Association of the extent of resection with survival in glioblastoma a systematic review and meta-Analysis

Timothy J. Brown, Matthew C. Brennan, Michael Li, Ephraim W. Church, Nicholas J. Brandmeir, Kevin L. Rakszawski, Akshal S. Patel, Elias Rizk, Dima Suki, Raymond Sawaya, Michael Glantz

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142 Citations (Scopus)

Abstract

IMPORTANCE Glioblastoma multiforme (GBM) remains almost invariably fatal despite optimal surgical and medical therapy. The association between the extent of tumor resection (EOR) and outcome remains undefined, notwithstanding many relevant studies. OBJECTIVE To determine whether greater EOR is associated with improved 1-and 2-year overall survival and 6-month and 1-year progression-free survival in patients with GBM. DATA SOURCES Pubmed, CINAHL, andWeb of Science (January 1, 1966, to December 1, 2015) were systematically reviewed with librarian guidance. Additional articles were included after consultation with experts and evaluation of bibliographies. Articles were collected from January 15 to December 1, 2015. STUDY SELECTION Studies of adult patients with newly diagnosed supratentorial GBM comparing various EOR and presenting objective overall or progression-free survival data were included. Pediatric studies were excluded. DATA EXTRACTION AND SYNTHESIS Datawere extracted from the text of articles or the Kaplan-Meier curves independently by investigators who were blinded to each other's results. Data were analyzed to assess mortality after gross total resection (GTR), subtotal resection (STR), and biopsy. The body of evidence was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and PRISMA guidelines. MAIN OUTCOME AND MEASURES Relative risk (RR) for mortality at 1 and 2 years and progression at 6 months and 1 year. RESULTS The search produced 37 studies suitable for inclusion (41 117 unique patients). The meta-Analysis revealed decreased mortality for GTR compared with STR at 1 year (RR, 0.62; 95%CI, 0.56-0.69; P < .001; number needed to treat [NNT], 9) and 2 years (RR, 0.84; 95% CI, 0.79-0.89; P < .001; NNT, 17). The 1-year risk for mortality for STR compared with biopsy was reduced significantly (RR, 0.85; 95%CI, 0.80-0.91; P < .001). The risk for mortality was similarly decreased for any resection compared with biopsy at 1 year (RR, 0.77; 95%CI, 0.71-0.84; P < .001; NNT, 21) and 2 years (RR, 0.94; 95%CI, 0.89-1.00; P = .04; NNT, 593). The likelihood of disease progression was decreased with GTR compared with STR at 6 months (RR, 0.72; 95%CI, 0.48-1.09; P = .12; NNT, 14) and 1 year (RR, 0.66; 95%CI, 0.43-0.99; P < .001; NNT, 26). The quality of the body of evidence by the GRADE criteria was moderate to low. CONCLUSION AND RELEVANCE This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.

Original languageEnglish (US)
Pages (from-to)1460-1469
Number of pages10
JournalJAMA Oncology
Volume2
Issue number11
DOIs
StatePublished - Nov 1 2016

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Glioblastoma
Meta-Analysis
Numbers Needed To Treat
Survival
Mortality
Disease-Free Survival
Biopsy
Librarians
Neoplasms
Bibliography
PubMed
Disease Progression
Referral and Consultation
Research Personnel
Guidelines
Pediatrics

All Science Journal Classification (ASJC) codes

  • Oncology
  • Cancer Research

Cite this

Brown, Timothy J. ; Brennan, Matthew C. ; Li, Michael ; Church, Ephraim W. ; Brandmeir, Nicholas J. ; Rakszawski, Kevin L. ; Patel, Akshal S. ; Rizk, Elias ; Suki, Dima ; Sawaya, Raymond ; Glantz, Michael. / Association of the extent of resection with survival in glioblastoma a systematic review and meta-Analysis. In: JAMA Oncology. 2016 ; Vol. 2, No. 11. pp. 1460-1469.
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abstract = "IMPORTANCE Glioblastoma multiforme (GBM) remains almost invariably fatal despite optimal surgical and medical therapy. The association between the extent of tumor resection (EOR) and outcome remains undefined, notwithstanding many relevant studies. OBJECTIVE To determine whether greater EOR is associated with improved 1-and 2-year overall survival and 6-month and 1-year progression-free survival in patients with GBM. DATA SOURCES Pubmed, CINAHL, andWeb of Science (January 1, 1966, to December 1, 2015) were systematically reviewed with librarian guidance. Additional articles were included after consultation with experts and evaluation of bibliographies. Articles were collected from January 15 to December 1, 2015. STUDY SELECTION Studies of adult patients with newly diagnosed supratentorial GBM comparing various EOR and presenting objective overall or progression-free survival data were included. Pediatric studies were excluded. DATA EXTRACTION AND SYNTHESIS Datawere extracted from the text of articles or the Kaplan-Meier curves independently by investigators who were blinded to each other's results. Data were analyzed to assess mortality after gross total resection (GTR), subtotal resection (STR), and biopsy. The body of evidence was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and PRISMA guidelines. MAIN OUTCOME AND MEASURES Relative risk (RR) for mortality at 1 and 2 years and progression at 6 months and 1 year. RESULTS The search produced 37 studies suitable for inclusion (41 117 unique patients). The meta-Analysis revealed decreased mortality for GTR compared with STR at 1 year (RR, 0.62; 95{\%}CI, 0.56-0.69; P < .001; number needed to treat [NNT], 9) and 2 years (RR, 0.84; 95{\%} CI, 0.79-0.89; P < .001; NNT, 17). The 1-year risk for mortality for STR compared with biopsy was reduced significantly (RR, 0.85; 95{\%}CI, 0.80-0.91; P < .001). The risk for mortality was similarly decreased for any resection compared with biopsy at 1 year (RR, 0.77; 95{\%}CI, 0.71-0.84; P < .001; NNT, 21) and 2 years (RR, 0.94; 95{\%}CI, 0.89-1.00; P = .04; NNT, 593). The likelihood of disease progression was decreased with GTR compared with STR at 6 months (RR, 0.72; 95{\%}CI, 0.48-1.09; P = .12; NNT, 14) and 1 year (RR, 0.66; 95{\%}CI, 0.43-0.99; P < .001; NNT, 26). The quality of the body of evidence by the GRADE criteria was moderate to low. CONCLUSION AND RELEVANCE This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.",
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Association of the extent of resection with survival in glioblastoma a systematic review and meta-Analysis. / Brown, Timothy J.; Brennan, Matthew C.; Li, Michael; Church, Ephraim W.; Brandmeir, Nicholas J.; Rakszawski, Kevin L.; Patel, Akshal S.; Rizk, Elias; Suki, Dima; Sawaya, Raymond; Glantz, Michael.

In: JAMA Oncology, Vol. 2, No. 11, 01.11.2016, p. 1460-1469.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Association of the extent of resection with survival in glioblastoma a systematic review and meta-Analysis

AU - Brown, Timothy J.

AU - Brennan, Matthew C.

AU - Li, Michael

AU - Church, Ephraim W.

AU - Brandmeir, Nicholas J.

AU - Rakszawski, Kevin L.

AU - Patel, Akshal S.

AU - Rizk, Elias

AU - Suki, Dima

AU - Sawaya, Raymond

AU - Glantz, Michael

PY - 2016/11/1

Y1 - 2016/11/1

N2 - IMPORTANCE Glioblastoma multiforme (GBM) remains almost invariably fatal despite optimal surgical and medical therapy. The association between the extent of tumor resection (EOR) and outcome remains undefined, notwithstanding many relevant studies. OBJECTIVE To determine whether greater EOR is associated with improved 1-and 2-year overall survival and 6-month and 1-year progression-free survival in patients with GBM. DATA SOURCES Pubmed, CINAHL, andWeb of Science (January 1, 1966, to December 1, 2015) were systematically reviewed with librarian guidance. Additional articles were included after consultation with experts and evaluation of bibliographies. Articles were collected from January 15 to December 1, 2015. STUDY SELECTION Studies of adult patients with newly diagnosed supratentorial GBM comparing various EOR and presenting objective overall or progression-free survival data were included. Pediatric studies were excluded. DATA EXTRACTION AND SYNTHESIS Datawere extracted from the text of articles or the Kaplan-Meier curves independently by investigators who were blinded to each other's results. Data were analyzed to assess mortality after gross total resection (GTR), subtotal resection (STR), and biopsy. The body of evidence was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and PRISMA guidelines. MAIN OUTCOME AND MEASURES Relative risk (RR) for mortality at 1 and 2 years and progression at 6 months and 1 year. RESULTS The search produced 37 studies suitable for inclusion (41 117 unique patients). The meta-Analysis revealed decreased mortality for GTR compared with STR at 1 year (RR, 0.62; 95%CI, 0.56-0.69; P < .001; number needed to treat [NNT], 9) and 2 years (RR, 0.84; 95% CI, 0.79-0.89; P < .001; NNT, 17). The 1-year risk for mortality for STR compared with biopsy was reduced significantly (RR, 0.85; 95%CI, 0.80-0.91; P < .001). The risk for mortality was similarly decreased for any resection compared with biopsy at 1 year (RR, 0.77; 95%CI, 0.71-0.84; P < .001; NNT, 21) and 2 years (RR, 0.94; 95%CI, 0.89-1.00; P = .04; NNT, 593). The likelihood of disease progression was decreased with GTR compared with STR at 6 months (RR, 0.72; 95%CI, 0.48-1.09; P = .12; NNT, 14) and 1 year (RR, 0.66; 95%CI, 0.43-0.99; P < .001; NNT, 26). The quality of the body of evidence by the GRADE criteria was moderate to low. CONCLUSION AND RELEVANCE This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.

AB - IMPORTANCE Glioblastoma multiforme (GBM) remains almost invariably fatal despite optimal surgical and medical therapy. The association between the extent of tumor resection (EOR) and outcome remains undefined, notwithstanding many relevant studies. OBJECTIVE To determine whether greater EOR is associated with improved 1-and 2-year overall survival and 6-month and 1-year progression-free survival in patients with GBM. DATA SOURCES Pubmed, CINAHL, andWeb of Science (January 1, 1966, to December 1, 2015) were systematically reviewed with librarian guidance. Additional articles were included after consultation with experts and evaluation of bibliographies. Articles were collected from January 15 to December 1, 2015. STUDY SELECTION Studies of adult patients with newly diagnosed supratentorial GBM comparing various EOR and presenting objective overall or progression-free survival data were included. Pediatric studies were excluded. DATA EXTRACTION AND SYNTHESIS Datawere extracted from the text of articles or the Kaplan-Meier curves independently by investigators who were blinded to each other's results. Data were analyzed to assess mortality after gross total resection (GTR), subtotal resection (STR), and biopsy. The body of evidence was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and PRISMA guidelines. MAIN OUTCOME AND MEASURES Relative risk (RR) for mortality at 1 and 2 years and progression at 6 months and 1 year. RESULTS The search produced 37 studies suitable for inclusion (41 117 unique patients). The meta-Analysis revealed decreased mortality for GTR compared with STR at 1 year (RR, 0.62; 95%CI, 0.56-0.69; P < .001; number needed to treat [NNT], 9) and 2 years (RR, 0.84; 95% CI, 0.79-0.89; P < .001; NNT, 17). The 1-year risk for mortality for STR compared with biopsy was reduced significantly (RR, 0.85; 95%CI, 0.80-0.91; P < .001). The risk for mortality was similarly decreased for any resection compared with biopsy at 1 year (RR, 0.77; 95%CI, 0.71-0.84; P < .001; NNT, 21) and 2 years (RR, 0.94; 95%CI, 0.89-1.00; P = .04; NNT, 593). The likelihood of disease progression was decreased with GTR compared with STR at 6 months (RR, 0.72; 95%CI, 0.48-1.09; P = .12; NNT, 14) and 1 year (RR, 0.66; 95%CI, 0.43-0.99; P < .001; NNT, 26). The quality of the body of evidence by the GRADE criteria was moderate to low. CONCLUSION AND RELEVANCE This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.

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