Introduction: There has been a definite trend toward conservatism in North America regarding the
management of small and medium-size vestibular schwannomas (VS). Newly diagnosed tumors
in minimally symptomatic patients are often observed with serial imaging and treatment
is deferred until there is documented tumor growth or progressive symptoms. There
is concern this approach could result in the development of irreversible bothersome
symptoms or neurologic deficits that could have been avoided with early proactive
treatment, or worsened overall outcome from having to treat a larger tumor after growth
during follow-up. The purpose of this analysis was to assess quality of life in VS
patients who underwent a period of observation prior to eventual treatment compared
with a cohort who underwent upfront treatment.
Methods: Patients seen at a tertiary referral center as well as patients enrolled through
the Acoustic Neuroma Association (ANA) completed the Penn Acoustic Neuroma Quality
of Life (PANQOL) survey at diagnosis, then every 6 months for a year, then annually.
Four cohorts were examined: patients who underwent surgery within 1 year of diagnosis,
patients who underwent radiosurgery within 1 year of diagnosis, both considered the
upfront cohorts, and patients who underwent surgery ≥ 1 year after diagnosis and patients
who underwent radiosurgery ≥ 1 year after diagnosis, constituting the delayed treatment
group. Outcomes studied included the PANQOL domain scores. Covariates of interest
included age, sex, source of data (ANA vs. our center), tumor size and time from treatment.
Associations of time from diagnosis to treatment with PANQOL scores were further evaluated
using linear regression models.
Results: A total of 588 patients (418 had surgery, 170 received radiation) treated between
2000 and 2017 were eligible for analysis. Among those treated with surgery, 366 were
treated upfront and 52 delayed; 119 radiation patients had upfront treatment and 51
had delayed treatment. Patients in the surgery cohorts treated in a delayed fashion
had overall statistically better scores on the facial dysfunction, energy, pain and
total PANQOL subscales. There was no difference in PANQOL scores comparing the upfront
and delayed radiation groups. However, on multivariable analysis, there was no statistical
difference for either surgery or radiation comparing upfront versus delayed treatment
in the PANQOL anxiety, facial dysfunction, general health, balance, hearing, energy
and total subscales. Patients treated in a delayed fashion in the surgery group had
statistically better pain subscale scores.
Conclusion: Delaying VS treatment ≥ 1 year until tumor growth is documented, further symptomatology
develops or the patient makes a definitive decision to proceed with treatment is safe
and does not result in a demonstrable decline in quality of life.
