Astrocytoma, IDH-mutant: the decisions you may face
6 treatment settings, 6 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Newly diagnosed, all grades
Maximal safe resection with awake or functional mapping where needed; integrated histological and molecular diagnosis (IDH, 1p/19q, ATRX, CDKN2A/B, methylation class).
Reading chemical tags on DNA that reveal a cell's identity, used to classify brain tumours and to detect cancer in blood.
- Cell-of-origin memory
- Stable analyte in blood
MRI uses a strong magnet and radio waves, with no ionising radiation, to picture soft tissue in finer contrast than CT, so it is the standard scan for brain tumours, prostate, rectal cancer staging, liver lesions and breast screening in high-risk women. It is slow, expensive and blurred by movement.
- No ionising radiation
- Best soft-tissue and brain imaging
- Functional sequences (diffusion, perfusion)
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Reference cohort dependence
- Slow and expensive
- Motion artefacts
- Gadolinium concerns in renal impairment
- Between DNA methylation profiling and MRI, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (newly diagnosed, all grades), which of the standard options do you recommend and why?Why: Guideline options include: Maximal safe resection with awake or functional mapping where needed; integrated histological and molecular diagnosis (IDH, 1p/19q, ATRX, CDKN2A/B, methylation class).
Add these to your appointment list, or take the full question set for this cancer.
Grade 2, residual or recurrent, low risk
Observation with serial MRI, or vorasidenib for grade 2 tumours not needing immediate radiotherapy or chemotherapy (INDIGO).
The first targeted therapy for low-grade brain tumours, delaying the need for radiation and chemotherapy by years.
For low-risk prostate cancer, monitoring with PSA, MRI, and repeat biopsy instead of treating, because most such cancers never cause harm.
- Avoids incontinence and erectile dysfunction of treatment in men who would never be harmed
- Level-1 evidence of safety (ProtecT)
- Tests VorasidenibResidual or recurrent grade 2 IDH-mutant astrocytoma or oligodendroglioma after surgery, no prior RT/chemo: vorasidenib vs placebo
PFS 27.7 vs 11.1 months, HR 0.39.
Progression-free survival (BIRC) (months): Vorasidenib 27.7 (n=168) vs Placebo 11.1 (n=163) · HR 0.39 · source
- Anxiety and adherence
- Repeat biopsies
- Under-used outside high-income countries
- Between Vorasidenib and Active surveillance, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in INDIGO, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (grade 2, residual or recurrent, low risk), which of the standard options do you recommend and why?Why: Guideline options include: Observation with serial MRI, or vorasidenib for grade 2 tumours not needing immediate radiotherapy or chemotherapy (INDIGO).
- Am I a candidate for Vorasidenib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of INDIGO apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Grade 2, high risk (age 40 or over, subtotal resection)
Radiotherapy followed by PCV (procarbazine, lomustine, vincristine) as in RTOG 9802, or radiotherapy with temozolomide; temozolomide alone was not better than radiotherapy alone in EORTC 22033.
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
Procarbazine (Matulane) is an old chemotherapy capsule from the MOPP regimen for Hodgkin lymphoma; it is now used mainly in the PCV combination for certain brain tumours.
An old chemotherapy pill used when glioblastoma comes back, and the control arm most new glioblastoma drugs must beat.
A plant-derived chemotherapy from the Madagascar periwinkle that has been in almost every childhood leukaemia and lymphoma regimen since the 1960s.
The only chemotherapy proven to extend life in glioblastoma, given during and after radiation. It works best when the tumour has switched off a repair gene called MGMT.
- High-risk low-grade glioma: radiotherapy versus temozolomide alone as first treatment
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- Median progression-free survival 46 (radiotherapy) vs 39 months (temozolomide), no significant difference.
Progression-free survival (months): Radiotherapy (50.4 Gy) 46 (n=240) vs Dose-dense temozolomide 39 (n=237) · HR 1.16 · source
- Low-dose bath to normal tissue
- Motion management
- Fatal if given intrathecally: label all syringes.
- Take on an empty stomach or at bedtime to reduce nausea; PJP prophylaxis during concurrent chemoradiation.
- Between IMRT / IGRT (modern external beam), Procarbazine, Lomustine (CCNU) and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in EORTC 22033-26033, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (grade 2, high risk (age 40 or over, subtotal resection)), which of the standard options do you recommend and why?Why: Guideline options include: Radiotherapy followed by PCV (procarbazine, lomustine, vincristine) as in RTOG 9802, or radiotherapy with temozolomide; temozolomide alone was not better than radiotherapy alone in EORTC 22033.
- Am I a candidate for Procarbazine, Lomustine (CCNU), Vincristine or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EORTC 22033-26033 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Grade 3
Radiotherapy followed by twelve cycles of adjuvant temozolomide (CATNON); concurrent temozolomide is not needed in non-codeleted tumours.
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
The only chemotherapy proven to extend life in glioblastoma, given during and after radiation. It works best when the tumour has switched off a repair gene called MGMT.
- Newly diagnosed anaplastic glioma without 1p/19q co-deletion: radiotherapy with or without concurrent and with or without adjuvant temozolomide
Concurrent temozolomide benefit confined to IDH-mutant tumours.
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- Adjuvant temozolomide: overall survival hazard ratio 0.65; 5-year survival 55.9% vs 44.1%.
Overall survival at 5 years (%): Adjuvant temozolomide 55.9 vs No adjuvant temozolomide 44.1 · HR 0.65 · source
- Low-dose bath to normal tissue
- Motion management
- Take on an empty stomach or at bedtime to reduce nausea; PJP prophylaxis during concurrent chemoradiation.
- Between IMRT / IGRT (modern external beam) and Temozolomide, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in CATNON (EORTC 26053-22054), and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (grade 3), which of the standard options do you recommend and why?Why: Guideline options include: Radiotherapy followed by twelve cycles of adjuvant temozolomide (CATNON); concurrent temozolomide is not needed in non-codeleted tumours.
- Am I a candidate for Temozolomide, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CATNON (EORTC 26053-22054) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Grade 4
Radiotherapy with concurrent and adjuvant temozolomide, extrapolated from glioblastoma; trials of IDH inhibitors preferred where available.
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
The only chemotherapy proven to extend life in glioblastoma, given during and after radiation. It works best when the tumour has switched off a repair gene called MGMT.
- Newly diagnosed glioblastoma: radiotherapy + concurrent and adjuvant temozolomide vs radiotherapy alone
OS 14.6 vs 12.1 months, HR 0.63.
Overall survival (months): Radiotherapy + temozolomide 14.6 (n=287) vs Radiotherapy alone 12.1 (n=286) · HR 0.63 · source
- Low-dose bath to normal tissue
- Motion management
- Take on an empty stomach or at bedtime to reduce nausea; PJP prophylaxis during concurrent chemoradiation.
- Between IMRT / IGRT (modern external beam) and Temozolomide, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in EORTC 26981 / NCIC CE.3 (Stupp trial), and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (grade 4), which of the standard options do you recommend and why?Why: Guideline options include: Radiotherapy with concurrent and adjuvant temozolomide, extrapolated from glioblastoma; trials of IDH inhibitors preferred where available.
- Am I a candidate for Temozolomide, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EORTC 26981 / NCIC CE.3 (Stupp trial) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Recurrence
Re-resection, re-irradiation, lomustine or temozolomide re-challenge, bevacizumab for oedema and symptoms; clinical trials.
An old chemotherapy pill used when glioblastoma comes back, and the control arm most new glioblastoma drugs must beat.
The only chemotherapy proven to extend life in glioblastoma, given during and after radiation. It works best when the tumour has switched off a repair gene called MGMT.
A blood-vessel-blocking antibody that shrinks glioblastoma on scans and reduces swelling, but has never been shown to help patients live longer.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Take on an empty stomach or at bedtime to reduce nausea; PJP prophylaxis during concurrent chemoradiation.
- Between Lomustine (CCNU), Temozolomide and Bevacizumab (glioblastoma use), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (recurrence), which of the standard options do you recommend and why?Why: Guideline options include: Re-resection, re-irradiation, lomustine or temozolomide re-challenge, bevacizumab for oedema and symptoms; clinical trials.
- Am I a candidate for Lomustine (CCNU), Temozolomide, Bevacizumab (glioblastoma use), and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.