Treating glioblastoma in the elderly

Management of elderly patients with gliomas

The current progressive aging of the population is resulting in a continuous increase in the incidence of gliomas in elderly people, especially the most frequent subtype, glioblastoma (GBM). This sociohealth shift, known as the "silver tsunami," has prompted the neuro-oncology community to investigate the role of specific antitumor treatments, such as surgery, radiotherapy, chemotherapy, and other targeted therapies, for these traditionally undertreated patients. Advanced age, a widely recognized poor prognostic factor in both low-grade glioma (LGG) and high-grade glioma patients, should no longer be the sole reason for excluding such older patients from receiving etiologic treatments. Far from it, results from recent prospective trials conducted on elderly patients with GBM demonstrate that active management of these patients can have a positive impact on survival without impairing either cognition or quality of life. Although prospective studies specifically addressing the management of grade 2 and 3 gliomas are lacking and thus needed, the aforementioned tendency toward acknowledging a therapeutic benefit for GBM patients might also apply to the treatment of patients with LGG and anaplastic gliomas. In order to optimize such etiologic treatment in conjunction with symptomatic management, neuro-oncology multidisciplinary boards must individually consider important features such as resectability of the tumor, functional and cognitive status, associated comorbidities, and social support.

Treating glioblastoma patients with poor performance status: where do we go from here?

Approximately one third of all glioblastoma patients exhibit an impaired functional status in the perioperative setting. Their optimal management is difficult to define. The only available prospective study in poor performance status (PS) patients has been performed in elderly patients (≥ 70 years). In this population, treatment with temozolomide was shown to be safe and to be associated with a clinically significant improvement of PS in one third of patients. In young patients (<70 years), daily clinical experience and retrospective data show that some patients can benefit from temozolomide radiochemotherapy, abbreviated radiation courses, upfront chemotherapy or early use of bevacizumab. However, prospective studies are needed to correctly evaluate these strategies, namely their impact on functional status and quality of life.