Effect of health disparities on overall survival of patients with glioblastoma.

BACKGROUND: Examine the potential effects of health disparities in survival of glioblastoma (GB) patients. METHODS: We conducted a retrospective chart review of newly diagnosed GB patients from 2000 to 2015 at a free standing dedicated cancer center (MD Anderson Cancer Center-MDACC) and a safety net county hospital (Ben Taub General Hospital-BT) located in Houston, Texas. We obtained demographics, insurance status, extent of resection, treatments, and other known prognostic variables (Karnofsky Score-KPS) to evaluate their role on overall GB survival (OS). RESULTS: We identified 1073 GB patients consisting of 177 from BT and 896 from MDACC. We found significant differences by ethnicity, insurance status, KPS at diagnosis, extent of resection, and percentage of patients receiving standard of care (SOC) between the two centers. OS was 1.64 years for MDACC patients and 1.24 years for BT patients (p < 0.0176). Only 81 (45.8%) BT patients received SOC compared to 577 (64%) of MDACC patients (p < 0.0001). However, there was no significant difference in OS for patients who received SOC, 1.84 years for MDACC patients and 1.99 years for BT patients (p < 0.4787). Of the 96 BT patients who did not receive SOC, 29 (30%) had KPS less than 70 at time of diagnosis and 77 (80%) lacked insurance. CONCLUSIONS: GB patients treated at a safety net county hospital had similar OS compared to a free standing comprehensive cancer center when receiving SOC. County hospital patients had poorer KPS at diagnosis and were often lacking health insurance affecting their ability to receive SOC.

Estimated lifetime survival benefit of tumor treating fields and temozolomide for newly diagnosed glioblastoma patients.

AIM: To estimate the mean lifetime survival benefit, an essential component of health economic evaluations in oncology, of adding tumor treating fields (TTFields) to maintenance temozolomide (TMZ) for newly diagnosed glioblastoma patients. METHODS: We integrated EF-14 trial data with glioblastoma epidemiology data. The model provided for an evidence-based approach to estimate lifetime survival for the material number of EF-14 trial patients still alive at 5 years. RESULTS & CONCLUSION: Patients treated with TTFields and TMZ had an incremental mean lifetime survival of 1.8 years (TTFields/TMZ: 4.2 vs TMZ alone: 2.4). Patients alive at year 2 after starting TTFields had a 20.7% probability of surviving to year 10. The results presented here provide the required incremental survival benefit necessary for a future assessment of the incremental cost-effectiveness of TTFields.

Application of tumor treating fields for newly diagnosed glioblastoma: understanding of nationwide practice patterns.

BACKGROUND: Tumor treating fields (TTF) harness magnetic fields to induce apoptosis in targeted regions. A 2015 landmark randomized phase III trial of newly diagnosed glioblastoma (GBM) patients demonstrated TTF + temozolomide to be superior to temozolomide alone. Given these results, we sought to assess practice patterns of providers in TTF utilization for GBM. METHODS: A survey was administered to practices in the United States self-identifying as specializing in radiation oncology, medical oncology, neuro-oncology, neurosurgery, and/or neurology. Responses were collected anonymously; analysis was performed using Fisher's exact test. RESULTS: A total of 106 providers responded; a minority (36%) were in private practice. Regarding case volume, 82% treated at least six high-grade gliomas/year. The provider most commonly certified to offer TTF therapy to GBM patients was the neuro-oncologist (40%), followed by the radiation oncologist (34%); 31% reported no TTF-certified physician in their practice. TTF users were more likely to have high volume, and be aware of TTF inclusion in National Comprehensive Cancer Network (NCCN) guidelines (p < 0.05). CONCLUSIONS: More than 80% of TTF for GBM in the United States is performed by groups who treat at least six high-grade gliomas per year; unfortunately more than 30% were in practices bereft of anyone certified to offer TTF therapy. These results indicate that there remains fertile soil for TTF therapy nationwide to be introduced into practices for GBM treatment. Providers seeking to refer newly diagnosed GBM patients for TTF should seek out practices with TTF user-associated characteristics to ensure optimal access for their patients.

Glioblastoma multiforme in the very elderly.

Glioblastoma is the most malignant and most common primary brain tumour and is treated with resection followed by post-operative radiotherapy and chemotherapy. However, a significant amount of patients are older than 80 years, and such an approach may not be appropriate. Data on patients aged 80 or older with glioblastoma from two hospitals was collected using the CNS Tumour Database on the Australian Comprehensive Cancer Outcomes and Research Database (ACCORD) system operated by BioGrid. Between 2008 and July 2011, 40 patients aged 80 years or older were diagnosed with glioblastoma. The median ECOG PS was 2 and the ASA score was 3. All 40 patients underwent surgery and 33% had a gross total resection. Only six patients (15%) had either post-operative radiotherapy or chemotherapy. The overall median survival was 4 months (range 0-18 months) and 28% of patients lived between 6 and 24 months. This is the largest reported cohort of very elderly patients with glioblastoma. Patients tolerated surgery but few went on to receive post-operative radiotherapy or chemotherapy. This patient population requires special attention and in particular would benefit from participation in suitable clinical trials to determine the best care regime.

Patterns of care and survival for glioblastoma patients in the Veterans population.

Survival outcomes and patterns of care for brain tumor patients in the USA Veterans population have not been previously published and the extent of variation in outcomes between Veterans and the rest of the USA is currently unknown. The Veterans healthcare administration (VA) provides comprehensive care to Veterans and their families and maintains the Veterans affairs central cancer registry (VACCR). This was a retrospective review of microscopically-confirmed, supratentorial glioblastoma multiforme in male Veterans actively followed by the VACCR; survival was analyzed and compared to a national cohort from the surveillance, epidemiology and end results program. We analyzed 1,219 Veterans with glioblastomas diagnosed between 1997 and 2006. Median survival was 6.5 months and 1, 2, and 5 years survival rates were 26.8, 5.4, and 0.5%, respectively. Patients receiving all three treatment modalities (surgical resection, radiotherapy, and chemotherapy) did best; these findings remained true among patients aged 70 and older such that these patients had an overall survival similar to those age <70. A comparable national cohort had longer median survival (9.0 months) and greater 1, 2, and 5 years survival rates (37.8, 12.8, and 4.1%) than the VA cohort. Survival and patterns of care are presented for the first time for Veterans with glioblastoma multiforme. In conclusion, we found that more aggressive therapy was associated with better survival, even among elderly Veterans and whether compared overall or by age group, VA patients showed decreased survival relative to a national cohort. We believe this potential disparity warrants further investigation.

Distress persists in long-term brain tumor survivors with glioblastoma multiforme.

INTRODUCTION: Glioblastoma multiforme (GBM) is the most common and aggressive type of primary brain tumor. The prognosis for GBM patients is extremely poor with an estimated median survival of 12 months. Despite this statistic, a number of GBM patients are living longer than in the past as new detection and treatment approaches are used. However, little is known about the psychological correlates of this disease. To address this issue we investigated distress and its sources in long-term survivors (LTS) of this disease. MATERIALS AND METHODS: Participants were asked to complete the National Comprehensive Cancer Network's (NCCN) Distress Thermometer, a single-item rapid screening tool for distress. Participants were also asked to designate sources of distress from a 34-item list developed by the NCCN. Distress scores and sources of distress for long-term GBM survivors (>18 months) were compared to patients diagnosed within the last 18 months (<18 months). RESULTS: Eight-three brain tumor patients participated in this study. Fifty-nine percent of LTS met the > or = 4 cut-off score for distress (M = 4.61, SD 3.12) as compared to 49% of patients diagnosed less than 18 months (M = 3.93, SD = 2.21; x(2) = 0.406, NS), LTS reported fewer items of concern while more LTS reported being distressed. CONCLUSIONS: This study indicates that LTS of GBM report experiencing distress at similar levels to other brain tumor patients. Level of distress for LTS is directly related to the total number of concerns in both emotional and physical domains. IMPLICATIONS FOR CANCER SURVIVORS: Regardless of LTS status, distress continues to be a part of the disease trajectory for many GBM patients. As such, attention to distress in these survivors of a major life threatening disease is warranted in follow up surveillance visits.

Case-control study of use of nonsteroidal antiinflammatory drugs and glioblastoma multiforme.

Evidence from epidemiologic and experimental studies suggests that use of nonsteroidal antiinflammatory drugs (NSAIDs) reduces risk of colon and breast cancer. The association between use of aspirin and other NSAIDs and risk of adult glioblastoma multiforme (GBM) was evaluated among 236 incident GBM cases and 401 population-based controls frequency-matched on age, gender, and ethnicity from the San Francisco Bay Area Adult Glioma Study. Cases (or proxies) and controls were interviewed in person between May 1997 and August 2000. Cases with self-reported GBM reported less use of at least 600 pills of all types of NSAIDs combined during the 10-year prediagnostic period than did controls (odds ratio (OR) = 0.53, 95% confidence interval (CI): 0.3, 0.8). Findings were consistent for aspirin (OR = 0.51, 95% CI: 0.3, 0.8), ibuprofen (OR = 0.41, 95% CI: 0.2, 0.8), and naproxen/other NSAIDs (OR = 0.34, 95% CI: 0.1, 0.8). GBM cases also reported less use of acetaminophen than did controls (OR = 0.51, 95% CI: 0.3, 1.0). Eliminating participants who initiated NSAID use within 2 years of diagnosis yielded similar results. These findings show an inverse association between NSAID use and GBM. Further studies are warranted to determine whether NSAIDs might be effective in the inhibition of GBM development or progression.

Thermoradiotherapy of recurrent malignant brain tumors.

In an attempt to improve local control and survival over those achieved with brain implant alone, a Phase I/II study of interstitial thermoradiotherapy was undertaken for recurrent malignant gliomas and recurrent solitary brain metastases. Between June 1987 and September 1990, 49 tumors in 48 patients were treated with thermoradiotherapy, including 26 glioblastoma multiforme (GM), 16 anaplastic astrocytomas (AA), 4 adenocarcinomas, and 3 melanomas. Patient age ranged from 18 to 71 years and Karnofsky Performance Status from 40 to 90. Stereotactically implanted catheters were used for both hyperthermia and brachytherapy. Hyperthermia was administered immediately before and after brachytherapy, heating as much of the tumor as possible to 42.5 degrees C for 30 min using helical coil microwave antennas. High-activity iodine-125 sources delivered tumor doses of 32.6 to 63.3 Gy. Complications included reversible neurologic changes in 13 patients, 9 seizures, 4 infections, 1 deep venous thrombosis with pulmonary embolus, and 1 scalp burn. Eighteen patients underwent reoperation for tumor and/or necrosis. Follow-up ranged from 9 to 166+ weeks. The median follow-up for living patients with GM and AA was 37 weeks and 92 weeks, respectively. Actuarial median survival was 47 weeks for patients with GM. For patients with AA, actuarial survival was 65% at 18 months and median survival has not yet been reached. Multivariate analysis showed a strong correlation between freedom from local tumor progression and "T90" temperature or minimum tumor temperature. Interstitial brain thermoradiotherapy is now being evaluated in a randomized Phase II trial for previously untreated GM.

Risk of astrocytic brain tumors associated with occupational chemical exposures. A case-referent study.

A case-referent study was conducted on the risk of brain tumors among workers exposed to organic chemicals in petroleum refining and chemical manufacturing. Brain tumor cases in northern New Jersey, Philadelphia, and the Gulf Coast of Louisiana were identified from death certificates of a recent three-year period. The cases (N = 300) were white men aged greater than or equal to 30 years with a confirmed diagnosis of glioblastoma multiforme, astrocytoma, or a mixed glioma with astrocytic cells. The referents (N = 386) were white men who died from causes other than brain tumor, epilepsy, cerebrovascular disease, suicide, or homicide and were frequency-matched with the cases on age at death, year of death, and study area. Next-of-kin were interviewed for complete occupational histories. No statistically significantly elevated odds ratios (OR) were associated with employment in the chemical industry. The risk of astrocytic tumors was elevated among the subjects with production or maintenance jobs in petroleum refining (OR 1.7, 95% confidence interval 0.7-4.2); however, it decreased with duration employed. There were nonsignificant excess risks of astrocytic tumors among the men exposed to cutting fluids (OR 1.6) or organic solvents (OR 1.3), and also among the subjects exposed to lubricating oils (OR 1.4), organic solvents (OR 1.5), or cutting fluids (OR 1.8) for greater than or equal to 20 years.

The morbidity and mortality of brain tumors. A perspective on recent advances in therapy.

This article reviews current morbidity and mortality statistics for the major classes of primary brain tumors including malignant astrocytoma, glioblastoma, low-grade astrocytoma, oligodendroglioma, meningioma, and other benign tumors and metastatic tumors. Innovations in therapy are discussed for surgery, radiation, chemotherapy, and such newer areas as hyperthermia, immunotherapy, and phototherapy.