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.