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Top Line: Some of the most difficult decisions on who to treat in pandemic conditions come for elderly patients, who are at exponentially higher risk of fatality with COVID-19.
The Study: Here’s a fresh take on analyzing the new risk / benefit ratio for treatment of glioblastoma multiforme (GBM) in patients over 60-70 years old. Biostaticians had a field day with this meta-analysis, extrapolating individual patient-level data from five prospective randomized trials on the treatment of GBM in elderly patients (n=1321) and incorporating risk models for COVID-19 related mortality in various scenarios. In low and medium risk scenarios (≤5% risk of acquiring infection with each fraction), hypofractionated radiation with concurrent and adjuvant temozolomide resulted in the best outcomes. Remember, the data for the combo is with 45Gy/15 fractions, though the authors note combining temozolomide with shorter established regimens of 25Gy/5 or 34Gy/10 may make the most sense—we just don’t have the data. The only scenario where radiation lost its luster was for patients with MGMT-methylated tumors in high risk scenarios (≥10% risk of acquiring infection with each fraction, such as peak pandemic when your hospital is overwhelmed), in which case temozolomide monotherapy is a good option.
TBL: In the first quantitative risk assessment of its kind, short-course radiation with temozolomide continues to be recommended for elderly patients with GBM in low to medium risk pandemic conditions. | Tbarizi, Neuro Oncol 2020