Supportive Care in Cancer

, Volume 19, Issue 11, pp 1849–1855

Prospective comparison of the prognostic utility of the Mini Mental State Examination and the Montreal Cognitive Assessment in patients with brain metastases

  • Robert Olson
  • Scott Tyldesley
  • Hannah Carolan
  • Maureen Parkinson
  • Taruna Chhanabhai
  • Michael McKenzie
Original Article

Abstract

Purpose

The Mini Mental State Examination (MMSE) is the most commonly chosen cognitive screening test (CST) in clinical practice and trials, despite its poor sensitivity, likely because of its prognostic utility. The Montreal Cognitive Assessment (MoCA) is an alternative CST, is more sensitive, and is better correlated with quality of life.

Methods

Sixty-five patients with brain metastases were prospectively accrued and completed both the MMSE and MoCA. We compared the prognostic utility of both CSTs.

Results

The mean age of patients was 59.0 years; 42.0% had single brain metastases. Median MMSE and MoCA scores were 28 and 22, respectively. Median overall survival (OS) was worse for individuals with below- versus above-average MMSE scores (10.4 versus 36.3 weeks, p = 0.007). Likewise, below- versus above-average MoCA scores were prognostic (6.3 versus 50.0 weeks, p < 0.001). Median OS for MoCA scores <22, 22–26, and >26 were 6.3, 30.9, and 61.7 weeks, respectively (p < 0.001). On multivariable analysis, below-average MMSE scores were no longer prognostic (hazard ratio [HR] = 1.71 [0.90–3.26]), though below-average MoCA scores were (HR = 5.44 [2.70–10.94]). Furthermore, the MoCA demonstrated superior prognostic utility when comparing multivariable models with continuous CST scores.

Conclusions

Our results indicate that the MoCA is a superior prognostic indicator than the MMSE. Furthermore, given its superior sensitivity and better correlation with quality of life, the MoCA should be preferentially chosen in clinical practice and trials.

Keywords

Montreal Cognitive Assessment Mini Mental State Examination Prognosis Brain metastases Cognition 

References

  1. 1.
    Klein M, Taphoorn MJB, Heimans JJ, van der Ploeg HM, Vandertop WP, Smit EF, Leenstra S, Tulleken CAF, Boogerd W, Belderbos JSA, Cleijne W, Aaronson NK (2001) Neurobehavioral status and health-related quality of life in newly diagnosed high-grade glioma patients. J Clin Oncol 19:4037–4047PubMedGoogle Scholar
  2. 2.
    Murray KJ, Scott C, Zachariah B, Michalski JM, Demas W, Vora NL, Whitton A, Movsas B (2000) Importance of the mini-mental status examination in the treatment of patients with brain metastases: a report from the radiation therapy oncology group protocol 91-04. Int J Radiat Oncol Biol Phys 48:59–64PubMedCrossRefGoogle Scholar
  3. 3.
    Weitzner MA, Meyers CA (1997) Cognitive functioning and quality of life in malignant glioma patients: a review of the literature. Psychooncology 6:169–177PubMedCrossRefGoogle Scholar
  4. 4.
    Meyers CA, Hess KR (2003) Multifaceted end points in brain tumor clinical trials: cognitive deterioration precedes MRI progression. Neuro-oncology 5:89–95PubMedGoogle Scholar
  5. 5.
    Meyers CA, Smith JA, Bezjak A, Mehta MP, Liebmann J, Illidge T, Kunkler I, Caudrelier J, Eisenberg PD, Meerwaldt J, Siemers R, Carrie C, Gaspar LE, Curran W, Phan S, Miller RA, Renschler MF (2004) Neurocognitive function and progression in patients with brain metastases treated with whole-brain radiation and motexafin gadolinium: results of a randomized phase III trial. J Clin Oncol 22:157–165PubMedCrossRefGoogle Scholar
  6. 6.
    Meyers CA, Brown PD (2006) Role and relevance of neurocognitive assessment in clinical trials of patients with cns tumors. J Clin Oncol 24:1305–1309PubMedCrossRefGoogle Scholar
  7. 7.
    Hegi ME, Diserens A, Gorlia T, Hamou M, de Tribolet N, Weller M, Kros JM, Hainfellner JA, Mason W, Mariani L, Bromberg JEC, Hau P, Mirimanoff RO, Cairncross JG, Janzer RC, Stupp R (2005) MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 352:997–1003. doi:10.1056/NEJMoa043331 PubMedCrossRefGoogle Scholar
  8. 8.
    Meyers CA, Hess KR, Yung WKA, Levin VA (2000) Cognitive function as a predictor of survival in patients with recurrent malignant glioma. J Clin Oncol 18:646–650PubMedGoogle Scholar
  9. 9.
    Chang EJ, Wefel JS, Maor MH, Hassenbush SJ III, Mahajan A, Lang FF, Woo SY, Mathews LA, Allen PK, Shiu AS, Meyers CA (2007) A pilot study of neurocognitive function in patients with one to three new brain metastases initially treated with stereotactic radiosurgery alone. Neurosurg 60:277–284Google Scholar
  10. 10.
    Olson R, Parkinson M, McKenzie M (2010) Selection bias introduced by neuropsychological assessments. Can J Neurol Sci 37:264–268PubMedGoogle Scholar
  11. 11.
    Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psych Res 12:189–198CrossRefGoogle Scholar
  12. 12.
    Brown PD, Buckner JC, O’Fallon JR, Iturria NL, Brown CA, O’Neill BP, Scheithauer BW, Dinapoli RP, Arusell RM, Curran WJ, Abrams R, Shaw EG (2003) Effects of radiotherapy on cognitive function in patients with low-grade glioma measured by the folstein mini-mental state examination. J Clin Oncol 21:2519–2524PubMedCrossRefGoogle Scholar
  13. 13.
    Meyers CA, Wefel JS (2003) The use of the mini-mental state examination to assess cognitive functioning in cancer trials: no ifs, ands, buts, or sensitivity. J Clin Oncol 21:3557–3558PubMedCrossRefGoogle Scholar
  14. 14.
    Olson R, Ellwood A, Parkinson M, Carolan H, Ferguson K, Iverson G, McKenzie M (2009) Canadian Association of Psychosocial Oncology Annual Conference, Vancouver, British Columbia. April 1-4, 2009. Abstract ID: B246Google Scholar
  15. 15.
    Shibamoto Y, Baba F, Oda K, Hayashi S, Kokubo M, Ishihara S, Itoh Y, Ogino H, Koizumi M (2008) Incidence of brain atrophy and decline in mini-mental state examination score after whole-brain radiotherapy in patients with brain metastases: a prospective study. Int J Radiat Oncol Biol Phys 72:1168–1173. doi:10.1016/j.ijrobp.2008.02.054 PubMedCrossRefGoogle Scholar
  16. 16.
    Pereira J, Hanson J, Bruera E (1997) The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 79:835–842PubMedCrossRefGoogle Scholar
  17. 17.
    Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H (2005) The montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriat Soc 53:695–699PubMedCrossRefGoogle Scholar
  18. 18.
    Olson RA, Chhanabhai T, McKenzie M (2008) Feasibility study of the Montreal Cognitive Assessment (MoCA) in patients with brain metastases. Support Care Cancer 16:1273–1278. doi:10.1007/s00520-008-0431-3 PubMedCrossRefGoogle Scholar
  19. 19.
    Olson RA, Iverson G, Parkinson M, Carolan H, Ellwood A, McKenzie M (2009) Investigation of cognitive screening measures in patients with brain tumors: diagnostic accuracy and correlation with quality of life. J Clin Oncol (Meeting Abstracts) 27:e13000Google Scholar
  20. 20.
    Gauthier S, Reisberg B, Zaudig M, Petersen RC, Ritchie K, Broich K, Belleville S, Brodaty H, Bennett D, Chertkow H, Cummings JL, de Leon M, Feldman H, Ganguli M, Hampel H, Scheltens P, Tierney MC, Whitehouse P, Winblad B (2006) Mild cognitive impairment. Lancet 367:1262–1270PubMedCrossRefGoogle Scholar
  21. 21.
    Akaike H (1974) A new look at the statistical model identification. IEEE Trans Automat Contr 19:716–723CrossRefGoogle Scholar
  22. 22.
    Posada D, Buckley TR (2004) Model selection and model averaging in phylogenetics: advantages of Akaike information criterion and Bayesian approaches over likelihood ratio tests. Syst Biol 53:793–808. doi:10.1080/10635150490522304 PubMedCrossRefGoogle Scholar
  23. 23.
    Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, McKenna WG, Byhardt R (1997) Recursive partitioning analysis (RPA) of prognostic factors in three radiation therapy oncology group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 37:745–751. doi:10.1016/S0360-3016(96)00619-0 PubMedCrossRefGoogle Scholar
  24. 24.
    Sherman AM, Jaeckle K, Meyers CA (2002) Pretreatment cognitive performance predicts survival in patients with leptomeningeal disease. Cancer 95:1311–1316PubMedCrossRefGoogle Scholar
  25. 25.
    Patchell RA, Tibbs PA, Regine WF, Dempsey RJ, Mohiuddin M, Kryscio RJ, Markesbery WR, Foon KA, Young B (1998) Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 280:1485–1489. doi:10.1001/jama.280.17.1485 PubMedCrossRefGoogle Scholar
  26. 26.
    Liu IY, Lacroix AZ, White LR, Kittner SJ, Wolf PA (1990) Cognitive impairment and mortality: a study of possible confounders. Am J Epidemiol 132:136–143PubMedGoogle Scholar
  27. 27.
    Bezjak A, Adam J, Barton R, Panzarella T, Laperriere N, Wong CS, Mason W, Buckley C, Levin W, McLean M, Wu JS, Sia M, Kirkbride P (2002) Symptom response after palliative radiotherapy for patients with brain metastases. Eur J Cancer 38:487–496PubMedCrossRefGoogle Scholar
  28. 28.
    Andrews DW, Scott CB, Sperduto PW, Flanders AE, Gaspar LE, Schell MC, Werner-Wasik M, Demas W, Ryu J, Bahary J, Souhami L, Rotman M, Mehta MP, Curran J, Walter J (2004) Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 363:1665. doi:10.1016/S0140-6736(04)16250-8 PubMedCrossRefGoogle Scholar
  29. 29.
    Regine WF, Scott C, Murray K, Curran W (2001) Neurocognitive outcome in brain metastases patients treated with accelerated-fractionation vs. accelerated-hyperfractionated radiotherapy: an analysis from Radiation Therapy Oncology Group Study 91-04. Int J Radiat Oncol Biol Phys 51:711–717PubMedCrossRefGoogle Scholar
  30. 30.
    Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJB, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO, the European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups and the National Cancer Institute of Canada Clinical Trials Group (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987–96. doi:10.1056/NEJMoa043330 PubMedCrossRefGoogle Scholar
  31. 31.
    Curran WJ Jr, Scott CB, Horton J, Nelson JS, Weinstein AS, Fischbach AJ, Chang CH, Rotman M, Asbell SO, Krisch RE, Nelson DF (1993) Recursive partitioning analysis of prognostic factors in three radiation therapy oncology group malignant glioma trials. J Natl Cancer Inst 85:704–710. doi:10.1093/jnci/85.9.704 PubMedCrossRefGoogle Scholar
  32. 32.
    Sperduto PW, Berkey B, Gaspar LE, Mehta M, Curran W (2008) A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1, 960 patients in the RTOG database. Int J Radiat Oncol Biol Phys 70:510–514. doi:10.1016/j.ijrobp.2007.06.074 PubMedCrossRefGoogle Scholar
  33. 33.
    Sperduto PW, Chao ST, Sneed PK, Luo X, Suh J, Roberge D, Bhatt A, Jensen AW, Brown PD, Shih H, Kirkpatrick J, Schwer A, Gaspar LE, Fiveash JB, Chiang V, Knisely J, Sperduto CM, Mehta M (2010) Diagnosis-specific prognostic factors, indexes, and treatment outcomes for patients with newly diagnosed brain metastases: a multi-institutional analysis of 4, 259 patients. Int J Radiat Oncol Biol Phys 77:655–661. doi:10.1016/j.ijrobp.2009.08.025 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Robert Olson
    • 1
    • 2
  • Scott Tyldesley
    • 1
    • 2
  • Hannah Carolan
    • 1
    • 2
  • Maureen Parkinson
    • 1
    • 3
  • Taruna Chhanabhai
    • 1
  • Michael McKenzie
    • 1
    • 2
  1. 1.Vancouver Cancer CentreBC Cancer AgencyVancouverCanada
  2. 2.Division of Radiation Oncology and Developmental RadiotherapeuticsUniversity of British ColumbiaVancouverCanada
  3. 3.Fraser Valley Cancer CentreBC Cancer AgencyVancouverCanada

Personalised recommendations