Tumor-Treating Field Therapy in Glioblastoma: Patient Selection
Insights From: Maciej Mrugala, MD, PhD, MPH, University of Washington Medical Center; Suriya Jeyapalan, MD, MPH, Tufts Medical Center; Daniela Bota, MD, UC Irvine Medical Center
Daniela Bota, MD: I think that there is a reluctance on the physician’s standpoint to embrace the treatment, because the original results published were interim results on only half of the patients. I think the release of the new data that incorporate all the patients with long-term follow-up—we are talking about 4-year data right now, and hopefully by the time of the ASCO conference, we’re going to have 5-year’s data—will go a long way to convincing the physician that this is the right treatment. It is something new. We always have used surgery, radiation, and chemotherapy. To come in with a different device takes a little bit of getting used to, but I think we’re going to have to for the good of our patients, because this is really effective. And this is now well proven with a long-term follow-up and a much larger number of patients.
For the patients—I have this discussion in my clinic every day—I think increasing awareness and increasing understanding, it’s a great step forward. And part of it is coming from the physician presenting the data, as we talked about them today, and letting the patients know, number 1, about the efficacy, and number 2, about the fact that the side effects are very limited, because this gets added to the treatments that the patients already have and it’s adding very little side effects. It’s preserving and maintaining the quality of life, a topic that we also have touched on.
So, with all of those data, I think more and more patients are going to be convinced and embrace the therapy. I will also add a small caveat here, which is that it’s very hard to be the first patient in a practice, adopting it. I strongly recommend for the physicians that are just getting started with 1 patient, if the patient is still reluctant, that they be put in touch either with the ABTA (American Brain Tumor Association) and NBTF (National Brain Tumor Foundation), and they will talk about support groups for the patients wearing the device. The company also has a great ambassador program where patients can be paired with patients that are already using the device, and learn from other people’s experience how to incorporate it in the daily life.
Suriya Jeyapalan, MD, MPH: I think for oncologists, you have to understand, this treatment strategy is here. It’s a novel treatment, it’s going to be around. You’re going to see this more and more. I think you should try and familiarize yourself with it. It’s a pretty easy training process to figure out how to prescribe the rays, and figure out how to plan the rays so that you can treat your own individual patient. Patients usually tolerate it very well. The FDA has approved the next generation device, which now only weighs 2.5 pounds. It used to weigh 6 pounds. And my patients tell me it’s so much better, it’s so much easier to work with. The design is like a messenger bag to wear over your shoulder. One of my patients had a cousin who was a seamstress and they turned it into a fanny pack. He wears it as a fanny pack. And it’s very well tolerated. As for skin reaction to the adhesive, 15% to 20% have that, and we just deal with that with corticoid steroid creams. But, there are a lot of published data out there on how to deal with that.
So, I think what people have to do is realize the world is not flat; the world is round. There are a lot of things out there that can help us treat our patients. And you have to convince yourself first. Look at the data. But, then you should also talk to your patients. Because I have to say, the number 1 feature of this device is alternative therapy. This is not chemotherapy, this is not radiation, this is not surgery. This is something patients wanted. They were tired of feeling sick with chemotherapy. They were tired of feeling tired with radiation. They were tired of going through surgeries. This is something they do themselves. The company comes to the person’s house, sets up the rays. We just make the plan. They shave their heads every 3 or 4 days, they put it on or a family member helps them, they carry it around, and they do it. In the trial, they had to do it 18 hours or more a day for 2 years, and people did it. And we had 1 patient that tested it and has still not taken it off of his head 7 years later. The tumor still hasn’t come back 7 years later.
So, people are willing to do it. It clearly impacts quality of life, but so does everything else we do. I think the patients have found that the quality-of-life impact is acceptable to them. And the trial has shown a survival advantage. I’d say come do it with an open mind. Share it with your patients. Let them make the decision. I’ve had young women with long hair, that I thought would never be interested in the device, and they sign up right away. I’ve had middle-aged guys who basically had lost their hair and who haven’t been interested in the device. So, it’s been surprising to me. Let them make the decision and you’ll be surprised who makes the decision to do it. Because at the end of the day, they’re all coming to you to live longer, and this is what this device has shown. I got rid of my prejudice about the device because I saw that it had a survival advantage, and now I’m a firm believer in it. I hope that you will open your minds up to it as well and realize the same that I did.
People have asked me, “Who are the best candidates for Optune?” I have to say I think everybody is a candidate for Optune. And I think it’s a personal preference on the part of the patient about whether they want to do it or not. Because if you think about it, all they have to be able to do, or family has to be able to do, is shave their head, stick these adhesive pads—front, back, left, right—and connect it to a 2-pound device. So, I told people it’s like dropping you from a 6-pound Dell laptop to our MacBook Air basically. You just can put it as a fanny pack or as a shoulder pack, and that’s all you do. You just walk around with it. You have to wear it 18 hours a day; that’s actually been shown in the trials to be the minimum that you should do to get an effect from it. And that doesn’t take a lot. In fact, it was interesting. In the EF-11 trial, which is a recurrent GBM trial, some people were essentially bed bound, couldn’t do anything, but they were still expressing a need to want to be treated, or their families wanted them to be treated, and they could still be treated. You don’t really need to do much. You really just have to shave your head, put some adhesive pads on your head, connect it up to the device and then you’re done. So, I think almost everybody is a candidate. It’s a personal preference on the patient. And what I’ve been impressed with is that patients have been wanting these alternative therapies, and I’m so glad that this alternative therapy has worked for them.