Assessment and treatment relevance in elderly glioblastoma patients

Abstract

Glioblastoma (GBM) is the most common malignant primary brain tumor. Its incidence continues to increase in the elderly because the older segment of the population is growing faster than any other age group. Most clinical studies exclude elderly patients, and "standards of care" do not exist for GBM patients aged >70 years. We review epidemiology, tumor biology/molecular factors, prognostic factors (clinical, imaging data, therapeutics), and their assessments as well as classic and specific endpoints plus recent and ongoing clinical trials for elderly GBM patients. This work includes perspectives and personal opinions on this topic. Although there are no standards of care for elderly GBM patients, we can hypothesize that (i) Karnofsky performance status (KPS), probably after steroid treatment, is one of the most important clinical factors for determining our oncological strategy; (ii) resection is superior to biopsy, at least in selected patients (depending on location of the tumor and associated comorbidities); (iii) specific schedules of radiotherapy yield a modest but significant improvement; (iv) temozolomide has an acceptable tolerance, even when KPS <70, and could be proposed for methylated elderly GBM patients; and (v) the addition of concomitant temozolomide to radiotherapy has not yet been validated but shows promising results in some studies, yet the optimal schedule of radiotherapy remains to be determined. In the future, specific assessments (geriatric, imaging, biology) and use of new endpoints (quality of life and toxicity measures) will aid clinicians in determining the balance of potential benefits and risks of each oncological strategy.

Keywords: assessment; database; elderly; glioblastoma; neuro-oncology.

Fig. 1.

Suggested personal, nonstandardized approach for oncology care management of elderly patients (aged >70 years) with presumed and confirmed newly diagnosed glioblastoma (GBM). ^aCGA includes G8 questionnaire, IADL questionnaire, information about social situation, Charlson Comorbidity Index (CCI) (available at http://annonc.oxfordjournals.org/content/suppl/2010/11/08/mdq687.DC1/Appendix_ETF_CGA_dataset.doc), geriatric consultation, and other exams according to the preference of the geriatric physician (eg, balance and gait assessment, anxiety scale, etc.) ^bWhen the rationale supports the resection, but the post steroids MMSE or MoCA is very low, the proposal could be directed towards biopsy or best supportive care. ^cAt the presurgical stage, when hesitating between biopsy and best supportive care, if there is no possibility of radiotherapy or chemotherapy, we suggest opting for the best supportive care. ^dTMZ: temozolomide; Stupp protocol and RT40Gy/15f-TMZ include concomitant and adjuvant TMZ. Note: When high volumes are to be irradiated, we are careful to propose treatments that include radiotherapy, but we may also propose TMZ only, especially for methylated MGMT_p tumors.

Fig. 1.

Suggested personal, nonstandardized approach for oncology care management of elderly patients (aged >70 years) with presumed and confirmed newly diagnosed glioblastoma (GBM). ^aCGA includes G8 questionnaire, IADL questionnaire, information about social situation, Charlson Comorbidity Index (CCI) (available at http://annonc.oxfordjournals.org/content/suppl/2010/11/08/mdq687.DC1/Appendix_ETF_CGA_dataset.doc), geriatric consultation, and other exams according to the preference of the geriatric physician (eg, balance and gait assessment, anxiety scale, etc.) ^bWhen the rationale supports the resection, but the post steroids MMSE or MoCA is very low, the proposal could be directed towards biopsy or best supportive care. ^cAt the presurgical stage, when hesitating between biopsy and best supportive care, if there is no possibility of radiotherapy or chemotherapy, we suggest opting for the best supportive care. ^dTMZ: temozolomide; Stupp protocol and RT40Gy/15f-TMZ include concomitant and adjuvant TMZ. Note: When high volumes are to be irradiated, we are careful to propose treatments that include radiotherapy, but we may also propose TMZ only, especially for methylated MGMT_p tumors.