Developing an Algorithm for Optimizing Care of Elderly Patients With Glioblastoma

Flanigan, Patrick M.; Jahangiri, Arman; Kuang, Ruby; Truong, Albert; Choi, Sarah; Chou, Alvin; Molinaro, Annette M.; McDermott, Michael W.; Berger, Mitchel S.; Aghi, Manish K.

doi:10.1093/neuros/nyx148

Cited by 21 publications

(27 citation statements)

References 28 publications

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“…A total of 76 studies were retrieved for full-text evaluation, and 57 were further excluded due to the following reasons: no appropriate control (n = 29), inclusion of younger patients (n = 20), and no sufficient data (n = 8). Therefore, 19 studies met our inclusion criteria and were selected for final meta-analysis (24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42). There were no additional eligible studies from the manual search of the reference lists of these studies.…”

Section: Literature Searchmentioning

confidence: 99%

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

et al. 2020

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Background: The optimal strategy for the management of high-grade glioma in the elderly (≥60.0 years) remains controversial, especially regarding the effects of surgical extent on survival outcomes. The purpose of this study was to compare gross total resection (GTR) with subtotal resection (STR) for treatment effects in elderly patients with high-grade glioma.Methods: Three electronic databases were systematically searched, including PubMed, EmBase, and the Cochrane library, from inception to August 2018. Hazard ratios (HRs) or odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used to express summary effect estimates using the random-effects model. Nineteen retrospective observational studies involving a total of 10,815 elderly patients with high-grade glioma were included in this meta-analysis.Results: The summary results indicated that GTR was associated with a significant improvement in overall survival (OS) compared with STR (HR = 0.70, 95% CI = 0.64-0.77). In addition, elderly patients administered GTR showed lower risk of 3-month mortality (OR = 0.47, 95% CI = 0.24-0.93), 6-month mortality (OR = 0.38, 95% CI = 0.26-0.56), 9-month mortality (OR = 0.35, 95% CI = 0.25-0.49), and 1-year mortality (OR = 0.40, 95% CI = 0.29-0.56). Pooled OS data differed when stratified by publication year, country, sample size, disease status, and study quality.Conclusion: GTR seems to be more effective than STR in achieving longer survival in elderly patients with high-grade glioma.

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Section: Literature Searchmentioning

confidence: 99%

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

et al. 2020

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“…Recent studies have shown that, in addition to conventional prognostic factors, the molecular profile of tumors can be used to select from these treatment alternatives. [3][4][5][6][7][8][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] Microsurgery's place within this framework remains unclear. 6,[18][19][20][21][22] Even though gross total resection (GTR) has been proven to increase OS, little data are available concerning the risks and benefits of resections in older adults.…”

Section: Introductionmentioning

confidence: 99%

Risks and Benefits of Glioblastoma Resection in Older Adults: A Retrospective Austrian Multicenter Study

Schwartz

Romagna

Stefanits³

et al. 2020

World Neurosurgery

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To assess the prognostic profile, clinical outcome, treatment-associated morbidity, and treatment burden of elderly patients with glioblastoma (GBM) undergoing microsurgical tumor resection as part of contemporary treatment algorithms.-METHODS: We retrospectively identified patients with GBM ‡65 years of age who were treated by resection at 2 neuro-oncology centers. Survival was assessed by Kaplan-Meier analyses; log-rank tests identified prognostic factors.-RESULTS: The study population included 160 patients (mean age, 73.1 AE 5.1 years), and the median contrastenhancing tumor volume was 31.0 cm 3 . Biomarker analyses revealed O( 6)-methylguanine-DNA methyltransferasee promoter methylation in 62.7% and wild-type isocitrate dehydrogenase in 97.5% of tumors. The median extent of resection (EOR) was 92.3%, surgical complications were noted in 10.0% of patients, and the median postoperative hospitalization period was 8 days. Most patients (60.0%) received adjuvant radio-/chemotherapy. The overall treatment-associated morbidity was 30.6%. The median progression-free and overall survival were 5.4 months (95% confidence interval [CI], 4.6e6.4 months) and 10.0 months (95% CI, 7.9e11.7 months). The strongest predictors for favorable outcome were patient age £73.0 years (P [ 0.0083), preoperative Karnofsky Performance Status Scale score ‡80% (P [ 0.0179), postoperative modified Rankin Scale score £1 (P < 0.0001), adjuvant treatment (P < 0.0001), and no treatmentassociated morbidity (P [ 0.0478). Increased EOR did not correlate with survival (P [ 0.5046), but correlated significantly with treatment-associated morbidity (P [ 0.0031).-CONCLUSIONS: Clinical outcome for elderly patients with GBM remains limited. Nonetheless, the observed treatment-associated morbidity and treatment burden were moderate in the patients, and patient age and performance status remained the strongest predictors for survival. The risks and benefits of tumor resection in the age of Key words -Adjuvant treatment -Biomarker -Elderly -Glioblastoma multiforme -Outcome -Resection -Treatment-associated morbidity

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“…10,15,19,26 In the same multivariate model, treatment with both TMZ and XRT (HR 0.60 [95% CI 0.45–0.81, p = 0.001) and postoperative clinical trial enrollment (HR 0.54 [95% CI 0.41–0.71, p < 0.0001) were independent predictors of improved overall survival in our patient cohort.…”

Section: Resultsmentioning

confidence: 65%

Disparities in health care determine prognosis in newly diagnosed glioblastoma

Chandra¹,

Rick²,

Ore³

et al. 2018

Neurosurgical Focus

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OBJECTIVEGlioblastoma (GBM) is an aggressive brain malignancy with a short overall patient survival, yet there remains significant heterogeneity in outcomes. Although access to health care has previously been linked to impact on prognosis in several malignancies, this question remains incompletely answered in GBM.METHODSThis study was a retrospective analysis of 354 newly diagnosed patients with GBM who underwent first resection at the authors’ institution (2007–2015).RESULTSOf the 354 patients (median age 61 years, and 37.6% were females), 32 (9.0%) had no insurance, whereas 322 (91.0%) had insurance, of whom 131 (40.7%) had Medicare, 45 (14%) had Medicaid, and 146 (45.3%) had private insurance. On average, insured patients survived almost 2-fold longer (p < 0.0001) than those who were uninsured, whereas differences between specific insurance types did not influence survival. The adjusted hazard ratio (HR) for death was higher in uninsured patients (HR 2.27 [95% CI 1.49–3.33], p = 0.0003). Age, mean household income, tumor size at diagnosis, and extent of resection did not differ between insured and uninsured patients, but there was a disparity in primary care physician (PCP) status—none of the uninsured patients had PCPs, whereas 72% of insured patients had PCPs. Postoperative adjuvant treatment rates with temozolomide (TMZ) and radiation therapy (XRT) were significantly less in uninsured (TMZ in 56.3%, XRT in 56.3%) than in insured (TMZ in 75.2%, XRT in 79.2%; p = 0.02 and p = 0.003) patients. Insured patients receiving both agents had better prognosis than uninsured patients receiving the same treatment (9.1 vs 16.34 months; p = 0.025), suggesting that the survival effect in insured patients could only partly be explained by higher treatment rates. Moreover, having a PCP increased survival among the insured cohort (10.7 vs 16.1 months, HR 1.65 [95% CI 1.27–2.15]; p = 0.0001), which could be explained by significant differences in tumor diameter at initial diagnosis between patients with and without PCPs (4.3 vs 4.8 cm, p = 0.003), and a higher rate of clinical trial enrollment, suggesting a critical role of PCPs for a timelier diagnosis of GBM and proactive cancer care management.CONCLUSIONSAccess to health care is a strong determinant of prognosis in newly diagnosed patients with GBM. Any type of insurance coverage and having a PCP improved prognosis in this patient cohort. Higher rates of treatment with TMZ plus XRT, clinical trial enrollment, fewer comorbidities, and early diagnosis may explain survival disparities. Lack of health insurance or a PCP are major challenges within the health care system, which, if improved upon, could favorably impact the prognosis of patients with GBM.

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Developing an Algorithm for Optimizing Care of Elderly Patients With Glioblastoma

Abstract: Further optimization of the medical and surgical care of elderly glioblastoma patients may be achieved by providing more beneficial therapies while avoiding unnecessary resection in those not likely to receive benefit from this intervention.

Cited by 21 publications

References 28 publications

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

Risks and Benefits of Glioblastoma Resection in Older Adults: A Retrospective Austrian Multicenter Study

Disparities in health care determine prognosis in newly diagnosed glioblastoma

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