Developing an Algorithm for Optimizing Care of Elderly Patients With Glioblastoma

• Published in: Neurosurgery Vol. 82; no. 1; pp. 64 - 75
• Main Authors: Flanigan, Patrick M, Jahangiri, Arman, Kuang, Ruby, Truong, Albert, Choi, Sarah, Chou, Alvin, Molinaro, Annette M, McDermott, Michael W, Berger, Mitchel S, Aghi, Manish K
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01-01-2018; Copyright by the Congress of Neurological Surgeons; Wolters Kluwer Health, Inc
• Subjects: Adult; Aged; Aged, 80 and over; Algorithms; Antineoplastic Agents, Alkylating - therapeutic use; Biopsy; Brain cancer; Brain Neoplasms - diagnosis; Brain Neoplasms - mortality; Brain Neoplasms - therapy; Comorbidity; Dacarbazine - analogs & derivatives; Dacarbazine - therapeutic use; Female; Glioblastoma - diagnosis; Glioblastoma - mortality; Glioblastoma - therapy; Humans; Male; Medical prognosis; Middle Aged; Multivariate Analysis; Neurosurgery; Older people; Retrospective Studies; Prognosis; Biopsy; Comorbidity; Glioblastoma; Oncology; Elderly; Survival
• ISSN: 0148-396X; 1524-4040
• DOI: 10.1093/neuros/nyx148

Abstract
BACKGROUND
Elderly patients with glioblastoma have an especially poor prognosis; optimizing their medical and surgical care remains of paramount importance.
OBJECTIVE
To investigate patient and treatment characteristics of elderly vs nonelderly patients and develop an algorithm to predict elderly patients’ survival.
METHODS
Retrospective analysis of 554 patients (mean age = 60.8; 42.0% female) undergoing first glioblastoma resection or biopsy at our institution (2005-2011).
RESULTS
Of the 554 patients, 218 (39%) were elderly (≥65 yr). Compared with nonelderly, elderly patients were more likely to receive biopsy only (26% vs 16%), have ≥1 medical comorbidity (40% vs 20%), and develop postresection morbidity (eg, seizure, delirium; 25% vs 14%), and were less likely to receive temozolomide (TMZ) (78% vs 90%) and gross total resection (31% vs 45%). To predict benefit of resection in elderly patients (n = 161), we identified 5 factors known in the preoperative period that predicted survival in a multivariate analysis. We then assigned points to each (1 point: Charlson comorbidity score >0, subtotal resection, tumor >3 cm; 2 points: preoperative weakness, Charlson comorbidity score >1, tumor >5 cm, age >75 yr; 4 points: age >85 yr). Having 3 to 5 points (n = 78, 56%) was associated with decreased survival compared to 0 to 2 points (n = 41, 29%, 8.5 vs 16.9 mo; P = .001) and increased survival compared to 6 to 9 points (n = 20, 14%, 8.5 vs 4.5 mo; P < .001). Patients with 6 to 9 points did not survive significantly longer than elderly patients receiving biopsy only (n = 57, 4.5 vs 2.7 mo; P = .58).
CONCLUSION
Further optimization of the medical and surgical care of elderly glioblastoma patients may be achieved by providing more beneficial therapies while avoiding unnecessary resection in those not likely to receive benefit from this intervention.