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|NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS
|Year : 2019 | Volume
| Issue : 2 | Page : 410-411
Shifting goal posts and paradigm shifts: Trends in outcome evaluation in glioma management
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Web Publication||13-May-2019|
Dr. A Arivazhagan
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Arivazhagan A. Shifting goal posts and paradigm shifts: Trends in outcome evaluation in glioma management. Neurol India 2019;67:410-1
The outcome in cancer has always been quantified in terms of survival. Survival would be further subcategorized as overall survival and disease-free/progression free survival. As modern medicine developed, so did treatments, which can control cancer and can induce remission or cure in a few cancers. Thus, the medical community started looking beyond survival in these patients. For example, radical surgery was replaced by conservative surgery and breast reconstruction in breast cancer, with the addition of effective chemotherapy and targeted therapy.
Cure for brain tumors, especially the malignant ones, is still elusive in almost all histological subtypes. Glioma, the most common primary malignant tumor in the brain, has been a subject of intense research for novel therapies, with some improvements obtained in the survival parameters. The addition of temozolomide (TMZ) has been the last game-changing therapy, which evolved into the standard of care. Nevertheless, recent outcome evaluation studies and trials have begun to shift the goals of treatment beyond prolonging survival.
As the survival of patients with brain tumor improves, the clinician and the patient together start looking forward towards a meaningful quality of living rather than being merely alive. The effects of the treatment for disease should provide a better life and not become a burden. This change in perspective occurred early in medulloblastoma, which was nicely elucidated by Gudrunardottir et al., in their review of literature on childhood medulloblastomas from 1920 to 2014. They noted that the quality-of-life outcomes in medulloblastoma gained importance as these children achieved excellent 5- and 10-year survival rates.
With the advent of the realization that holistic improvement in patient health is more important than mere survival, quality of life is being regarded as an important endpoint in glioma care. Such evolution is evident in two realms, namely, patient care and research. Many recent landmark trials which evaluate the outcome of newer treatments include health-related quality of life (HRQoL) and cognitive assessment as a part of the study.,, The EF-14 trial, which is a randomized phase III trial evaluating the utility of tumor-treating fields (TTF) in glioblastoma, noted that, initially, HRQoL improved in patients treated with TTF/TMZ (change from baseline [CFB] at 3 months: 24% and CFB at 6 months: 13%) versus TMZ (CFB3: −7% and CFB6: −17%), although this difference was no longer evident at the 9-month point.
Similarly, a number of clinical studies now include functional and QoL assessment as a part of the standard of care.,, Duffau et al., stressed the importance of maintaining the onco-functional balance in treatment, wherein the goal should be to achieve maximal tumor resection while preserving QoL. Minniti et al., used the European Organization for Research and Treatment of Cancer quality-of-life questionnaire version 3 (QLQ-C30) and QLQ-(brain cancer module) BN20 questionnaire to evaluate elderly patients with a glioblastoma (GBM) treated with shorter course radiotherapy and TMZ, and reported that this abbreviated course was associated with survival benefit with no adverse effect on HRQoL until the time of disease progression.
Khatri et al., have addressed the QoL outcomes in patients with glioma and reported improvements in QoL following surgical resection, which are sustained on longitudinal assessment. Very few studies on QoL in glioma have been reported from India.,, Region-specific evaluation is extremely relevant since the functional outcomes are often influenced by sociocultural and economic factors, which vary across regions. The previous studies have performed a cross-sectional assessment at some time point of the treatment. Mahalakshmi et al., reported QoL measures preoperatively, while Budrukkar et al., evaluated the status after surgery and before starting adjuvant therapy. Solanki et al., reported QoL at follow-up in long-term survivors of GBM. The present study by Khatri et al., has prospectively assessed the functional status using both patient-reported outcome (PRO) and clinician-reported outcome scores before surgery and at various time period of follow-up, thereby providing strong evidence of functional improvement following treatment. HRQoL was assessed using the short form-36 questionnaire, and they utilized effect size, relative efficiency, and minimal clinically important differences for assessing responsiveness. A subset analysis of the different histological subgroups, namely, Grade II and Grade III/IV gliomas, may be pertinent. Many factors, such as adjuvant treatment, steroid effect, sociocultural, and financial-educational status, can influence the QoL and need to be considered while interpreting the QoL data.
QoL outcome measures can be varied, which comprise PROs, performance outcomes, clinician-reported outcomes, and observer-reported outcomes. A number of scores and scales are available, which address diverse components of health and function., Blakeley et al., lucidly reported that the selection of the specific tool should be based on the outcome/component of QoL, which is addressed by a study, the strength and limitations of the tool, and the ability of the tool to identify the meaningful change. In the same direction, the Response Assessment in Neuro-Oncology-Patient-Reported Outcome working group has recently deliberated on the issue and recommended the application of appropriate PRO tools, with defined outcomes both for research trials and clinical practice. The era for defining the management outcome more comprehensively to provide a meaningful better life to patients has arrived and we, the clinicians, should start looking beyond overall survival and disease-free survival.
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