STEP 4: Treatment

Step 4 describes the optimal treatments for high-grade glioma, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for high-grade glioma. For detailed clinical information on treatment options refer to these resources:

The intent of treatment can be defined as one of the following:

  • longer term survival without expectation of cure
  • maintenance of quality of life
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

Surgery is commonly the first therapeutic approach for tumour debulking and for obtaining tissue for diagnosis. All patients with presumed high-grade glioma should be considered for surgery and, at the discretion of the treating neurosurgeon, maximal safe resection is encouraged.

The volume of residual-enhancing disease is correlated with overall survival of patients newly diagnosed with high-grade glioma (Ellingson et al. 2018). Pre- and post-contrast MRIs should be conducted 48 hours after resection surgery to determine the volume of residual-enhancing disease.

Advanced surgical options to achieve maximal safe resection, such as fluorescence-assisted resection, intraoperative imaging and awake surgery, should be considered.

Timeframe for starting treatment

Surgery should occur immediately for most cases or within four weeks of diagnosis if not urgent (according to clinical need).

Training and experience required of the surgeon

Fellow of the Royal Australian College of Surgeons or equivalent, with adequate training and experience that enables institutional credentialing and agreed scope of practice within brain cancer.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with high-grade glioma and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

  • a full neurosurgical service for cranial neurosurgery, neuroradiology including MRI services and a post-operative high dependency unit
  • appropriate nursing and theatre resources to manage complex neurosurgery
  • critical care support
  • 24-hour medical staff availability
  • 24-hour operating room access and intensive care unit
  • diagnostic imaging
  • pathology
  • nuclear medicine imaging.

High-volume centres generally have better clinical outcomes (Trinh et al. 2015). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to high-volume centres.

All patients should be considered for radiation therapy after surgery (Sulman et al. 2017).

Fraction, dose and field is determined by age and performance status:

  • Patients younger than 65 years should be considered for a fully fractionated course of highly conformal radiotherapy using intensity-modulated techniques, with concurrent chemotherapy as per the Stupp protocol.
  • Patients aged between 65 and 70 years and older than 70 years, with a good performance status, should be considered for hypo-fractionated radiotherapy, with or without concurrent chemotherapy.
  • MRI image fusion is recommended.

Timeframe for starting treatment

Radiation therapy should begin within six weeks after surgery.

Training and experience required of the appropriate specialists

Fellowship of the Royal Australian and New Zealand College of Radiologists or equivalent in radiation oncology with adequate training and experience treating brain tumours. Active involvement in multidisciplinary care is essential.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation treatment, health services should have these features:

  • linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
  • dedicated CT planning
  • access to MRI imaging
  • automatic record-verify of all radiation treatments delivered
  • a treatment planning system
  • trained medical physicists, radiation therapists and nurses with radiation therapy experience
  • coordination for combined therapy with systemic therapy, especially where facilities are not co-located
  • participation in Australian Clinical Dosimetry Service audits
  • an incident management system linked with a quality management system.

All patients should be referred to a medical oncologist or neuro-oncologist. Patients with high-grade glioma have specialised medication needs (corticosteroids, anticonvulsants, anticoagulants) and should be managed in conjunction with a specialist practitioner.

Timeframes for starting treatment

  • Chemotherapy or drug therapy given in conjunction with radiotherapy should begin within six weeks after surgery.
  • Chemotherapy given after radiotherapy or drug therapy should begin within six weeks after completing radiotherapy.

Training and experience required of the appropriate specialists

Medical oncologists and neuro-oncologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access.

There is currently one approved targeted therapy available to treat patients with recurrent high-grade glioma. The targeted therapy is bevacizumab, which targets new blood vessel formation and has recently been listed on the Pharmaceutical Benefit Scheme for patients with symptomatic recurrent glioblastoma resistant to temozolomide.

A number of emerging therapies are being investigated for high-grade glioma. Most of these emerging therapies are aimed at improving the targeted delivery of anticancer drugs to the tumour without damaging the surrounding tissue (Jain 2018).

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.

Early referral to palliative care can improve the quality of life for people with cancer (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). Given the poor prognosis of high-grade glioma, all patients should have a palliative care approach introduced to care. Referral to a palliative care specialist and interdisciplinary palliative care team is required.

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent or progressive disease.

More information

These online resources are useful:

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

COGNO coordinates large-scale multi-centred neuro-oncology trials in Australia. For more information visit the COGNO website.

The Cancer Australia website also provides information about trials.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
  • alteration in cognitive functioning, behaviour and personality, which are common with gliomas and are often unrecognised but can significantly affect normal activities and family and carer relationships
  • assistance with activities of daily living and instrumental activities of daily living
  • assistance with managing complex medication regimens, multiple medications (including oral chemotherapy), assessment of side effects and assistance with difficulties swallowing medications may be required (refer to a pharmacist if necessary; for patients with neurocognitive impairment, administration of medication may need daily supervision)
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • management of symptoms such as headaches and cognitive impairment or dementia, particularly in patients treated with postoperative irradiation
  • swallowing and aspiration risk
  • impact of corticosteroids on weight gain
  • decline in mobility or functional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
  • informing patients/carers about who to contact in the case of corticosteroid overdose (corticosteroids are commonly used at high doses over prolonged periods of time, increasing the likelihood of significant side effects)
  • providing information about seizures to the family and carers (this information should cover what to expect and what to do in the event of a seizure, such as maintaining the person’s airway and removing dangerous objects from the area; this may help relieve the anxiety of family and carers)
  • providing appropriate information to the person’s carer about managing altered cognitive function and behaviour (when there are significant cognitive impairments, carers are likely to assume a central role in communication and decision making)
  • providing information about safe mobility to carers and patients
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
    • the treatment plan, including intent and potential side effects
    • supportive and palliative care requirements
    • the patient’s prognosis and their understanding of this
    • enrolment in research or clinical trials
    • changes in treatment or medications
    • the presence of an advance care directive or appointment of a substitute decision-maker
    • recommendations from the multidisciplinary team.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.