86-year-old man, developed recent onset of memory disturbance, general fatiguability and visual disturbance initially attributed to cataract. CT scan is suggestive of high grade glioma with mass effect in the right temporal lobe. Other than for mild attention span deficit and hemianopia, he has no deficits. He has good insight and judgment. Comorbid illnesses are unstable angina and well controlled diabetes. He and his relatives are afraid of surgery (who isnt?), risks of GA and ask “I am 86 yr old… can you give some medicines and manage this for one or two years?”
What do you do?
The options range from
- Operative decompression [as total and safe as possible], ‘full’ radiation, chemotherapy.
- Biopsy [open/STB] and adjuvant therapy [may be - palliative and less than full RT]
- Do nothing definitive. Symptomatically treat with steroids, anticonvulsants, counselling for the terminal event.
Consider this ...
Substitute the 86 year old with a 30 year old young man.
The surgeon immediately offers option number one. Most of the time we do not offer or even consider options two and three. Why is that?
Is it because we are prejudiced against the elderly?
“He is 86 year old. Why take the effort and risk of resecting the tumor, subjecting him to the ‘stresses’ of surgery and GA at this advanced age? He could very well develop post op life threatening post op complications."
"Hasn’t he lived enough?"
Life expectancy statistics_____________________________
Life expectancy at birth in India is 64.35Life expectancy for an 86 year old will be 87.30 [calculated from life table analysis, considering various risk factors]. Upper quartile being 87.85. That is around one and a half years of life left.
-With aggressive treatment of GBM, median survival is 8 months to one year.
-With no treatment it is 1-2 months
-With “suboptimal treatment” [like option two] it is 3-4 months.
That is, with optimal treatment, you are giving him 50-75% of the rest of his life back.
On the other hand, consider the case of the 30 year old man with life expectancy of 72 years, [42 years left]:
Even with aggressive treatment, you are only giving 2.4% of the rest of his life back. Even if he is a long term survivor of GBM [3% of GBM patients survive 3 years or more], that gives him back only 7% of the expected life span
So isn’t it in keeping with sound logic to offer aggressive treatment for the elderly with good KPS? Even eight months of quality life would mean so much for an 86 year old man.
Nobody has lived enough.
1 comment:
Thanks Dr Pillai for the answer. Ask the resident in back benches
always sleeping. What is the commonest cause for space occupying
lesion in 86 year old man. There is nothing to get surprised. The
answer is metastasis vs GBM. fail is guarantee in boards if you tell
abscess, fungal etc etc.
Logical thinking points to some sort of conservative management.
Capitalsitic thinking leads to PET scan, SPECT, Spectroscopy,
neuronavigation, intraop MRI, gliadel wafers, latest chemotheraphy and
intensive rehabilitation. The important cause for bankruptcy in US is
health insurance related issues. There are instances where bill for
glioma as come to 5 lakh USD.
As per Gopals summary the patient has already made decision. Family
also looks like they know what they want. Respect there views.
Be compassionate and empathetic to the patient views. There is not
much increase in the survival rate in GBM with all the new modalities
statistically.
Leave this old man in peace. Dont subject him to stress of surgery,
financial and mental trauma. See the life tables and asses his
survival rate. Is the surgery or aggressive management is really going
to improve his actual survival rate. Assess benefit of surgery vs
complication risks
Are you all following ethics in neurosurgery?
NOTE:
None of our NIMHANITES incuding skull base gurus are presenting any
papers in international conference. Recently in European skull base
society meeting as per the abstracts three papers from AIIMS, Two from
SGPGI and one from Calcutta. Wake up guys.
Thanks
Neurosurgery resident
Pramod Pillai wrote
> Do not label the patient as " High Grade Glioma" merely on the CT
Scan in an "old" man
> To your surprise, it could be an abscess, tuberculoma, fungal
granuloma, metastasis etc
> How well is the diabetes controlled?
> Dont give "medicines" without knowing what it is
> Being 86 yr old, risk of anesthesia complication goes up only by
1%, provided his cardiac functions are intact,but I would be concerned
about his unstable angina, which is known to progress to a full blown
MI at any time, esp without treatment.
> I would definitely offer a tissue diagnosis, procedure and extent
of resection would depend on cardiac and anesthesiologic
evaluation,meanwhile do a complete work up for other possible DDs
Pramod Pillai
>
>
>
> Dr Satish S wrote:
> Congragulations to pramod on becoming a proud father of a
US citizen!
> Regards to the clinical problem of GBM in elderly, there is now
> sufficient evidence in literature to follow an aggressive treatment
> protocol for the elderly as this not only improves survival albeit
> modestly and in consonance with what we know of malignant gliomas in
> younger people but more importantly one can be reasonable to expect
> to give a better quality of life which is more important at that age.
> The oft repeated 'physiological age' being more important than actual
> age applies to this patent and having a Right temporal lobe mass one
> could expect him to have a uneventful surgical course provided his
> general and cardiac risk factors are taken care of.
Dr Satish S
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