NICE guidelines

The management of patients with brain tumours in the UK has changed considerably over the last few years with potentially significant benefits to many sufferers. There have been 3 important reviews carried out by NICE which are currently influencing many of these changes. In Wessex we have introduced procedures in line with the guidelines from NICE. Check with your specialist that you are offered treatment according to these guidelines.

NICE IMPROVING OUTCOMES GUIDANCE FOR BRAIN AND CNS TUMOURS

In 2006 NICE published its definitive guide for the optimal management of patients with brain and other nervous system tumours. 

• Visit NICE website 
• Download the manual of guidance

I believe that treating patients according to this model of care will improve outcomes. In Southampton we have embraced the key recommendations of this guidance, in particular 2 of these have dramatically changed the way that patients are treated:

• management of all patients should be through a multi-disciplinary team - to ensure the best consensus opinion on your care
• surgery should be performed by dedicated specialist neurosurgeons - this is defined as surgeons who spend >50% of their clinical practice treating patients with brain tumours, run dedicated neuro-oncology clinics and attend weekly MDT meetings

Previously patients with brain tumours were managed by all neurosurgeons but this is no longer acceptable. If you have a brain tumour (primary, secondary, meningioma, etc) then you should now be treated by a designated specialist neuro-oncology surgeon working as part of an MDT. In Wessex we have fully adopted these recommendations but unfortunately these guidelines have not yet been fully realised across the UK. Most units in this country are now working hard to achieve full compliance with the IOG over the next few years and we will all be audited against national standards from 2010 onwards.

It is also recommended that certain other nervous system tumours are managed by additional separate MDTs as follows:

• skull-base tumours
• pituitary tumours
• spinal cord tumours

NICE TECHNOLOGY APPRAISAL ON CARMUSTINE IMPLANTS AND TEMOZOLOMIDE FOR NEWLY DIAGNOSED HIGH-GRADE GLIOMA

In 2007 NICE completed a review of the evidence for 2 new chemotherapy products that are proven to increase survival in patients who are diagnosed with high-grade gliomas (see link http://www.nice.org.uk/Guidance/TA121)

• download full guidance 
• download public information

Carmustine wafers (Gliadel) are now recommended for use by NICE for selected patients provided the following criteria are satisfied:

• you have pre-operative MRI suggestive of high-grade glioma
• your case is discussed before surgery in a neuro-oncology MDT
• you have a specialist neuro-oncology surgeon (defined as above)
• your surgeon is able to remove >90% of the tumour
• the pathologist confirms your tumour is HGG during surgery
• the ventricle (fluid space) in the brain is not widely opened

In Wessex we use Gliadel in line with these criteria. These are wafers of a slow-release chemotherapy drug placed into the cavity after your tumour has been removed. Unfortunately, this treatment is not widely used in the UK at present despite its approval by NICE. Please ask your specialist about this treatment if appropriate. The main risk of using this treatment appears to be a higher risk of fluid leak from a wound after surgery.

Temozolomide is now recommended by NICE for the treatment of glioblastoma alongside radiotherapy provided patients are WHO performance status 0 or 1 i.e. you are active and capable of anything except heavy physical work. This drug appears to have most benefit if your surgeon has been able to resect your tumour first. All systemic chemotherapy agents have side effects and risks, therefore, not all patients can complete the full course of treatment. Please discuss this with your oncologist.

Some patients will potentially be able to receive both of these treatments. Although it is not definitely known if this is of additional benefit, it does appear to be safe. Recent research has indicated that this combined treatment might actually benefit patients in the future. (for futher information click here).