ASTRO 2015

First ASTRO glioblastoma guidelines under review

Dr Stephen Lutz - Eastern Woods Radiation, Findlay, USA

Really, the best way to start in to the background is that ASTRO has just recently become very interested in doing guidelines that are meaningful, both for other physicians in the specialty but also for patients. So one of the most important guidelines, for my mind, was to do one for glioblastoma, brain tumour, the reason being really one has not been done and people in general think they understand this topic but doing the guideline proved that there’s a lot to it.

Why does glioblastoma need specific radiotherapy guidelines?

I think there are several reasons. One is there’s certainly some variability in how these patients are treated also irradiation is used for most all of these patients. But, for my interest, one of the biggest concerns is that there are times when unfortunately some of these patients, either because of their tumour or their other health issues, may not be able to tolerate what has been considered standard. So we have to figure out how to taper it for those patients.

What is the evidence for using radiation for treating glioblastoma?

There’s a lot of evidence and it goes back years. Literally one of the best studies written in radiation oncology was in the late 1960s for glioblastoma; parts of what we learned from that study are still true. So, on the one hand, it’s frustrating, things have not progressed, on the other hand, the technology and also our understanding of who to approach and how to give the treatments has progressed.

What are the outcomes and the natural history of glioblastoma?

In a word, unfortunately, it’s really bad. It’s really bad historically and still even today, even with the advances we’ve had in radiation and adding Temodar chemotherapy, many patients don’t live a year. So part of the issue we have is the standard treatment would be five days a week for six weeks, there are some patients whose prognosis is so poor that some of the data that interests us are data where maybe we can just do ten treatments over two weeks and get about as much out of it. So it’s a tough illness to face and it’s just as tough to treat. You become very attached and you understand these people are facing amongst the most lethal types of cancers that we face.

What about some of the advances in chemotherapy and immunotherapy for glioblastoma?

What’s interesting is that until maybe seven or eight years ago a lot of different chemotherapies were tried but the brain is made in a very intelligent way. There’s a filter to keep the chemotherapy from getting to the brain. So there’s an oral agent called Temodar, temozolomide, that’s given along with radiation and then even for several months after and that has improved outcomes some. What we really need, though, are other agents. There are some that have been tried and have been shown to be promising but at this point all of us would be really excited to have one or two more that could help.

Is there anything specific about the ASTRO glioblastoma guidelines that you would like to highlight?

Three things. One is the standard that has always been there is there for a reason, it’s based on data. The second thing is in terms of how to shape the dose, that has been probably the most variable part and the guideline does approach that in terms of the best way to do that. But, third, what will probably be most provocative is that the patients who do need to have, perhaps from a common sense standpoint, either a shortened course to two weeks or maybe no treatment at all, this guideline approaches that and that is going to be the part that is going to have people thinking and talking after it is presented.

What are the options for people who cannot have radiation therapy?

Sometimes just the chemotherapy alone, sometimes just supportive care. For this, many of the symptoms come from swelling in the brain. Some patients will just get a steroid to try and keep down the swelling and pain medicine to help pain and that will be as far as anyone goes to help them. When some patients, especially those that are ill with other health problems, understand what a glioblastoma diagnosis means, some of them actually willingly choose supportive care as the only means to treat this.

What can you tell us about end of life care?

What we’ve really learned is that patients, when presented with the truth about this illness or other life-threatening illnesses, sometimes actually do pick and choose more than they used to. When I think of the generation that was raised in the World War II era, they really went to the physician looking to be told. People now want much more information about longevity, quality of life, sometimes even cost of treatment. So in terms of end of life care that’s really a huge burgeoning part of our speciality is to deal with folks in a much more holistic sense of what their wants and needs are. I always tell, folks knowledge is power and we’ll share everything we can. It’s interesting, patients feel much more comfortable, even when there’s something out of control and life-threatening, to know they have the knowledge and can choose. It’s a big deal.

Would patients not choose radiotherapy because of the side effects?

Sometimes that or sometimes it’s simply hard to travel. A lot of what we face now are patients who are caregivers for a spouse or someone else is trying to give care for them and has a full-time job. Sometimes people just can’t make it back and forth ten minutes a day, five days a week for six weeks. So to fit what we can offer in the bigger picture of their life and their families’ lives, I think that’s a big deal now. It’s not as simple as ‘Here’s what you have, here’s what the standard is,’ it’s much more personalised to someone’s bigger picture.

Is there anything else you’d like to highlight about the ASTRO glioblastoma guidelines or end of life care?

The biggest thing I can say is that the guidelines take a lot of effort to create and the presentation of the guidelines leads to a lot of very sometimes contentious discussions. But people that are facing these illnesses need to understand that this is a huge step forward, it’s databased, it’s open and the discussions are useful. Sometimes hard discussions end up with much better outcomes so I think the guidelines in and of themselves are worth the effort. The fact that they’re made available for patients and all caregivers is a big deal, it’s a huge issue.