The sequential use of carmustine wafers (Gliadel®) and post-operative radiotherapy with concomitant temozolomide followed by adjuvant temozolomide: a clinical review

In patients with glioblastoma multiforme (GBM), there is no consensus on the sequential use of two existing regimens: post-operative Gliadel implantation into the surgical cavity and concomitant temozolomide with radiotherapy followed by adjuvant temozolomide (‘Stupp protocol’). NICE in the guideline TA121 (July 2007) could not pass any judgement on the sequential use of both the regimens due to lack of evidence at the time of consultation. Since then, few prospective studies and retrospective series have been reported using these two regimens sequentially. Except in one study, results were indicative of an incremental gain of 2–3 months in median survival in comparison to the published results using Gliadel or ‘Stupp Protocol’ alone. Post-surgical complications were manageable and within an acceptable range, when the sequential regimen was managed under defined guidelines and surgery was performed in a high volume centre. Moderate degree of increased myelosuppression has been reported in few series, however. In the absence of a phase III trial and the small number of patients in each series, the reported trend of toxicities and efficacy could only be substantiated by setting up a national database. Contributing to such a national database and toxicity recording could be made mandatory through peer review programme for the neurooncological services. Based on the preclinical and albeit lower level of clinical evidence, demonstrating temporal and spatial co-operation between two regimens (Gliadel and ‘Stupp Protocol’), resulting in incremental 2–3 months median survival gain, should enable NICE in its next review to issue a favourable guidance. Depending on the number of patients eligible for such a sequential regimen, which could be 15%–25% of Glioblastoma patients diagnosed in England per annum, the additional annual cost of concomitant temozolomide would be approximately £640,000 to £1 million.