined to give physical and mental component summary scores. The Nottingham Health Profile consists of two components; a subjective assessment of their general health and the impact on their activities of daily living. The EQ-5D-5L assesses level of difficulty with five aspects of daily living.
   • The research fellow will ask participants the assessment questions, document their responses and calculate the overall scores (where necessary).

   Study visit one is then complete.

   Review of Pituitary Assessments:

   • Baseline and dynamic test results will be reviewed after study visit one by the principal investigator and research fellow.
   • Selected patients whose GST identifies cortisol deficiency will be asked to attend the RCSI-CRC for an additional study visit to undergo a short synacthen test (SST). This is to confirm adrenal insufficiency as the GST has a false positive rate of approximately 20% for ACTH deficiency.
   • A SST involves a cannula being inserted into the forearm and baseline serum samples for ACTH and cortisol being taken. Synacthen® 250mcg will then be administered intravenously. A second cortisol sample will be taken after 30 mins.
   • Patients diagnosed with hypopituitarism will have their hormone deficits replaced as per best clinical practice by the endocrinology service. In the event of a patient being diagnosed with growth hormone deficiency, growth hormone replacement will be discussed with the radiation oncology team is not appropriate in all types of brain tumours.
   • Patients will be counselled on the diagnosis of hypopituitarism and any questions or concerns addressed.
   • Follow up blood tests may be required to assess the adequacy of pituitary hormone replacement, as per routine clinical practice.

   Treatment History and Radiotherapy Dose Calculation:

   • The patient's tumour histology, staging and neurosurgical treatment history will be obtained from their physical and electronic medical records in Beaumont Hospital and St Luke's Centre Radiation Oncology at Beaumont Hospital.
   • The type, dose, dose per fraction of radiotherapy received by the hypothalamus/ pituitary (which will be estimated from planning scans using the biological equivalent dose) will be recorded in collaboration with Professor Clare Faul, Dr David Fitzpatrick's and Dr Nazmi ElBeltagi's in St Luke's Radiation Oncology Centre at Beaumont Hospital.

   Study Visit Two • All study participants will be asked to return for a second study visit, four months after their first visit.

   • Repeat measurements will be taken including:

     o Weight, blood pressure and body composition.

     o Fasting 9am blood samples to assess baseline pituitary function and metabolic phenotype [as previously outlined].

   • All patients will have their HR-QOL and neuropsychological functioning reassessed to measure the change over the course of the study.

   End of study

   • Patients diagnosed with hypopituitarism during the study will be followed up in the endocrinology clinic in Beaumont Hospital (as is the case for all patients with hypopituitarism).