What Does Quality of Care Mean in Lower-Grade Glioma Patients: A Precision Molecular-Based Management of the Tumor or an Individualized Medicine Centered on Patient's Choices?

Abstract

Neurooncology is a young specialty which initially dealt mostly with glioblastoma patients with a short overall survival (OS). Yet, recently the scope gradually expanded by taking care of lower-grade glioma (LGG) patients with a longer OS (1). Historically, these patients were managed with a “wait and see attitude” claiming “benignity” despite 6 to 7 years OS (2, 3). Therefore, quality of care was mainly based on physician’s subjectivity and not on the natural history, leading to beliefs that early surgery was not adapted due to “normal neurological examination”. Twenty years later, it is now admitted that (i) beyond seizures, LGG patients suffer from cognitive and behavioral deficits at diagnosis even in incidental cases (4) (ii) this tumor will inescapably transform in higher grades, explaining the use of “lower-grade glioma” (mixing II/III) expression (5) (iii) early surgery is a main therapeutic factor (significant correlation between extent of resection and OS) (6, 7) (iv) early radiotherapy, at least given alone, is not associated with decreased mortality (6, 8). These changes resulted in a longer life expectancy now over 15 to 16 years (9–11). Moreover, neurooncologists had to pay more attention to quality of life (QoL) for patients who must learn to live with a chronic neoplastic disease. On the other hand, because LGG will systematically recur, further adapted treatments have to be administrated (12). However, heterogeneity of progression patterns (13) makes the prediction of timescales of proliferation, migration, and degeneration at the individual level impossible. To provide more reliable prognostic factors, advances in molecular biology led to a new classification designed for more appropriate decisions (14). Surprisingly, although genetics was initially a tool to better dissociate types of LGG with distinct prognosis, molecular biology rapidly became the first parameter in guidelines (15). Although useful, by taking mostly account of genetics criteria and extrapolating a correlation to specific OS based upon statistical analysis, there is a risk to neglect tumor-host interactions, patient’s wishes, and long-term QoL. Here, the main purpose is to redefine what “best quality of care” means by considering both tumor characteristics and patient’s personal criteria. The ultimate goal is to give the choice of therapeutic orientation at each step thanks to honest although complex and time-consuming information highlighting oncofunctional balance and various strategies individually adapted over time in parallel with changes in tumor behavior and patient’s expectations.