The first 60 days: Glioma & glioblastoma
Gliomas are now diagnosed by molecular class, and three classes got their first targeted drugs in 2024-25 (vorasidenib for IDH-mutant glioma, tovorafenib for BRAF-altered paediatric glioma, dordaviprone for H3 K27M). Glioblastoma itself is the hardest to treat and has kept the same standard since 2005; CAR-T delivered into the brain and focused-ultrasound drug delivery are the live directions. Below, week by week, is what OnCo's record of Glioma & glioblastoma says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
MRI with contrast; maximal safe resection with 5-ALA and intraoperative mapping, with early postoperative MRI to measure the extent of resection; integrated histo-molecular diagnosis with methylation classification where available.
Radiotherapy 60 Gy in 30 fractions with concurrent and 6 cycles adjuvant temozolomide; from age 65, short-course radiotherapy (40 Gy in 15 fractions) with temozolomide (CCTG CE.6); for older patients unfit for combined treatment, temozolomide alone or hypofractionated radiotherapy alone, chosen by MGMT status (Nordic, NOA-08); TTFields with maintenance temozolomide; trials for MGMT-unmethylated patients.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Diagnosis.
- RadiologistNamed in the standard of care for: Glioblastoma, Diagnosis.
- SurgeonNamed in the standard of care for: Glioblastoma, IDH-mutant grade 2, Diagnosis, Glioblastoma, recurrent and 2 more.
- Medical oncologistNamed in the standard of care for: Glioblastoma, IDH-mutant grade 2, Glioblastoma, newly diagnosed, Glioblastoma, recurrent and 4 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Glioblastoma, Glioblastoma, newly diagnosed, Glioblastoma, recurrent, IDH-mutant grade 2 glioma and 3 more.
- Transplant and cell therapy teamNamed in the standard of care for: Glioblastoma, recurrent, H3 K27M diffuse midline glioma.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Resection → RT + temozolomide → TTFields; lomustine/bevacizumab at relapse.
Resection → vorasidenib or observation; RT/PCV for high-risk.
Re-resection or LITT if feasible; lomustine; bevacizumab for oedema/steroid sparing; re-irradiation; clinical trial (CAR-T, FUS-BBB, vaccines) strongly preferred.
Maximal resection; vorasidenib for residual/recurrent disease (INDIGO); radiotherapy plus PCV or temozolomide for high-risk or progressive disease.
Radiotherapy plus PCV (RTOG 9402, EORTC 26951) or temozolomide (CATNON).
Radiotherapy; dordaviprone at progression (2025); GD2 CAR-T and ONC201 first-line trials.
Resection where safe; chemotherapy (carboplatin/vincristine) or tovorafenib / dabrafenib-trametinib for BRAF-altered relapsed disease; avoid radiation in young children.
- Is MGMT methylated, and is the patient fit for the full course?
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example IDH1/2, 1p/19q codeletion, MGMT methylation, H3K27M, EGFR amplification), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Glioblastoma, IDH-wild-type, Astrocytoma, IDH-mutant, Oligodendroglioma, IDH-mutant and 1p/19q-codeleted.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Glioblastoma
- For my situation (glioblastoma), which of the standard options do you recommend and why?Guideline options include: Resection → RT + temozolomide → TTFields; lomustine/bevacizumab at relapse.
- Am I a candidate for Optune / Optune Pax (TTFields), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
IDH-mutant grade 2
- For my situation (idh-mutant grade 2), which of the standard options do you recommend and why?Guideline options include: Resection → vorasidenib or observation; RT/PCV for high-risk.
- Am I a candidate for Vorasidenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Diagnosis
- For my situation (diagnosis), which of the standard options do you recommend and why?Guideline options include: MRI with contrast; maximal safe resection with 5-ALA and intraoperative mapping, with early postoperative MRI to measure the extent of resection; integrated histo-molecular diagnosis with methylation classification where available.
Glioblastoma, newly diagnosed
- For my situation (glioblastoma, newly diagnosed), which of the standard options do you recommend and why?Guideline options include: Radiotherapy 60 Gy in 30 fractions with concurrent and 6 cycles adjuvant temozolomide; from age 65, short-course radiotherapy (40 Gy in 15 fractions) with temozolomide (CCTG CE.6); for older patients unfit for combined treatment, temozolomide alone or hypofractionated radiotherapy alone, chosen by MGMT status (Nordic, NOA-08); TTFields with maintenance temozolomide; trials for MGMT-unmethylated patients.
- Am I a candidate for Temozolomide, Optune / Optune Pax (TTFields), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EORTC 26981 / NCIC CE.3 (Stupp trial) and CCTG CE.6 / EORTC 26062-22061 (Perry trial) apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Glioblastoma, recurrent
- For my situation (glioblastoma, recurrent), which of the standard options do you recommend and why?Guideline options include: Re-resection or LITT if feasible; lomustine; bevacizumab for oedema/steroid sparing; re-irradiation; clinical trial (CAR-T, FUS-BBB, vaccines) strongly preferred.
- Am I a candidate for Lomustine (CCNU), Bevacizumab (glioblastoma use), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
IDH-mutant grade 2 glioma
- For my situation (idh-mutant grade 2 glioma), which of the standard options do you recommend and why?Guideline options include: Maximal resection; vorasidenib for residual/recurrent disease (INDIGO); radiotherapy plus PCV or temozolomide for high-risk or progressive disease.
- Am I a candidate for Vorasidenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of INDIGO apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Oligodendroglioma grade 3 / astrocytoma grade 3
- For my situation (oligodendroglioma grade 3 / astrocytoma grade 3), which of the standard options do you recommend and why?Guideline options include: Radiotherapy plus PCV (RTOG 9402, EORTC 26951) or temozolomide (CATNON).
- Am I a candidate for Temozolomide, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
H3 K27M diffuse midline glioma
- For my situation (h3 k27m diffuse midline glioma), which of the standard options do you recommend and why?Guideline options include: Radiotherapy; dordaviprone at progression (2025); GD2 CAR-T and ONC201 first-line trials.
- Am I a candidate for Dordaviprone, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Paediatric low-grade glioma
- For my situation (paediatric low-grade glioma), which of the standard options do you recommend and why?Guideline options include: Resection where safe; chemotherapy (carboplatin/vincristine) or tovorafenib / dabrafenib-trametinib for BRAF-altered relapsed disease; avoid radiation in young children.
- Am I a candidate for Tovorafenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Armoured, logic-gated & next-gen CARs, Boron neutron capture therapy, Hyperthermia, LAM561?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Blood-brain barrier”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Immunologically cold, heterogeneous, infiltrative”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- A Prospective Pivotal Study to Evaluate the Efficacy and Safety of Avastin® Bevacizumab (BEV) With or Without Microbubble-mediated Focused Ultrasound (FUS-MB) Using NaviFUS System in Recurrent Glioblastoma Multiforme PatientsPhase 3 · recruiting · NCT06496971A Prospective, Randomized, Standard of Care Controlled, Parallel, Open-Label, Multicenter Pivotal Study to Evaluate the Efficacy and Safety of Avastin® in Combination With NaviFUS System Compared With Avastin® Alone for the Treatment of Recurrent Glioblastoma Multiforme (rGBM)
- Beginning Radiation Immediately With GammaTile at GBM Excision Versus Standard of CarePhase 3 · recruiting · NCT07195591Randomized Study of Resection and GammaTile® Followed by Concurrent External Beam Radiation Therapy (EBRT) and Temozolomide (TMZ) and Adjuvant TMZ Versus Standard of Care in Newly Diagnosed Glioblastoma (GBM)
- DAY101 vs. Standard of Care Chemotherapy in Pediatric Participants With Low-Grade Glioma Requiring First-Line Systemic Therapy (LOGGIC/FIREFLY-2)Phase 3 · active · NCT05566795LOGGIC/FIREFLY-2: A Phase 3, Randomized, International Multicenter Trial of DAY101 Monotherapy Versus Standard of Care Chemotherapy in Patients With Pediatric Low-Grade Glioma Harboring an Activating RAF Alteration Requiring First-Line Systemic Therapy
- EF-41/KEYNOTE D58: Phase 3 Study of Optune Concomitant With Temozolomide Plus Pembrolizumab in Newly Diagnosed GlioblastomaPhase 3 · recruiting · NCT06556563A Phase 3, Randomized, Double-Blind, Placebo-Controlled Study of Optune® (TTFields, 200 kHz) Concomitant With Maintenance Temozolomide and Pembrolizumab Versus Optune® Concomitant With Maintenance Temozolomide and Placebo for the Treatment of Newly Diagnosed Glioblastoma (EF-41/KEYNOTE D58).
- SIGMA (Safusidenib in IDH1 Mutant Glioma Maintenance)Phase 3 · recruiting · NCT05303519A Phase 3, Multicenter, Clinical Study to Evaluate the Efficacy and Safety of Safusidenib Erbumine in Participants With Isocitrate Dehydrogenase 1 (IDH1)-Mutant Glioma
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Glioma & glioblastoma: the full pageGliomas are now diagnosed by molecular class, and three classes got their first targeted drugs in 2024-25 (vorasidenib for IDH-mutant glioma, tovorafenib for BRAF-altered paediatric glioma, dordaviprone for H3 K27M). Glioblastoma itself is the hardest to treat and has kept the same standard since 2005; CAR-T delivered into the brain and focused-ultrasound drug delivery are the live directions.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment journey: Newly diagnosedSurgery within days, six weeks of daily radiotherapy with temozolomide tablets, a month off, then six monthly cycles of temozolomide (with the option of a scalp device), and an MRI every two to three months.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- EGFRvIII: EGFRvIII is a mutant, tumour-only version of the EGFR receptor found in about a third of glioblastomas.
- Necrosis: Messy, uncontrolled cell death, where the cell bursts and spills its contents.
- Extent of resection (RANO resect classes): How much of a brain tumour the surgeon removes, measured on an MRI scan soon after the operation.
- Accelerated approval: FDA approval based on early evidence (like tumour shrinkage) on condition that a confirmatory trial follows.
- Hot vs cold tumours: 'Hot' tumours are full of immune cells and respond to immunotherapy; 'cold' tumours have kept the immune system out.
- Metabolic theory of cancer: from Warburg to oncometabolites: Otto Warburg noticed a century ago that cancer cells ferment glucose even when oxygen is plentiful and concluded that damaged respiration causes cancer.
- Bioelectric theory of cancer (Levin): Cells hold a voltage across their membranes, and tissues share these voltages as patterns that guide growth and regeneration.
- MGMT promoter methylation: A chemical switch that turns off a DNA-repair gene.
- H3 K27M (diffuse midline glioma): A single change in a histone protein that defines diffuse midline glioma, the childhood brain tumour with the fewest treatment options, and now the target of the first approved drug for it.
- Cancer stem cell theory and phenotypic plasticity: The idea that a tumour is organised like a tissue, with a small pool of stem-like cells that renew it and a bulk that cannot, so killing the bulk shrinks the tumour but the stem-like cells regrow it.
Every term links to the glossary.