Trading mental and physical health in vestibular schwannoma treatment decision

Abstract

Objective: Observation, radiotherapy and surgery are treatment options in vestibular schwannomas (VS). Decision making differs between centers and is usually based on tumor characteristics (e.g., size) and the expected physical health (PH) outcome (i.e., hearing and facial function). However, mental health (MH) is often under-reported. The objective of the present study was to ascertain the impact of VS treatment on PH and MH.

Methods: PH and MH were assessed in a prospective cross-sectional study including 226 patients with unilateral sporadic VS before and after surgical removal (SURG). Quality-of-life (QoL) was estimated by self-rating questionnaires: general Short-Form Health Survey (SF-36), Penn Acoustic Neuroma Quality-of-Life Scale (PANQOL), Dizziness Handicap Inventory (DHI), Hearing Handicap Inventory (HHI), Tinnitus Handicap Inventory (THI), and Facial Disability Index (FDI). QoL changes over time as well as predictive factors were accessed by multivariate analyses of covariance (MANCOVA).

Results: In total, 173 preoperative and 80 postoperative questionnaires were analyzed. There was a significant PH deterioration related to facial function (FDI, PANQOL-face) after surgery. In line with facial rehabilitation, however, FDI improved within the first five years after surgery and did not differ compared to the preoperative patient cohort, eventually. In contrast, MH (i.e., PANQOL-anxiety) and general health (i.e., PANQOL-GH) improved with surgery and correlated with the extent-of-resection.

Conclusion: Physical and mental health is significantly influenced by VS surgery. While PH might decrease after surgery, MH potentially increases when patient is cured. Practitioners should take MH into account before advising an incompletely VS treatment (e.g., subtotal resection, observation or radiosurgery).

Keywords: extent of resection (EOR); mental health; physical health; quality of life; vestibular schwannoma (VS).

Figure 1

Flow chart of patients’ cohort. DHI, Dizziness Handicap Inventory; FDI, Facial Disability Index; HHI, Hearing Handicap Inventory; PANQOL, Penn Acoustic Neuroma Quality-of-Life Scale; SF-36: Short-Form Health Survey 36.

Figure 2

Changes of physical (PH) mental health (MH) after surgery. While SF36 (A) did not depict any surgery-related changes in QoL, PANQOL (B) showed a decline of PH (related to the facial function, PAN-FACE) after surgery. At the same time, surgery improved MH related to anxiety (PAN-ANX) and general health (PAN-GH). Multivariate analysis also depicted an effect of gender (C) and tumor size (D) on QoL. Bars in (C, D) demonstrate data from both, pre- and postoperatively. PANQOL, Penn Acoustic Neuroma Quality-of-Life Scale; PAN-ANX, PANQOL anxiety; PAN-ENGY, PANQOL energy; PANQOL-GH, PANQOL general health; PAN-FACE, PANQOL facial; PAN-BAL, PANQOL balance; PAN-HEAR, PANQOL hearing; PAN-PAIN, PANQOL pain; SF36-PF: SF36 physical function; SF36-RP: SF36 role physical; SF36-BP: SF36 bodily pain; SF36-GH: SF36 general health; SF36-VT: SF36 vitality; SF36-SF: SF36 social functioning; SF36-RE: SF36 role emotional; SF36-MH: SF36 mental health. Significance is indicated by an asterisk (*; p<0.05, MANOVA).

Figure 3

Symptom-specific quality of life (QoL) over time. PAN-FACE (A) and FDI scores (B) improved after surgery in line with the facial rehabilitation (see distribution of H&B scores in the inlay). After 5 years, PAN-FACE and FDI differed significant in comparison to the preoperative patient cohort. In contrast, neither DHI, THI and HHI (C) nor PAN-ANX/PAN-GH (D) changed during follow-up. The numbers under the pie charts in (B) indicate the total number of patients in each time period. DHI, dizziness handicap inventory; THI, tinnitus handicap inventory; HHI, hearing handicap inventory; FDI-PF, Facial disability index - physical function; FDI-SF, Facial disability index – social function; TSD, time-since-diagnosis; TSS, time-since-surgery. Significance is highlighted by an asterisk (*; p<0.05, Dunn’s test, corrected).

Figure 4

Relationship between mental health and extent-of-resection (EOR). Both PAN-ANX (A) and PAN-GH (B) correlated with EOR. Patients with significant residual tumor (partial resection, PR) claimed higher level of anxiety and a reduced level of general health in comparison to patients undergoing a gross total resection (GTR) or subtotal resection (STR). Significance is highlighted by an asterisk (*; p<0.05, Dunn’s test, corrected).