Recommendations for Front-line Systemic Therapy for Glioblastoma

All members of the workgroup supported the adoption of NCCN guidelines. There is unanimous agreement that fractionated RT concurrent with temozolomide followed by adjuvant temozolomide is the standard of care for glioblastoma patients age 70 years with good PS, defined by WHO PS 2 (Category I). Similar efficacy to European Multicentre Phase III trial has been demonstrated in a local study.16Dose-dense therapy is not recommended. For glioblastoma patients age >70 years with good PS, options of treatment include hypofractionated RT, temozolomide with deferred RT or RT with concurrent temozolomide followed by adjuvant temozolomide. We suggest checking MGMT promoter methylation status in this group, and recommend temozolomide therapy, if positive. The routine addition of bevacizumab as upfront therapy is not recommended. The role of nimotuzumab as front-line therapy was debated. One of the workgroup members felt that the randomised phase II Cuban trial provided sufficient evidence to recommend nimotuzumab, in addition to RT, as frontline therapy in rare situations where myelosuppression of temozolomide cannot be tolerated. The rest of the workgroup members argued that the trial was conducted with small patient numbers with results not reproduced in other trials, had also not been supported by other national guidelines committees and that given its additional cost and lack of confirmatory trial data, nimotuzumab cannot be recommended as standard front-line therapy. Given the lack of data on front-line therapy in patients with poor PS, combination therapy with PCV, temozolomide monotherapy, RT alone or best supportive care is reasonable.