Surveillance imaging after surgery for glioblastoma does not appear to improve outcomes
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Routine surveillance imaging after surgery did not appear to improve outcomes among patients with glioblastoma, according to study results published in World Neurosurgery.
“Patients with sporadic follow-up imaging and patients who had follow-up imaging at regular intervals had the same outcome in terms of survival,” N. Scott Litofsky, MD, professor and chief of neurological surgery, director of neuro-oncology and radiosurgery, and program director of the neurological surgery residency program at University of Missouri School of Medicine, told Healio. “Right now, we are all dealing with COVID-19. Many physicians are changing current clinic operations, particularly those with hospital-based practices, to reduce exposure of vulnerable patients. We may find that regular inpatient visits may not be as necessary as other means of following patients with glioblastoma throughout their disease course.”
Investigators pooled data on 74 patients with glioblastoma receiving ongoing care at University of Missouri Health Care. They compared patients who underwent routine surveillance (n = 47) with patients who did not undergo routine surveillance but returned when they felt recurrence symptoms (n = 27).
Median PFS was 6.1 months in the surveillance group vs. 6 months in the symptomatic group. Researchers also observed no significant difference between the surveillance and symptomatic groups in median post-recurrence survival (6.4 months vs. 7.7 months), median OS (14.8 months vs. 15.7 months) and post-recurrence neurologic function.
Litofsky told Healio what prompted this research, the implications of the findings and the impact of COVID-19 on the follow-up care of patients with glioblastoma.
Question: What prompted this research?
Answer: At University of Missouri, many of our patients with brain tumors travel long distances for their neurosurgical care and subsequent treatment with radiation and chemotherapy. For those with glioblastoma, we typically schedule follow-up every 3 months with brain imaging. Intuitively, one would think that patients with regular follow-up would have better outcomes because tumor recurrence would be diagnosed before it became highly symptomatic and such recurrences would be easier to treat. We thought that if we could show that patients who have routine surveillance follow-up with imaging did better than those who did not have regular follow-up, we could encourage patients who had more difficulty keeping their follow-up appointments to make greater effort to participate in ongoing care.
Q: What are the clinical implications of the findings?
A: Regular follow-up may not be as important to patient outcome as we think it ought to be. As physicians, we need to consider other models to help our patients deal with the resources, costs and time involved with follow-up so that we can improve their satisfaction and quality of life with the care throughout their disease process.
Q: Were you surprised by your findings?
A: Our findings were a bit surprising. I was firmly convinced that rigorous follow-up would be superior to being diagnosed with progression when symptoms occurred, because patients with rigorous follow-up would be less ill and better able to tolerate additional treatment. However, the outcome measure we used showed equivalency. We did not look at size of tumor, recurrence or functional status, which we probably should have. The relatively small number of patients may also have impacted the findings. But the study is a start at looking at different ways of providing care.
Q: Do you have plans for future research on this?
A: We are in the process of developing a pilot study to look at correlations of patient-reported outcomes with data obtained at follow-up clinic visits. In this planned study, we will have patients complete surveys about their current symptoms at regular intervals through electronic questionnaires and see if we can identify symptoms that suggest that a tumor is progressing. We will compare this information with what we see at the patient’s routine follow-up. The long-term goal is to see if such patient-reported outcomes could potentially replace regular in-person clinic visits and to only schedule those in-person visits if disease progression is suspected. This type of resource utilization could reduce costs and improve patient satisfaction by reducing the anxiety many patients have about their impending follow-up visits.
Q: How is COVID-19 changing your approach to care for patients with glioblastoma and what changes could occur in the future?
A: Because of COVID-19, we are trying to keep patients out of the hospital so that the risk for exposure to themselves, as well as others, is reduced. We have been using telehealth techniques to communicate with our patients, many of whom usually need to travel several hours for their care with us. Many still have surveillance imaging, so that we have some information beyond what the patient tells us. Much of that imaging can be performed in patients’ communities and sent electronically, so risk to the patient is low because they are not sitting in a waiting room with lots of others around. We are providing reasonable care without missing an opportunity to intervene in a timely manner, and patients appear to be satisfied with their interactions with the health care team. For many patients, this type of follow-up is reasonable.
Hopefully, third-party payers will realize this is an opportunity to reduce costs associated with health care. Physicians are compensated for their time, which is generally less than a standard appointment, and patient travel is less. Care can be provided to more patients, and that care appears to be more efficient. If possible, I hope to continue to offer this type of follow-up care for some patients after COVID-19 is all said and done. In addition, the concept of patient-reported outcomes can be linked to methods of surveillance, but we still need to refine this process. We can ask patients questions at regular intervals, and if the patient responds in a particular way, a follow-up appointment can be made. We need to study if this method of delivering care is as good as what we currently do. We still have some research to complete.
Reference:
Monroe CL, et al. World Neurosurg. 2020;doi:10.1016/j.wneu.2019.12.001.
For more information:
N. Scott Litofsky, MD, can be reached at University of Missouri School of Medicine, 1 Hospital Drive, Columbia, MO 65212; email: litofskyn@health.missouri.edu.
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