Introduction

Glioblastoma multiforme (GBM) is the most common primary brain tumor and unfortunately the most difficult tumor to effectively treat, despite the significant advances in recent research. Because of this, unknowingly, many medical professionals might advocate for aggressive interventions that may adversely affect the quality of life (QOL) and outcome of these patients. Given the various neurologic deteriorations and psychopathological impairments that these patients tend to suffer during the course of this rapidly progressive disease, not all of these patients stand to benefit from certain of these therapies, at least from a QOL standpoint. In addition, there are few robust trials that have evaluated the QOL in patients with high-grade glioma.

The goal of treatment for the cancer patient should go beyond increasing survival. Rather, maintenance or improvement of the health-related QOL (HRQOL) must be a physician’s prerogative when evaluating this goal. Hence, the benefits of the cancer treatment must be weighed against the adverse effects and potential psychopathological impairments. HRQOL, a multidimensional concept that includes self-reported measures of physical and mental health has become a tool to support clinical decision-making in patients with cancer that cannot be cured, such as GBM. Specifically, HRQOL evaluates physical, psychological, and social aspects of human functionality.

Previously, the use of the Karnofsky Performance Status was a common method to evaluate QOL. However, this measure did not incorporate a multidimensional approach to cost, QOL, and return to work, all of which are gaining importance as outcome measures, especially because of the intense resource use that brain cancer treatment demands. Better technology and therapeutic interventions have yielded a marginal increase in survival after surgery, radiation, and chemotherapy for GBM, and the attention is shifting toward evaluation of the QOL gained by these therapies during those additional weeks or months.

Depending on tumor location, surgical intervention, and radiation therapy and chemotherapy administered, certain patients benefit from this marginal increase in survival, but may sustain a decline in their HRQOL. Other patients might do quite well after receiving treatment both clinically and from an HRQOL standpoint, which urges further research and clinical interventions.

The most commonly used metrics to evaluate HRQOL in patients with brain cancer are role participation, social functioning and global QOL, visual disorder, motor dysfunction, communication deficit, and drowsiness ( Box 1 ). Most papers agree that improvement in QOL is demonstrated by a 10-point positive change in HRQOL score from baseline.

Divergent views of the HRQOL model exist, and there are several other formulations to evaluate physical and social functioning, and role participation that conceptualize disruptions caused by a disease to the community, family and work. Because these formulations or metrics may vary by societal beliefs or norms, at least 1 paper has sought to establish equivalence of language and interpretation of the metric. To add to this complexity, Herdman and colleagues found 19 different types of equivalence, but these standards were not clearly defined, and the theoretical framework for equivalence lacked. Their literature review revealed vague or conflicting definitions to define HRQOL, particularly in the case of conceptual equivalence definitions of equivalence in the HRQOL literature. They concluded that conceptual equivalence definitions are cultural in nature, and there existed an urgent need to establish universalist standardized terminology within the HRQOL field, which would require substantial changes to guidelines and more empiric work on the conceptualization of HRQOL in different cultures.

Radiological considerations on the quality of life and outcomes in GBM

Radiological predictors of poor prognosis in GBM have been studied in multiple articles. Intensity of enhancement of the tumor nodule and extent of peritumoral edema are commonly cited factors that portend a poorer prognosis ( Table 1 ). Interestingly, location and tumor volume have not correlated as predictors of survival.

Hobbs and colleagues found that in GBM, the intensity of contrast enhancement on magnetic resonance imaging (MRI) correlated with differences in gene expression. The expression of certain genes has been used to determine the most appropriate individualized treatment. This intratumoral heterogeneity noted on MRI highlights the need for multidisciplinary multimodal treatment, to adequately address all aspects of the biology of GBMs and possibly extend the long-term HRQOL. In summary, GBM patients with little or no necrosis and with less tumor nodule enhancement on preoperative MRI survive longer than patients with greater amounts of necrosis and greater degrees of tumor enhancement.

An increasing body of evidence demonstrates the utility of expression profiling in stratification of patients with GBM in terms of tumor classification and survival.

Radiological considerations on the quality of life and outcomes in GBM

Radiological predictors of poor prognosis in GBM have been studied in multiple articles. Intensity of enhancement of the tumor nodule and extent of peritumoral edema are commonly cited factors that portend a poorer prognosis ( Table 1 ). Interestingly, location and tumor volume have not correlated as predictors of survival.

Hobbs and colleagues found that in GBM, the intensity of contrast enhancement on magnetic resonance imaging (MRI) correlated with differences in gene expression. The expression of certain genes has been used to determine the most appropriate individualized treatment. This intratumoral heterogeneity noted on MRI highlights the need for multidisciplinary multimodal treatment, to adequately address all aspects of the biology of GBMs and possibly extend the long-term HRQOL. In summary, GBM patients with little or no necrosis and with less tumor nodule enhancement on preoperative MRI survive longer than patients with greater amounts of necrosis and greater degrees of tumor enhancement.

An increasing body of evidence demonstrates the utility of expression profiling in stratification of patients with GBM in terms of tumor classification and survival.

Surgical considerations on the QOL and outcomes in GBM

Surgery in glioblastoma is mainstay treatment for both histopathological tissue diagnosis and tumor debulking. Extent of tumor resection slightly increases survival, but this must be weighed against the removal of eloquent cortex, resection of which would decrease postoperative QOL. It is the opinion of the authors, that in cases where the malignant glial tumor invades eloquent cortex, a discussion of postoperative QOL must be performed during the preoperative phase, to avoid misunderstandings and conserve patient expectations. Many patients prefer to preserve functions like speech and movement, even at the expense of leaving behind significant amounts of tumor. Importantly, the continuum of open dialogue of specialists within a multidisciplinary team when caring for patients with GBM is key, since loss of communication among providers may result in delayed treatment. Interdisciplinary discussions are imperative, since aggressive early intervention retards tumor progression and leads to improved survival. Surgery should be combined with chemotherapy and radiation, as both add survival benefit. Continuous communication of all parties involved with care of these patients is vital.

A presurgical consideration to preserve the QOL in patients with malignant glioma depends on 2 factors;

• 1.
  

  Location of the tumor

  
  
• 2.
  

  Aggressiveness of the tumor.

Tumors located within the left hemisphere, primary speech area, or primary motor areas are associated with decreased QOL. Preoperatively, patients with tumors located in the speech area of the brain may present with aphasia, or if in the motor area, with paresis, leading to the need for continuous dedicated care in the postoperative phase.

Rapidly progressive tumors are associated with a rapid decline of cognitive function. Early reoccurrence of tumors usually portends a poor prognosis, but pseudoprogression must be excluded.