Practical guidance for telemedicine use in neuro-oncology.

While the COVID-19 pandemic has catalyzed the expansion of telemedicine into nearly every specialty of medicine, few articles have summarized current practices and recommendations for integrating virtual care in the practice of neuro-oncology. This article identifies current telemedicine practice, provides practical guidance for conducting telemedicine visits, and generates recommendations for integrating virtual care into neuro-oncology practice. Practical aspects of telemedicine are summarized including when to use and not use telemedicine, how to conduct a virtual visit, who to include in the virtual encounter, unique aspects of telehealth in neuro-oncology, and emerging innovations.

Tele-neuro-oncology: Current Practices and Future Directions.

PURPOSE OF REVIEW: The purpose of this review is to describe the current state of telemedicine within neuro-oncology. This article will address the development of tele-neuro-oncology over time with a focus on current use and applications of telemedicine within the field. Current modalities and practical considerations for tele-neuro-oncology visits and opportunities for growth will be highlighted. RECENT FINDINGS: The use of telemedicine has expanded significantly during the COVID-19 pandemic, particularly within neuro-oncology. The use of telemedicine is widely accepted by neuro-oncologic patients and providers and continues to expand in utilization and scope. The use of tele-neuro-oncology is expected to develop further with opportunities for multidisciplinary and integrated care, clinical trials, research, and education. Telemedicine provides a unique, patient-centered approach to neuro-oncologic care. Telehealth will remain a valuable tool, and its use and role are expected to expand within neuro-oncology.

Meet the expert: How I treat chemotherapy-induced peripheral neuropathy.

Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent, often irreversible and disabling adverse effect of many commonly used chemotherapeutic agents. Older patients are at particular risk of developing CIPN due to comorbid conditions affecting the health of peripheral nerves. Symptoms of CIPN include paresthesias, dysesthesias, sensory loss, motor weakness, dysautonomia, and falls. Pharmacologic management of CIPN involves use of medications including antidepressants, anticonvulsants, and topical treatments for modulation of neuropathic pain. These medications should be used and monitored carefully in older patients as they may increase the risk of confusion, falls, and drug-drug interactions. Patients with CIPN are at an increased risk of falls and should be considered for supportive care interventions including physical and occupational therapy, assistive devices, and safety evaluations. Surveillance of CIPN during and following treatment is essential. The development of neuropathic symptoms may require dose reduction, drug holiday, or transitioning to another chemotherapeutic agent. Symptoms of CIPN typically improve following exposure to neurotoxic therapy, although in older adults the rate of improvement may be slow, and recovery is often incomplete. Early involvement of a neurologist should be considered in patients with atypical, progressive, motor- or autonomic- predominant presentations of neuropathy. Patients with refractory neuropathic pain or those who cannot tolerate standard symptomatic treatment should be referred to a pain specialist or palliative care.

Chemotherapy toxicities and geriatric syndromes in older patients with malignant gliomas.

OBJECTIVE: To describe treatment toxicities and polypharmacy in older patients with malignant gliomas (MG). BACKGROUND: Advanced age in cancer patients is associated with increased treatment-related toxicities, acute care utilization and functional decline. Most patients with MG are over age 65, yet treatment patterns and toxicities are poorly defined. METHODS: A retrospective chart review of 125 patients with MG age 65 or older at the University of Rochester from January 2012 to December 2018. RESULTS: 115 patients with glioblastoma and 10 with anaplastic astrocytoma had a median age of 71 (range 65-89) at diagnosis and median overall survival (OS) of 10.3 months. Radiotherapy (RT) was offered and completed in 79% (fractionated, n = 69, hypofractionated, n = 30). 24% of the 98 patients treated with concurrent temozolomide (TMZ) experienced treatment delays (n = 24). Median of 4 cycles of adjuvant TMZ were taken by 61% (n = 76). Delays and dose reductions occurred in 55% during treatment with adjuvant TMZ, most commonly due to thrombocytopenia (n = 29) and fatigue (n = 15). 16/98 patients required transfusions during treatment with concurrent or adjuvant TMZ. At baseline, patients were prescribed a median of 11 medications. OS was longer in patients prescribed less than 8 medications vs. 8 or more (14 vs. 8.6 months, p = .0738). 96% experienced a non-elective hospital admission and 64% reported at least one fall. CONCLUSION: Older patients with MG experience significant polypharmacy, treatment toxicities and falls. Studies incorporating geriatric assessment tools may better determine associations between geriatric syndromes and survival. Clinical trials in older patients should also include non-survival outcomes.

Differentiation of rare brain tumors through unsupervised machine learning: Clinical significance of in-depth methylation and copy number profiling illustrated through an unusual case of IDH wildtype glioblastoma.

Methylation profiling has become a mainstay in brain tumor diagnostics since the introduction of the first publicly available classification tool by the German Cancer Research Center in 2017. We demonstrate the capability of this system through an example of a rare case of IDH wildtype glioblastoma diagnosed in a patient previously treated for T-cell acute lymphoblastic leukemia. Our novel in-house diagnostic tool EpiDiP provided hints arguing against a radiation-induced tumor, identified a novel recurrent genetic aberration, and thus informed about a potential therapeutic target.

Disparities in patient enrollment on glioblastoma clinical trials.

Aim: To determine if enrollment on glioblastoma (GBM) interventional clinical trials (ICTs) in the USA is representative of the population. Materials & methods: We queried ClinicalTrials.gov for all ICTs in GBM from 1994 to 2019. Demographics were obtained from ClinicalTrials.gov or the trial publication and compared with population data from Central Brain Tumor Registry of the United States. Results: In total, 10617 GBM patients were enrolled in 118 adult ICTs: median age was 54.0 (10.05 years younger than Central Brain Tumor Registry of the United States). Age was most discrepant in recurrent tumors, nonrandomized trials and consortium studies. Median age improved from 52.0 to 59.5 over 25 years. Women represented 37.5% of subjects. Conclusion: GBM ICTs under-represent older patients but representation of women reflects the population. ICTs need to be designed to better represent the population.

Epilepsy education in gliomas: engaging patients and caregivers to improve care.

BACKGROUND: Tumor-related epilepsy (TRE) is the most common cause of hospitalizations in patients with malignant gliomas leading to increased distress and decreased quality of life (QOL) for patients and caregivers. PURPOSE: We sought to determine the feasibility of incorporating a structured TRE-specific education intervention into clinical practice while assessing effect on distress and TRE knowledge. METHODS: We prospectively enrolled glioma patients and their caregivers on an IRB-approved study. Subjects underwent a pre-test to assess baseline knowledge regarding seizure management. A neuro-oncology provider guided subjects through a presentation focused on safety and home management of seizures. Seizure-related distress was measured before and after the educational intervention using a distress thermometer. A post-test was completed. At 2 and 6 months, distress was re-assessed and post-tests were repeated. Subject satisfaction was assessed. RESULTS: Fifty subjects (23 patients, 27 caregivers) were enrolled. Median age was 59. Fifty-seven percent of patients had TRE. Median time to completion was 21.5 min. Median baseline distress scores were 2/10 for patients and 5/10 for caregivers. Distress scores decreased by a mean of 1.5 points and TRE knowledge increased by 2 points for all subjects between the initial and 2-month visit. Ninety-eight percent of subjects strongly agreed that the education was helpful and informative. Caregivers reported more distress despite better baseline seizure knowledge than patients. CONCLUSION: Structured TRE education is feasible in patients with gliomas and their caregivers and may be effective in reducing distress. Further prospective studies are warranted to assess effects on hospitalizations, cost, and QOL.

Durable response to bevacizumab in adults with recurrent pilocytic astrocytoma.

BACKGROUND: Adult pilocytic astrocytomas are rare and highly vascular tumors. AIM: We hypothesized that they may be uniquely responsive to bevacizumab (BEV). PATIENTS: We present four adult patients with pathologically diagnosed WHO grade I pilocytic astrocytoma who had robust and durable responses to BEV at time of recurrence. Three patients developed radiographic changes on MRI, consistent with progressive disease based on response assessment in neuro-oncology criteria. Median time to recurrence was 8.5 months. METHODS: All patients were treated with six cycles of BEV for recurrence. RESULTS: At the end of treatment, all patients had achieved a clinical and radiographic response. Median follow-up time after BEV is 20.5 months. CONCLUSION: This suggests that BEV may have true antitumor activity in adult pilocytic astrocytomas and may be important for achieving durable disease control.

Acute care in glioblastoma: the burden and the consequences.

BACKGROUND: The utilization of inpatient medical services by patients with glioblastoma (GBM) is not well studied. We sought to describe causes, frequency, and outcomes of acute care visits in GBM. METHODS: We conducted a retrospective study of 158 GBM patients at the University of Rochester over 5 years. Electronic medical records were reviewed to identify all local and outside acute care visits. Acute care visits were defined as any encounter resulting in an emergency department visit or inpatient admission. RESULTS: Seventy-one percent (112/158) of GBM patients had 235 acute care visits corresponding to 163 hospitalizations (69%) and 72 emergency department visits (31%). Sixty-three percent of patients had multiple visits. Admission diagnoses were seizure (33%), neurosurgical procedure (15%), infection (12%), focal neurologic symptoms (9%), and venous thromboembolism (VTE, 9%). Forty-six patients had 1 or more visits for seizures. Median time to first acute care visit was 65.6 days and 22% of patients had an acute care visit within 30 days of diagnosis. Median length of stay was 5 days. Thirty-five percent of admitted patients were discharged home; 62% required a higher level of care than prior to admission (23% were discharged home with services, 17% to a nursing facility, 16% to hospice, 6% to acute rehab) and 3% died. Thirty-eight percent of patients had ACV within 30 days of death. Median survival was 14 months for patients who had acute care visits and 22.2 months for patients who did not. CONCLUSION: The majority of GBM patients utilize acute care, most commonly for seizures. The high number of emergency department visits, short length of stay, and many patients discharged home suggest that some acute care visits may be avoidable.