The Age Factor in the Treatment of Glioblastoma

of diagnosed cancers in the United States will occur in patients older than 65 years. 2 It is logical to assume that this trend will also occur in the primary brain tumor, glioblastoma (GBM). This presents a problem for neuro-oncologists because older patients have been historically underrepresented in neuro-oncology trials. The lack of representation coupled with toxicity concerns often leads to undertreatment in these patients. Given the imminent increasing numbers of elderly patients with GBM, more representation in clinical studies, as well as clear treatment guidelines, is needed for this population. In this issue of JAMA Neurology, Rusthoven et al 3 performed a retrospective analysis of a cohort of 16 717 patients 65 years or older with newly diagnosed GBM. This analysis was based on data from the National Cancer Database (NCDB), which is a prospectively maintained, multi-institutional national registry. The authors queried the NCDB for patients who were both 65 years or older with newly diagnosed GBM and had complete data for the following: treatment (radiation therapy, chemotherapy [CT], and surgery), Charlson-Deyo comorbidity score, sex, age, and year of diagnosis. They confined their search to patients treated during or after 2005 to target patients treated only in the temozolomide era. The authors evaluated median overall survival (OS) between treatment groups: (1) combined-modality therapy (CMT), consisting of radiation therapy (RT) together with CT, temozolomide; (2) RT alone; and (3) CT alone (temozolomide). Median OS was 9.0 months with CMT, 4.7 months with RT alone, and 4.3 months for patients receiving CT alone; furthermore, multivariate Cox analysis showed that CMT was superior to both RT alone (HR, 1.47; 95% CI, 1.39-1.55) and CT alone (HR, 1.50; 95% CI, 1.40-1.60) and this superiority held up across age stratification (65-69, 70-74, 75-79, and ≥80 years). These results imply that the Stupp protocol 4 of CMT with temozolomide, now used as the standard of care for patients younger than 65 years, should be considered in patients older than 65 years. The primary finding of increased OS in patients 65 years or older treated with CMT is in line with previous findings (eTable 7 in the article by Rusthoven et al 3 ); many of these findings were in smaller retrospective studies, and except for