Every day, Lisa Kahalley, PhD, works to improve the lives of children with brain tumors through research that integrates with clinical care.
As a pediatric psychologist integrated in Texas Children’s Hospital neuro-oncology program in Houston, Kahalley — an associate professor of pediatrics in the section of psychology at Baylor College of Medicine — and her team have performed hundreds of neurocognitive evaluations on children with brain tumors. The goal is to provide recommended post-treatment surveillance per clinical guidelines and to identify areas of concern that require intervention.
And as a researcher funded by the National Cancer Institute, Kahalley is gathering data on these patients to inform future treatment.
One patient, followed by Kahalley’s team for five years post-treatment, experienced sluggish processing that was identified on testing. Annual evaluation reports provided detailed recommendations for classroom accommodations, such as extended time on classwork and tests, which enabled the patient to optimize her learning and academic performance.
"Today, she’s in college, preparing for a career as a medical professional," Kahalley says.
Such success stories can be attributed to the program’s collaborative approach to patient care, says M. Douglas Ris, PhD, chief of psychology at Texas Children’s Hospital. Working as part of an integrated team of neuro-oncologists, clinical psychologists, neurosurgeons, nurses and other health-care professionals, Kahalley has achieved "an uncommon synergy between patient care and clinical research" to improve patient outcomes and advance this field of study.
"It’s a great example of how psychological outcomes are informing modern treatments of childhood cancer, thereby contributing to the quality of life of survivors," Ris says.
Targeted therapy
Brain tumors are the second most common cancer in children, with more than 4,000 U.S. children and teenagers diagnosed each year, according to the American Cancer Society. Even if a tumor is benign, it may need treatment because it can grow to press on sensitive brain areas or may become malignant over time. Treatments often take a multidisciplinary approach and typically include some combination of neurosurgery, radiation therapy, chemotherapy and immunotherapies, says Murali Chintagumpala, MD, who co-directs the neuro-oncology program at Texas Children’s Cancer Center.
Kahalley’s research team includes four master’s-level researchers specializing in neurocognitive assessment. To ensure they stay abreast of how study participants are doing day to day and understand their evolving treatment plans, team members attend the neuro-oncology program’s weekly tumor board and rounds. During these meetings, team members discuss new or complicated cases, their treatment plans and the timing of presenting treatment options to patients and their families.
During treatment and for years afterward, Kahalley and her team assess patients for changes in neurocognitive and behavioral functioning and make recommendations to address areas of concern. Those recommendations may be for school services or accommodations or for therapy or behavioral interventions, often with a pediatric psychologist working with the Texas Children’s Cancer Center. An evaluation may also lead the psychologists to refer a patient for physical or occupational therapy or consultation with another medical team, including clinicians from psychiatry, neurology or ophthalmology.
The benefit of an integrated environment is that it enables patients to have access to all of the professional resources they need on one campus. The Cancer Center, for example, is just two floors down from the Psychology Service, where Kahalley conducts her evaluations and where most of the clinical psychologists practice.
"This close proximity makes it easier for patients and families to navigate between professionals to ensure we are able to provide the best care possible to our patients," she says.
Kahalley and her team also work closely with the pediatric psychologists who provide clinical care to brain tumor patients and their families. If a mood or behavioral issue arises during the patient’s neurocognitive evaluation—such as depression, anger or difficulty adhering to treatment—the patient can immediately be referred for further assessment, says Nicole Schneider, PsyD, an assistant professor of pediatrics at Baylor College of Medicine and a pediatric health psychologist at Texas Children’s Hospital.
"Most of the kids I see are having difficulties with issues related to cancer and its demands," Schneider says. "For example, I have seen many kids and teenagers who are frustrated that they have restrictions due to their cancer diagnosis and treatment, such as not being able to attend school and see friends, or not being able to play the sports they once enjoyed."
Kahalley notes that, while many of the patients she sees through her research exhibit favorable outcomes after treatment, some experience persistent challenges.
"A lot of these kids are very aware of those changes in themselves and know that they don’t have the ability that they used to have, and that’s really hard for them to process and to be OK with," she says. She also has seen some patients who experience bullying when they return to school after treatment. With regular evaluations, psychosocial concerns can be identified and addressed.
"We do our best to make sure that, whether it’s here or out in the community, patients are getting the support that they need," she says.
Research informing treatment
One increasingly popular treatment for children with brain tumors is proton beam radiation therapy (PBRT), which delivers the clinical radiation dose to the tumor or tumor bed while minimizing the dose to surrounding healthy brain tissue. The hope is that the reduced dose to healthy brain tissue made possible with PBRT will result in better neurocognitive outcomes after treatment. Patients at Texas Children’s Cancer Center receive PBRT at the MD Anderson Proton Therapy Center, one of only about 25 medical centers in the United States to offer the treatment.
"Preserving basic neurodevelopmental processes in these survivors translates into improved educational, occupational, psychosocial and quality-of-life outcomes for the growing numbers of survivors of pediatric brain tumors," says Ris.
When Kahalley started this line of research in 2010, there were only four proton centers in the United States. Since then, Kahalley has established one of the world’s largest cohorts of pediatric brain tumor patients.
Initial findings from this line of research are encouraging: In a retrospective comparison, Kahalley and colleagues found stable IQs in patients treated with PBRT, while IQs declined significantly among patients treated with conventional photon radiation therapy (Journal of Clinical Oncologyopens in new window, Vol. 34, No. 10, 2016). When the team examined attention, processing speed and executive functioning in a sample of survivors previously treated with PBRT, they found no evidence of cognitive impairment nearly four years post-treatment on average (Radiotherapy and Oncologyopens in new window, Vol. 124, No. 1, 2017). In October 2017, the team also presented early outcomes from a large, longitudinal study at the 49th Congress of the International Society of Pediatric Oncology in Washington, D.C., showing that up to five years after PBRT, patients exhibited stable IQs, working memories and normal processing speeds.
"Processing speed and working memory are areas that are particularly sensitive to radiation, so the fact that we haven’t seen signs of significant decline in those domains is very hopeful," Kahalley says.
As Kahalley and her team continue to research how radiation therapy affects brain development and, thereby, cognitive functioning, their findings could have an important impact on future treatment recommendations aimed at minimizing negative long-term impacts of radiation.
Kahalley says, "If we’re able to show that PBRT preserves cognitive functioning better than traditional radiation therapy approaches, it could lead more medical centers to make the investment in PBRT and increase it’s availability nationwide."
The Monitor’s "Adventures in Integrated Care" series explores the work psychologists are doing as members of interdisciplinary teams. If you have a story to share, contact editor Sara Martin at smartin@apa.org.
