Japanese Journal of Clinical Oncology, 2022, 52(8)843–849

https://doi.org/10.1093/jjco/hyac060
Advance Access Publication Date: 23 April 2022
Original Article

Original Article

Current trend of radiotherapy for glioblastoma

in the elderly: a survey study by the brain tumor
Committee of the Korean Radiation Oncology

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Group (KROG 21–05)
1 ,2
Chan Woo Wee , Hong In Yoon3 , Sea-Won Lee4 , and Do Hoon Lim5 ,*
1
Department of Radiation Oncology, Seoul Metropolitan Government-Seoul National University Boramae Medical
Center, Seoul, Republic of Korea, 2 Department of Radiation Oncology, Seoul National University College of
Medicine, Seoul, Republic of Korea, 3 Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University
College of Medicine, Seoul, Republic of Korea, 4 Department of Radiation Oncology, Eunpyeong St. Mary’s Hospital,
College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea, and 5 Department of Radiation
Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
*For reprints and all correspondence: Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan
University School of Medicine, 81 Irwon-ro, Gangnam-gu, 06351 Seoul, Republic of Korea. E-mail: dh8lim@skku.edu
Received 23 January 2022; Editorial Decision 3 April 2022; Accepted 5 April 2022

Abstract
Background: To investigate the current variability in radiotherapy practice for elderly glioblastoma
patients.
Methods: A questionnaire comprising general information on elderly glioblastoma, treatment
selection, radiotherapy and 16 clinical case-scenario-based questions (based on age, perfor-
mance, extent of resection and MGMT promoter methylation) was sent to brain tumor radiation
oncologists.
Results: Twenty-one responses were recorded. Most (71.4%) stated that 70 years is an adequate
cut-off for ‘elderly’ individuals. The most preferred hypofractionated short-course radiotherapy
schedule was 40–45 Gy over 3 weeks (81.3%). The median margin for high-dose target volume
was 5 mm (range, 0–20 mm) from the T1-enhancement for short-course radiotherapy. The case-
scenario-based questions revealed a near-perfect consensus on 6-week standard radiotherapy
plus concurrent/adjuvant temozolomide as the most appropriate adjuvant treatment in good
performing patients aged 65–70 years, regardless of surgery and MGMT promoter methylation.
Notably, in 75-year-old patients with good performance, the most preferred treatment was 6-week
radiotherapy (81.0–90.5%) plus concurrent/adjuvant temozolomide (71.4–95.2%) rather than short-
course radiotherapy or radiotherapy alone. Although the use of 3-week short-course radiotherapy
increased with age and decreased performance status (all P < 0.05), 6-week radiotherapy was
adopted in a significant proportion of responders (14.3–23.8%) even for wheelchair-bound, 75-
year-old patients. Temozolomide use was affected by age, performance and MGMT promoter (all
P < 0.05).
Conclusions: A high level of consensus was observed in treating elderly glioblastoma patients with
good performance status. However, the variability increased, especially for older patients and those
with poor performance. This study serves as a basis for designing future clinical trials in elderly
glioblastoma.

© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 843
844 Survey of RT for glioblastoma in the elderly
Key words: glioblastoma, elderly, radiotherapy, temozolomide, survey
Introduction
Glioblastoma (GBM), the most common malignant brain tumor in
adults, is diagnosed at a median age of 65 years and <5% of patients
older than 65 years of age survive beyond 5 years (1,2). Although
survival further declines with increasing age, the incidence rate of
GBM peaks at ∼80 years of age (2,3).
Although an increased survival benefit for radiotherapy (RT)
compared with best supportive care was confirmed in elderly GBM
(e-GBM) patients (4), the optimal dose fractionation schedule for
RT remains controversial. In the setting of RT alone, investigators
from Canada and Europe reported that a 6-week course of 60 Gy
(standard conventional RT, SRT) showed no survival benefit com-
pared with an abbreviated 2–3-week course of 34 Gy or 40 Gy
(hypofractionated short-course RT, HRT) in e-GBM patients older
than 60–65 years (5–7). Furthermore, Roa et al. demonstrated com-
parable efficacy between HRT of 40 Gy and an even more abbre-
viated 1-week course of 25 Gy in five fractions for frail or elderly
patients (8).
In patients aged under 70 years, Stupp et al. have proved a
survival benefit of 2–3-month by combining concurrent and adjuvant
temozolomide (TMZ) to SRT. Similarly, Perry et al. showed a modest
but significant survival benefit with concurrent and adjuvant TMZ
combined with HRT of 40 Gy in e-GBM patients (10). In this study,
only patients who were not deemed suitable to receive 60 Gy SRT
by their radiation oncologist were eligible. Therefore, the optimal
RT schedule for TMZ-based chemoradiation remains unclear for
e-GBM. Several retrospective studies have hypothesized a potential
survival benefit of SRT over HRT when combined with TMZ in e-
GBM (11–13), warranting evaluation via prospective studies. Wee
et al. showed that in e-GBM patients treated with TMZ-based
chemoradiation, SRT was more frequently used than HRT, although
selection bias was presumed (13).
Through the present survey study by the Korean Radiation
Oncology Group (KROG), we therefore sought to gain insight into
the current real-world trend of RT for e-GBM patients among brain
tumor expert radiation oncologists. Data derived from this study are
expected to serve as a rationale for the urgent need for prospective
trials evaluating SRT versus HRT combined with TMZ.
Materials and methods
Data acquisition and questionnaire
This study was performed under the approval by the Institutional
Review Board of the SMG-SNU Boramae Medical Center (IRB No.
10–2022-1). The current study was approved by the KROG and was
initiated in March 2021. At that time, 51 radiation oncologists were
registered with the Brain Tumor Committee of the KROG. The ques-
tionnaire was sent to physicians via email and returned to C.W.W.
In brief, the survey questionnaire focused on the following issues in
e-GBM: (i) the optimal age and assessment for defining ‘elderly’; (ii)
factors considered in deciding the RT schedule and TMZ use; (iii)
RT technique, dose fractionation and target volume delineation for
SRT and HRT; (iv) preferred adjuvant treatment options and/or RT
schedule in 16 clinical case scenarios based on age (68 vs. 75 years
old), performance status (Karnofsky performance score, 90 vs. 60),
extent of resection (gross total resection vs. partial resection) and
methylation status of the O6 -methylguanine–DNA methyltransferase
gene promoter (MGMTp) (methylated vs. unmethylated). An English
version of the survey questionnaire is shown in Supplementary 1.
Statistical analysis
Statistical analyses were performed using the Statistical Package for
the Social Sciences software (version 26.0; IBM Inc., Armonk, NY).
A Chi-squared test was performed to compare responses between the
groups. A logistic regression model was used to evaluate the impact
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of age, performance status, extent or resection and methylation
profile of MGMTp in guiding the use of TMZ and SRT. Statistical
significance was set at P < 0.05.
Results
Responders
A total of 21 board-certified radiation oncologists (41.2%) who are
brain tumor specialists from 19 institutions (17 university affiliated
hospitals; 2 private general hospitals) responded to the survey. Of
the 21 responders, 9 (42.9%), 8 (38.1%) and 4 (19.0%) physicians
had been treating brain tumor patients for <5 years, 5–10 years
and > 10 years, respectively. The returned questionnaires were
meticulously reviewed by C.W.W. and D.H.L. In cases of missing or
ambiguous answers, the questionnaires were sent back to responders
for clarification. Complete information was finally obtained for
all returned questionnaires. Five (23.8%), eight (38.1%) and eight
(38.1%) radiation oncologists treated >10, 5–10 and < 5 e-GBM
patients aged 65 years or older per year, respectively.
Selection of adjuvant treatment in the elderly
The age of 70 years or older was suggested as the most appropriate
cut-off to define ‘elderly’ in GBM (71.4%, 15/21), followed by
75 (14.3%, 3/21), 65 (9.5%, 2/21) and 60 (4.8%, 1/21) years.
Unfortunately, only one radiation oncologist responded that geriatric
assessment had been applied to guide the treatment of e-GBM. For
GBM patients considered as elderly by the physician, 66.7% (14/21)
responded that patient- or disease-related variables influenced the
selection of RT dose fractionation (SRT vs. HRT) and the decision to
combine the use of TMZ with RT. The most frequently considered
factor for scheduling RT was performance status, followed by life
expectancy of the patient. For combining the use of TMZ, perfor-
mance status and methylation status of MGMTp were considered
equally important. Five (23.8%) responders always used an SRT
schedule of 60 Gy for 6 weeks for e-GBM. Only one (4.8%) radiation
oncologist did not consider combining TMZ with RT as a treatment
option for e-GBM.
RT technique and dose fractionation
The most frequently adopted RT technique for e-GBM was volumet-
ric modulated arc therapy (VMAT) (57.1%, 12/21) followed by non-
VMAT intensity-modulated RT (38.1%, 8/21). No responder used
three-dimensional conformal RT in e-GBM. For the 16 radiation
oncologists who considered HRT as an option in e-GBM, 40 Gy in 15

Figure 1. Preferred dose fractionation regimens for hypofractionated short-
course radiotherapy in elderly glioblastoma patients.
fractions (50.0%, 8/16) was the most frequently used regimen, fol-
lowed by 45 Gy in 15 fractions (31.3%, 5/16) (Fig. 1). RT schedules
shorter than 3 weeks were not used.
RT target volume
For SRT, nearly all responders (95.2%, 20/21) adopted a cone-
down technique. The total dose was 60 Gy in 30 fractions for most
responders (90.5%, 19/21). For the low-dose (large field) target, the
median prescribed dose was 50 Gy in 25 fractions (range, 44–54 Gy
in 22–30 fractions). To delineate the clinical target volume (CTV)
of the low-dose field, a median 15-mm (range, 5–20 mm) margin
expansion was determined from the combined gross tumor volume
(GTV) from the high signal intensity on T2-weighted magnetic res-
onance images (T2HSI) and abnormal enhancement on T1-weighed
contrast-enhanced images (T1CE) by 55.0% (11/20) of responders.
In 45.0% (9/20) of responders, a median margin of 15 mm (range,
10–20 mm) was determined using only the T1CE to create the low-
dose CTV. However, although an additional margin was not used,
77.8% (7/9) of responders additionally included the T2HSI in the
low-dose CTV. For the high-dose CTV, 90.5% (19/21) of responders
used a median 5–10-mm (range, 5–20 mm) margin expansion from
the T1CE-based GTV.
For HRT, 62.5% (10/16) of responders used a cone-down tech-
nique. For those using a cone-down technique, the median prescribed
dose to the low-dose target was 37.5–40 Gy in 15 fractions (range,
30–48 Gy in 10–20 fractions; 90% used the simultaneous integrated
boost technique). Most (60%, 6/10) used a margin expansion from
the combined GTV from T1CE plus T2HSI to delineate the low-dose
CTV (median margin, 10–15 mm; range, 5–20 mm). In three out of
four cases (75.0%) using GTV from T1CE alone, T2HSI was added
for determining the low-dose CTV without margins. For the high-
dose CTV, the median prescribed dose was 45 Gy in 15 fractions
(range, 40–56 Gy in 15–20 fractions). A margin expansion (median,
5 mm; range, 5–20 mm) was applied from the T1CE-based GTV
in 87.5% (14/16) of the responders to delineate the high-dose CTV.
Jpn J Clin Oncol, 2022, Vol. 52, No. 8 845
The most frequently adopted schemes for CTV delineation and dose
prescription are shown in Fig. 2.
Clinical case-scenarios
The most frequent responses and the proportions of different
responses for case-scenario-based questions are summarized in
Tables 1 and 2, respectively. There was a high level of consen-
sus (90–100%) that RT plus concurrent and adjuvant TMZ
(RT/TMZ → TMZ) with SRT of 60 Gy or higher is the appropriate
adjuvant treatment in 68-year-old patients with good performance
status, regardless of the extent of resection or methylation status of
MGMTp. Although the level of consensus decreased in patients of the
same age with poor performance status, RT/TMZ → TMZ with SRT
was the most preferred regimen irrespective of surgery and MGMTp
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status. Of note, in patients aged 75 years, RT/TMZ → TMZ
with SRT was still the most preferred regimen in patients with
good performance (Table 1). The rate of combining TMZ with
RT decreased depending on the methylation profile of MGMTp
from 90.5–95.2% to 71.4% in these patients. SRT of 60 Gy or
higher was preferred in these 75-year-old patients by >80% of
the responders. For patients aged 75 years with poor performance
status, RT alone was the most preferred adjuvant treatment in
patients with unmethylated MGMTp. However, 23.8–28.6% of
the radiation oncologists still preferred RT/TMZ → TMZ in these
patients. Moreover, although a 3-week HRT was the most preferred
RT scheduled in wheelchair-bound patients aged 75 years, 14.3–
23.8% of responders used SRT of 60 Gy or higher over 5–6 weeks
(Table 1, Supplementary 2).
Utilization of SRT with doses of 60 Gy or higher over 5–6 weeks
significantly decreased with increased age (85.7–52.4%) and poor
performance status (92.3–45.8%) (all P < 0.001). However, surgical
extent (gross total resection, 71.4% vs. partial resection, 66.7%;
P = 0.345) and methylation status of MGMTp (methylated, 70.2%
vs. unmethylated, 67.9%; P = 0.637) did not affect physicians’ choice
of RT schedule. The use of TMZ also significantly decreased with
older age (93.5–75.6%), worse performance status (94.0–75.0%)
and unmethylated MGMTp (97.6–71.4%) (all P < 0.001). However,
the extent of resection did not affect the use of TMZ (gross total
resection, 85.7% vs. partial resection, 83.3%; P = 0.546). In the
multivariate logistic regression model, younger age and good perfor-
mance score also significantly guided radiation oncologists to choose
SRT over HRT or no RT (all P < 0.001). Age, performance status and
MGMTp methylation status significantly affected the use of TMZ
(all P < 0.001) (Table 2). The Hosmer–Lemeshow test showed that
both models fit well (P = 0.820 for SRT; P = 0.711 for TMZ).
Discussion
This survey study among brain tumor expert radiation oncologists
has elicited valuable information regarding the current trend of RT
for e-GBM, including the age that defines the ‘elderly’, manner of
choosing adjuvant treatment, RT dose prescription and target vol-
ume delineation, and mostly importantly, actual real-world practices
based on specific clinical scenarios. Most of the members (71.4%)
of the Brain Tumor Committee of the KROG believe that 70 years
of age is the most appropriate cut-off for defining ‘elderly’ in future
clinical trials, which is in line with the current clinical guidelines of
the National Comprehensive Cancer Network, Society for Neuro-
Oncology, European Association of Neuro-Oncology and Korean
846 Survey of RT for glioblastoma in the elderly
Figure 2. Scheme of radiotherapy dose and clinical target volume delineation frequently adopted by responders in the survey for (a) standard conventional
radiotherapy and (b) hypofractionated short-course radiotherapy. T1CE, abnormal contrast enhancement on T1-weighted magnetic resonance imaging; T2HSI,
T2 high signal intensity; CTV, clinical target volume.
Society for Neuro-Oncology (2,14–16). However, 14.3% of respon-
ders considered 75 years of age to be the most adequate cut-off. This
might reflect the current health status in Korea where life expectancy
at birth and 60 years are 83.3 years and 25.8 years, respectively,
which is ∼10 years higher than the global average (17). In contrast,
recent landmark prospective Phase 3 clinical trials in e-GBM used a
cut-off of 60–65 years (5–8,10).
There are several major challenges in treating e-GBM, such as the
frailty of patients and their aged brains, underlying comorbidities and
difficulty in assessing treatment tolerability. The American Society
of Clinical Oncology recommends performing a geriatric assessment
and tailoring treatment based on the results for cancer patients older
than 65 years (18), and several studies have reported reduced toxicity
with acceptable outcomes using geriatric assessment-based individu-
alized strategies (19,20). Indeed, Cloney et al. using the Canadian
Study of Health and Aging Modified Frailty Index, demonstrated
that frailer GBM patients show significantly less resection, longer
hospitalization, increased complication risks and decreased survival
(21). Moreover, Deluche et al. reported that scores of the G-8 geriatric
screening tool were significantly correlated with overall survival,
particularly in e-GBM (22). Unfortunately, nearly all responders in
our survey did not apply any kind of geriatric assessment. Although
the clinic may be crowded and busy, simple assessment using tools
such as the G-8 would take ∼5 min or less, and therefore should be
considered for e-GBM patients to assess treatment tolerability with
RT or TMZ.
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The high-dose CTV in SRT tended to be smaller among Korean
radiation oncologists with a margin of 5–10-mm from the surgical
cavity plus T1CE (Fig. 2a) compared with the 20–25-mm margin
around T1CE specified by the European Organisation for Research
and Treatment of Cancer or Radiation Therapy Oncology Group
protocols (9,23). The American Brain Tumor Consortium recom-
mends a smaller margin, similar to the findings of our study. For SRT
and HRT, 95.2% and 62.5% of responders used a 2-field cone-down
technique, respectively. The high usage rate of cone-down techniques
was interesting since major prospective Phase 3 trials incorporating
HRT as a study arm did not (5,8,10). The margin of 5–10 mm to the
high-dose CTV from GTV was also smaller than that of 15 mm used
in the landmark study comparing HRT plus concurrent and adjuvant
to HRT alone by Perry et al. (10) (Fig. 2b).
There was a near-perfect level of consensus for RT/TMZ → TMZ
as the most appropriate adjuvant treatment for 68-year-old patients
with good performance status, regardless of MGMTp methylation
status and extent of resection. All responders agreed to use SRT of
≥60 Gy over 5–6 weeks in these patients (Table 1). This was probably
due to the inclusion of 68-year-old patients in the landmark trial
demonstrating survival benefit of RT/TMZ → TMZ over RT alone
of 60 Gy of 6 weeks by Stupp et al. (9), and the fact most radiation
oncologists consider patients older than 70 years as ‘elderly’, as
shown in our study. The level of consensus decreased with increas-
ing age and decreasing performance status. Age and performance
significantly affected the RT schedule (SRT vs. HRT), whereas the
 Jpn J Clin Oncol, 2022, Vol. 52, No. 8 847

GTR, gross total resection; PR, partial resection; MGMTp, O6-methylguanine–DNA methyltransferase promoter; KPS, Karnofsky performance score; ECOG, Eastern Cooperative Oncology Group performance score;
use of TMZ was affected by age, performance status and MGMTp

(100.0%)
methylation status.

(90.5%)

(71.4%)

(81.0%)

(66.7%)

(66.7%)

(61.9%)

(76.2%)
Several interesting results should be noted. For 75-year-old
patients with good performance status, most responders would have
MGMTp: unmethylated

treated patients with a prolonged schedule of SRT despite the fact

that there is no high-level evidence demonstrating the superiority
RT/TMZ → TMZ

RT/TMZ → TMZ

RT/TMZ → TMZ
of the regimen over HRT of 2–3 weeks (5,6). The Canadian and
Nordic trials reported an increased demand for post-RT steroids
Surgery: PR

or a possible deteriorative effect on survival in patients older than

RT alone
70 years with SRT compared with HRT (5,6). The American Society

HRT
SRT

SRT

SRT
for Radiation Oncology also states that there is no evidence that
SRT is more efficacious than HRT (24). Nevertheless, the results
from our survey suggest that many radiation oncologists in the real
world believe in the potential benefit of SRT over HRT in certain
(100.0%)

(100.0%)

(95.2%)

(81.0%)

(81.0%)

(61.9%)

(52.4%)

(66.6%)
e-GBM patients older than 70 years, which warrants a prospective

a Standard conventional radiotherapy (≥60 Gy in 5–6 weeks; median 60 Gy). b Hypofractionated short-course radiotherapy (40–56 Gy in 3–4 weeks; median 40 Gy).

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evaluation, especially in the context of RT/TMZ → TMZ. Nearly
half a century ago, Walker et al. from the Brain Tumor Study Group
showed an RT dose–effect relationship up to 60 Gy in high-grade
MGMTp: methylated

RT/TMZ → TMZ

RT/TMZ → TMZ

RT/TMZ → TMZ

RT/TMZ → TMZ

gliomas (25). Furthermore, although the selected patients were

assumed to be highly fit, Wee et al. reported a significant survival
Surgery: PR

benefit with SRT of 60 Gy compared with HRT of 45 Gy in the

context of RT/TMZ → TMZ, including 260 and 134 patients
HRT

older than 65 years and 70 years, respectively (13). The survival

SRT

SRT

SRT
Table 1. Most frequently answered adjuvant treatment and radiotherapy dose-fractionation schedule per case-scenario

benefit of SRT was valid throughout all subgroups depending on

performance status, extent of resection and MGMTp methylation
status. However, no prospective trial has compared SRT to HRT
(100.0%)

in the setting of RT/TMZ → TMZ to date. In e-GBM patients

(90.5%)

(71.4%)

(85.7%)

(71.4%)

(76.2%)

(52.4%)

(76.2%)

with frail brain tissues, a strategy to balance the increased burden

of toxicity with disease control using an RT schedule of higher
MGMTp: unmethylated

biologically effective dose needs investigation. Of note, few (12.5%,

2/16) radiation oncologists adopted 56 Gy in 20 fractions as part of
RT/TMZ → TMZ

RT/TMZ → TMZ

RT/TMZ → TMZ

their HRT regimen for e-GBM, which is a dose-escalated regimen

Surgery: GTR

in terms of biologically effective dose to the normal brain compared

with 40 Gy in 15 fractions. This might reflect the fact that some
RT alone

RT/TMZ → TMZ, radiotherapy plus concurrent and adjuvant temozolomide; RT, radiotherapy.

physicians believe the dose of 40 Gy in 15 fractions is suboptimal

HRT
SRT

SRT

SRT

even in e-GBM who are not candidates of SRT.

The use of TMZ alone as an adjuvant strategy was extremely
limited in our study, even in patients with methylated MGMTp
(Supplementary 2). Malmström et al. and Wick et al. firmly estab-
(100.0%)
(95.2%)

(90.5%)

(90.5%)

(81.0%)

(81.0%)

(57.1%)

(66.6%)

lished TMZ alone as a viable option, especially for e-GBM patients

with methylated MGMTp (6,7). This is probably because of the cur-
rent Korean insurance system in which TMZ alone is not approved
MGMTp: methylated

as a first-line adjuvant treatment for GBM. TMZ can only be used

RT/TMZ → TMZ

RT/TMZ → TMZ

RT/TMZ → TMZ

RT/TMZ → TMZ

when combined with RT as a first-line treatment and in recurrent

Surgery: GTR

high-grade gliomas. Last, for wheelchair-bound (ECOG 3), 75-year-

old e-GBM patients with methylated MGMTp, the most preferred
adjuvant treatment was RT/TMZ → TMZ, although these patients
HRTb
SRTa

SRT

SRT

would not have been eligible for the trial by Perry et al. (10). SRT
would still have been used by 14.3–23.8% of the responders for
75-year-olds with poor performance status, reflecting the variability
Adjuvant therapy

Adjuvant therapy

Adjuvant therapy

Adjuvant therapy

in real-world clinical practice. Of note, although the EF-14 trial

proved a survival benefit of tumor-treating fields in combination with
Treatment

adjuvant TMZ in newly diagnosed GBM, we did not include it as an

option for adjuvant treatment in this survey due to the unavailability
RT

RT

RT

RT

in Korea (16,26).
In summary, this study demonstrated the large variability in
current clinical practice for e-GBM, especially for older patients and
those with poor performance status. For patients of older age and
ECOG: 1

ECOG: 1

ECOG: 3

ECOG: 3

good performance status, a prolonged RT schedule was preferred

KPS: 90

KPS: 90

KPS: 60

KPS: 60
Age: 68

Age: 75

Age: 68

Age: 75

despite the lack of high-level evidence. For patients of older age and
poor performance status, SRT of 6 weeks was still adopted in a
848 Survey of RT for glioblastoma in the elderly

Table 2. Multivariate logistic regression model of variables affecting the use of standard conventional radiotherapy and temozolomide

Variables Exp(B) (95% confidence interval) P

Standard conventional radiotherapya

Age (68 vs. 75 years) 11.824 (5.948–23.505) <0.001
Performance (KPS 90 vs. 60) 27.081 (12.650–57.977) <0.001
Extent of resection (GTR vs. PR) 1.485 (0.799–2.761) 0.211
MGMTp (methylated vs. unmethylated) 1.218 (0.657–2.259) 0.530
Constant 0.170 <0.001
Temozolomide
Age (68 vs. 75 years) 8.065 (3.477–18.709) <0.001
Performance (KPS 90 vs. 60) 9.246 (3.923–21.791) <0.001
Extent of resection (GTR vs. PR) 1.335 (0.632–2.818) 0.449
MGMTp (methylated vs. unmethylated) 28.141 (9.082–87.196) <0.001
Constant 0.381 0.009

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KPS, Karnofsky performance status; GTR, gross total resection; PR, partial resection; MGMTp, O6-methylguanine–DNA methyltransferase promoter. a ≥60 Gy
in 5–6 weeks.

significant proportion of patients with e-GBM. There is an urgent
need for a well-designed randomized prospective trial comparing RT
schedules in combination with TMZ. The results of this study will
serve as a rationale for designing future clinical trials in e-GBM.
Supplementary material
Supplementary material is available at Japanese Journal of Clinical
Oncology online.
Authors’ contributions
Conceived and designed the study: C.W.W., D.H.L.; Development
of questionnaire: C.W.W., D.H.L.; Data collection: C.W.W.; Data
interpretation and analysis: C.W.W., H.I.Y., S.W.L., D.H.L.; Wrote
the original manuscript: C.W.W; Reviewed the manuscript: C.W.W.,
H.I.Y., S.W.L., D.H.L.; Approved the final version of the manuscript:
C.W.W., D.H.L.
Acknowledgements
We thank Nalee Kim, Sang-Won Kim, Sup Kim, Sunghyun Kim, Young Suk
Kim, Jin Hee Kim, Hyun Ju Kim, Hyeli Park, Chang-Ok Suh, Jin Ho Song, Kang
Kyoo Lee, Sunyoung Lee, Yun Hee Lee, Joo Ho Lee, Jihae Lee, Jung Ho Im,
and Bum-Sup Jang from the Brain Tumor Committee of the Korean Radiation
Oncology Group for responding to the survey.
Funding
No funding was received for conducting this study.
Conflicts of interest statement
Do Hoon Lim is currently the Chair of the Brain Tumor Committee
of the Korean Radiation Oncology Group.
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