Conditional survival after diagnosis with malignant brain and central nervous system tumor in the United States, 1995-2012

Survival differences in malignant meningiomas: a latent class analysis using SEER data

BACKGROUND

Several studies have used demographic characteristics to examine differences in survival time for patients with malignant meningioma (MM). Latent class analysis (LCA), with its ability to identify mutually patterns of patients in a heterogeneous population. The aim of our study was to analyze the heterogeneity of sociodemographic characteristics in meningioma.

METHODS

The data of patients diagnosed with malignant meningioma (n = 1,562, age > 18 years old) were extracted from the Surveillance, Epidemiology, and End Result database. Data on sociodemographic characteristics such as age, sex, race, NHIA, marital status, household income, rural or urban residential area, and overall survival time were included. LCA was used to identify heterogeneous patterns of MM. each group was explored using Bayesian network analysis.

RESULTS

In total, 1562 patients with MM were processed by the LCA model; the 4-class latent class models were the best fit. LCA identified four survival groups: highest, intermediate-high, low-to-moderate, and lowest survival groups. Patients with the longest survival times-93.59 months-were 40-59 years old, female, Black, non-Hispanic, married, and had a family income of $60,000-$74,999 and lived in densely populated areas. Bayesian networks revealed correlations between patients with MM and sociodemographic characteristics in different latent class groups.

CONCLUSION

We identified and verified differences in clinical and sociodemographic characteristics between survival groups. A comprehensive understanding of the "people-oriented" subgroup characteristics will greatly benefit the diagnosis and treatment of MM.

Conditional survival after surgery for metastatic tumors of the spine: does prognosis change over time?

PURPOSE

Conditional survival (CS) provides a dynamic prediction of patient survival by incorporating the time an individual has already survived given their disease specific characteristics. The objective of the current study was to estimate CS among patients after surgery for spinal cord compression or spinal instability, as well as stratify CS according to relevant patient- and disease-related characteristics.

METHODS

The clinical outcomes of 361 patients undergoing surgical management of metastatic spinal tumors were retrospectively analyzed. Stratification of this cohort according to disease and surgery-specific characteristics allowed for univariate and multivariate statistical analyses of our study population. Observed overall and conditional survival estimates were calculated by the Kaplan-Meier method.

RESULTS

12-month conditional survival in patients undergoing surgical management of metastatic spine tumors increased from 57% at baseline to 70% at 24 months following spine surgery. Overall survival (OS) was influenced by CCI grade, Katagiri tumor type, presence of lung metastasis, type of spine surgery, presence of postoperative systemic therapy and ambulatory status at follow-up. Analyses of OS and CS by prognostic strata were similar with exception of stratification by surgery type. Differences in survival between strata tend to converge over time. Unfavorable factors for OS appear to be less relevant after a period of 24 months following spine surgery.

CONCLUSION

Patients after surgery for metastatic tumors of the spine can expect a positive trend in conditional survival as survivorship increases. Even patients with a more severe disease can be encouraged with gains in conditional survival over time.

LEVEL OF EVIDENCE

Level IV (retrospective cohort study).

Conditional Vasospasm-Free Survival Following Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Following aneurysmal subarachnoid hemorrhage (SAH), patients are monitored closely for vasospasm in the intensive care unit. Conditional vasospasm-free survival describes the risk of future vasospasm as a function of time elapsed without vasospasm. Conditional survival has not been applied to this clinical scenario but could improve patient counseling and intensive care unit use. The objective of this study was to characterize conditional vasospasm-free survival following SAH.

METHODS

This was a single institution, retrospective cohort study of patients treated for aneurysmal SAH between 1/1/2000-6/1/2020. The primary outcome was the development of vasospasm defined by the first instance of either radiographic vasospasm on computed tomography angiography, Lindegaard Index > 3.0 by transcranial doppler ultrasonography, or vasospasm-specific intraarterial therapy. Multivariable Cox regression was performed, and conditional vasospasm-free survival curves were constructed.

RESULTS

A total of 528 patients were treated for aneurysmal SAH and 309 (58.5%) developed vasospasm. Conditional survival curves suggest patients who survive to postbleed day 10 without vasospasm have a nearly 90% chance of being discharged without vasospasm. The median onset of vasospasm was postbleed day 6. Age more than 50 years was associated with a lower risk (hazard ratio [HR] = .76; 95% confidence interval [CI] 0.64-0.91; p < 0.001). Higher initial systolic blood pressure (HR = 1.18; 95% CI 1.046-1.350; p = .008), Hunt-Hess grades 4 or 5 (HR = 1.304; 95% CI 1.014-1.676), and modified Fisher scale score of 4 (HR = 1.808; 95% CI 1.198-2.728) were associated with higher vasospasm than the respective lower grades.

CONCLUSION

Conditional survival provides a useful framework for counseling patients and making decisions around vasospasm risk for patients with aneurysmal SAH, while risk factor-stratified plots facilitate a patient-centric, evidence-based approach to these conversations and decisions.

Comparative epidemiology of gliosarcoma and glioblastoma and the impact of Race on overall survival: A systematic literature review

OBJECTIVE

Gliosarcoma (GSM) is a rare subtype of glioblastoma (GBM) that accounts for approximately four percent of high-grade gliomas. There is scarce epidemiological data on patients with GSM as a distinct subgroup of GBM.

METHODS

A systematic literature review was performed of peer-reviewed databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to evaluate the impact of race and ethnicity on survival in patients with GSM compared to patients with GBM.

RESULTS

Following initial abstract screening, a total of 138 articles pertaining to GSM and 275 pertaining to GBM met criteria for full-text review, with 5 and 27 articles included in the final analysis for GSM and GBM, respectively. The majority of patients in both cohorts were non-Hispanic Whites, representing 85.6 % of total GSM patients and 87.7 % of GBM patients analyzed. Two GSM studies stratified survival by race, with one reporting the longest median survival for the Hispanic population of 10.6 months and the shortest median survival for the Asian population of 9 months. Among the GBM studies analyzed, the majority of studies reported shorter survival and higher risk of mortality among White Non-Hispanics compared to non-White patients; and of the 15 studies which reported data for the Asian population, 12 studies reported this race category to have the longest survival compared to all other races studied. Younger age, female sex, MGMT promoter methylation status, and adjuvant chemoradiation therapy were associated with improved survival in both GSM and GBM cohorts, although these were not further stratified by race.

CONCLUSION

GSM portends a similarly poor prognosis to other GBM subtypes; however, few studies exist which have examined factors associated with differences in survival between these histologic variants. This review of the literature suggests there is a possible association between race and survival for patients with GBM, however data supporting this conclusion for patients with GSM is lacking. These findings suggest that GSM is a distinct disease from other GBM subtypes, with epidemiologic differences that should be further explored.

Inequalities in Meningioma Survival: Results from the National Cancer Database

Background

Meningiomas are the second most common primary tumors of the central nervous system. However, there is a paucity of literature examining how healthcare, demographic, and socioeconomic factors impact patient outcomes.

Methods

We conducted a retrospective study of 65,812 patients from the National Cancer Database (NCDB; 2004-2012) who received treatment for their meningioma. Univariate and multivariate analyses were performed with the overall five-year survival as the primary outcome, and the following factors: facility type, geography, housing area, patient insurance, sex, ethnicity, race, income, and education. The multivariate model was adjusted for patient age, co-morbidity, tumor size, behavior, and treatment strategy.

Results

Diagnosis and treatment at an academic/research program, private insurance, female sex, Hispanic ethnicity, and high school diploma conferred a survival advantage on both univariate and multivariate analyses.

Conclusions

Disparities in survival outcomes in patients with meningiomas exist across multiple healthcare, demographic, and socioeconomic factors. Additional research is needed to elucidate the genetic and environmental factors driving these inequalities.

Tumor treating fields and maintenance temozolomide for newly-diagnosed glioblastoma: a cost-effectiveness study

Purpose: The EF-14 trial demonstrated that adding tumor treating fields (TTFields) to maintenance temozolomide (TMZ) significantly extends progression-free survival (PFS) and overall survival (OS) for newly-diagnosed glioblastoma (GBM) patients. This study assessed the cost-effectiveness of TTFields and TMZ for newly-diagnosed GBM from the US healthcare system perspective. Methods and materials: Outcomes for newly-diagnosed GBM patients were estimated over a lifetime horizon using an area under the curve model with three states: stable disease, progressive disease, or death. The survival model integrated the 5-year EF-14 trial results with long-term GBM epidemiology data and US background mortality rates. Adverse event rates were derived from the EF-14 trial data. Utility values to determine quality-adjusted life-years, adverse event costs, and supportive care costs were obtained from published literature. A 3% discount rate was applied to future costs and outcomes. One-way and probabilistic sensitivity analyses were performed to assess result uncertainty due to parameter variability. Results: Treatment with TTFields and TMZ was estimated to result in a mean increase in survival of 1.25 life years (95% credible range [CR] = 0.89-1.67) and 0.96 quality-adjusted life years (QALYs) (95% CR = 0.67-1.30) compared to treatment with TMZ alone. The incremental total cost was $188,637 (95% CR = $145,324-$225,330). The incremental cost-effectiveness ratio (ICER) was $150,452 per life year gained and $197,336 per QALY gained. The model was most sensitive to changes in the cost of TTFields treatment. Conclusions: Adding TTFields to maintenance TMZ resulted in a substantial increase in the estimated mean lifetime survival and quality-adjusted survival for newly-diagnosed GBM patients. Treatment with TTFields can be considered cost-effective within the reported range of willingness-to-pay thresholds in the US.

Between-hospital variation in mortality and survival after glioblastoma surgery in the Dutch Quality Registry for Neuro Surgery

PURPOSE

Standards for surgical decisions are unavailable, hence treatment decisions can be personalized, but also introduce variation in treatment and outcome. National registrations seek to monitor healthcare quality. The goal of the study is to measure between-hospital variation in risk-standardized survival outcome after glioblastoma surgery and to explore the association between survival and hospital characteristics in conjunction with patient-related risk factors.

METHODS

Data of 2,409 adults with first-time glioblastoma surgery at 14 hospitals were obtained from a comprehensive, prospective population-based Quality Registry Neuro Surgery in The Netherlands between 2011 and 2014. We compared the observed survival with patient-specific risk-standardized expected early (30-day) mortality and late (2-year) survival, based on age, performance, and treatment year. We analyzed funnel plots, logistic regression and proportional hazards models.

RESULTS

Overall 30-day mortality was 5.2% and overall 2-year survival was 13.5%. Median survival varied between 4.8 and 14.9 months among hospitals, and biopsy percentages ranged between 16 and 73%. One hospital had lower than expected early mortality, and four hospitals had lower than expected late survival. Higher case volume was related with lower early mortality (P = 0.031). Patient-related risk factors (lower age; better performance; more recent years of treatment) were significantly associated with longer overall survival. Of the hospital characteristics, longer overall survival was associated with lower biopsy percentage (HR 2.09, 1.34-3.26, P = 0.001), and not with academic setting, nor with case volume.

CONCLUSIONS

Hospitals vary more in late survival than early mortality after glioblastoma surgery. Widely varying biopsy percentages indicate treatment variation. Patient-related factors have a stronger association with overall survival than hospital-related factors.

The effect of race on the prognosis of the glioblastoma patient: a brief review

Objectives: Glioblastoma is the most common primary malignant brain tumor in adults, and despite decades of intensive research regarding its pathophysiology and treatment, the prognosis for glioblastoma patients remains poor. While many studies have analyzed various factors that may influence survival outcomes, the focus of this brief review is to discuss the influence that apatient's race/ethnicity has on survival. This factor has been investigated in large population-based studies and in smaller institutional analyses, but the prognostic utility of this factor has been inconsistent. Discussion of this topic is therefore warranted to better equip providers to counsel and treat patients with glioblastoma, as well as to identify areas of future research. Methods: A comprehensive literature search is performed to identify studies that reported GBM survival outcomes by race/ethnicity. Results: Although some discrepancies exist, asignificant survival benefit is associated with the Asian or Pacific Islander (API) race, whereas white patients have the poorest survival and highest incidence. Hispanic patients tend to fare better than white patients but have worse survival than APIs. Discussion: Further analysis into the differences in survival among different races may lead to an increased understanding of potential molecular and genetic targets, thus guiding future treatment plans for these patients. Abbreviations: AAAIR: Average Annual Age-Adjusted Incidence Rate; AI/AN: American Indian or Alaska Native; API: Asian or Pacific Islander; CBTRUS: Central Brain Tumor Registry of the United States; CUMC: Columbia University Medical Center; EOR: Extent of Resection; Exc: Excluded; GBM: Glioblastoma; GTR: Gross Total Resection; IDH-1: Isocitrate Dehydrogenase 1; MGMT: O6-Methylguanine DNA Methyltransferase; NCDB: National Cancer Database; OS: Overall Survival; O/U: Other/Unknown; PFS: Progression-Free Survival; SEER: Surveillance, Epidemiology, and End Results; S&W BTR: Scott & White Brain Tumor Registry; UCLA: University of California Los Angeles; UM: University of Miami.

Genetic and molecular epidemiology of adult diffuse glioma

The WHO 2007 glioma classification system (based primarily on tumour histology) resulted in considerable interobserver variability and substantial variation in patient survival within grades. Furthermore, few risk factors for glioma were known. Discoveries over the past decade have deepened our understanding of the molecular alterations underlying glioma and have led to the identification of numerous genetic risk factors. The advances in molecular characterization of glioma have reframed our understanding of its biology and led to the development of a new classification system for glioma. The WHO 2016 classification system comprises five glioma subtypes, categorized by both tumour morphology and molecular genetic information, which led to reduced misclassification and improved consistency of outcomes within glioma subtypes. To date, 25 risk loci for glioma have been identified and several rare inherited mutations that might cause glioma in some families have been discovered. This Review focuses on the two dominant trends in glioma science: the characterization of diagnostic and prognostic tumour markers and the identification of genetic and other risk factors. An overview of the many challenges still facing glioma researchers is also included.

Increasing use of immunotherapy and prolonged survival among younger patients with primary CNS lymphoma: a population-based study

Background: Primary CNS lymphoma is a highly aggressive and rare type of extranodal non-Hodgkin lymphoma. Although, new therapeutic approaches have led to improved survival, the management of the disease poses a challenge, practice patterns vary across institutions and countries, and remain ill-defined for vulnerable patient subgroups. Material and Methods: Using information from the Austrian Brain Tumor Registry we followed a population-based cohort of 189 patients newly diagnosed from 2005 to 2010 through various lines of treatment until death or last follow-up (12-31-2016). Prognostic factors and treatment-related data were integrated in a comprehensive survival analysis including conditional survival estimates. Results: We find variable patterns of first-line treatment with increasing use of rituximab and high-dose methotrexate (HDMTX)-based poly-chemotherapy after 2007, paralleled by an increase in median overall survival restricted to patients aged below 70 years. In the entire cohort, 5-year overall survival was 24.4% while 5-year conditional survival increased with every year postdiagnosis. Conclusion: In conclusion, we show that the use of poly-chemotherapy and immunotherapy has disseminated to community practice to a fair extent and survival has increased over time at least in younger patients. Annually increasing conditional survival rates provide clinicians with an adequate and encouraging prognostic measure.

Estimated lifetime survival benefit of tumor treating fields and temozolomide for newly diagnosed glioblastoma patients

Aim:

To estimate the mean lifetime survival benefit, an essential component of health economic evaluations in oncology, of adding tumor treating fields (TTFields) to maintenance temozolomide (TMZ) for newly diagnosed glioblastoma patients.

Methods:

We integrated EF-14 trial data with glioblastoma epidemiology data. The model provided for an evidence-based approach to estimate lifetime survival for the material number of EF-14 trial patients still alive at 5 years.

Results & conclusion:

Patients treated with TTFields and TMZ had an incremental mean lifetime survival of 1.8 years (TTFields/TMZ: 4.2 vs TMZ alone: 2.4). Patients alive at year 2 after starting TTFields had a 20.7% probability of surviving to year 10. The results presented here provide the required incremental survival benefit necessary for a future assessment of the incremental cost–effectiveness of TTFields.

The association between race and survival in glioblastoma patients in the US: A retrospective cohort study

BACKGROUND

Glioblastoma is the most common primary brain cancer in adults with an incidence of 3.4 per 100,000, making up about 15% of all brain tumors. Inconsistent results have been published in regard differences in survival between white and black glioblastoma patients. The objective of this to study the association between race and in Glioblastoma patients in the USA during 2010-2014.

METHODS AND FINDINGS

The National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database were used to evaluate race/ethnicity (White non-Hispanic, Black non-Hispanic, Asian/Pacific Islanders non-Hispanic (API)) and Hispanic) adults patients with first-time diagnosis of glioblastoma (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3], codes C711-C714, and histology type 9440/3) from 2010-2014. The primary outcome was 3-year overall survival which was defined as months from diagnosis to death due to any cause and cancer, Kaplan-Meier (KM) and log-rank test were used to compare overall survival times across race groups. Cox proportional hazard models were used to determine the independent effect of race on 3-year survival. Age, gender, health insurance coverage, primary site, tumor size, extent of surgery and year of diagnosis were included in the adjusted model. The 3-year overall survival for API-non Hispanic (NH) patients decreased by 25% compared with White NH glioblastoma patients (hazard ratio (HR) 0.75; 95% confidence interval (CI) 0.62-0.90)) after adjusting for age, gender, health insurance, primary site, tumor size, and extent of the surgery. Black NH (HR 0.95; 95% CI 0.80-1.13) and Hispanic (HR 1.01, 95% CI 0.84-1.21) exhibited similar mortality risks compared with White NH patients.

CONCLUSION

Compared with White NH, API NH with glioblastoma have a better survival. The findings from this study can help increase the accuracy of the prognostic outlook for white, black and API patients with GBM.

From imaging to biology of glioblastoma: new clinical oncology perspectives to the problem of local recurrence

GBM is one of the most common and aggressive brain tumors. Surgery and adjuvant chemoradiation have succeeded in providing a survival benefit. Although most patients will eventually experience local recurrence, the means to fight recurrence are limited and prognosis remains poor. In a disease where local control remains the major challenge, few trials have addressed the efficacy of local treatments, either surgery or radiation therapy. The present article reviews recent advances in the biology, imaging and biomarker science of GBM as well as the current treatment status of GBM, providing new perspectives to the problem of local recurrence.

Conditional survival after a diagnosis of malignant brain tumour in Canada: 2000-2008

BACKGROUND

"Conditional survival probability" is defined as the probability that a patient will survive an additional time, given that the patient has already survived a defined period of time after diagnosis. Such estimates might be more relevant for clinicians and patients during post-diagnosis care, because survival probability projections are based on the patient's survival to date. Here, we provides the first population-based estimates of conditional survival probabilities by histology for brain cancer in Canada.

METHODS

Canadian Cancer Registry data were accessed for patients diagnosed with primary brain cancers during 2000-2008. Kaplan-Meier survival probabilities were estimated by histology. Conditional survival probabilities at 6 months (short-term, denoted scs) and 2 years (long-term, denoted lcs) were derived from the Kaplan-Meier survival estimates for a range of time periods.

RESULTS

Among the 20,875 patients who met the study criteria, scs increased by a margin of 16-18 percentage points from 6-month survivors to 2-year survivors for the three most aggressive brain cancers. The lcs for 2-year survivors was 66% or greater for all tumour groups except glioblastoma. The lcs for 4-year survivors was 62% or greater for all histologies. For glioblastoma and diffuse astrocytoma, the lcs increased each year after diagnosis. For all other histologies, the lcs first increased and then plateaued from 2 years after diagnosis. The lcs and scs both worsened with increasing older age at diagnosis.

SUMMARY

We report histologically specific conditional survival probabilities that can have value for clinicians practicing in Canada as they plan the course of follow-up for individual patients with brain cancer.

Effects of Copper Reduction on Angiogenesis-Related Factors in Recurrent Glioblastoma Cases

Purposeː To evaluate the therapeutic effects of copper reduction on angiogenesis-related factors in patients with glioblastoma multiforme treated by gamma knife radiosurgery. Materials and Methodsː In the present block randomized, placebo-controlled trial, fifty eligible patients with a diagnosis of glioblastoma multiforme who were candidates for gamma knife radiosurgery were randomly assigned into two groups to receive daily either 1gr penicillamine and a low copper diet or placebo for three months. The intervention started on the same day as gamma knife radiosurgery. Serum interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), vascular endothelial growth factor (VEGF) and copper levels were measured at baseline and after the intervention. The serum copper level was used as the final index of compliance with the diet. In order to control probable side effects of intervention, laboratory tests were conducted at the beginning, middle and end of the study. Resultsː The patients had a mean age and Karnofsky Performance Scale of 43.7 years and 75 respectively. Mean serum copper levels were significantly reduced in intervention group. Mean survival time was 18.5 months in intervention group vs. 14.9 in placebo group. VEGF and IL-6 levels in the intervention group were also significantly reduced compared to the placebo group and TNF-α increased less. Conclusionsː It seems that reducing the level of copper in the diet and dosing with penicillamine leads to decline of angiogenesis-related factors such as VEGF, IL-6 and TNF-α. Approaches targeting angiogenesis may improve survival and can be used as a future therapeutic strategy.