![Page 1: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/1.jpg)
Oncology management
of CNS tumours
Neil Burnet
University of Cambridge Department of Oncology & Oncology Centre, Addenbrooke’s Hospital
ECRIC CNS study day7th April 2009
![Page 2: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/2.jpg)
• Treatment modalities for cancer
• What data do oncologists want?
• Examples of uses of Registry data
Introduction
![Page 3: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/3.jpg)
![Page 4: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/4.jpg)
Cancer treatment modalities
![Page 5: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/5.jpg)
Cancer treatment modalities
• Modalities
• (Surgery)
• Radiotherapy
• Chemotherapy
• Consider efficacy
• Consider costs
![Page 6: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/6.jpg)
Oncology management
![Page 7: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/7.jpg)
![Page 8: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/8.jpg)
Radiotherapy
• Radiotherapy is an anatomical treatment
• Treats a specific area
• Localising the tumour target is crucial
• Imaging is key
• Better localisation – better outcome
• Localising normal structures allows avoidance
![Page 9: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/9.jpg)
CT – the technology advance
Late 1970s 1980s 2003
![Page 10: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/10.jpg)
Glioblastoma imaging
• T2 • T1 • T1 + Gd contrast
MR (magnetic resonance) imaging
![Page 11: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/11.jpg)
Radiotherapy
• Immobilise the patient
• Relate today's patient position to tumour imaging
![Page 12: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/12.jpg)
Radiotherapy
• High precision positioning
• Relocatable stereotactic frame
![Page 13: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/13.jpg)
Radiotherapy
![Page 14: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/14.jpg)
Radiotherapy imaging
CT MRI
![Page 15: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/15.jpg)
MRI CT
• GBM planning
• Using CT +MR together
![Page 16: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/16.jpg)
Radiotherapy imaging
• Pre-op CT • Post-op planning CT
![Page 17: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/17.jpg)
Target volume delineation
![Page 18: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/18.jpg)
Radiotherapy
• Planning and delivery technology now very different
• Old ‘square’ planning• Was conventional in 1960s – 1990s
• Conformal (dose conforms to shape of target in 3D)
• ‘Ultra-conformal’ (includes concave shape)• known as IMRT (intensity modulated radiotherapy)
• 21st century technology
![Page 19: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/19.jpg)
Treatment volumes compared
‘Square’ plan Conformal Ultra-conformal
IMRT
![Page 20: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/20.jpg)
• Old ‘square’ planning
![Page 21: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/21.jpg)
• Some shielding with ‘lead’ blocks
![Page 22: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/22.jpg)
Treatment volumes compared
‘Square’ plan Conformal Ultra-conformal
IMRT
![Page 23: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/23.jpg)
Conformal RT plan
![Page 24: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/24.jpg)
IMRT plan (TomoTherapy)
• Ca nasopharynx
• 68 Gy to primary (34#)
• 60 Gy to nodes (34#)
• Cord dose < 45 Gy
• No field junctions
• No electrons
![Page 25: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/25.jpg)
IMRT plan
• Skull base meningioma
• Shaping of dose around optic nerves and chiasm
• Tumour ~ 60 Gy
• Optic chiasm 50 Gy
![Page 26: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/26.jpg)
![Page 27: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/27.jpg)
Radiotherapy dose
• Biological effect depends on
• Total dose
• Number of fractions
(Dose per fraction)
• Overall treatment time
Complex relationship
![Page 28: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/28.jpg)
Radiotherapy dose
• Single fraction
• Very destructive
• Known as radiosurgery
• Must physically avoid normal tissue
• Multiple fractions
• Spare normal tissue
• Enhances therapeutic radio
• Allows treatment including normal tissue
![Page 29: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/29.jpg)
RT dose and fractions
• For a given dose, and overall time, biological effect depends on number of #
• Actually depends on dose/#
Biologically Effective Dose for 60 Gyfor variable fraction number
0
200
400
600
800
1000
1200
1 5 10 15 20 25 30
Fractions
Bio
log
ical
do
se
Tumour
Brain
0
200
400
600
800
1000
1200
1 5 10 15 20 25 30
![Page 30: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/30.jpg)
Chemotherapy
• Use in accordance with NICE Guidelines
• At first presentation, with (surgery &) RT• Temozolomide
• Also at relapse• PCV
• Monitor• Blood count, nausea, liver function (+ other s/e)• Progression
![Page 31: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/31.jpg)
Chemotherapy
• Most chemo for CNS tumours is oral
• Temozolomide
• Invented in UK
• Revolutionised treatment of GBM
![Page 32: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/32.jpg)
RT + TMZ for GBM
P<0.001
EORTCRandomised trial results
![Page 33: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/33.jpg)
Cancer cure and cost
![Page 34: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/34.jpg)
Cancer cures by modality
References
• SBU. The Swedish council on technology assessment in health care: Radiotherapy for Cancer. 1996
• Cancer Services Collaborative 2002
![Page 35: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/35.jpg)
Funding World Class Cancer Care (Chapter 10)
Total expenditure: Around £4.35bn pa in England.
Expenditure per head of population = £80 (compared with £121 in France and £143 in Germany)
0 200 400 600 800 1000 1200 1400
Other [8]
Specialist Palliative Care (excluding voluntary sector) [7]
Radiotherapy [6]
Screening [5]
Outpatients (diagnostics, first and follow-up appointments) [4]
Drugs (cost of medicine, preparation and administration) [3]
Surgery (including day cases and inpatient stays) [2]
Inpatient costs (excluding those related to surgery) [1]
Cost (£ million per annum)
10%
5%
8%
18%
22%
27%
5%
5%
Estimated total NHS spend on cancer care
The Cancer Reform Strategy Prof. Mike Richards 2007
![Page 36: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/36.jpg)
Effectiveness and cost
% cures % of cancer Ratio care cost
• Radiotherapy 40% 5% 8.0
• Chemotherapy 11% 18% 0.6
• Surgery 49% 22% 2.2
![Page 37: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/37.jpg)
What data do oncologists really want?
![Page 38: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/38.jpg)
• What data do oncologists really want or need?
• Types of CNS tumour
• Prognostic factors
• Treatment intent
• Treatment details
• Dates
What data do oncologists really want?
![Page 39: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/39.jpg)
Tumour types in oncology clinic
• Note ~20% with benign tumours
![Page 40: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/40.jpg)
CNS tumour types - 1
• Glial tumours
• Astrocytoma (inc Pilocytic & Juvenile Pilocytic)
• Oligodendroglioma
• Oligo-astrocytoma
• Glioblastoma (GBM)
• Ependymoma (+ subependymoma)
• Meningioma
• Pituitary adenoma + Craniopharyngioma
![Page 41: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/41.jpg)
CNS tumour types - 2
• Vestibular schwannoma (aka acoustic neuroma)
• Medulloblastoma
• Germinoma + teratoma
• Lymphoma
• Neurocytoma + Ganglioglioma
• Pineoblastoma
• Primitive neuro-ectodermal tumour (PNET)
• (Chordoma + chondrosarcoma)
• (Metastases)
![Page 42: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/42.jpg)
CNS tumour types - 3
• Many tumour types
• Prognosis varies enormously• Survival from “days to weeks” to cure• Affected by tumour type• Grade (ie how malignant)
• Essential to know detail• Detail must be collected
![Page 43: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/43.jpg)
Grade affects prognosis
• High grade glioma
• Grade III
• Grade IV = GBM
- Surgery + RT only
- Radical treatment
- Addenbrooke’s data
![Page 44: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/44.jpg)
Grade affects prognosis
• Histology is not the only tumour feature which affects outcome
![Page 45: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/45.jpg)
• Radiology adds to pathology grade
• Need to include information from imaging
Radiotherapy & Oncology 2007; 85:371-378
![Page 46: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/46.jpg)
What data do oncologists really want?
• Prognostic factors
• Age
• Performance status
• ? Size
• Extent of surgical resection (hard to evaluate)
• Treatment intent
• Radical
• Palliative
![Page 47: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/47.jpg)
• Treatment intent
• Might be clear from treatment
• GBM – RT 60 Gy (30#) = radical
30 Gy (6#) = palliative
• Need to know if intent changes
• eg due to progression
What data do oncologists really want?
![Page 48: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/48.jpg)
Radiotherapy details
• Area treated
• Total dose
• Number of fractions
• Overall treatment time
• Dates
• Time (delay) to start RT
• Overall time (duration) of RT
![Page 49: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/49.jpg)
Chemotherapy details
• Drug(s)
• Dose
• Number of cycles given
• Dates
![Page 50: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/50.jpg)
![Page 51: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/51.jpg)
• Measuring disease burden - AYLL
• GBM outcome
• Modelling chemotherapy use
Examples of Registry data use
![Page 52: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/52.jpg)
Measuring disease burden
• Simple mortality figures do not tell the whole story
• Other measures show alternative aspects of mortality:
• Burden on society
• Burden to the individual affected
• With particular thanks to Peter Treasure at ECRIC
1
![Page 53: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/53.jpg)
Measuring disease burden
• Method
• Detail deaths from specific tumour type
• Compare to standardised matched population
• Sum the difference
DeathDiagnosis
Life expectancy at diagnosis
Years of Life Lost
![Page 54: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/54.jpg)
Measuring disease burden
• CNS tumours
• 2% of cancer deaths – simple mortality
• 3% of the years of life lost - YLL
• YLL shows the burden on society
![Page 55: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/55.jpg)
Average Years of Life Lost
• Divide YLL by number of affected patients
• Average Years of Life Lost – AYLL
• AYLL shows the burden to the affected person
• Easily understood measure, including by patients
• CNS tumours account for ~ 20 years of lost life
• This is higher than any other adult tumour type
![Page 56: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/56.jpg)
Average Years of Life Lost
Average Years of Life Lost for 17 cancer sites
0.0
5.0
10.0
15.0
20.0
25.0
Ave
rag
e Y
ears
of
Lif
e L
ost
per
aff
ecte
d in
div
idu
al
![Page 57: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/57.jpg)
Measuring disease burden
• CNS tumours
• 2% of cancer deaths
• 3% of the years of life lost – YLL
• ~ 20 years of lost life per individual - AYLL
![Page 58: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/58.jpg)
Average Years of Life Lost
• In the 2007 Cancer Reform Strategy reference made to the poor overall outcome of brain & CNS tumours in terms of AYLL ¶
• Encouraging that alternative measures of mortality are being acknowledged by the government
¶ UK Government Department of Health (2007) http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_080975
![Page 59: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/59.jpg)
Measuring disease burden
• AYLL is an effective measure of disease burden to the affected person
• AYLL has other uses
• Compare disease burden with research spending
• AYLL does not match NCRI research spending
• The mis-match is most extreme for CNS tumours
![Page 60: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/60.jpg)
Burnet et al. Br J Cancer 2005; 92(2): 241-5
Average Years of Life Lost per affected patient versus %NCRI spending
![Page 61: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/61.jpg)
GBM outcome2
![Page 62: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/62.jpg)
GBM outcome
• GBM – traditionally terrible outloook
• Addition of temozolomide (TMZ) chemotherapy has transformed the outlook
• Can we reproduce trial results?
The scream – Edvard Munck
![Page 63: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/63.jpg)
TMZ + RT for GBM
P<0.001
EORTCRandomised trial results
![Page 64: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/64.jpg)
TMZ + RT for GBM
Addenbr RT alone
![Page 65: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/65.jpg)
TMZ + RT for GBM
Addenbr RT + TMZAddenbr RT alone
![Page 66: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/66.jpg)
TMZ + RT for GBM
P<0.001
Addenbr RT+TMZ
![Page 67: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/67.jpg)
GBM outcome
• Our results match the international trial
• Endorsement of our treatment pathway
• Good news for patients !
Patient photo
![Page 68: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/68.jpg)
Modelling chemotherapy use3
![Page 69: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/69.jpg)
Modelling chemotherapy use
• TMZ chemo combined with RT (& surgery) has revolutionised the outcome for patients with GBM
• TMZ is given in 2 parts
• Concurrent daily with RT
• Adjuvant for 6 cycles after RT
• Are both parts of value?
![Page 70: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/70.jpg)
TMZ treatment schema
0 6 10 14 18 22 26 30 34
RTTMZ
• Chemo-RT programme with temozolomide (TMZ)
• Component 2
• Adjuvant
• 5 days every 28, x 6 cycles
• Component 1
• Concurrent with RT
• Daily for 42 days
Week
![Page 71: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/71.jpg)
Modelling chemotherapy use
• Build model of patient survival
• Allow treatment with RT and with chemo
• Fit model to Kaplan Meier survival curves to derive values for tumour growth and response to treatment
• Test
• TMZ + RT = concurrent
• RT followed by TMZ = adjuvant
![Page 72: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/72.jpg)
EORTC trialModel - RT + concurrent TMZ
RT + concurrent TMZnear perfect fit
![Page 73: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/73.jpg)
Modelling chemotherapy use
• RT + concurrent TMZ produces near perfect fit
• Suggests concurrent TMZ is the effective component
• Suggests adjuvant TMZ may not add anything
• Omitting 6 cycles of adjuvant TMZ would:
• Spare toxicity
• Improve QoL (likely) - finish treatment 6/12 earlier
• Save money
![Page 74: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/74.jpg)
Modelling chemotherapy use
• Incidence of GBM• 33 cases per million population per annum
• Cost of TMZ – 1 course• Concurrent £3900• Adjuvant £7100
• With thanks to:• David Greenberg & Peter Treasure,
Eastern Cancer Registration & Information Centre (ECRIC), Cambridge• Brendan O’Sullivan,
Chemotherapy Pharmacist, Addenbrooke’s Hospital
![Page 75: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/75.jpg)
Modelling chemotherapy use
• UK
• Population 60 m
• GBM cases (33 x 60) 1,980 p.a.
• GBM patients treated radically 50%
• Number ‘requiring’ TMZ 990 p.a.
![Page 76: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/76.jpg)
Modelling chemotherapy use
• UK
• Population 60 m
• GBM cases (33 x 60) 1,980 p.a.
• GBM patients treated radically 50%
• Number ‘requiring’ TMZ 990 p.a.
• Cost TMZ £11 m p.a.
• Saving by using only concurrent TMZ £ 7 m p.a.
![Page 77: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/77.jpg)
Improving survivorship
• AW on the beach
• AS at Christmas
Patient photo
Photo of patient and family
![Page 78: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/78.jpg)
Acknowledgements• Colleagues
• Sarah Jefferies• Raj Jena• Fiona Harris• Phil Jones
• National Institute for Health Research (NIHR) Cambridge Biomedical Research Centre
• RJ is supported by The Health Foundation, UK
• NFK was supported by an EPSRC discipline-hopping grant
• Peter Treasure
• Norman Kirkby
• Lara Barazzuol
• EORTC
![Page 79: Oncology management of CNS tumours Neil Burnet](https://reader036.vdocuments.mx/reader036/viewer/2022062322/5681432e550346895daf9f85/html5/thumbnails/79.jpg)