By Jackie Kruszewski
C. Kenneth and Dianne Wright Center for Clinical and Translational Research

A diagnosis of brain cancer is always devastating. There’s no cure or remission, only levels of stability and estimations of time.

Many patients with cancer struggle with mental health and maintaining quality of life, and psychological services or therapy is a standard part of holistic cancer treatment. But patients with brain cancer often aren’t offered that element of care.

“Patients with brain cancer have historically been excluded from psychological research because of a misunderstanding that they are too ill or cognitively impaired to participate,” said Ashlee Loughan, Ph.D. “As such, there is a lack of interventional studies shown to be effective in our patient population.” 

Now the U.S. Department of Defense has awarded Loughan, a Virginia Commonwealth University researcher, four years of funding to study just that. Armed with $1.5 million, the associate professor in the Department of Neurology’s Division of Neuro-Oncology at the VCU School of Medicine will test the effectiveness of a newly developed therapy in reducing distress and improving the quality of life for people living with advanced brain cancer.

The study, which began in August, should lead to a refined version of that therapy, which could provide a measure of relief for people struggling with brain cancer.

Clinical work revealed a gap in care

As a clinical neuropsychologist at VCU Health, Loughan assesses and manages the mental health and quality of life for patients with a brain injury or other medical diagnosis that can affect cognition and brain function.

Since coming to VCU six years ago, her interest has centered on cancer — specifically, patients with brain tumors. 

“Through my clinical work I’ve observed significant levels of distress in our patients — primarily depression and fear, centered around thoughts of mortality, or death-related anxiety,” said Loughan, who is also director of VCU’s LiveNOW Lab. “They’re struggling because their life has been drastically changed, and it’s permanent.”

The word “remission” is seldom used in brain cancer. There’s no cure, and the goal of care is stabilization.

Throughout treatment, patient cognition declines. Physical abilities decline. People with brain cancer might become dependent on loved ones. They might lose their job or be unable to drive. They might not be able to care for their children. 

“And this could be for months, a year, or it could be for 20 years,” Loughan said. 

She started looking into psychological interventions to support her patients’ well-being.

One effective therapy helps people with advanced cancers

Loughan found one effective therapy called Managing Cancer and Living Meaningfully, or CALM, a psychotherapeutic intervention shown to be effective for people with advanced or terminal cancers. 

A patient receives, on average, three to six sessions with a therapist, who provides a framework for reflecting about the situation and future. There are four domains to the framework: symptom management and communication with health care providers, understanding changes in yourself and relationships, finding a sense of meaning and purpose in life, and planning for the future and mortality.

“The therapist touches upon all domains, but it’s really patient guided, based on what areas are most relevant to them,” said Loughan, who, after a years-long training process, became the first CALM-certified therapist in the United States in August 2020.  

The CALM process helps a patient balance living purposefully and meaningfully, while knowing they have a disease that can’t be cured. Loughan said it helps them answer the question of how they will plan for the future when their time is limited.

“Getting too wrapped up in ‘I’m dying’ often sends patients into a spiral of depression,” Loughan said. “But if you’re living in denial of that, anytime something bad happens patients experience that initial shock and trauma all over again.” 

Families of people with terminal cancer are often scared to talk about these topics, Loughan said. And with physicians being trained to cure, they struggle to engage patients’ mental health or discuss sensitive topics such as mortality. CALM therapy provides a platform where patients can discuss their psychological challenges. 

Caregivers aren’t required to participate, but they’re encouraged.

“Cancer is not an individual disease. It's a family disease,” Loughan said. “And oftentimes the communication between the family members is important for the quality of life of the patient, and vice versa.”

Research on the effective therapy excluded patients with brain cancer

Cognitive decline is a common side effect of the tumor and treatments, but many patients with brain cancer are not impaired. 

The developers of CALM, Loughan said, excluded patients with brain tumors from its development and research.

“One reason why patients with brain tumors are excluded is because psychotherapists or counselors are often not trained to work with patients who have cognitive limitations and, if they don't have that experience, tend to shy away from it,” Loughan said.

A blanket exclusion of anyone with brain cancer can ignore the nuanced reality of individual cases. Someone with severe dementia or severe neurocognitive impairment wouldn’t be a good fit, Loughan said. But those who have mild memory difficulties, some distractibility, or even slight difficulty finding words, yet are still functioning and insightful, can benefit from psychotherapeutic intervention. 

“I feel strongly that neuropsychologists should be part of the development and implementation of interventions,” Loughan said. “My experience affords an understanding of brain function, disability or intellectual impairment, cognitive capacity, and I can take interventions, like CALM, that have been shown to be beneficial in other cancer patients, adapt or optimize them, and use them in patients who are mildly cognitively impaired.”

Adapting CALM for patients with brain cancer

For the study, Loughan will team up with the Central Virginia VA Health Care System to recruit about 70 people with brain cancer — with a focus on cancers that have spread from their original site to the brain. The VA connects Loughan to veterans, who have a high prevalence of that type of cancer.

The project will focus on adapting CALM, molding it into the best possible program for patients with brain tumors and their specific challenges. Volunteer participants will go through the CALM therapy process, and Loughan will evaluate the feasibility of its use and adaptations needed.

Loughan’s project, “Managing Distress in Malignant Brain Cancer,” was funded through the Department of Defense’s Behavioral Health Science Award.

“Maintaining mental health should be an essential consideration when treating people with advanced cancers such as brain tumors,” said Peter Buckley, M.D., dean of the VCU School of Medicine. “Dr. Loughan has identified a significant gap in the holistic care of these individuals, and her drive to improve treatment is what makes research coming from our faculty so invaluable.” 

Loughan is an Emerging Scholar at the VCU C. Kenneth and Dianne Wright Center for Clinical and Translational Research, a training and mentorship program where junior faculty have 20% of their time dedicated to research. She credits that, her co-investigators and the support of leaders from the VCU Center for Rehabilitation Science and Engineering for this grant.

“Ron Seel and David Cifu [of CERSE] both helped mentor me in grant writing specific to the Department of Defense,” she said. “I was connected with them through the Wright Center. To be honest, if I had not received the award of Emerging Scholar, we wouldn’t be having this conversation. That program has absolutely provided the mentorship, platform and connections for me to obtain funding.”

Her co-investigators include VCU researchers Autumn Lanoye, Ph.D., Mark Malkin, M.D., Dace Svikis, Ph.D., Suzanne Mazzeo, Ph.D., and Leroy Thacker, Ph.D. External to VCU, Loughan’s collaborators include Gary Rodin, M.D., and Leigh Swartz, M.D.

“Dr. Loughan perceived a dearth of psychiatrists and psychologists trained and willing to carry out her recommendations, and she not only created a cognitive behavioral model to help brain cancer patients, but is now pushing the envelope with this grant examining the CALM therapy,” said Malkin, chair in neuro-oncology in the VCU School of Medicine. “It’s a program director’s dream to mentor such a talented, driven clinician-scientist, and I fully expect continued impactful contributions to the field of neuro-oncology from Dr. Loughan and the LiveNOW Lab.”

Loughan is also a research member at VCU Massey Cancer Center, where she received early funding for her research on this topic. Massey’s research accelerator funded focus groups and community engagement with patients with brain tumors. More funds from Massey, via the American Cancer Society, helped her determine the early feasibility of studying CALM.

“The Massey and American Cancer Society grants were like seedlings to help me obtain the DoD grant,” she said.

Ultimately, Loughan hopes to bring effective treatments back to patients, like those at Massey, to improve their quality of life in a challenging time.

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