title: Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas.
abstract: BACKGROUND
  There are no controlled studies on surgical treatment of diffuse low-grade gliomas (LGGs), and management is controversial.
  
  
  OBJECTIVE
  To examine survival in population-based parallel cohorts of LGGs from 2 Norwegian university hospitals with different surgical treatment strategies.
  
  
  METHODS
  Both neurosurgical departments are exclusive providers in adjacent geographical regions with regional referral practices. In hospital A diagnostic biopsies followed by a "wait and scan" approach has been favored (biopsy and watchful waiting), while early resections have been advocated in hospital B (early resection). Thus, the treatment strategy in individual patients has been highly dependent on the patient's residential address. Histopathology specimens from all adult patients diagnosed with LGG from 1998 through 2009 underwent a blinded histopathological review to ensure uniform classification and inclusion. Follow-up ended April 11, 2011. There were 153 patients (66 from the center favoring biopsy and watchful waiting and 87 from the center favoring early resection) with diffuse LGGs included.
  
  
  METHODS
  The prespecified primary end point was overall survival based on regional comparisons without adjusting for administered treatment. Results Initial biopsy alone was carried out in 47 (71%) patients served by the center favoring biopsy and watchful waiting and in 12 (14%) patients served by the center favoring early resection (P < .001). Median follow-up was 7.0 years (interquartile range, 4.5-10.9) at the center favoring biopsy and watchful waiting and 7.1 years (interquartile range, 4.2-9.9) at the center favoring early resection (P=.95). The 2 groups were comparable with respect to baseline parameters. Overall survival was significantly better with early surgical resection (P=.01). Median survival was 5.9 years (95% CI, 4.5-7.3) with the approach favoring biopsy only while median survival was not reached with the approach favoring early resection. Estimated 5-year survival was 60% (95% CI, 48%-72%) and 74% (95% CI, 64%-84%) for biopsy and watchful waiting and early resection, respectively. In an adjusted multivariable analysis the relative hazard ratio was 1.8 (95% CI, 1.1-2.9, P=.03) when treated at the center favoring biopsy and watchful waiting.
  
  
  CONCLUSIONS
  For patients in Norway with LGG, treatment at a center that favored early surgical resection was associated with better overall survival than treatment at a center that favored biopsy and watchful waiting. This survival benefit remained after adjusting for validated prognostic factors.
authors.affiliation: DepartmentofNeurosurgery, St Olavs University Hospital,Trondheim, Norway. asgeir.s.jakola@ntnu.no
authors.forename: Asgeir S
authors.initials: AS
authors.lastname: Jakola
authors.forename: Kristin S
authors.initials: KS
authors.lastname: Myrmel
authors.forename: Roar
authors.initials: R
authors.lastname: Kloster
authors.forename: Sverre H
authors.initials: SH
authors.lastname: Torp
authors.forename: Sigurd
authors.initials: S
authors.lastname: Lindal
authors.forename: Geirmund
authors.initials: G
authors.lastname: Unsgård
authors.forename: Ole
authors.initials: O
authors.lastname: Solheim
mesh_terms: D000328:Adult; D001706:Biopsy; D001932:Brain Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005910:Glioma / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009664:Norway; D011379:Prognosis; D016019:Survival Analysis; D057832:Watchful Waiting