Surgical outcomes for older patients with glioblastoma multiforme: preoperative factors associated with decreased survival. Clinical article

Abstract

Object: As the population ages, the incidence of glioblastoma multiforme (GBM) among older patients (age > 65 years) will increase. Older patients, unlike their younger counterparts, are not often offered aggressive surgery because of their age, comorbidities, and potential inability to tolerate surgery. The goal of this study was to identify preoperative factors associated with decreased survival for older patients who underwent resection of a GBM. The identification of these factors may provide insight into which patients would benefit most from aggressive surgery.

Methods: All patients older than 65 years who underwent nonbiopsy resection of an intracranial GBM at a single institution between 1997 and 2007 were retrospectively reviewed. Factors associated with overall survival were assessed using multivariate proportional hazards regression analysis after controlling for peri- and postoperative factors known to be associated with outcome (extent of resection, carmustine wafer implantation, temozolomide chemotherapy, and radiation therapy). Variables with p < 0.05 were considered statistically significant.

Results: A total of 129 patients with an average age of 73 ± 5 years met the inclusion/exclusion criteria. At last follow-up, all 129 patients had died, with a median survival of 7.9 months. The preoperative factors that were independently associated with decreased survival were Karnofsky Performance Scale (KPS) score less than 80 (p = 0.001), chronic obstructive pulmonary disease (p = 0.01), motor deficit (p = 0.01), language deficit (p = 0.005), cognitive deficit (p = 0.02), and tumor size larger than 4 cm (p = 0.002). Patients with 0-1 (Group 1), 2-3 (Group 2), and 4-6 (Group 3) of these factors had statistically different survival times, where the median survival was 9.2, 5.5, and 4.4 months, respectively. In log-rank analysis, the median survival for Group 1 was significantly longer than that for Group 2 (p = 0.004) and Group 3 (p < 0.0001), while Group 2 had longer survival than Group 3 (p = 0.02).

Conclusions: Older patients with an increasing number of these factors may not benefit as much from aggressive surgery as patients with fewer factors. This may provide insight into identifying which patients older than 65 years of age may benefit from aggressive surgery.

Fig. 1

Survival of all patients older than 65 years with an intracranial GBM. The median survival was 7.9 months, where the 3-, 6-, and 12-month survival rates were 81%, 57%, and 23%, respectively.

Fig. 2

Survival of patients with intracranial GBM, older and younger than 75 years by age group. Patients younger than 75 years had a median survival of 8.7 months compared with 5.1 months for individuals older than 75 years (p = 0.009).

Fig. 3

Survival of older patients by number of factors associated with survival. One point was given for each of the following: KPS score lower than 80, COPD, motor deficit, language deficit, cognitive deficit, and tumor size larger than 4 cm. The median survival for patients in Group 1 (0–1 points) was 9.2 months, Group 2 (2–3 points) was 5.5 months, and Group 3 (4–6 points) was 4.4 months. In log-rank analysis, the median survival for Group 1 was significantly longer than that for Groups 2 (p = 0.004) and 3 (p < 0.0001). Likewise, the median survival for individuals in Group 2 was significantly longer than for individuals in Group 3 (p = 0.02).