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Raymond J, Darsaut TE. Understanding how to move from dogmatic to outcome-based neurosurgical care: Lessons from past surgical studies on ruptured aneurysm patients. Neurochirurgie 2022; 68:478-482. [DOI: 10.1016/j.neuchi.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patel M, Au K, Davis FG, Easaw JC, Mehta V, Broad R, Chow MMC, Hockley A, Kaderali Z, Magro E, Nataraj A, Scholtes F, Chagnon M, Gevry G, Raymond J, Darsaut TE. Clinical Uncertainty and Equipoise in the Management of Recurrent Glioblastoma. Am J Clin Oncol 2021; 44:258-263. [PMID: 33782334 DOI: 10.1097/coc.0000000000000812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A significant proportion of glioblastoma (GBM) patients are considered for repeat resection, but evidence regarding best management remains elusive. Our aim was to measure the degree of clinical uncertainty regarding reoperation for patients with recurrent GBM. METHODS We first performed a systematic review of agreement studies examining the question of repeat resection for recurrent GBM. An electronic portfolio of 37 pathologically confirmed recurrent GBM patients including pertinent magnetic resonance images and clinical information was assembled. To measure clinical uncertainty, 26 neurosurgeons from various countries, training backgrounds, and years' experience were asked to select best management (repeat surgery, other nonsurgical management, or conservative), confidence in recommended management, and whether they would include the patient in a randomized trial comparing surgery with nonsurgical options. Agreement was evaluated using κ statistics. RESULTS The literature review did not reveal previous agreement studies examining the question. In our study, agreement regarding best management of recurrent GBM was slight, even when management options were dichotomized (repeat surgery vs. other options; κ=0.198 [95% confidence interval: 0.133-0.276]). Country of practice, years' experience, and training background did not change results. Disagreement and clinical uncertainty were more pronounced within clinicians with (κ=0.167 [0.055-0.314]) than clinicians without neuro-oncology fellowship training (κ=0.601 [0.556-0.646]). A majority (51%) of responders were willing to include the patient in a randomized trial comparing repeat surgery with nonsurgical alternatives in 26/37 (69%) of cases. CONCLUSION There is sufficient uncertainty and equipoise regarding the question of reoperation for patients with recurrent glioblastoma to support the need for a randomized controlled trial.
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Affiliation(s)
- Mukt Patel
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Karolyn Au
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | | | - Jacob C Easaw
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, AB
| | - Vivek Mehta
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Robert Broad
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Michael M C Chow
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Aaron Hockley
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | - Zul Kaderali
- Section of Neurosurgery, GB1-Health Sciences Centre, Winnipeg, MB, Canada
| | - Elsa Magro
- Neurosurgery service, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Boulevard Tanguy-Prigent Brest, France
| | - Andrew Nataraj
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
| | | | - Miguel Chagnon
- Department of Mathematics and Statistics, André-Aisenstadt Pavillon (AA-5190)
| | - Guylaine Gevry
- Department of Radiology, Centre Hospitalier of University of Montreal (CHUM), Montreal, QC, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier of University of Montreal (CHUM), Montreal, QC, Canada
| | - Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre
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