10 Chapter 1 Figure 2. Treatment volumes for SRS overlaid on a T1-weighted MRI. COGNITIVE PERFORMANCE In the context of prolonged life expectancy, potential treatment-related cognitive impairment has become an increasingly important topic. Especially since nearly 50% of patients with BMs already have cognitive deficits prior to radiotherapy.19–21 The acute radiation-induced injury that occurs in the first weeks is typically transient.22,23 However, delayed brain toxicity has been shown following radiation, leading to irreversible cognitive deterioration.22–24 Cognitive difficulties can have far-reaching impacts on various aspects of life such as work, relationships, and leisure activities.25 In fact, the impact of cognitive impairment on an individuals’ QoL has now been recognized as second only to survival in clinical trials.26 Importantly, not only severe cognitive impairment (e.g. dementia) can impact QoL, but mild cognitive changes are also perceived as a significant burden to both patients and caregivers.25 This highlights the importance of not only assessing objective cognitive functioning, but also subjective cognitive performance. Regrettably, a significant drawback of previous research is the reliance on cognitive screenings tests like the Mini-Mental Status Examination (MMSE), which cannot accurately detect these subtle, but burdensome, cognitive impairments. Additionally, studies have predominantly used group-level analyses and/or employed a focused, and thereby restricted, range of cognitive tests, thus limiting our understanding of the extent of cognitive difficulties and their full impact on individuals’ daily life. EFFECT OF BRAIN METASTASES ON THE BRAIN As briefly mentioned previously, approximately half of the patients with BMs already have cognitive problems before radiotherapy due to negative effects of
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