Poor-prognosis high-grade gliomas: evolving an evidence-based standard of care

Patients with high-grade glioma (HGG) can be classified as having a favourable prognosis (younger or with good performance status) or a poor prognosis (older or with poor performance status) with median survival of 12-24 months and 6-9 months, respectively. The standard management for the favourable subgroup is maximum safe resection followed by adjuvant conventionally fractionated radiotherapy, with or without chemotherapy. However, most patients with HGG have a poor prognosis and their optimum management has yet to be defined. In the poor-prognosis HGG subgroup, short-course radiotherapy is equivalent to conventional radiotherapy in terms of survival and palliation (level II evidence), but chemotherapy is not recommended (level II evidence). The problems with the existing systems of prognosis are discussed and a pragmatic system proposed. Owing to lack of any level I evidence, the need to conduct prospective randomised trials with quality of life and palliative effect as primary endpoints is emphasised. Until such time, maximum safe resection followed by a short course of focal radiotherapy is recommended as the standard of care in poor prognosis HGG.