Glaser Scott M, Dohopolski Michael J, Balasubramani Goundappa K, Flickinger John C, Beriwal Sushil
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA.
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
J Neurooncol. 2017 Aug;134(1):107-118. doi: 10.1007/s11060-017-2493-x. Epub 2017 May 19.
The EORTC trial which solidified the role of external beam radiotherapy (EBRT) plus temozolomide (TMZ) in the management of GBM excluded patients over age 70. Randomized studies of elderly patients showed that hypofractionated EBRT (HFRT) alone or TMZ alone was at least equivalent to conventionally fractionated EBRT (CFRT) alone. We sought to investigate the practice patterns and survival in elderly patients with GBM. We identified patients age 65-90 in the National Cancer Data Base (NCDB) with histologically confirmed GBM from 1998 to 2012 and known chemotherapy and radiotherapy status. We analyzed factors predicting treatment with EBRT alone vs. EBRT plus concurrent single-agent chemotherapy (CRT) using multivariable logistic regression. Similarly, within the EBRT alone cohort we compared CFRT (54-65 Gy at 1.7-2.1 Gy/fraction) to HFRT (34-60 Gy at 2.5-5 Gy/fraction). Multivariable Cox proportional hazards model (MVA) with propensity score adjustment was used to compare survival. A total of 38,862 patients were included. Initial treatments for 1998 versus 2012 were: EBRT alone = 50 versus 10%; CRT = 6 versus 50%; chemo alone = 1.6% (70% single-agent) versus 3.2% (94% single-agent). Among EBRT alone patients, use of HFRT (compared to CFRT) increased from 13 to 41%. Numerous factors predictive for utilization of CRT over EBRT alone and for HFRT over CFRT were identified. Median survival and 1-year overall survival were higher in the CRT versus EBRT alone group at 8.6 months vs. 5.1 months and 36.0 versus 15.7% (p < 0.0005 by log-rank, multivariable HR 0.65 [95% CI = 0.61-0.68, p < 0.0005], multivariable HR with propensity adjustment 0.66 [95% CI = 0.63-0.70, p < 0.0005]). For elderly GBM patients in the United States, CRT is the most common initial treatment and appears to offer a survival advantage over EBRT alone. Adoption of hypofractionation has increased over time but continues to be low.
欧洲癌症研究与治疗组织（EORTC）的试验确定了外照射放疗（EBRT）联合替莫唑胺（TMZ）在胶质母细胞瘤（GBM）治疗中的作用，但该试验排除了70岁以上的患者。针对老年患者的随机研究表明，单纯超分割EBRT（HFRT）或单纯TMZ至少与单纯常规分割EBRT（CFRT）等效。我们试图调查老年GBM患者的治疗模式和生存率。我们在国家癌症数据库（NCDB）中确定了1998年至2012年组织学确诊为GBM且已知化疗和放疗情况的65 - 90岁患者。我们使用多变量逻辑回归分析预测单纯EBRT与EBRT联合同步单药化疗（CRT）治疗的因素。同样，在单纯EBRT队列中，我们将CFRT（1.7 - 2.1 Gy/分次，总剂量54 - 65 Gy）与HFRT（2.5 - 5 Gy/分次，总剂量34 - 60 Gy）进行比较。使用倾向评分调整的多变量Cox比例风险模型（MVA）比较生存率。共纳入38,862例患者。1998年与2012年的初始治疗情况如下：单纯EBRT分别为50%和10%；CRT分别为6%和50%；单纯化疗分别为1.6%（70%为单药）和3.2%（94%为单药）。在单纯EBRT治疗的患者中，HFRT的使用（与CFRT相比）从13%增加到41%。确定了许多预测使用CRT而非单纯EBRT以及使用HFRT而非CFRT的因素。CRT组的中位生存期和1年总生存率高于单纯EBRT组，分别为8.6个月对5.1个月以及36.0%对15.7%（对数秩检验p < 0.0005，多变量风险比HR 0.65 [95%置信区间CI = 0.61 - 0.68，p < 0.0005]，倾向调整后的多变量HR 0.66 [95%置信区间CI = 0.63 - 0.70，p < 0.0005]）。对于美国的老年GBM患者，CRT是最常见的初始治疗方法，似乎比单纯EBRT具有生存优势。超分割放疗的采用率随时间有所增加，但仍然较低。
