Combined-Modality Therapy With Radiation and Chemotherapy for Elderly Patients With Glioblastoma in the Temozolomide Era

Abstract

IMPORTANCE The optimal management for elderly patients with glioblastoma (GBM) is controversial. Following maximal safe resection or biopsy, accepted treatment paradigms for elderly patients with GBM include combined-modality therapy (CMT) with both radiotherapy (RT) and chemotherapy (CT), RT alone, and CT alone. OBJECTIVE To evaluate the overall survival (OS) outcomes associated with RT, CT, and CMT for elderly patients with GBM in the modern temozolomide era. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study of a prospectively maintained, multi-institutional national cancer registry, the National Cancer Database was queried for elderly patients (Ն65 years) with newly diagnosed GBM from January 1, 2005, through December 31, 2011, with complete data sets for RT, CT, tumor resection, Charlson-Deyo comorbidity scores, age, sex, and year of diagnosis. Data analysis was performed from October 2015 through December 2015. INTERVENTIONS Combined-modality therapy, RT, CT. MAIN OUTCOMES AND MEASURES Survival by treatment cohort was estimated using the Kaplan-Meier method and analyzed using the log rank test, univariate and multivariate Cox models, and propensity score-matched analyses. RESULTS A total of 16 717 patients (median [range] age, 73 [65-Ն90 y]; 8870 [53%] male) were identified. The median OS by treatment was 9.0 (95% CI, 8.8-9.3) months with CMT (8435 patients), 4.7 (95% CI, 4.5-5.0) months with RT alone (1693 patients), 4.3 (95% CI, 4.0-4.7) months with CT alone (1018 patients), and 2.8 (95% CI, 2.8-2.9) months with no therapy (5571 patients) (P < .001). On multivariate analysis, CMT was superior to both CT alone (hazard ratio, 1.50 [95% CI, 1.40-1.60]; P < .001) and RT alone (hazard ratio, 1.47 [95% CI, 1.39-1.55]; P < .001), whereas no differences were observed between CT alone vs RT alone (P = .60). Propensity score-matched analyses redemonstrated improved OS with CMT over CT alone (P = .002) and RT alone (P < .001); no differences were observed between CT alone vs RT alone (P = .44). On subgroup analyses, a consistent OS advantage was observed with CMT over both CT alone and RT alone across each age stratification (65-69, 70-74, 75-79, and Ն80 years) and among patients treated with or without tumor resection (all P < .001). CONCLUSIONS AND RELEVANCE In this analysis of multimodality therapy for elderly patients with GBM, OS was superior with CMT compared with CT alone and RT alone. Survival was similar between CT alone and RT alone, and both CT alone and RT alone were superior to no therapy. This analysis supports the use of CMT for suitable elderly candidates.

A comprehensive comparative analysis of treatment modalities for sinonasal malignancies

“…The same variables used in the multivariate analysis were accounted for, including age, sex, CDCC score, race/ethnicity, year of diagnosis, site, T classification, N classification, facility volume, and surgical margin status. One‐to‐1 matching without replacement was completed using the nearest neighbor match on the logit of the propensity score for treatment approach with the caliper width set to 0.05 times the standard deviation of the logit of the propensity score, as previously described . Univariate cox hazard ratios (HRs) are reported.…”

Patterns of care and predictors of adjuvant therapies in elderly patients with glioblastoma: An analysis of the National Cancer Data Base

“…12,22 In addition to age, patient demographic and treatment factors, including sex, race, and treatment facility type, predict the receipt of adjuvant therapy. The youngest patients in our study were significantly more likely to receive adjuvant therapy with CRT, CT, or RT than no adjuvant therapy compared with the oldest patients.…”

“…4,5 Elderly patients have frequently been excluded from clinical trials, 6 and those studies that do examine this population have demonstrated suboptimal survival outcomes. Chemotherapy (CT) alone, 8,9 radiotherapy (RT) alone, 10 and combined-modality therapy using CT and RT (CRT), 11,12 have all produced improved outcomes in select elderly patients. Chemotherapy (CT) alone, 8,9 radiotherapy (RT) alone, 10 and combined-modality therapy using CT and RT (CRT), 11,12 have all produced improved outcomes in select elderly patients.…”

Current Standards of Care in Glioblastoma Therapy

“…A retrospective analysis of 293 patients over the age of 65 showed a benefit for the combined regimen (222). A retrospective survey of the National Cancer Database yielded similar results, with combined modality treatment showing superiority over both chemotherapy alone and RT alone, in a group of 16,717 patients, with nGBM, aged 65 years or older (223). Two prospective randomized studies addressed the question of which single modality treatment would be best for elderly patients.…”