Clinical Management of Primary Brain Tumors

Sean Grimm, MD

At NCONN 2011, Sean Grimm, MD, discussed the management of Glioblastoma multiforme, the most common malignant primary brain tumor. Approximately 4000 patients in the Unites States are diagnosed with glioblastoma each year, according to Grimm, an assistant professor of Neurology in the Feinberg School of Medicine at Northwestern University. The median age at diagnosis is 65 years, and median survival with treatment is 9 to 14 months.

There are only 2 main risk factors for glioblastoma: extremely rare genetically inherited syndromes, including Li-Fraumeni syndrome and Turcot’s syndrome, and exposure to ionizing radiation. Grimm said that although the World Health Organization recently raised the risk of cell phones to being a “possible” cause of brain tumors, the data are still “inconclusive at this point.”

Glioblastoma patients usually present with increased intracranial pressure and/or focal neurologic symptoms. Some patients also have seizures. Specifi c symptoms can include headache, personality change, weakness, sensory symptoms, gait ataxia, and language dysfunction.

Treatment

Glioblastoma treatment begins with surgery with the goal of maximal resection, said Grimm. He added that within 48 hours after surgery, an MRI should be done to find any residual tumor cells.

Nurses Perspective

Marieta Branis, RN, APN-C, DNP(c) John Theurer Cancer Center Hackensack, New Jersey

Glioblastoma multiforme is a devastating disease that has a signifi cant negative impact on the patient and his or her family. Patients diagnosed with glioblastoma multiforme experience a rapid onset of symptoms resulting in severe and marked disability. Headache, memory loss, severe cognitive changes, mobility and language defi cits, nausea, vomiting, blurry vision, impaired decision making, and personality changes are some of the common problems experienced by the patient diagnosed with glioblastoma multiforme.

The oncology nursing team plays a crucial role in identifying opportunities for intervention, education, counseling, and referral, in order to achieve the best possible outcomes for each glioblastoma patient. Quality of life in this patient population can be improved substantially if side effects and disease symptoms are managed through a well-coordinated plan of care and open communication between all involved parties.

Implications for nursing practice include, but are not limited to, communication of pertinent information in a clear and concise way, and coordination of medical, emotional, and social support. Good nursing practice also encourages the patient to ask questions about all aspects of the treatment plan, and elicits the patients’ input when it comes to preferences and values.

Sources

American Brain Tumor Association. Facts and statistics, 2010. http://bit.ly/t8f1ST. Accessed October 28, 2011.

Bachuss CA. Nursing management of glioblastoma multiforme. Topics in Advanced Practice Nursing. 2008;8(4). http://bit.ly/vVhkpJ. Published December 17, 2008. Accessed October 28, 2011.

Henriksson R, Asklund T, Poulsen HS. Impact of therapy on quality of life, neurocognitive function and their correlates in glioblastoma multiforme: a review. J Neurooncol. 2011;104(3):639-646.

Following surgery, the standard of care is radiation therapy, which is typically administered 5 days per week for 6 weeks. Grimm said that studies have not demonstrated a clinical benefit to using radiation doses above the current standard of care, or treating patients with gamma knife or other forms of stereotactic radiosurgery.

Temozolomide chemotherapy, which has become the standard of care, is typically given both during and after radiation therapy. Stupp et al demonstrated that 1 in every 10 patients treated with radiotherapy plus temozolomide is alive at 5 years, according to Grimm. Further, the data reveal that temozolomide does not have a negative impact on quality of life (QOL).

The RTOG 0525 phase III trial demonstrated that increasing the dose of temozolomide above the current standard does not increase its effi cacy. The study did confi rm, however, that the enzyme O6-methylguanine-DNA methyltransferase (MGMT) is a good prognostic marker for survival in glioblastoma patients treated with temozolomide.

If glioblastoma progresses after initial treatment, monotherapy with bevacizumab (Avastin) is FDA-approved as salvage therapy.

Pseudoprogression

Grimm noted that lesions on imaging following radiation and chemotherapy might appear to have worsened, even though the glioblastoma has not actually progressed. The phenomenon, known as pseudoprogression, occurs in approximately 25% of patients receiving temozolomide chemoradiotherapy. “The lesions are often asymptomatic and may decrease or stabilize in size without a change in treatment,” said Grimm. He added that pseudoprogression might even be a positive prognostic factor indicating which patients respond best to temozolomide.

There is no reliable noninvasive option to differentiate between pseudoprogression and actual progression. Grimm said that until imaging parameters become more reliable, adjuvant temozolomide should be continued in asymptomatic patients whose imaging indicates progression, and surgery should be considered for patients with symptoms.

Quality of Life

Improving survival is just part of the goal in managing patients with primary brain tumors. “We know that radiation and chemotherapy may improve duration of survival, but we need to balance this against toxicity and side effects of these agents,” said Grimm.

The side effects of glioblastoma and its treatment include aphasia, hemiparesis, seizures, and visual loss. Supportive care treatments for side-effect management include antiepileptic medications and steroids.

Grimm said that nurses are crucial to side-effect management because patients are wary about discussing QOL issues with their doctors. “Patients are often scared to tell the physician about the negative effects on their quality of life. They’re afraid that if they tell me some of these things, that I’m going to stop their treatment.”

Reference

Stupp R, Hegi ME, Mason WP, et al. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol. 2009;10(5):459-466.