Treatment for brain tumor does not always follow recommendations

01/26/05

An examination of how the most common type of primary brain tumor is treated found that care does not always follow established practice guidelines, according to a study in the February 2 issue of JAMA.

Malignant gliomas (brain tumors, grade III or IV) are the most common primary brain tumor, and their incidence is increasing over time, according to background information in the article. These tumors are the second-most common cause of cancer-related death in the young-adult age group and are associated with extensive illness. Despite intensive research, the prognosis for patients with malignant glioma remains poor. Typical survival for patients with grade III glioma is 3 to 5 years and is less than 1 year for patients with glioblastoma multiforme (grade IV glioma). Current treatment for patients with malignant glioma includes maximum safe resection (surgical removal), radiation therapy, and chemotherapy.

Susan M. Chang, M.D., of the University of California, San Francisco, and colleagues conducted a study to provide data to enable comparison of individual practice patterns and outcomes for adults with malignant glioma. The Glioma Outcomes (GO) Project enrolled 788 patients at 52 clinical sites, both academic and community practices, between December 1997 and July 2000. The enrollment criteria included adult patients with primary grade III or IV glioma undergoing a first or second operation for diagnosis or treatment. The data collection instruments included questionnaire forms given at enrollment, during the perioperative period, and at follow-up intervals of 3 months until death or a maximum of 24 months. Of the patients recorded in the GO database, 565 patients with newly diagnosed tumors were used for this analysis.

The researchers found that most patients underwent magnetic resonance imaging (n = 518; 92 percent) and an attempt at tumor resection (n = 425; 75 percent). Most received perioperative corticosteroids (n = 535; 99 percent) and antiepileptic medications (n = 497; 88 percent), but few received antidepressants (n = 38; 8 percent) or prophylactic heparin (n=42; 7 percent). Most received radiation therapy (n = 479; 87 percent) in addition to other therapy, but fewer received chemotherapy (n = 300; 54 percent). Practice patterns varied significantly between academic and community settings.

"We present patterns of care for a large group of patients with newly diagnosed malignant glioma treated in the modern era. Some common practice patterns are in keeping with published literature (e.g., use of radiation therapy), some contradict published guidelines (e.g., frequent prophylactic antiepileptic drug administration) or may conflict with published literature (e.g., relatively infrequent use of chemotherapy), and still others point out areas for further investigation in this population, including heparin prophylaxis for venous thromboembolism, antidepressant medication, corticosteroid dosing, and use of surgical adjuncts. Variations in patterns of care were associated with differences in survival; establishing further practice guidelines may help reduce this variability. One of the major benefits of the GO Project is that it provides a broad historical cohort that can be used as a comparison for future prospective studies," the authors conclude.

(JAMA. 2005;293:557-564. Available post-embargo at JAMA.com)

Editor's Note: For funding and financial disclosure information, please see the JAMA article.

Editorial: Malignant Gliomas in 2005 - Where to GO From Here?

In an accompanying editorial, Paul Graham Fisher, M.D., of Stanford University, Stanford, Calif., and Patricia A. Buffler, Ph.D., of the University of California, Berkeley discuss the findings by Chang et al.

"Where should treatment of gliomas go from here? Neuro-oncology requires a major paradigm shift and substantial changes in treatment and research involving malignant gliomas. Wider availability of novel approaches and increased cooperation between academic institutions and community centers must occur to improve care patterns for patients with malignant glioma. In addition, for any clinical trial, correlative biological studies of tumor specimens need to be wedded to the trial, particularly when end points may be biological change rather than tumor reduction demonstrated on MRI. As oncology takes on increasingly specific, targeted approaches, it is inappropriate to continue rolling out new therapies indiscriminately and often conclude that they are not effective in 'malignant gliomas,' a molecularly heterogeneous group of tumors lumped together based on light microscopy. Some treatments may be highly beneficial to a select few patients, yet ineffective in many others. At the same time, phase 1 trials in oncology that have traditionally excluded patients with brain tumors should be made more widely available to those with malignant glioma ," the editorialists write.

"There are few proven risk factors for the development of brain tumors. It is difficult to imagine advancing cures unless the genetic, environmental, dietary, other risk factors, and their interactions that cause brain tumors are more clearly established. Biological studies need to be incorporated into these epidemiologic investigations to enhance the informativeness of these studies. Increased funding via governmental grant mechanisms or philanthropic foundations will be paramount for the progress needed to achieve this progress. Advancements for patients with malignant glioma have been negligible, and there is a real risk of going nowhere by simply continuing to travel the same path," they conclude.

(JAMA. 2005;293:615-617. Available post-embargo at JAMA.com)

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