Does a Period of Observation before Treatment Lead to Worse Quality of Life in Vestibular Schwannoma Patients?

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.

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