How do brain tumours affect social cognition following brain tumour treatment?: A systematic review
- May 19
- 16 min read
Written by: Parishi K. Shah and Christina M. Sharkey
Edited by: Fahad Hassan Shah
Abstract
Introduction: Understanding the effect of brain tumors on social cognition in brain tumour survivors’ post-treatment is essential due to its implications on neurocognitive functioning, especially stress and memory. Stress, particularly oxidative stress, plays a critical role in cognitive decline, yet its specific influence on memory in this population remains understudied.
Method: This systematic review examines existing literature to examine changes in social cognition among adult brain tumour survivors. Inclusion criteria focused on studies published post-2018 involving survivors who had completed treatment. Data extraction included assessment methods, sample characteristics, and outcomes related to stress and memory.
Results: Preliminary trends indicate significant impairments in social cognition among brain tumour survivors. Studies highlight factors such as cranial radiation therapy’s effects on neural networks and the importance of rehabilitation on health-related quality of life (HRQOL) and functional independence. Social cognition, including emotion recognition, is particularly vulnerable.
Conclusions: The findings emphasize the necessity of targeted clinical interventions and rehabilitation strategies to mitigate stress-related cognitive deficits. Future research should explore longitudinal outcomes and develop standardized tools to assess social cognition in this population.
Keywords: brain tumor survivors, stress, memory, social cognition, systematic review, rehabilitation, cognitive deficits, oxidative stress, quality of life, cranial radiation therapy.
1. Introduction
Brain tumors, while relatively rare, are a significant cause of morbidity and mortality, often leading to long-term challenges even after treatment. The incidence of brain and central nervous system (CNS) cancers is 7.08% across all ages, with an incidence rate of 3.39% in adults. The treatment of brain tumors requires a highly personalized approach, taking into account tumor size, location, and the patient’s age, along with their overall health (Sharkey et al., 2021). Surgical resection is typically the first line of treatment, followed by radiation or chemotherapy as needed (Sharkey et al., 2021). Although medical advancements have improved survival rates, with a five-year survival rate of 36%, many survivors continue to experience long-term symptoms and complications (Sharkey et al., 2021). Treatments such as radiation and chemotherapy are known to cause neurocognitive impairments, particularly in areas such as memory, concentration, and executive function (Hardy et al., 2023).
One critical area of cognitive function that may be affected is social cognition. Social cognition involves the mental processes we use to perceive, interpret, and respond to social situations such as recognizing emotions in others and adjusting our behavior accordingly. These skills are essential for social integration and overall mental health (Pertz et al., 2024). Social cognition relies on a network of brain regions, including the temporal lobe and amygdala, which help us process emotions and understand social cues. Deficits in social cognition are common in various neurological conditions and can significantly impact the quality of life. For brain tumor survivors, social cognition impairments can affect their ability to maintain relationships and engage in daily social activities, further affecting their overall well-being. Studies suggest that both the tumor itself and the treatment methods, particularly radiation and chemotherapy, can impair social cognitive abilities (Pertz et al., 2024).
Stress is well researched for its negative effects on cognitive function, particularly memory. Chronic stress can lead to structural and functional changes in the brain, especially in areas like the hippocampus that are vital for memory consolidation (Watanabe et al., 2022). For brain tumor survivors, the stress of diagnosis, treatment, and recovery can aggravate memory problems, making it more difficult to concentrate, retain information, and process new experiences. Research has shown that stress can impair cognitive flexibility and executive function, which in turn can make it harder to manage daily tasks and remember key information. Moreover, stress is known to negatively impact social cognition, making it harder for individuals to interpret social cues and interact effectively with others. This combination of memory and social cognition difficulties is particularly pronounced in brain tumour survivors, affecting their ability to engage in social activities and maintain interpersonal relationships (Pertz et al., 2024).
Although significant research has been done on the cognitive impairments experienced by brain tumour survivors, particularly in the immediate aftermath of treatment, there is a lack of studies focusing on the long-term effects on social cognition. Most existing studies have mainly concentrated on the short-term impacts of treatment, leaving a gap in understanding how the cognitive functions are impacted years after treatment. There is also a lack of research on effective methods for assessing social cognition in these patients. Further research is needed to explore the complex relationship between brain tumor treatment and social cognition.
This systematic review seeks to examine the relationship between brain tumor treatment and social cognition. The primary hypothesis is that brain tumour survivors face impaired social cognition. A secondary objective is to evaluate the current methods used to assess social cognition in brain tumour survivors, assessing their effectiveness and the scope of measures utilized. By reviewing recent studies published after 2018, this review aims to fill the gaps in existing research and provide a comprehensive understanding of the current research on social cognition in brain tumour survivors.
The findings of this systematic review could have significant implications for improving the care and support available to brain tumour survivors. By better understanding the effects on social cognition, healthcare providers could be better equipped to design targeted treatment plans that address these cognitive issues. These interventions could improve survivors’ quality of life by helping them manage social interaction difficulties. Additionally, this review could contribute to the development of more effective rehabilitation programs and inform strategies to support brain tumour survivors in managing cognitive challenges.
2. Literature Review
2.1 Neurocognitive Impact of Brain Tumour Treatments
Brain tumour treatments such as surgery, radiation, and chemotherapy can significantly impair memory, executive functions, and social cognition. Common challenges include difficulties with working memory, verbal fluency, and attention. Survivors often experience a reduction in their ability to retain and recall information, with verbal and non-verbal memory being notably affected (Pertz et al., 2024; Papini et al., 2023). Tools like the Functional Independence Measure (FIM) and neuropsychological tests (e.g., Digit Span and Go/ No-Go tasks) are used to measure these deficits. Survivors of high-grade tumours, especially those undergoing aggressive treatments like craniospinal irradiation, report more severe impairments (Tay et al., 2022)
In a cohort of 163 patients undergoing inpatient rehabilitation, high-grade tumour survivors had significantly lower Functional Independence Measure (FIM) cognitive scores at admission (mean = 18.9) compared to low-grade tumour survivors (mean = 24.7), indicating greater cognitive impairment (Tay et al., 2022).
Chronic stress plays a critical role in exacerbating memory deficits and, in turn, modulating social cognition. Survivors exhibit a 30%-50% increase in cognitive dysfunction when chronic stress is present (Pertz et al., 2024; Tay et al., 2022). Stress amplifies cognitive problems such as working memory deficits and recall difficulties. It is closely linked to the disruption of brain structures like the hippocampus, a region vital for learning and memory. Mechanisms include HPA-axis dysregulation and oxidative stress, which contribute to hippocampal atrophy and impaired neurogenesis. Stress-related inflammation has also been implicated as a mediator of cognitive decline (Tay et al., 2022).
2.2 Role of Stress in Social Cognitive Decline
Stress includes psychological (e.g., emotional distress) and physiological (e.g., oxidative stress) components. Oxidative stress leads to cellular damage, while psychological stress disrupts hormonal balance, worsening memory and attention problems. These affect cognitive domains by disrupting neural circuits involving the hippocampus and prefrontal cortex (Tay et al., 2022; Pertz et al., 2024).
Survivors treated with intensive therapies report a higher prevalence of stress-related cognitive impairments. For instance, survivors of craniospinal irradiation performed nearly 1 SD worse on social cognition measures compared to non-irradiated groups (Papini et al., 2023). Among long-term survivors, social problem-solving fluency (measured by SCAMPS) is reduced, with employed survivors generating significantly better solutions compared to their unemployed counterparts (p = 0.003, η² = 0.386) (Pertz et al., 2024).
2.3 Social Cognition and Its Influence on Survivors
Social cognition refers to the ability to understand and interpret social cues, such as facial expressions and emotional states. These skills are essential for maintaining relationships and professional reintegration (Papini et al., 2023). Impairments in social cognition are linked to poorer quality of life and reduced employment rates among survivors. Adult survivors frequently struggle with recognizing and interpreting emotional cues, which hinders their ability to return to work or engage socially (Pertz et al., 2024).
Survivors of high-dose craniospinal irradiation display significant deficits in emotion recognition, with their performance being nearly one standard deviation below that of survivors who did not receive radiation. They reported 8-11 times greater impairments in tasks requiring facial emotion recognition compared to those who underwent focal radiation or no radiation. About 60% of survivors face challenges in recognizing facial expressions or processing social interactions (Tay et al., 2022). These deficits hinder full-time employment and educational achievements, showing that impaired social cognition directly affects functional outcomes (Pertz et al., 2024).
2.4 Identified Research Gaps and Justification
Research on how stress interacts with memory and social cognition in adult brain tumour survivors is limited. Most studies focus on paediatric populations or general neurocognitive outcomes without exploring these specific relationships. Existing studies highlight significant gaps in understanding the interaction between stress and memory impairments in adult brain tumour survivors. While stress mechanisms are established, their specific contribution to cognitive and social deficits remains unclear (Pertz et al., 2024; Papini et al., 2023).
3. Methodology
3.1 Systematic Review Protocol
A systematic review was conducted following established protocols to identify relevant studies addressing the relationship between stress, memory, and social cognition in post-treatment brain tumour survivors. Databases such as “PubMed” and “Google Scholar” were searched using a combination of keywords including "brain tumour," "stress," "memory," "social cognition," and "cognitive impairment." Boolean operators such as AND, OR were used to refine results and include various terms like "neurocognition," "emotion recognition," and "psychosocial outcomes."
The search strategy targeted peer-reviewed literature published between 2015 and 2023 to ensure the inclusion of contemporary findings. The reference lists of identified articles were manually screened to shortlist additional relevant studies. Search results were exported to data management software (spreadsheet) for further screening and organization.
To ensure the accuracy of the review, a two-step screening process was conducted. The inclusion criteria required studies to meet the following conditions: they had to be peer-reviewed and focus on adult brain tumor survivors who had completed treatment. The research needed to explore stress, memory, or social cognition as primary outcomes and include original quantitative or qualitative data. Studies also had to feature clear neurocognitive or psychosocial assessments with participants being adults diagnosed with any type of brain tumor after surgical treatment. On the other hand, the exclusion criteria eliminated studies involving patients still undergoing active treatment. Non-original research, such as reviews, meta-analyses, editorials, or commentaries, was also excluded. Additionally, research that did not address memory or social cognition as key outcomes was omitted.
Both authors reviewed the screened titles and abstracts independently for relevance. Discrepancies were resolved through discussion between the authors. Full-text articles were assessed based on inclusion and exclusion criteria, along with inter-reviewer consistency checks to minimize bias.
3.2 Data Collection and Extraction
Data extraction was performed using a standardized template to maintain consistency across studies, wherein several types of data were collected during this process. First, information was gathered on assessment methods, including details about neurocognitive tests and tools used to evaluate social cognition, such as the Facial Expressions of Emotion–Stimuli and Tests (FEEST) for measuring emotion recognition (Buunk et al., 2022). Second, data on sample characteristics were recorded, which included patient demographics such as age and gender, treatment details like the type of surgery and tumor grade, and specifics about the study design, whether observational or longitudinal. Finally, outcome variables were extracted focusing on how stress influenced memory, social cognition, or overall neurocognitive functioning. These included correlations between cognitive impairments and neuroimaging findings (Sinha et al., 2020).
3.3 Data Sources and Analysis:
As part of a neuropsychological assessment, patients were assessed preoperatively and six months postoperatively using validated tools. Emotion recognition was measured using FEEST (Facial Expressions of Emotion–Stimuli and Tests), and general cognition was evaluated using a battery of neuropsychological tests (Buunk et al., 2022).
In intraoperative data collection, a subgroup of 15 patients who underwent intraoperative brain mapping (ioBM) during awake resective surgery was analyzed. These patients were compared with 15 controls who underwent surgery under general anesthesia without mapping. Specific tasks corresponding to the tumour location in the right hemisphere were administered during surgery to monitor and register neurocognitive changes for 6 consecutive months (Prat-Acín et al., 2021).
Neuroimaging and tract-based spatial statistics made use of advanced neuroimaging techniques, including tract-based spatial statistics, which were applied to assess changes in white matter integrity. Fractional anisotropy (FA) was measured in key tracts such as the inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, anterior thalamic radiation, and uncinate fasciculus in the right hemisphere. The study identified a correlation between reductions in FA and deficits in emotion recognition (p = 0.009), further linking cognitive changes to surgical and treatment impacts (Sinha et al., 2020).
Using the data from the sample size, the following comparisons could be made: a total of 30 patients with LGG (low-grade gliomas) were included, with additional comparisons to 63 healthy controls for statistical analysis. Correlations and inter-group and intra-group comparisons were performed to evaluate neurocognitive and emotional deficits post-surgery (Buunk et al., 2022).
3.4 Ethical Considerations
All studies included in the review adhered to ethical guidelines, along with patient consent obtained for participation. The systematic review followed PRISMA guidelines to ensure transparency and precision. The combined methodology of quantitative neurocognitive tests, longitudinal designs, and advanced imaging analyses offers substantial evidence to understand the deep correlation between stress, memory, and social cognition in brain tumour survivors. This approach allows for significant insights into adversities caused by both tumour-related and treatment-related factors on the health-related quality of life (HRQOL) of brain tumour survivors (Watanabe et al., 2022).
4. Results
The systematic review evaluated multiple studies that investigated the effects of brain tumors and their treatments on social cognition, memory, and stress-related cognitive impairments. These studies collectively demonstrated that brain tumor survivors often experience significant deficits in these areas following treatment. A recurring focus in the reviewed articles was the impact of cranial radiation therapy (CRT) on cognitive functions. Survivors who underwent high-dose CRT exhibited notable impairments in social cognition, particularly in tasks involving emotion recognition. The reviewed studies also highlighted the importance of rehabilitation and its influence on health-related quality of life. Survivors who participated in rehabilitation programs demonstrated improved cognitive and functional outcomes, although the extent of improvement varied based on the severity of initial impairments and the type of treatment received.
One consistent trend identified in the review was the strong relationship between chronic stress and cognitive decline in brain tumor survivors, wherein it was found that chronic stress exacerbated impairments in memory and social cognition, with survivors experiencing a 30% to 50% increase in cognitive dysfunction when chronic stress was present. The impact of stress was further linked to structural and functional disruptions in the brain, particularly in regions like the hippocampus, which is critical for memory and emotional processing. Also, reductions in white matter integrity, as measured by fractional anisotropy in pathways such as the inferior longitudinal fasciculus and anterior thalamic radiation, were significantly correlated with deficits in emotion recognition (p = 0.009). Emotion recognition emerged as a particularly vulnerable aspect of social cognition, as it was reported that survivors of high-dose craniospinal irradiation exhibited 8 to 11 times greater impairments in facial emotion recognition tasks compared to individuals who underwent focal therapy or no radiation. The studies also emphasized that such deficits directly affect survivors’ abilities to interpret social cues and engage effectively in social interactions. Furthermore, these impairments were shown to hinder survivors’ return to full-time employment and educational pursuits, which are critical markers of functional recovery and quality of life. Employment outcomes provided additional insights into the cognitive challenges faced by survivors, as it was observed that employed survivors performed significantly better in social problem-solving tasks than their unemployed counterparts, with statistical significance (p = 0.003). This finding suggests that occupational reintegration may serve as both a marker of recovery and a potential contributor to cognitive improvement.
The findings also highlighted distinct differences between survivors based on the grade of their tumors and the intensity of treatments. Survivors of high-grade tumors had lower cognitive Functional Independence Measure (FIM) scores at admission (mean = 18.9) compared to those with low-grade tumors (mean = 24.7), indicating greater cognitive impairment. The articles further noted that the use of craniospinal irradiation was associated with significantly worse outcomes in social cognition compared to focal radiation or no radiation. In addition to cognitive challenges, the role of rehabilitation was underscored as a critical intervention to mitigate deficits and improve quality of life. Survivors who underwent structured rehabilitation programs demonstrated gains in cognitive and functional outcomes, particularly in tasks related to memory and social cognition. However, the degree of improvement was found to vary depending on the severity of impairments and the type of treatment received.
Overall, the reviewed studies consistently pointed to the interplay between treatment intensity, stress, and social cognitive outcomes. The findings emphasize the need for targeted interventions that address stress management, social cognition deficits, and functional reintegration to improve the overall quality of life for brain tumor survivors.
5. Discussion
The findings of this systematic review reinforce and expand upon existing knowledge regarding the social cognitive challenges faced by brain tumor survivors, particularly in the domains of social cognition, stress, and memory. Chronic stress was identified as a key factor aggravating cognitive deficits, with survivors experiencing a 30% to 50% increase in dysfunction when stress was present (Pertz et al., 2024; Tay et al., 2022). These results align with previous studies highlighting the detrimental impact of stress on brain structures such as the hippocampus and prefrontal cortex, which are essential for memory and emotional regulation. Social cognition, especially emotion recognition, was found to be particularly vulnerable among survivors of high-dose craniospinal irradiation. These findings are consistent with neurobiological theories suggesting that social cognition relies heavily on intact neural networks involving the amygdala and temporal lobe. The significant impairments in emotion recognition demonstrate how treatment-induced disruptions to white matter pathways can severely compromise survivors’ abilities to interpret social cues and engage effectively in interpersonal interactions (Papini et al., 2023; Sinha et al., 2020).
When compared to earlier studies, the results highlight both continuity and new insights. Earlier studies (pre-2018) emphasized the psychosocial consequences of cognitive deficits in brain tumor survivors, particularly the challenges they face in occupational reintegration and maintaining relationships (Pertz et al., 2024). The current review extends these findings by incorporating recent evidence such as the correlation between reductions in fractional anisotropy and emotion recognition deficits (Sinha et al., 2020). Furthermore, pre-2018 studies primarily focused on short-term cognitive outcomes immediately following treatment. This review highlights a growing trend in recent research toward examining long-term effects, particularly the role of chronic stress in sustaining or worsening cognitive deficits over time (Pertz et al., 2024; Papini et al., 2023). The emphasis on rehabilitation and its potential to mitigate cognitive impairments also reflects a shift toward proactive and patient-centered care strategies.
Moreover, the findings underscore the importance of integrating stress management and cognitive rehabilitation into the treatment care plans for brain tumor survivors. Stress as a modifiable factor can prove to be a valuable target for intervention. Programs designed to reduce stress through mindfulness, cognitive-behavioral therapy, or structured support groups could potentially alleviate memory impairments and improve social cognition. Rehabilitation programs focusing on emotion recognition and social problem-solving skills could further enhance survivors’ quality of life and functional independence. For instance, targeted therapies using tools like the Facial Expressions of Emotion-Stimuli and Tests (FEEST) could help survivors rebuild their abilities to interpret social cues. Additionally, occupational therapy tailored to address specific cognitive deficits, such as those measured by Functional Independence Measure (FIM) scores, could support survivors in returning to work or achieving other personal goals.
While this review provides valuable insights, several limitations should be acknowledged. First, the reliance on studies published after 2018 may have been excluded earlier, but they still contain relevant findings. However, this approach was taken to purposely focus on recent advancements in understanding the long-term social cognitive effects of brain tumor treatments. Second, many of the included studies had relatively small sample sizes, which may limit the generalisability of the findings. Taking the example of neuroimaging studies, while providing detailed insights into structural changes, it often involves fewer participants, making it difficult to draw broad conclusions about the entire population of brain tumor survivors. Third, there is a lack of longitudinal data exploring cognitive changes over extended periods. Most studies measured outcomes at single or short-term time points, thereby leaving gaps in understanding the progression of cognitive impairments over years or decades. This limitation highlights the need for future research to adopt longitudinal designs to better capture the trajectory of cognitive and social recovery.
Future studies should prioritize several areas to address existing gaps. Long-term follow-up studies are crucial in understanding how cognitive deficits, memory, and social cognition in particular evolve over time and whether interventions can have sustained long-term effects. Such research would provide valuable data on the effectiveness of rehabilitation programs and stress management strategies over the long term. Additionally, there is a need for more intervention studies focused on improving emotion recognition and social problem-solving. While current research emphasizes the importance of rehabilitation, few studies have rigorously tested specific therapies or programs. Randomized controlled trials evaluating interventions such as cognitive training, virtual-reality (VR)-based social simulations, or group therapy sessions could offer clearer guidance on best practices. Lastly, future research should also explore the role of individualized treatment care plans that consider patient-specific factors such as tumor grade, treatment type, and baseline cognitive function. Advanced neuroimaging techniques could be further developed to identify individuals at high risk and customize precaution plans accordingly.
6. Conclusion
This systematic review highlights the significant challenges faced by brain tumor survivors in areas of social cognition, memory, and stress management as long-term effects of having sustained metastatic cancerous brain tumours at an early age. While recent research has improved understanding and provided valuable insights in these domains, there remains a critical need for long-term studies and targeted interventions. By addressing these gaps, future efforts can improve not only the social cognitive outcomes of survivors but also their overall quality of life and ability to readapt into society.
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