|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 3 | Page : 576-577
Bevacizumab in recurrent glioma: Variable doses, volatile benefits
Sujith Kumar Mullapally, Pankaj Kumar Panda
Department of Medical Oncology, Neuro-Oncology Cancer Management Team, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
|Date of Submission||23-Jul-2021|
|Date of Decision||01-Aug-2021|
|Date of Acceptance||07-Aug-2021|
|Date of Web Publication||10-Sep-2021|
Sujith Kumar Mullapally
Department of Medical Oncology, Neuro-Oncology Cancer Management Team, Apollo Proton Cancer Centre, 4/661, Dr. Vikram Sarabai Instronic Estate 7th Street, Dr. Vasi Estate, Phase II, Tharamani, Chennai - 600 041, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mullapally SK, Panda PK. Bevacizumab in recurrent glioma: Variable doses, volatile benefits. Cancer Res Stat Treat 2021;4:576-7
It was with great interest that we read the article by D'Souza et al. on the use of low-dose bevacizumab in recurrent glioma and the accompanying editorial by Dr. Biswas. The authors must be congratulated for this interesting and pertinent study done in the context of recurrent glioma with no definite treatment options when re-surgery or re-irradiation is not feasible. The recently concluded American Society of Clinical Oncology annual meeting 2021 included a few studies in recurrent glioma in which the therapy was based on the presence of driver mutations such as BRAF and NTRK, but these cases constitute only a minority of the clinical burden we see in neuro-oncology practice.
Bevacizumab, although approved, is yet to be established as an effective agent for widespread use in recurrent glioma. The current use is based on the studies by Taal et al. and Vredenburgh et al., which had shown symptomatic relief and improved progression-free survival (PFS). These studies done in combination with chemotherapy such as irinotecan and lomustine failed to change the practice primarily because of the low magnitude of benefit and high toxicity rates. Treatment-related toxicities such as hypertension and bleeding have been attributed to bevacizumab. Whether low-dose bevacizumab would have resulted in lesser toxicities with similar benefits is an open question.
The majority of patients with recurrent glioma have residual neurological deficits affecting their performance status and quality of life in terms of increased dependence in their activities of daily living and lack of social engagements. For any drug to be accepted as a standard of care, significant and meaningful improvement in overall survival with an acceptable or minimal toxicity profile is desirable. Financial toxicity also should be considered as an important factor in such scenarios as many of these patients tend to be in the young or middle-age groups, whereby their social and economic independence is severely compromised.,, It is in this context that the current study assumes importance for clinical practice in patients with recurrent glioma.
In spite of the dose used, the main concern is the short PFS duration (3–4 months). Often, patients experience improvement in their symptoms and imaging studies show a reduction in the tumor edema/fluid-attenuated inversion recovery changes; however, during subsequent visits, clinical and radiological progression secondary to bevacizumab resistance is usually noted. This “volatile” response of bevacizumab has prevented its routine adoption in clinical practice.
The study by D'Souza et al. has attempted to provide preliminary answers to the conundrum of the optimal dosing of bevacizumab. Future randomized studies comparing low and high doses of bevacizumab may not be of relevance if they do not incorporate the appropriate study arms including the combination of bevacizumab with drugs which might help in sustaining the response achieved with bevacizumab. Future studies could possibly include three arms with low dose and high dose of bevacizumab each in combination with the trial drug and the control arm with high dose bevacizumab alone. The trial drug can be a repurposed drug as used in metronomic chemotherapy or newer molecules such as immunotherapy. Multi-institutional collaborative trials could provide the required impetus to solve this intriguing clinical dilemma.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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