Study characteristics

A total of N = 3000 studies were identified through database searches from EMBASE (N = 1258), Scopus (N = 1020), MEDLINE (N = 495), CINAHL (N = 85) and PsycINFO (N = 22), including an additional N = 120 identified via MEDLINE biweekly email updates. Two more studies were identified via snowballing. After duplicates were removed, N = 1550 studies underwent title and abstract screening, of which N = 38 met eligibility criteria and were sought for full-text retrieval. One full-text study was unavailable leaving N = 37 studies for full-text review. Two studies were subsequently excluded for failure to meet inclusion criteria, and four additional studies were also excluded after critical appraisal due to a combination of reasons each contributing to a higher risk of bias. A total of N = 31 studies were included for data extraction and synthesis after consensus. The results of the search and the study inclusion process are depicted in Figure 1.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of study inclusion.

A summary of characteristics of the included studies is presented in Table 1. Of the N = 31 included studies, cross-sectional designs were the most common (N = 16), followed by retrospective cohorts (N = 7) and prospective cohorts (N = 7), with only one case-control (N = 1). Studies were conducted in 14 different countries, the most common being Germany (N = 8), USA (N = 4), the Netherlands (N = 4) and Australia (N = 3). The HRQOL of meningioma patients was compared to healthy controls in four studies and normative population data in eight. Pre-treatment HRQOL data were compared to post-treatment data in 11 studies of which one involved comparisons to both normative and preoperative data. Other studies included HRQOL comparisons based on different meningioma locations, different brain tumours, previous cohorts and on the basis of age, surgical approach, psychological impairments, epilepsy and sleep disturbance. Five studies reported HRQOL results of meningioma patients without any comparisons to other groups.

Table 1. Summary of characteristics of included studies (N = 31)

Notes: AED = antiepileptic drug; ASBQ = Anterior Skull Base Questionnaire; BL = baseline; CC = case-control; CS = cross-sectional; CSF = cerebrospinal fluid; EEA = endoscopic endonasal approach; EORTC QLQ-BN20 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Brain Neoplasm 20; EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; EQ-5D = EuroQOL-5 Dimensions; FACT-Br = Functional Assessment of Cancer Therapy-Brain; FACT-G = Functional Assessment of Cancer Therapy-General; GBM = glioblastoma patients; HRQOL = health-related quality of life; IQR = interquartile range; KPS = Karnofsky performance scale; LPPM = lateral posterior surface of the pyramid meningioma patients; MGM = meningioma patients; PC = prospective cohort; PCM = petroclival meningioma patients; PS = planum sphenoidale; PT = pituitary tumour patients; PTBE = peritumoural brain oedema; PTSS = post-traumatic stress symptoms; RC = retrospective cohort; SF-36 = 36-item Short Form Survey; SNOT-22 = Sinonasal Outcome Test 22; SO = supraorbital; SRT = stereotactic radiotherapy; TS = tuberculum sellae; UK = United Kingdom; USA = United States of America; VAS = Visual Analogue Scale; WHO = World Health Organization; ↑= increase(d); ↓= decrease(d).

Over one-third of studies (N = 11) included patients with all types of meningioma, typically without reporting results by specific location. The majority of the remaining studies specifically focused on meningiomas of intracranial (N = 8), skull base (N = 5) or sphenoid wing (N = 2) locations. In terms of treatment, 21 studies included patients post-surgery, and only three focused solely on radiotherapy. Six focused on surgery and/or radiotherapy, two on patients prior to treatment and one on patients in any treatment phase.

HRQOL of meningioma patients

In addition to factor-specific findings, several studies also examined the overall status of HRQOL in meningioma patients compared to healthy populations (N = 11). ^{Reference Pintea, Kandenwein and Lorenzen15–Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25} Although not a focus of our review, the results provide important context for our findings, suggesting that meningioma patients as a whole tend to experience inferior HRQOL in cognitive functioning, general health and vitality and most notably in role-physical, role-emotional and social functioning ^{Reference Pintea, Kandenwein and Lorenzen15–Reference Nassiri, Price and Shehab19} compared to healthy populations, irrespective of any treatment-related improvements.

Factor-specific findings

Tables 2, 3 and 4 present key findings from the included studies related to patient-, tumour- and treatment-related factors, respectively. A detailed summary of results is provided in Supplementary Appendices II–IV. Statistically significant or clinically relevant results are presented here.

Table 2. Summary of patient-related factors explored and their association with health-related quality of life (HRQOL)

Notes: ADS = Allgemeine Depressionsskala; ASA = American Society of Anesthesiologists; KPS = Karnofsky performance scale; PROs = patient-reported outcomes; PTSS-10 = Post-traumatic Symptom Scale-10 items; STAI-S = State-Trait Anxiety Inventory-State; STAI-T = State-Trait Anxiety Inventory-Trait; WHO = World Health Organization; ↑= increase(d); ↓= decrease(d).

Table 3. Summary of tumour-related factors explored and their association with health-related quality of life (HRQOL)

Notes: MGM = meningioma; PTBE = peritumoural brain oedema; ↑= increase(d); ↓= decrease(d).

Table 4. Summary of treatment-related factors explored and their association with health-related quality of life (HRQOL)

Notes: AED = antiepileptic drug; BL = baseline; CSF = cerebrospinal fluid; KPS = Karnofsky performance scale; SRT = stereotactic radiotherapy; ↑ = increase(d); ↓ = decrease(d).

Patient-related factors

Various patient-related factors and their associations with HRQOL in meningioma patients were explored across studies. Three of five studies on comorbidities evaluated severity using scales such as the American Society of Anesthesiologist classification and Charlson Comorbidity Index, ^{Reference Keshwara, Gillespie and Mustafa18,Reference Timmer, Seibl-Leven and Wittenstein26,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27} while the others looked at the effect of a certain comorbidity. In one study, cardiac disease specifically was associated with lower postoperative HRQOL, ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} and another found that diabetes was associated with lower 36-item Short Form Survey physical component scale (SF-36 PCS), mental component scale (MCS) and Functional Assessment of Cancer Therapy (FACT) scores. ^{Reference Tanti, Marson and Jenkinson29} Although cohesive deductions could not be made due to heterogeneity in the scales used, the presence of severe comorbidities appears to be consistently associated with inferior HRQOL.

Functional status, primarily assessed using the Karnofsky Performance Scale (KPS), was found to influence HRQOL across six studies. Five studies reported a positive association between functional status and postoperative HRQOL, with four specifically finding that patients with higher KPS scores tended to have better SF-36 PCS and MCS scores. ^{Reference Pintea, Kandenwein and Lorenzen15,Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20,Reference Timmer, Seibl-Leven and Wittenstein26,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27} One study found a negative association between preoperative, as opposed to postoperative, KPS score and postoperative HRQOL. ^{Reference Ouyang, Zhang, Wang, Li and Chen30} This finding mirrors other work where patients with higher preoperative HRQOL tended towards worsening scores post-surgery. ^{Reference Jakola, Gulati, Gulati and Solheim31}

Two studies exploring fatigue found a significant negative association with postoperative HRQOL. In one study, greater fatigue was associated with lower postoperative EuroQOL-5 Dimension (EQ-5D) scores on univariate analysis, ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20} and another demonstrated a strong correlation between increased fatigue and lower global HRQOL across all follow-up time points. ^{Reference Nassiri, Price and Shehab19}

In terms of the impact of sleep, greater sleep quality was associated with better HRQOL ^{Reference Lin, Chen, Wang, Lin, Lee and Chiu32} and increased sleep disturbance was associated with worse HRQOL ^{Reference Nassiri, Price and Shehab19} as assessed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) tools. Another study found that patients with sleep disturbance had lower PCS and MCS scores and lower scores in all individual domains of SF-36, except for physical functioning. ^{Reference Zhang, Wang and Gu33}

Three studies ^{Reference Tanti, Marson and Jenkinson29,Reference Wagner, Shiban and Lange34,Reference Kangas, Williams and Smee35} examined the influence of psychological impairment on HRQOL in meningioma patients. One investigated the influence of abnormal preoperative anxiety, post-traumatic stress symptoms (PTSS) and depression scores on HRQOL before and after surgery and found that they were associated with decreased EuroQOL-5 Dimension 5 Level (EQ-5D-5L) and SF-36 scores. ^{Reference Wagner, Shiban and Lange34} Similarly, another found that elevated PTSS scores were associated with reduced physical, emotional and functional well-being ^{Reference Kangas, Williams and Smee35} . Depression was found to be associated with reduced MCS scores on SF-36. ^{Reference Tanti, Marson and Jenkinson29,Reference Wagner, Shiban and Lange34}

The impact of illness perception on HRQOL in meningioma patients was explored in one study ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20} , which found negative illness perception to be associated with decreased EQ-5D scores. Likewise, the absence of social support was linked with compromised HRQOL. ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20} Indirect insights on social support also emerge from Krupp et al.’s work exploring the influence of marital status on HRQOL, which may serve as a proxy for social support. Their findings suggest that patients who are single express lower life satisfaction compared to those in marital or partnered relationships. ^{Reference Krupp, Klein, Koschny, Holland, Seifert and Meixensberger36}

Several other patient-reported outcomes were examined by a limited number of studies. Headaches at presentation were associated with increased preoperative HRQOL in one study, ^{Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37} but others found no relationship. ^{Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Jones, Iannone and Patel38,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} Lower global HRQOL correlated with decreased cognitive, physical and social function and increased pain. ^{Reference Nassiri, Price and Shehab19}

Mixed results emerged across 14 studies examining the impact of age on HRQOL. ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20,Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Timmer, Seibl-Leven and Wittenstein26,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28,Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Jakola, Gulati, Gulati and Solheim31,Reference Kangas, Williams and Smee35–Reference Wirsching, Morel, Roth and Weller42} Interestingly, three studies determined that younger age was associated with worse HRQOL ^{Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Krupp, Klein, Koschny, Holland, Seifert and Meixensberger36,Reference Wirsching, Morel, Roth and Weller42} regarding extended recovery, lower self-esteem and reduced life satisfaction. Other studies, however, found that older age was associated with varying degrees of inferior HRQOL. ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20,Reference Timmer, Seibl-Leven and Wittenstein26,Reference Jones, Iannone and Patel38} Specifically, one found that individuals aged >75 exhibited worse physical functioning scores. ^{Reference Timmer, Seibl-Leven and Wittenstein26} Most studies compared age by dichotomizing participants as above or below the mean or median age, and those finding significant associations often had a broader age range beginning in the 20s, suggesting that differences in HRQOL may become more apparent with wider ranges.

The influence of sex or gender on HRQOL was assessed in 12 studies. ^{Reference Pintea, Kandenwein and Lorenzen15,Reference Keshwara, Gillespie and Mustafa18,Reference Pettersson-Segerlind, von Vogelsang and Fletcher-Sandersjoo22,Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Tanti, Marson and Jenkinson29,Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Krupp, Klein, Koschny, Holland, Seifert and Meixensberger36,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40,Reference Wirsching, Morel, Roth and Weller42} Among these, four found that females generally exhibited lower HRQOL scores compared to males, both on a global scale and within specific domains such as physical functioning and mobility, while also reporting higher levels of pain. ^{Reference Pintea, Kandenwein and Lorenzen15,Reference Pettersson-Segerlind, von Vogelsang and Fletcher-Sandersjoo22,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} In another study, single men were found to report lower life satisfaction than single women. However, when assessing sex independently, no statistically significant differences were observed between males and females. ^{Reference Krupp, Klein, Koschny, Holland, Seifert and Meixensberger36} Six of the 12 studies failed to establish any significant link between sex and HRQOL in meningioma patients. ^{Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Tanti, Marson and Jenkinson29,Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40,Reference Wirsching, Morel, Roth and Weller42} Differences in participant characteristics, treatment phases and HRQOL assessment tools, however, make it challenging to directly compare all 12 studies.

Employment status was associated with HRQOL in three studies. ^{Reference Keshwara, Gillespie and Mustafa18,Reference Tanti, Marson and Jenkinson29,Reference Wirsching, Morel, Roth and Weller42} Using multivariate regression analysis, each study found a statistically significant association between unemployment and inferior HRQOL scores. This finding was observed when evaluating the influence of preoperative ^{Reference Wirsching, Morel, Roth and Weller42} and postoperative employment status on EORTC QLQ scores. ^{Reference Keshwara, Gillespie and Mustafa18,Reference Tanti, Marson and Jenkinson29}

Education level was evaluated by three studies, of which two found a statistically significant association with HRQOL. ^{Reference Keshwara, Gillespie and Mustafa18,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Wirsching, Morel, Roth and Weller42} One found lower education level to be a determinant for a decreased PCS on SF-36, ^{Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27} and the other noted higher education levels were significantly associated with overall better EORTC QLQ-C30 scores. ^{Reference Keshwara, Gillespie and Mustafa18} Both of these studies were focused on long-term HRQOL outcomes following diagnosis and treatment of meningioma. The study failing to find a significant association was potentially influenced by recall bias due to retrospective interrogation. ^{Reference Wirsching, Morel, Roth and Weller42} The categories used to define educational level also varied between studies, potentially influencing the findings.

Tumour-related factors

The effect of tumour size on HRQOL was investigated across eight studies. ^{Reference Kofoed Lauridsen, Ciochon and Tolver24,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28,Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Jakola, Gulati, Gulati and Solheim31,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Zweckberger, Hallek, Vogt, Giese, Schick and Unterberg41,Reference Wirsching, Morel, Roth and Weller42} Only three reported a significant association, and no trends were observed. Greater tumour size was associated with lower preoperative HRQOL via Anterior Skull Base Questionnaire (ASBQ) ^{Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37} and lower postoperative HRQOL via KPS in univariate, but not multivariate, analysis. ^{Reference Ouyang, Zhang, Wang, Li and Chen30} One study found that greater tumour size before study participation was associated with lower PCS via SF-36. ^{Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27}

Ten studies ^{Reference Keshwara, Gillespie and Mustafa18,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28,Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Jakola, Gulati, Gulati and Solheim31,Reference Wagner, Shiban and Lange34,Reference Zweckberger, Hallek, Vogt, Giese, Schick and Unterberg41–Reference Lisowski, Tromel and Lutyj43} evaluated tumour location as a potential factor affecting HRQOL, with only one showing any significant association. Specifically, posterior skull base locations were linked to compromised role functioning, motor dysfunction, communication deficits and leg weakness compared to anterior/middle locations. ^{Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23} This study explored specific localizations within skull base meningiomas, ^{Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23} while the others only compared findings from skull base meningiomas to other broader categories of locations such as frontal or convexity meningiomas. This discrepancy suggests that the impact of tumour location on HRQOL might be more nuanced and context-dependent, though more uniform evaluation is needed.

Regarding tumour laterality, two of four studies ^{Reference Benz, Wrensch and Schildkraut16,Reference Keshwara, Gillespie and Mustafa18,Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Kangas, Williams and Smee35} found significant associations with HRQOL, though conflicting findings were reported. One study linked right-sided tumours and impaired HRQOL, ^{Reference Benz, Wrensch and Schildkraut16} whereas the other study identified a comparable association with left-sided tumours. ^{Reference Kangas, Williams and Smee35} Differences in intervention type, follow-up period, study design and HRQOL metrics used may have contributed to differing results.

Among three studies exploring the impact of histologic grade on HRQOL, ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28,Reference Wirsching, Morel, Roth and Weller42} a significant univariate association was found in only one. ^{Reference Ganefianty, Irawati, Dahlia, Kariasa and Sutiono20} The other two studies reported either minimal data ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} or acknowledged potential selection bias in favour of patients with lower WHO grade meningiomas. ^{Reference Wirsching, Morel, Roth and Weller42}

Other tumour characteristics, including adhesion of the tumour to surrounding structures, tumour encasement and tumour blood supply, were found to be associated with KPS scores by a single study. ^{Reference Ouyang, Zhang, Wang, Li and Chen30} However, the overall effect of these particular characteristics is difficult to ascertain due to a lack of corroborating evidence from additional studies.

The possible influence of various meningioma complications on HRQOL was investigated across several studies. Peritumoural brain oedema (PTBE) was investigated in three, ^{Reference Kofoed Lauridsen, Ciochon and Tolver24,Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Nassar, Smolanka, Smolanka, Chaulagain and Devinyak44} two of which found the presence of PTBE to be negatively associated with postoperative HRQOL. For one study, the association was found only in univariate analysis. ^{Reference Ouyang, Zhang, Wang, Li and Chen30} Another revealed lower KPS scores at three months post-surgery in patients with preoperative PTBE. ^{Reference Nassar, Smolanka, Smolanka, Chaulagain and Devinyak44} As cohort studies, both lacked sufficient information regarding patient follow-up and used KPS to measure HRQOL, which may be a limitation as the KPS tool is a non-specific measure of HRQOL focusing on functional status. Furthermore, both studies focused on sphenoid wing meningiomas, limiting the generalizability of results to other locations.

It is difficult to make conclusive remarks on epilepsy and sensory dysfunction as potential determinants of HRQOL as significant results were only obtained from single studies. One study found that surgically treated meningioma patients with epilepsy had impaired HRQOL scores on the Functional Assessment of Cancer Therapy-Brain (FACT-Br) and in all domains of SF-36, except for bodily pain, compared to those without epilepsy. ^{Reference Tanti, Marson and Jenkinson29} Visual dysfunction was associated with lower preoperative HRQOL, ^{Reference Ouyang, Zhang, Wang, Li and Chen30} and hypo- or anacusis was associated with lower vitality scores. ^{Reference Pintea, Kandenwein and Lorenzen15} More research is required as associations between visual, olfactory and gustatory dysfunction and postoperative HRQOL were not consistently studied.

Three studies ^{Reference Waagemans, van Nieuwenhuizen and Dijkstra21,Reference Pettersson-Segerlind, von Vogelsang and Fletcher-Sandersjoo22,Reference Wagner, Shiban and Lange34} evaluated the effect of neurological function on postoperative HRQOL, all finding a statistically significant positive association. Decreased postoperative neurological function measured via modified McCormick scale grade was associated with lower scores in the EQ-5D mobility domain, ^{Reference Pettersson-Segerlind, von Vogelsang and Fletcher-Sandersjoo22} and lower executive functioning was associated with lower scores on all SF-36 domains, except for bodily pain. ^{Reference Waagemans, van Nieuwenhuizen and Dijkstra21} Wagner et al. explored improvements in neurological function as a potential factor and discovered greater improvements to be associated with better MCS values on SF-36. ^{Reference Wagner, Shiban and Lange34}

A range of other neurological problems were linked to worse postoperative HRQOL in four separate studies. ^{Reference Pintea, Kandenwein and Lorenzen15,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28,Reference Tanti, Marson and Jenkinson29,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} These issues included optic nerve compression, ^{Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} proptosis, ^{Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} intracranial hypertension, ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} hemiparesis, ^{Reference Pintea, Kandenwein and Lorenzen15,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} hemiataxia, ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} seizures ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} , aphasia, ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28} swallowing disturbances ^{Reference Pintea, Kandenwein and Lorenzen15} and motor/sensory deficits. ^{Reference Tanti, Marson and Jenkinson29} However, these findings mainly emerged in individual studies and would benefit from additional research to solidify their validity. Other research examining more broadly the effects of preoperative neurological symptoms ^{Reference Zweckberger, Hallek, Vogt, Giese, Schick and Unterberg41} and postoperative neurological deficits ^{Reference Wirsching, Morel, Roth and Weller42} failed to find connections, rendering the impact of these various neurological problems on HRQOL uncertain.

Evidence for the clinical factors of symptoms and time since diagnosis was insufficient to allow for proper prognostic assessment.

Finally, four studies exploring tumour recurrence as a factor affecting HRQOL failed to find any significant associations. ^{Reference Kofoed Lauridsen, Ciochon and Tolver24,Reference Tanti, Marson and Jenkinson29,Reference Jones, Iannone and Patel38,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} However, to draw definitive conclusions, larger-scale prospective research is warranted, given that the current findings predominantly stem from small, cross-sectional and retrospective cohorts.

Treatment-related factors

Seven studies ^{Reference Jakola, Gulati, Gulati and Solheim31,Reference Wagner, Shiban and Lange34,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37–Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39,Reference Zweckberger, Hallek, Vogt, Giese, Schick and Unterberg41,Reference Wirsching, Morel, Roth and Weller42} evaluated the effect of surgical resection on HRQOL in meningioma patients. All but one ^{Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} found a statistically significant difference between HRQOL values before and after surgery. HRQOL tended to be worse in the immediate postoperative period before returning to preoperative levels in the first several weeks following surgery and continuing to improve long term. ^{Reference Jakola, Gulati, Gulati and Solheim31,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Zweckberger, Hallek, Vogt, Giese, Schick and Unterberg41} While patients still had worse on average HRQOL compared to healthy populations, surgery appears to have a beneficial effect on long-term HRQOL. Domains of HRQOL most improved at one-year post-surgery include headaches, seizures, role limitations due to physical problems and role limitations due to emotional problems. ^{Reference Wagner, Shiban and Lange34,Reference Wirsching, Morel, Roth and Weller42} Notably, one study found patients with better preoperative scores tended to report postoperative worsening of HRQOL scores. ^{Reference Jakola, Gulati, Gulati and Solheim31} Further research examining this possible association is warranted.

Six studies ^{Reference Nassiri, Price and Shehab19,Reference Pettersson-Segerlind, von Vogelsang and Fletcher-Sandersjoo22,Reference Kofoed Lauridsen, Ciochon and Tolver24–Reference Timmer, Seibl-Leven and Wittenstein26,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37} evaluated time since surgery as a distinct factor impacting HRQOL, with only one ^{Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37} noting a significant association. Unlike the other 5 studies with follow-up periods exceeding 12 months post-surgery, this study conducted follow-up immediately after surgery and at varying intervals up to one-year post-operation. It found that ASBQ scores increased beyond preoperative baseline after six months and one-year postoperatively. ^{Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37} This suggests that the relevance of time since surgery might be more pronounced when considering the initial year following the procedure, whereas its influence on HRQOL may weaken beyond that point. This is supported by the aforementioned trends in studies looking at HRQOL after surgical resection.

Seven studies examined whether there was an association between previous surgical resection and HRQOL, ^{Reference Keshwara, Gillespie and Mustafa18,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Kofoed Lauridsen, Ciochon and Tolver24,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Jones, Iannone and Patel38,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40} though differences in the specific variables assessed were present. One study with potential bias issues found that patients with previous surgical resection receiving stereotactic radiotherapy (SRT) tended to have better MCS results as compared to patients receiving primary SRT, ^{Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40} and the remaining found no association between the number of surgeries or previous resection and HRQOL. ^{Reference Keshwara, Gillespie and Mustafa18,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Kofoed Lauridsen, Ciochon and Tolver24,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Jones, Iannone and Patel38}

Findings regarding the long-term impact of the extent of resection on HRQOL predominantly indicated no association, ^{Reference Waagemans, van Nieuwenhuizen and Dijkstra21,Reference Jakola, Gulati, Gulati and Solheim31,Reference Castle-Kirszbaum, Kam, Dixon, Goldschlager, King and Wang37,Reference Jones, Iannone and Patel38} with only one study focused on sphenoid wing meningiomas finding that complete resection was associated with a decreased improvement in postoperative HRQOL via KPS. ^{Reference Ouyang, Zhang, Wang, Li and Chen30}

Three studies examined the impact of the surgical approach on HRQOL in meningioma patients, but they have limited comparability due to different scopes. ^{Reference Ouyang, Zhang, Wang, Li and Chen30,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39,Reference Torales, Di Somma and Alobid45} One study focused on sphenoid wing meningiomas and found no significant differences in KPS scores among three specific surgical approaches. ^{Reference Ouyang, Zhang, Wang, Li and Chen30} Another study focusing on anterior skull-base meningiomas found no significant differences in scores for all SF-36 domains between endonasal and supraorbital approaches. ^{Reference Torales, Di Somma and Alobid45} In contrast, other findings on skull-base meningioma patients showed improved EQ-5D-3L scores at the one-year follow-up for non-frontotemporal surgical approaches. ^{Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39}

Radiotherapy was evaluated by eight studies, ^{Reference Benz, Wrensch and Schildkraut16,Reference Keshwara, Gillespie and Mustafa18,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Jones, Iannone and Patel38,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40,Reference Lisowski, Tromel and Lutyj43} of which five specified the type of radiotherapy administered (SRT, ^{Reference Keshwara, Gillespie and Mustafa18,Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40,Reference Lisowski, Tromel and Lutyj43} fractionated radiotherapy, ^{Reference Keshwara, Gillespie and Mustafa18,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27} intensity-modulated radiotherapy ^{Reference Lisowski, Tromel and Lutyj43} or radiosurgery ^{Reference Lisowski, Tromel and Lutyj43} ). Overall, several studies revealed a consistent association with reduced HRQOL, ^{Reference Benz, Wrensch and Schildkraut16,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Jones, Iannone and Patel38,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40,Reference Lisowski, Tromel and Lutyj43} particularly in domains like vitality and physical role functioning as per SF-36 scores. ^{Reference Benz, Wrensch and Schildkraut16,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Henzel, Fokas, Sitter, Wittig and Engenhart-Cabillic40} However, only one study ^{Reference Keshwara, Gillespie and Mustafa18} directly compared the different types of radiotherapy to discern their specific impacts on HRQOL. Notably, Fisher et al. found no significant differences observed between surgery-only and surgery plus adjuvant radiotherapy groups, ^{Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23} though another study found that adjuvant radiotherapy was linked with worse ASBQ pain scores. ^{Reference Jones, Iannone and Patel38} Contrarily, Zamanipoor Najafabadi et al. observed no significant impact of any radiotherapy on SF-36 scores. ^{Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27} Both this study and Fisher et al. examined HRQOL at a median of nine years post-surgery but were not consistent in their evaluation of radiotherapy, which likely contributed to the observed discrepancies in the findings. ^{Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27}

Finally, the impact of discharge destination and active surveillance on HRQOL in meningioma patients was explored in only one study each. ^{Reference Zamanipoor Najafabadi, van der Meer and Boele17,Reference Kofoed Lauridsen, Ciochon and Tolver24} Discharge home was associated with better long-term HRQOL on the general FACT and FACT-Br. ^{Reference Kofoed Lauridsen, Ciochon and Tolver24} Patients under active MRI surveillance showed similar HRQOL scores compared to those receiving surgery or radiotherapy. ^{Reference Zamanipoor Najafabadi, van der Meer and Boele17} Additional research is needed to establish substantive conclusions regarding the influence of these factors.

Three of the seven studies ^{Reference Keshwara, Gillespie and Mustafa18,Reference Fisher, Zamanipoor Najafabadi, van der Meer and B.23,Reference Kofoed Lauridsen, Ciochon and Tolver24,Reference Zamanipoor Najafabadi, van der Meer, Boele and etal27,Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28,Reference Jakola, Gulati, Gulati and Solheim31,Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} examining whether there was an association between the presence of surgical complications and HRQOL found a significant association. The presence of surgical complications was associated with lower HRQOL at one-year post-surgery in one study ^{Reference Karsy, Jensen, Guan, Ravindra, Bisson and Couldwell39} and over five years post-surgery in another, ^{Reference Keshwara, Gillespie and Mustafa18} and intra- and postoperative bleeding, cerebrospinal fluid disturbances and cranial nerve disturbances were associated with worsened postoperative KPS scores in the third. ^{Reference Meixensberger, Meister, Janka, Haubitz, Bushe and Roosen28}

Antiepileptic drug (AED) use was associated with lower HRQOL scores in two of three studies, ^{Reference Keshwara, Gillespie and Mustafa18,Reference Waagemans, van Nieuwenhuizen and Dijkstra21,Reference Tanti, Marson and Jenkinson29} particularly in FACT-Br summary scores, SF-36 MCS and SF-36 domains of role-physical, social functioning, mental health, vitality and general health. ^{Reference Waagemans, van Nieuwenhuizen and Dijkstra21,Reference Tanti, Marson and Jenkinson29} However, when executive functioning was controlled for, a significant association was only found in one of the eight domains on SF-36. ^{Reference Waagemans, van Nieuwenhuizen and Dijkstra21}

HRQOL tools

A total of 11 unique tools were used to evaluate HRQOL in the included studies, with many studies using more than one (Table 5). The most common tools used were SF-36 ^{Reference Ware and Sherbourne46,Reference McHorney, Ware and Raczek47} (N = 13), followed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Brain Neoplasm 20 (EORTC QLQ-BN20) ^{Reference Taphoorn, Claassens and Aaronson48} (N = 6), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) ^{Reference Aaronson, Ahmedzai and Bergman49} (N = 6), EQ-5D ^{Reference Rabin and de Charro50} (N = 5), KPS (N = 5) and FACT-Br ^{Reference Weitzner, Meyers, Gelke, Byrne, Levin and Cella51} (N = 3). One article used a modified version of FACT-Br ^{Reference Kalkanis, Quinones-Hinojosa, Buzney, Ribaudo and Black25} . With the exception of KPS, which is a scale to measure functional status generally completed by the clinician, all tools are considered patient-reported outcome measures intended for completion by the patient themselves. Some studies have adopted KPS as a proxy of HRQOL, despite the fact that KPS may not encompass all aspects of HRQOL relevant to meningioma patients. The majority of these tools have undergone at least partial validation. However, only the FACT-Br tool has been validated in a diverse brain tumour population that includes meningioma patients. ^{Reference Weitzner, Meyers, Gelke, Byrne, Levin and Cella51} Of the tools used, four measure generic HRQOL, while others are specific to certain conditions including brain neoplasms (N = 2), cancer (N = 2), sinonasal outcomes (N = 1) and anterior skull-base surgery (N = 1). Despite this variety, we emphasize that none of these tools were specifically designed and fully validated for exclusive use in meningioma patients.

Table 5. Summary of quality of life (QOL) tools used in included articles (N = 31)

Notes: ASBQ-35 = Anterior Skull Base Questionnaire-35; EQ-5D = EuroQOL-5 Dimensions; EORTC QLQ-BN20 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Brain Neoplasm 20; EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; FACT-Br = Functional Assessment of Cancer Therapy-Brain; FACT-G = Functional Assessment of Cancer Therapy-General; KPS = Karnofsky performance scale; SF-36 = 36-item Short Form Survey; SNOT-22 = Sinonasal Outcome Test 22; VAS = Visual Analogue Scale.

* Many studies used more than one tool

** Questionnaire published in German only

*** Some included studies created a modified questionnaire based on existing tools, including FACT-Br (see Table 1)