Glioma Recurrence: How to Navigate Continued Treatment

“For glioma recurrences, the treatment paradigm includes some kind of surgery if possible, and radiation is integral in that aspect of it where it can actually treat the cancer cells a little bit more — give a little bit more radiation,” Dr. Prashant Vempati, a neuro-oncologist at UH Seidman Cancer Center in Cleveland, Ohio, tells SurvivorNet.

“We are usually limited by the previous radiation. The normal brain can only take so much radiation. So, we end up giving a certain amount of radiation over a certain period to be able to stop the cancer from growing,” he adds.

Making Treatment Decisions

The patient’s overall health status before beginning additional treatment helps doctors asses how likely it is that treatment will be successful. Other valuable factors that help predict the likelihood of benefit from second-line therapy include the extent of disease, the grade of the glioma (both at initial therapy and at recurrence), the time lapse between the last treatment and recurrence, and recurrence pattern (ie, local versus widely spread).

Patients with a localized recurrence, especially after a long period of stability, are better candidates for interventions such as reoperation or reirradiation than those with refractory disease or wide-spread (diffuse), multifocal tumors.

In some cases, the best treatment path may be looking into clinical trials.

“At our center, we usually try to enroll patients in clinical trials, especially on a recurrence,” Dr. Vempati explains.

Treating Options for Recurrent Glioma

Surgery

If the tumor recurrence is diagnosed in an area that surgeons can safely operate on, a second surgery might reduce the tumor size. This approach can alleviate pressure in the brain and may help with symptoms like headaches or seizures. Your surgical team will consider factors such as your overall health, tumor location, and how the tumor has changed since your first operation.

Chemotherapy

A new course of chemotherapy might be the most reasonable option. The drug of choice will depend on the patient’s performance status and prior treatment. The most commonly used systemic agents in recurrent gliomas are: bevacizumab, nitrosoureas, and temozolomide rechallenge.

In this setting, bevacizumab plays a crucial role. It is a targeted therapy designed to block a protein called VEGF (vascular endothelial growth factor), which helps tumors form new blood vessels. By cutting off the blood supply, Bevacizumab may help slow the growth of the tumor. Many patients find that it can also relieve symptoms like headaches or swelling in the brain.

“Bevacizumab is a VEGF inhibitor, which is a molecule that creates blood vessels or causes blood vessel proliferation or leaking of blood vessels. So, inhibiting that decreases the blood vessel proliferation, which the cancer tissue needs, which inflammatory areas need, so that there’s less fluid leaking into the brain. So, less fluid leaking into the brain, less swelling in the brain, so less symptoms,” Dr. Vempati explains.

Re-Irradiation (Radiation)

In some cases, doctors may recommend giving radiation therapy again (re-irradiation), especially if a long time has passed since the first treatment course. Advanced techniques like stereotactic radiosurgery (SRS) can target smaller areas of the tumor while minimizing damage to surrounding healthy tissue. However, re-irradiation is not always an option for everyone.

Your oncologist will weigh factors such as your previous radiation dose, treatment timeline, and overall health.

Tumor Treating Fields

Another option at recurrence is known as the Optune device.

“Optune was another great path forward for glioma patients that has come about in the last 10 to 15 years. Now it’s tumor-treating fields,” Dr. Vempati explains.

Optune is a wearable medical device that delivers low-intensity electrical fields, called Tumor Treating Fields (TTFields), to the area of the brain where the tumor is located. These electrical fields disrupt cancer cells when they try to divide and grow.

“So, every day you have to shave your head, you have to put four stickers — usually four stickers — that the company develops for you specifically on your head in different areas, that’s attached to a battery pack that you carry with you. Most patients wear that throughout the day while they’re sleeping, and they get about eight hours break during a day,” Dr. Vempati explains.

While there are documented benefits to using Optune, not all patients want the burden of wearing the device around for the majority of the day.

“You have to wear this thing on your head for 16 hours a day. Some patients don’t want the constant reminder of cancer throughout their lives, and I’m completely okay with that. I know there’s a benefit to it. I tell them what the benefit is, what the options are, but I let the patient decide because sometimes your mental health is more important than the extra few months or overall survival benefit,” he adds.

Questions to Ask Your Doctor

• Am I a good candidate for additional treatment with surgery, chemotherapy, or radiation?
• Are there any clinical trials I should consider?
• Am I a good candidate for Optune & what does day-to-day life look like with it?
• What interventions can we make for my quality of life?

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