Clinical uncertainty on recurrent glioblastoma management proves need for trial

Clinical uncertainty and equipoise concerning the question of reoperation for patients with recurrent glioblastoma (GBM) is enough to support the need for a randomized controlled trial (RCT), suggests a recent study.

“A significant proportion of GBM patients are considered for repeat resection, but evidence regarding best management remains elusive,” said the investigators, who then sought to measure the degree of clinical uncertainty regarding reoperation for patients with recurrent GBM.

A systematic review of agreement studies analysing the question of repeat resection for recurrent GBM was conducted. The investigators assembled an electronic portfolio of 37 pathologically confirmed recurrent GBM patients including pertinent magnetic resonance images and clinical information.

In the measurement of clinical uncertainty, 26 neurosurgeons from different countries, training backgrounds, and years of experience were asked to select best management (repeat surgery, other nonsurgical management, or conservative), confidence in recommended management, and whether they would include the patients in an RCT comparing surgery with nonsurgical options. κ statistics was used to assess agreement.

No previous agreement studies were found to have examined the question. The agreement regarding best management of recurrent GBM was slight even with dichotomized management options (repeat surgery vs other options; κ, 0.198, 95 percent confidence interval [CI], 0.133–0.276). Results were not changed by country of practice, years of experience, and training background.

Notably, disagreement and clinical uncertainty were more evident among clinicians with (κ, 0.167, 95 percent CI, 0.055–0.314) than without neuro-oncology fellowship training (κ, 0.601, 95 percent CI, 0.556–0.646). Furthermore, more than half of the responders (51 percent) were willing to include the patients in an RCT comparing repeat surgery with nonsurgical options in 26 of 37 (69 percent) of cases.