A qualitative evaluation of factors influencing Tumor Treating fields (TTFields) therapy decision making among brain tumor patients and physicians.

BACKGROUND: Tumor Treating Fields (TTFields) Therapy is an FDA-approved therapy in the first line and recurrent setting for glioblastoma. Despite Phase 3 evidence showing improved survival with TTFields, it is not uniformly utilized. We aimed to examine patient and clinician views of TTFields and factors shaping utilization of TTFields through a unique research partnership with medical neuro oncology and medical social sciences. METHODS: Adult glioblastoma patients who were offered TTFields at a tertiary care academic hospital were invited to participate in a semi-structured interview about their decision to use or not use TTFields. Clinicians who prescribe TTFields were invited to participate in a semi-structured interview about TTFields. RESULTS: Interviews were completed with 40 patients with a mean age of 53 years; 92.5% were white and 60% were male. Participants who decided against TTFields stated that head shaving, appearing sick, and inconvenience of wearing/carrying the device most influenced their decision. The most influential factors for use of TTFields were the efficacy of the device and their clinician's opinion. Clinicians (N = 9) stated that TTFields was a good option for glioblastoma patients, but some noted that their patients should consider the burdens and benefits of TTFields as it may not be the desired choice for all patients. CONCLUSIONS: This is the first study to examine patient decision making for TTFields. Findings suggest that clinician support and efficacy data are among the key decision-making factors. Properly understanding the path to patients' decision making is crucial in optimizing the use of TTFields and other therapeutic decisions for glioblastoma patients.

Medical management of meningiomas.

The efficacy of surgery and radiation has been well validated in the treatment of meningiomas, with efficacy depending on tumor pathology, size, symptomatology and rate of progression. The role of medical therapy has the least amount of data but is being increasingly investigated for tumors that are inoperable or those tumors that recur and/or progress despite standard therapy. In this review, current data on the use of chemotherapeutic agents in the management of meningiomas will be reviewed, including cytotoxic, biologic, targeted molecular and hormonal agents.

Antiangiogenic therapy for high-grade gliomas.

BACKGROUND: Gliomas and in particular high-grade gliomas (HGG) demonstrate when compared to other non-neural solid cancers amongst the highest levels of tumor angiogenesis (the formation of new blood vessels from pre-existing vasculature). METHODS: Angiogenesis is a common theme in cancer biology and reflects the requirement of a vascular network to support continued uncontrolled cancer growth. Early recognition of this paradigm suggested a potential and novel cancer treatment target that led to the discovery and implementation of antiangiogenic therapies. Two basic strategies of cancer antiangiogenic therapy have emerged, one targeting vascular endothelial growth factor, VEGF (growth factor ligand-based antagonists) and the second targeting the vascular endothelial growth factor receptor, VEGFR (receptor-based antagonists, small molecule tyrosine kinase inhibitors). Emerging literature suggests efficacy of antiangiogenic therapy for recurrent HGG. RESULTS: Notwithstanding the limited literature regarding the treatment of recurrent HGG with antiangiogenic therapy (predominantly ligand-based and administered in conjunction with cytotoxic chemotherapy), this therapy has become the de facto standard of care for many. Response rates vary from 30-60% and 6-month progression free survival varies from 25-50%. Problematic however are new antiangiogenic class side effects (hypertension, fatigue, proteinuria, intratumoral hemorrhage, arterial thrombosis and wound dehiscence), timing in relationship to surgery, measurements of response, lack of established dose response relationships and pharmacoeconomics and a possible change in tumor biology. CONCLUSIONS: Ligand-based antiangiogenic therapy (in particular bevacizumab) is a compelling new targeted therapy for HGG and will continue to emerge as an important novel anti-glioma therapy. Further studies are required to define the population of patients with HGG in whom this therapy is of benefit, identify the optimal dose and schedule, better characterize the value of co-administered (cytotoxic and targeted) therapies and establish validated response measures.

Phase II trial of tipifarnib in patients with recurrent malignant glioma either receiving or not receiving enzyme-inducing antiepileptic drugs: a North American Brain Tumor Consortium Study.

PURPOSE: A phase II study was undertaken in patients with recurrent malignant glioma to determine the efficacy and safety of tipifarnib, a farnesyltransferase inhibitor, dosed at the respective maximum-tolerated dose (MTD) for patients receiving and not receiving enzyme-inducing antiepileptic drugs (EIAEDs). Because tipifarnib undergoes extensive hepatic metabolism, MTD is doubled in patients on EIAEDs. The population included 67 patients with glioblastoma multiforme (GBM) and an exploratory group of 22 patients with anaplastic glioma (AG). PATIENTS AND METHODS: Patients received tipifarnib (300 and 600 mg bid for 21 days every 4 weeks in non-EIAED and EIAED patients, respectively). All patients were assessable for efficacy and safety. RESULTS: Two AG patients (9.1%) and eight GBM patients (11.9%) had progression-free survival (PFS) more than 6 months. Among the latter eight GBM patients, six of 36 patients (16.7%; 95% CI, 7% to 32%) were not receiving EIAEDs and two of 31 patients (6.5%; 95% CI, 1% to 20%) were receiving EIAEDs. Four patients had partial responses in group A GBM and one patient had a partial response group B GBM. An exploratory comparison of PFS between GBM groups A and B was statistically significant (P = .01). Patients not receiving EIAEDs had a higher incidence and increased severity of hematologic events. However, the incidence and severity of rash (the previously determined dose-limiting toxicity in patients receiving EIAEDs) seemed similar in EIAED and non-EIAED subgroups. CONCLUSION: Tipifarnib (300 mg bid for 21 days every 4 weeks) shows modest evidence of activity in patients with recurrent GBM who are not receiving EIAEDs and is generally well tolerated in this population.