Standard of Care for Glioblastoma: Combining Radiation, Chemotherapy, and Emerging Technologies

“Thats kind of how the entire world does it now,” Dr. Herbert Newton, a neuro-oncologist at UH Seidman Cancer Center in Cleveland, Ohio, tells SurvivorNet. “You get your radiation therapy, one session per day Monday through Friday, your rest on the weekends. You combine that with your oral temozolomide (TMZ) chemotherapy. You take it home, and that’s seven days a week.”

The Standard of Care for Glioblastoma

The treatment of glioblastoma requires a comprehensive approach involving multiple medical specialties. Your care team may include neurosurgeons, medical oncologists, radiation oncologists, neuro-oncologists, and supportive care specialists. The current standard of care for glioblastoma consists of the following steps:

1. Surgery: The first step in treatment is often surgical removal of the tumor, also known as resection. The goal of surgery is to remove as much of the tumor as possible while preserving neurological function. Complete removal is often difficult due to the tumor’s infiltrative nature, but reducing the tumor size can improve the effectiveness of subsequent treatments. In cases where surgery is not possible due to the tumor’s location, a biopsy may be performed to confirm the diagnosis.
2. Radiation Therapy: Following surgery, most patients undergo radiation therapy to target any remaining cancer cells. Radiation uses high-energy X-rays or protons to damage the DNA of tumor cells, preventing them from growing and dividing. It is typically administered five days a week over a period of six weeks. Radiation therapy is a crucial component in slowing tumor progression and improving survival rates.
3. Chemotherapy: Temozolomide (TMZ) is the standard chemotherapy drug used in glioblastoma treatment. It is taken orally and works by interfering with the tumor cells’ ability to replicate. TMZ is often used in combination with radiation therapy (concurrent chemoradiation) and then continued as maintenance therapy for several months. “With temozolomide, we did also get an increase in overall survival. But what was also really great was that the two-year survival jumped up a lot, and we ended up having more two-year survivors in that study than ever before,” Dr. Newton says.
4. Tumor Treating Fields (TTFs): TTFs are a newer, non-invasive treatment option that uses alternating electrical fields to disrupt cancer cell division. This therapy is discussed in more detail below.

Side Effects of Glioblastoma Treatment

Each glioblastoma treatment comes with potential side effects. Your medical team will work with you to manage these effects and improve your quality of life.

Surgery side effects can include:

• Swelling in the brain (edema), which may require steroids to reduce inflammation
• Neurological deficits, such as difficulty speaking, memory problems, or muscle weakness, depending on the tumor’s location
• Infection or bleeding at the surgical site

Radiation side effects can include:

• Fatigue, which can persist for weeks after treatment ends
• Hair loss in the treated area
• Skin irritation or redness
• Cognitive effects, such as difficulty concentrating or memory problems

Chemotherapy side effects can include:

• Nausea and vomiting
• Increased risk of infections due to lower white blood cell counts
• Fatigue
• Low blood platelet levels, which can increase the risk of bleeding or bruising

Tumor Treating Fields (TTFs) side effects can include:

• Skin irritation from the transducer arrays
• Mild to moderate headaches
• Scalp sensitivity
• Psychological adjustment to wearing the device for extended periods

When are Tumor Treating Fields Used?

Tumor Treating Fields (TTFs) represent an exciting advancement in glioblastoma treatment. This therapy is designed to slow tumor growth without affecting healthy brain tissue.

TTFs use low-intensity, alternating electric fields to disrupt cancer cell division. This is achieved through a wearable device that delivers continuous therapy on the scalp. These fields interfere with the tumor cells’ ability to multiply, ultimately slowing or stopping tumor progression.

Two major clinical trials, EF-11 and EF-14, demonstrated that TTFs provide a survival benefit for glioblastoma patients:

• EF-11 Trial: Focused on recurrent glioblastoma and found that patients receiving TTF therapy had comparable survival rates to those receiving chemotherapy, but with fewer side effects
• EF-14 Trial: Demonstrated that newly diagnosed glioblastoma patients who used TTFs alongside standard chemotherapy had significantly improved survival compared to those who received chemotherapy alone

TTFs may be recommended in the following scenarios:

1. Newly Diagnosed Glioblastoma: After surgery, radiation, and chemotherapy, TTFs can be integrated into the treatment plan to enhance survival rates. The device is typically used continuously for at least 18 hours per day to maximize its effectiveness.
2. Recurrent Glioblastoma: For patients whose tumors have returned, TTFs may be an option to extend survival and manage disease progression.

Your healthcare team will assess your overall health, tumor characteristics, and previous treatments to determine if TTFs are suitable for you. Factors such as your ability to wear the device consistently and your comfort with its use will also be considered.

“It’s not for everybody, but again, it has been proven in numerous clinical trials that it does add benefit to the radiation and chemotherapy,” Dr. Newton explains.

Supportive Care and Quality of Life

Glioblastoma treatment goes beyond just targeting the tumor; maintaining quality of life is essential. Supportive care services can help manage symptoms and improve well-being.

Palliative and supportive care approaches may include:

• Medications to reduce swelling and control seizures
• Physical therapy to address mobility issues
• Cognitive therapy to assist with memory and processing difficulties

Nutrition and wellness needs should also be part of the treatment discussion.

Eating a balanced diet and staying hydrated can support your body’s resilience during treatment. Some patients may benefit from working with a nutritionist to manage treatment-related side effects like nausea or appetite changes.

Though it often gets put on the back burner, emotional support is so important during the cancer journey as well.

A glioblastoma diagnosis can be emotionally challenging. Support groups, counseling, and psychiatric care can help patients and families cope with the stress of the disease. Organizations like the American Brain Tumor Association and the National Brain Tumor Society provide valuable resources.

The Future of Glioblastoma Treatment

Research into new glioblastoma treatments is ongoing.

Some promising areas of focus include:

• Immunotherapy: Exploring ways to activate the body’s immune system to fight the tumor
• Targeted Therapies: Investigating drugs that specifically attack glioblastoma cells with fewer side effects
• Gene Therapy: Studying methods to alter tumor cell genetics to stop growth

Clinical trials also offer access to experimental therapies that may improve outcomes. Patients interested in participating in clinical trials should discuss options with their oncologists. Check out SurvivorNet’s simple Clinical Trial Finder here.

Questions to Ask Your Doctor

If you have been diagnosed with glioblastoma and are feeling uneasy about the path forward, consider asking your doctor the following questions.

• What are the benefits of the current standard of care for glioblastoma?
• Would I benefit from Tumor Treating Fields (TTFs)?
• What side effects should I be on the lookout for?
• What if we have to adjust my treatment plan?

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