What is the treatment for glioblastoma?

From the Guidelines

The standard treatment for glioblastoma involves a multimodal approach beginning with maximal safe surgical resection, followed by radiation therapy (60 Gy delivered in 30 fractions over 6 weeks) combined with concurrent temozolomide chemotherapy, and then adjuvant temozolomide for 6-12 months, as recommended by the most recent guidelines 1. The treatment plan should be individualized based on the patient's performance status, age, and MGMT promoter methylation status.

• For patients younger than 70 years of age with good performance status, the optimal dose fractionation schedule for external beam radiation therapy after resection or biopsy is 60 Gy in 2-Gy fractions delivered over 6 weeks 1.
• For elderly patients, hypofractionated radiotherapy (e.g., 40 Gy in 15 fractions over 3 weeks) may be considered, and temozolomide monotherapy is an efficacious alternative for those with MGMT promoter methylation 1.
• The addition of concurrent and adjuvant temozolomide to hypofractionated radiotherapy seems to be safe and efficacious without impairing quality of life, particularly in patients with a methylated MGMT promoter 1.
• Supportive care addressing seizures, cognitive changes, and psychological support is essential throughout treatment. The aggressive nature of glioblastoma stems from its rapid growth, invasiveness into surrounding brain tissue, and resistance to treatment due to its heterogeneous cellular composition.
• At recurrence, options include reoperation, bevacizumab, lomustine, or clinical trials, but the standards of care are less well defined 1.
• Tumor treating fields (TTF) therapy, using the Optune device for at least 18 hours daily, may be added after radiation to improve survival.
• Corticosteroids like dexamethasone are often prescribed to manage brain swelling and symptoms. Despite aggressive treatment, glioblastoma typically recurs, and the treatment plan should be adjusted accordingly.
• The prognosis depends on tumor grade and histology, with glioblastoma carrying the worst prognosis, while pure oligodendroglioma tends to have a better outcome and improved response to therapy 1.
• The treatment plan should be evaluated by a specialized multidisciplinary team, taking into account the patient's performance status, neurological function, and tumor characteristics.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1.1 Newly Diagnosed Glioblastoma Multiforme Temozolomide capsules are indicated for the treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.

The treatment for glioblastoma includes Temozolomide concomitantly with radiotherapy, followed by maintenance treatment with Temozolomide, as indicated for adult patients with newly diagnosed glioblastoma multiforme 2.

• Key treatment components:
  • Temozolomide
  • Radiotherapy
  • Maintenance treatment with Temozolomide

From the Research

Treatment Overview

• The current mainstay of treatment for glioblastoma involves maximally safe surgical resection followed by radiotherapy and concomitant temozolomide chemotherapy, as stated in 3.
• The standard post-operative treatment for newly diagnosed glioblastoma patients is a combination of radiotherapy and temozolomide, with tumor treating fields (TTF) devices used in conjunction with temozolomide in some cases 4.

Surgical Resection

• Maximal safe resection is the first intervention for management of glioblastoma, offering tissue for diagnosis, decompression of the brain, cytoreduction, and has been associated with prolonged survival in numerous retrospective studies 5.
• Techniques that enhance extent of resection are crucial, and clinical and surgeon-variables play a significant role in the outcome of the resection 5.

Radiotherapy and Chemotherapy

• Radiotherapy alone is compared with radiotherapy plus temozolomide in terms of efficacy and safety, with the combination showing a clinically meaningful and statistically significant survival benefit with minimal additional toxicity 6.
• Concomitant treatment with radiotherapy plus temozolomide resulted in grade 3 or 4 hematologic toxic effects in 7 percent of patients, as reported in 6.
• Temozolomide maintenance is given after the initial treatment, as part of the standard of care for glioblastoma patients 3.

Recurrent Glioblastoma Treatment

• Available standard therapies for recurrent glioblastoma include nitrosureas, bevacizumab, and temozolomide rechallenge, as well as TTF devices 4.
• Agents that are being evaluated in clinical trials include novel targeted therapies, novel chemotherapies, and immunotherapies, which may potentiate the standard of care therapy and represent the next step in glioblastoma management research 7.