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Gately L, Mesía C, Sepúlveda JM, Del Barco S, Pineda E, Gironés R, Fuster J, Hong W, Dumas M, Gill S, Navarro LM, Herrero A, Dowling A, de Las Peñas R, Vaz MA, Alonso M, Lwin Z, Harrup R, Peralta S, Long A, Perez-Segura P, Ahern E, Garate CO, Wong M, Campbell R, Cuff K, Jennens R, Gallego O, Underhill C, Martinez-Garcia M, Covela M, Cooper A, Brown S, Rosenthal M, Torres J, Collins IM, Gibbs P, Balana C. A combined analysis of two prospective randomised studies exploring the impact of extended post-radiation temozolomide on survival outcomes in newly diagnosed glioblastoma. J Neurooncol 2024; 166:407-415. [PMID: 38153582 DOI: 10.1007/s11060-023-04513-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/15/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE The optimal duration of post-radiation temozolomide in newly diagnosed glioblastoma remains unclear, with no published phase III randomised trials. Standard-of-care stipulates 6 months. However, in routine care, it is often extended to 12 months, despite lacking robust supporting data. METHODS GEINO14-01 (Spain) and EX-TEM (Australia) studies enrolled glioblastoma patients without progression at the end of 6 months post-radiation temozolomide. Participants were randomised 1:1 to six additional months of temozolomide or observation. Primary endpoint was 6-month progression free survival from date of randomisation (6mPFS). Secondary endpoints included overall survival (OS) and toxicity. 204 patients were required to detect an improvement in 6mPFS from 50 to 60% (80% power). Neither study recruited sufficient patients. We performed a combined analysis of individual patient data. RESULTS 205 patients were recruited: 159 in GEINO14-01 (2014-2018) and 46 in EX-TEM (2019-2022). Median follow-up was 20.0 and 14.5 months. Baseline characteristics were balanced. There was no significant improvement in 6mPFS (57.2% vs 64.0%, OR0.75, p = 0.4), nor across any subgroups, including MGMT methylated; PFS (HR0.92, p = 0.59, median 7.8 vs 9.7 months); or OS (HR1.03, p = 0.87, median 20.1 vs 19.4 months). During treatment extension, 64% experienced any grade adverse event, mainly fatigue and gastrointestinal (both 54%). Only a minority required treatment changes: 4.5% dose delay, 7.5% dose reduction, 1.5% temozolomide discontinuation. CONCLUSION For glioblastoma patients, extending post-radiation temozolomide from 6 to 12 months is well tolerated but does not improve 6mPFS. We could not identify any subset that benefitted from extended treatment. Six months should remain standard-of-care.
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Affiliation(s)
- L Gately
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.
- Department of Medical Oncology, Alfred Health, Melbourne, VIC, Australia.
| | - C Mesía
- Medical Oncology Service, Institut Català d'Oncologia, Hospitalet de Llobregat, Barcelona, Spain
| | - J M Sepúlveda
- Medical Oncology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - S Del Barco
- Medical Oncology Service, Institut Català d'Oncologia Girona, Girona, Spain
| | - E Pineda
- Medical Oncology Service, Hospital Clinic de Barcelona, Barcelona, Spain
| | - R Gironés
- Medical Oncology Service, Hospital Universitario La Fe, Valencia, Spain
| | - J Fuster
- Medical Oncology Service, Hospital Son Espases, Palma de Mallorca, Spain
| | - W Hong
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - M Dumas
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - S Gill
- Department of Medical Oncology, Alfred Health, Melbourne, VIC, Australia
| | - L M Navarro
- Medical Oncology Service, Hospital de Salamanca, Salamanca, Spain
| | - A Herrero
- Medical Oncology Service, Hospital Miguel Servet, Zaragoza, Spain
| | - A Dowling
- Department of Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - R de Las Peñas
- Medical Oncology Service, Hospital Provincial de Castellón, Castellón, Spain
| | - M A Vaz
- Medical Oncology Service, Hospital Ramón y Cajal, Madrid, Spain
| | - M Alonso
- Medical Oncology Service, Hospital Virgen del Rocio, Seville, Spain
| | - Z Lwin
- Department of Medical Oncology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - R Harrup
- Department of Medical Oncology, Royal Hobart Hospital, Hobart, TAS, Australia
| | - S Peralta
- Medical Oncology Service, Hospital Sant Joan de Reus, Reus, Spain
| | - A Long
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - P Perez-Segura
- Medical Oncology Service, Hospital Clinico San Carlos, Madrid, Spain
| | - E Ahern
- Department of Medical Oncology, Monash Health, Melbourne, VIC, Australia
| | - C O Garate
- Medical Oncology Service, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - M Wong
- Department of Medical Oncology, Westmead Hospital, Westmead, NSW, Australia
| | - R Campbell
- Department of Medical Oncology, Bendigo Health, Bendigo, VIC, Australia
| | - K Cuff
- Department of Medical Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - R Jennens
- Department of Medical Oncology, Epworth Health, Richmond, VIC, Australia
| | - O Gallego
- Medical Oncology Service, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - C Underhill
- Department of Medical Oncology, Border Medical Oncology, East Albury, NSW, Australia
| | | | - M Covela
- Medical Oncology Service, Hospital Lucus Augusti, Lugo, Spain
| | - A Cooper
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia
| | - S Brown
- Department of Medical Oncology, Ballarat Health Services, Ballarat, VIC, Australia
| | - M Rosenthal
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - J Torres
- Department of Medical Oncology, Goulburn Valley Health, Shepparton, VIC, Australia
| | - I M Collins
- Department of Medical Oncology, South West Regional Cancer Centre, Geelong, VIC, Australia
| | - P Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - C Balana
- Medical Oncology Service, Institut Català d'Oncologia, Badalona, Spain
- Badalona Applied Research Group in Oncology (B-ARGO), Institut Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
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Gupta T, Selvarajan JMP, Kannan S, Menon N, Dasgupta A, Chatterjee A. Updated systematic review and meta-analysis of extended adjuvant temozolomide in patients with newly diagnosed glioblastoma. Neurooncol Adv 2023; 5:vdad086. [PMID: 37638346 PMCID: PMC10457033 DOI: 10.1093/noajnl/vdad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Background Contemporary standard-of-care for newly diagnosed glioblastoma (GBM) is maximal safe resection followed by postoperative focal conformal radiotherapy (RT) plus concurrent temozolomide (TMZ) and 6-cycles of adjuvant TMZ (Stupp regimen). However, many patients continue to receive extended adjuvant TMZ (beyond 6-cycles) without solid scientific evidence. This review pools data from nonrandomized studies and randomized controlled trials (RCTs) comparing extended adjuvant TMZ (>6-cycles) to standard adjuvant TMZ (6-cycles) in patients with newly diagnosed GBM for updated evidence-synthesis. Methods This systematic review and meta-analysis was carried out in accordance with the Cochrane methodology including quality assessment of primary studies. Primary outcome of interest was comparative efficacy defined as progression-free survival (PFS) and overall survival (OS). Hazard ratios (HRs) for PFS and OS with corresponding 95% confidence interval (CIs) were extracted/computed from individual primary studies and pooled using random-effects model. Any p-value <0.05 was considered statistically significant. Results Evidence-synthesis was based on pooling of data from 2578 patients enrolled in 16 nonrandomized comparative studies and 5 RCTs. Overall, extended adjuvant TMZ was associated with statistically significant reduction in the risk of progression (HR = 0.72, 95%CI: 0.60-0.87; p = 0.007) and death (HR = 0.71, 95%CI: 0.57-0.90; p = 0.004) compared to standard adjuvant TMZ. However, on subgroup analysis, survival benefit of extended adjuvant TMZ was limited to data synthesized from retrospective nonrandomized comparative studies with no statistically significant difference in outcomes seen after pooling of data from RCTs only. Conclusion Apparent survival benefit of extended adjuvant TMZ in newly diagnosed GBM is largely driven by nonrandomized comparative studies with high inherent potential for multiple biases.
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Affiliation(s)
- Tejpal Gupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | | | - Sadhana Kannan
- Department of Clinical Research Secretariat, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Nandini Menon
- Department of Medical Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Archya Dasgupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
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