Patterns of care in recurrent glioblastoma in Switzerland: a multicentre national approach based on diagnostic nodes

Abstract

Despite moderate improvements in outcome of glioblastoma after first-line treatment with chemoradiation recent clinical trials failed to improve the prognosis of recurrent glioblastoma. In the absence of a standard of care we aimed to investigate institutional treatment strategies to identify similarities and differences in the pattern of care for recurrent glioblastoma. We investigated re-treatment criteria and therapeutic pathways for recurrent glioblastoma of eight neuro-oncology centres in Switzerland having an established multidisciplinary tumour-board conference. Decision algorithms, differences and consensus were analysed using the objective consensus methodology. A total of 16 different treatment recommendations were identified based on combinations of eight different decision criteria. The set of criteria implemented as well as the set of treatments offered was different in each centre. For specific situations, up to 6 different treatment recommendations were provided by the eight centres. The only wide-range consensus identified was to offer best supportive care to unfit patients. A majority recommendation was identified for non-operable large early recurrence with unmethylated MGMT promoter status in the fit patients: here bevacizumab was offered. In fit patients with late recurrent non-operable MGMT promoter methylated glioblastoma temozolomide was recommended by most. No other majority recommendations were present. In the absence of strong evidence we identified few consensus recommendations in the treatment of recurrent glioblastoma. This contrasts the limited availability of single drugs and treatment modalities. Clinical situations of greatest heterogeneity may be suitable to be addressed in clinical trials and second opinion referrals are likely to yield diverging recommendations.

Applied Swarm-based medicine: collecting decision trees for patterns of algorithms analysis

“…The coordinating physicians from five finalized and two ongoing cancer clinical care projects investigating patterns of algorithms (treatment recommendations) were asked to summarize the steps that were required to establish an analysis of multiple decision trees using the objective consensus methodology [ 14 ]. The five concluded projects involved an analysis of patterns of care of radiotherapy and androgen deprivation therapy for prostate cancer in Switzerland [ 15 ], the multidisciplinary management of recurrent glioblastoma in Switzerland [ 17 ] and a review of systemic therapies for metastatic clear-cell renal cell cancer among international experts [ 16 , 18 ]. One project is investigating recommendations of international guidelines for urolithiasis.…”

Pre- and Postoperative Chemotherapy in Localized Extremity Soft Tissue Sarcoma: A European Organization for Research and Treatment of Cancer Expert Survey

“…The participants were initially asked to answer the following open question: “What is your treatment policy regarding pre‐ and/or postoperative chemotherapy in localized extremity STS?” For the purposes of the present analysis, additional treatment such as isolated limb perfusion (ILP) and regional hyperthermia (RH) were not considered, even though they supplement surgery, radiotherapy, and chemotherapy in some of the centers. The initial answers provided were collected and converted into decision trees by the coordinating center (St. Gallen), based on the objective consensus methodology as published previously . This process consisted of an initial manual transformation of the replies into simple decision trees; once these were created, the respondents were contacted again to fill in possible empty branches of the decision trees.…”

Decision Making Criteria in Oncology

“…There is emerging evidence that "elderly" people are offered less intensive treatment [38,39]. However, the interpretation of what "elderly" means and how it is interpreted can be very heterogeneous [40]. Underrepresentation of elderly patients in clinical trials adds to our dilemma in dealing with this population [41,42].…”

“…The Karnofsky performance status and the Eastern Cooperative Oncology Group Performance Status scales [46] are commonly used to quantify performance status. When in experienced hands, their measurement can be consistent [47]; however, the cut-off values for decision making are widely variable in clinical routine [40].…”

“…2) [7]. For various cancer forms and settings, even among highly specialized medical centers or experts, the use of decision criteria varies considerably [7,40,[78][79][80].…”