In regard to “Radiation for glioblastoma in the era of COVID-19: Patient selection and hypofractionation to maximize benefit and minimize risk”
Bibliographic record
Abstract
We read the article “Radiation for glioblastoma in the era of COVID-19: Patient selection and hypofractionation to maximize benefit and minimize risk” with great interest.1Noticewala S. Ludmir E. Bishop A. et al.Radiation for glioblastoma in the era of COVID-19: Patient selection and hypofractionation to maximize benefit and minimize risk [e-pub ahead of print].Adv Radiat Oncol. 2020; (Accessed May 6, 2020)https://doi.org/10.1016/j.adro.2020.04.040Abstract Full Text Full Text PDF Scopus (12) Google Scholar We congratulate the authors for drafting guidance for selecting patients with glioblastoma who would benefit from hypofractionated radiation therapy (RT) in the era of coronavirus disease 2019 (COVID-19). The authors suggest that elderly patients (aged ≥65 years) with glioblastoma should strongly be considered for hypofractionated RT regimens of 40 Gy in 15 fractions.2Perry J.R. Laperriere N. O’Callaghan C.J. et al.Short-course radiation plus temozolomide in elderly patients with glioblastoma.N Engl J Med. 2017; 376: 1027-1037Crossref PubMed Scopus (673) Google Scholar For patients with very poor performance status (PS; Karnofsky PS [KPS] < 50 or Eastern Cooperative Oncology Group [ECOG] score 3-4), the palliative regimens the authors recommended were of either 34 Gy in 10 fractions, 25 Gy in 5 fractions, or temozolomide with the omission of RT, and each regimen was supported by prospective trial data.3Roa W. Kepka L. Kumar N. et al.International Atomic Energy Agency randomized phase III study of radiation therapy in elderly and/or frail patients with newly diagnosed glioblastoma multiforme.J Clin Oncol. 2015; 33: 4145-4150Crossref PubMed Scopus (223) Google Scholar, 4Malmström A. Grønberg B.H. Marosi C. et al.Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised, phase 3 trial.Lancet Oncol. 2012; 13: 916-926Abstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar, 5OncologyPROPerformance scales: Karnofsky & ECOG Scores.https://oncologypro.esmo.org/oncology-in-practice/practice-tools/performance-scalesGoogle Scholar We suggest a cautious interpretation of the recommendations for a very poor PS (KPS < 50) subset. We want to highlight that these referenced landmark studies did not represent patients with very poor PS. The International Atomic Energy Agency trial included patients aged 50 years with a KPS of 50 to 70, elderly and frail patients aged 65 years and a KPS of 50 to 70, and elderly patients aged 65 years and a KPS of 80 to 100. With a median overall survival of 7.9 months with 25 Gy in 5 fractions compared with a median overall survival of 6.4 months with hypofractionated RT of 40 Gy in 15 fractions, there was no survival difference.3Roa W. Kepka L. Kumar N. et al.International Atomic Energy Agency randomized phase III study of radiation therapy in elderly and/or frail patients with newly diagnosed glioblastoma multiforme.J Clin Oncol. 2015; 33: 4145-4150Crossref PubMed Scopus (223) Google Scholar Similarly, the Nordic trial studied patients aged ≥60 years with World Health Organiozation performance scores of 0 to 2 (even if neurologic deficits showed a performance score of 3).4Malmström A. Grønberg B.H. Marosi C. et al.Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised, phase 3 trial.Lancet Oncol. 2012; 13: 916-926Abstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar Importantly, 78% of patients in this study had an ECOG score of 0 to 1. Although temozolomide alone is an appropriate option for individuals aged >60 years with an ECOG score of 0 to 2, its use in the current pandemic requires careful attention.4Malmström A. Grønberg B.H. Marosi C. et al.Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised, phase 3 trial.Lancet Oncol. 2012; 13: 916-926Abstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar Patients prescribed temozolomide alone had a higher risk of neutropenia (12%), thrombocytopenia (21%), and infection (19%).4Malmström A. Grønberg B.H. Marosi C. et al.Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised, phase 3 trial.Lancet Oncol. 2012; 13: 916-926Abstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar In the current scenario, temozolomide induces immunosuppression and could increase the risk of contracting COVID-19. Thus, the recommendation of its use in patients with poor PS (KPS < 50) deserves extreme caution.4Malmström A. Grønberg B.H. Marosi C. et al.Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised, phase 3 trial.Lancet Oncol. 2012; 13: 916-926Abstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar We recommend the best supportive care or an ultra-short course of International Atomic Energy Agency regimens, which may serve as a better option for patients with poor PS in the current COVID-19 times.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".