Glioblastoma at progression: therapy of a challenging problem addressed candidly with evidence-based techniques.

The development of evidence-based guidelines for multiple diseases is underway within organized neurosurgery with much of that effort being channeled through the Joint Guidelines Committee of the Congress of Neurological Surgeons and American Association of Neurological Surgeons. The set of documents that follow this introductory comment addresses progressive glioblastoma. It serves as a natural follow-up to the previously published guideline for newly diagnosed glioblastoma [1]. A major addition to these guidelines, not seen in the guidelines for newly diagnosed glioblastoma, is an entire section on targeted therapy, reflecting the real scientific and clinically useful advances coming to the forefront in this disease. The sections that follow are by no means presented as a definitive answer to this difficult circumstance in this already challenging disease. As has been the case in other guidelines, the goal is to provide a systematic description of the published data on hand to afford evaluation and treatment guidance and to set points of departure for future investigations. It has been noted that a portion of the purpose for development of guidelines for disease management is related to the need for governmental and industrial officials to have concrete data from which to act upon their mandated duties related to management of public health and business interests [2]. That may well be the case but such concerns are by no means the driving force here and at no point in the development of this set of recommendations, and I dare say this is the case for most evidence-based guidelines, was there discussion of regulatory needs or concerns in their construction. The methods for data screening, assessment and finally writing are designed to address patient management questions as they arise clinically with nonclinical drivers being of secondary or no concern. The proliferation of guidelines documents by various medical and nonmedical organizations has rightly raised concern over quality control and longevity of recommendation made even under the best circumstances [3]. Quantification of guideline quality has been provided by the Institute of Medicine (IOM) [4]. The IOM cites eight major items deemed important for a useful guideline document. Reames et al. [5] reviewed 593 sets of cancer-related guidelines published from January, 2005 through December, 2010 and found that none complied with all eight parameters and the average number of criteria met was 2.75/8. The IOM suggestions do not necessarily conform to the goals of all guideline development. However, a repeatedly valuable action they cite as important is the involvement of experts from multiple disciplines who deal with the same disease or clinical problem. Even though experts from different fields are often of the same mind in general on a given question, the unique approach and background experience frequently brings to light an understanding of the limits in our knowledge that might otherwise might not be appreciated by someone without that training. A successful effort to have input from multiple disciplines was made in the writing of each section of the current set of guidelines. The quality of these guidelines are substantially improved because of these multidisciplinary writing groups and the JGC is indebted to these writers for their selfless effort and provision of special expertise. A simple example illustrating this in the current context might be a neurosurgeon’s assumption that perfusion imaging data on a newly progressive glioblastoma is irrefutable fact when the imaging scientist knows that modulation of sequence parameters and scanning technique can substantially alter J. J. Olson (&) Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA e-mail: jolson@emory.edu