- Email: [email protected]
The author replies as follows
Correspondence
65
particularly as the assessment points seemed to be 'prior to radiation therapy' and at '4 weeks after completion', when the early delayed reaction must be at a maximum. In any case, many patients have made the decision not to go back to work, whether they are physically and intellectually capable of doing so or not, and the elderly are not working. The paper itself was also difficult to interpret because they do not comment on the age range of the patients treated, which is probably the most significant predictor of outcome. We do not have information on tumour grade (or indeed type), and, taken in conjunction with this insensitive performance scale with probable wide inter- and intraobserver variation, it is not possible even to analyse the survival rates in any meaningful form. Finally, I think it would be more correct to have mentioned throughout the paper (including in the title) that these were presumed malignant gliomas rather than 'high grade astrocytomas', since there is no histological proof of the diagnosis. The purpose of this letter is primarily to ensure that anyone reporting measurement of outcome, whether it be improvement in neurological impairment, improvement in disability, improvement in handicap, or changes in quality of life, uses an appropriately validated scale or questionnaire.
References
1. Fuentes R, Izquierdo AX, Canals E, et al. Neurological assessment of high grade astrocytomas following high dose radiotherapy a sole treatment. Clin Oncol 1995;7:110-2. 2. Order SE, Hellman S, von Essen CF, et al. Improvement of survival following wholebrain irradiation for brain metastases. Radiology 1968;91:149-53. R. GRANT
Department of Clinical Neurosciences Western General Hospital Crewe Road Edinburgh, UK
The author replies as follows: We read with interest the letter of Dr Grant regarding our paper [1], and we agree that treating histologically unverified brain tumours is a matter of debate. In our paper, the diagnosis of the 'presumed high grade astrocytomas' was based on clinical and radiological findings. The progressive nature of a lesion excludes,, almost certainly, an ischaemic or inflammatory condition, and the contrast enhanced CT scan is able to diagnose a high grade astrocytoma SIR -
in more than 95% of patients, according to published data [2]. A recent paper of the Neuro-oncology Group at the Royal Marsden Hospital, comparing a series treated with radiotherapy, with and without histological proof of malignancy, concluded that 'patients diagnosed on the basis of clinical features and imaging as having a presumed glioma have similar natural history and clinical behaviour after treatment with radiotherapy to those with histologically confirmed gliomas' [3]. In our paper, we conclude by saying, 'we consider that this was a special group of patients and it was not the objective of this study to highlight treating brain lesions without histological confirmation'. Nevertheless, patients with histologically unproved brain tumours (presumed gliomas) are occasionally seen in daily clinical practice for a variety of reasons (i.e. poor performance, inaccessible locations or failed stereotactic biopsies). Therefore, a certain amount of research should be done in order to define their optimum management. The rank scale we used for measuring the neurological status after radiotherapy, has shortcomings, as has any subjective measure. However, we tested the interobserver variations, finding a coincidence close to 100% (unpublished data). This fact, together with it being easy to use and not very time consuming, encouraged us to use this scale. However, we think that most of the concepts contained in the scale are selfdefining and not subject to many misinterpretations. For instance, using the concept quoted by Dr Grant of being 'physically able to work', in our opinion clearly applies to the ability to perform work. If the patient decided not to return to work, or is retired, this does not affect his/her 'ability' to do so. We think it is advisable to reach a consensus in the research group before any work is done using subjective scales, in order to avoid problems of interpretation. The assessment of the patients 4 weeks after radiotherapy was not an arbitrary decision. At this time, the acute side effects (i.e. those that happen during or immediately after treatment) should be over, and the early delayed reactions, which start 4 weeks after treatment, at the earliest, are not present. Thus, in the rare instances when they are present, they will be at onset and not 'at maximum' as he says [4]. There is no information in our paper about tumour type and grade for obvious reasons. The omission of the age was not deliberate. There was a median age of 57 years (range 48-71) and we must apologize for that. We agree that studies assessing thera-
peutic interventions in high grade gliomas have to use validated, reproducible and specific tests. Notwithstanding this, our patients are a well recognized poor prognostic group, as illustrated by a median survival of 22 weeks. For this reason, we do not think they represent the ideal subgroup to study impairment, disability, handicap and quality of life, using either more or less complicated tests (i.e. Barthel Index, Boston Scale, W H O / E C O G , etc.), otherwise they will spend a significant proportion of their expected survival time on treatment (if treated radically) and filling in questionnaires. Most probably, surgically removed gliomas or low grade astrocytomas offer a better subset of patients for this kind of study. : It is important to note that our main concern was to reinforce the idea of avoiding long lasting treatments, which are most probably not cost effective, using a simple method of evaluation, rather than an exhaustive neuropyschological surveillance. We admit, that the use of the term 'quality of life' was inappropriate according to the definitions provided by Dr Grant and we agree that histologically unverified brain tumours are more accurately defined as being 'presumed high grade astrocytomas'. Finally, we welcome the comments of Dr Grant which have no doubt come from an expert. However, we would appreciate the provision of references to support his statements, otherwise they can be misinterpreted as being personal opinions and lacking scientific consistency.
References
1. Fuentes R, Izquierdo AX, Canals E, et al. Neurological assessment of high grade astrocytomas following high dose radiotherapy as sole treatment. Clin Oncol 1995;7:110-2. 2. Butler AR, Horii SC, Kricheff II, et al. A statistical analysis of the parameters of malignancy and the positive contrast enhanced CT scan. Radiology 1978;129:433-9. 3. Rajan B, Pickuth D, Ashley S, et al. The management of histologically unverified presumed cerebral gliomas with radiotherapy. Int J Radiat Oncol Biol Phys 1994;28:405-13. 4. Hoffman WF, Levin VA, Wilson CB. Evaluation of malignant glioma patients during the postirradiation period. J Neurosug 1987; 50:624-8. R. FUENTES
Servei d' Oncologia Hospital Santa Caterina Girona, Spain
65
particularly as the assessment points seemed to be 'prior to radiation therapy' and at '4 weeks after completion', when the early delayed reaction must be at a maximum. In any case, many patients have made the decision not to go back to work, whether they are physically and intellectually capable of doing so or not, and the elderly are not working. The paper itself was also difficult to interpret because they do not comment on the age range of the patients treated, which is probably the most significant predictor of outcome. We do not have information on tumour grade (or indeed type), and, taken in conjunction with this insensitive performance scale with probable wide inter- and intraobserver variation, it is not possible even to analyse the survival rates in any meaningful form. Finally, I think it would be more correct to have mentioned throughout the paper (including in the title) that these were presumed malignant gliomas rather than 'high grade astrocytomas', since there is no histological proof of the diagnosis. The purpose of this letter is primarily to ensure that anyone reporting measurement of outcome, whether it be improvement in neurological impairment, improvement in disability, improvement in handicap, or changes in quality of life, uses an appropriately validated scale or questionnaire.
References
1. Fuentes R, Izquierdo AX, Canals E, et al. Neurological assessment of high grade astrocytomas following high dose radiotherapy a sole treatment. Clin Oncol 1995;7:110-2. 2. Order SE, Hellman S, von Essen CF, et al. Improvement of survival following wholebrain irradiation for brain metastases. Radiology 1968;91:149-53. R. GRANT
Department of Clinical Neurosciences Western General Hospital Crewe Road Edinburgh, UK
The author replies as follows: We read with interest the letter of Dr Grant regarding our paper [1], and we agree that treating histologically unverified brain tumours is a matter of debate. In our paper, the diagnosis of the 'presumed high grade astrocytomas' was based on clinical and radiological findings. The progressive nature of a lesion excludes,, almost certainly, an ischaemic or inflammatory condition, and the contrast enhanced CT scan is able to diagnose a high grade astrocytoma SIR -
in more than 95% of patients, according to published data [2]. A recent paper of the Neuro-oncology Group at the Royal Marsden Hospital, comparing a series treated with radiotherapy, with and without histological proof of malignancy, concluded that 'patients diagnosed on the basis of clinical features and imaging as having a presumed glioma have similar natural history and clinical behaviour after treatment with radiotherapy to those with histologically confirmed gliomas' [3]. In our paper, we conclude by saying, 'we consider that this was a special group of patients and it was not the objective of this study to highlight treating brain lesions without histological confirmation'. Nevertheless, patients with histologically unproved brain tumours (presumed gliomas) are occasionally seen in daily clinical practice for a variety of reasons (i.e. poor performance, inaccessible locations or failed stereotactic biopsies). Therefore, a certain amount of research should be done in order to define their optimum management. The rank scale we used for measuring the neurological status after radiotherapy, has shortcomings, as has any subjective measure. However, we tested the interobserver variations, finding a coincidence close to 100% (unpublished data). This fact, together with it being easy to use and not very time consuming, encouraged us to use this scale. However, we think that most of the concepts contained in the scale are selfdefining and not subject to many misinterpretations. For instance, using the concept quoted by Dr Grant of being 'physically able to work', in our opinion clearly applies to the ability to perform work. If the patient decided not to return to work, or is retired, this does not affect his/her 'ability' to do so. We think it is advisable to reach a consensus in the research group before any work is done using subjective scales, in order to avoid problems of interpretation. The assessment of the patients 4 weeks after radiotherapy was not an arbitrary decision. At this time, the acute side effects (i.e. those that happen during or immediately after treatment) should be over, and the early delayed reactions, which start 4 weeks after treatment, at the earliest, are not present. Thus, in the rare instances when they are present, they will be at onset and not 'at maximum' as he says [4]. There is no information in our paper about tumour type and grade for obvious reasons. The omission of the age was not deliberate. There was a median age of 57 years (range 48-71) and we must apologize for that. We agree that studies assessing thera-
peutic interventions in high grade gliomas have to use validated, reproducible and specific tests. Notwithstanding this, our patients are a well recognized poor prognostic group, as illustrated by a median survival of 22 weeks. For this reason, we do not think they represent the ideal subgroup to study impairment, disability, handicap and quality of life, using either more or less complicated tests (i.e. Barthel Index, Boston Scale, W H O / E C O G , etc.), otherwise they will spend a significant proportion of their expected survival time on treatment (if treated radically) and filling in questionnaires. Most probably, surgically removed gliomas or low grade astrocytomas offer a better subset of patients for this kind of study. : It is important to note that our main concern was to reinforce the idea of avoiding long lasting treatments, which are most probably not cost effective, using a simple method of evaluation, rather than an exhaustive neuropyschological surveillance. We admit, that the use of the term 'quality of life' was inappropriate according to the definitions provided by Dr Grant and we agree that histologically unverified brain tumours are more accurately defined as being 'presumed high grade astrocytomas'. Finally, we welcome the comments of Dr Grant which have no doubt come from an expert. However, we would appreciate the provision of references to support his statements, otherwise they can be misinterpreted as being personal opinions and lacking scientific consistency.
References
1. Fuentes R, Izquierdo AX, Canals E, et al. Neurological assessment of high grade astrocytomas following high dose radiotherapy as sole treatment. Clin Oncol 1995;7:110-2. 2. Butler AR, Horii SC, Kricheff II, et al. A statistical analysis of the parameters of malignancy and the positive contrast enhanced CT scan. Radiology 1978;129:433-9. 3. Rajan B, Pickuth D, Ashley S, et al. The management of histologically unverified presumed cerebral gliomas with radiotherapy. Int J Radiat Oncol Biol Phys 1994;28:405-13. 4. Hoffman WF, Levin VA, Wilson CB. Evaluation of malignant glioma patients during the postirradiation period. J Neurosug 1987; 50:624-8. R. FUENTES
Servei d' Oncologia Hospital Santa Caterina Girona, Spain