Pioneering NHS trial targets brain tumours before surgery

The NHS has begun a world-first clinical trial of a pioneering treatment technique aimed at extending the lives of people with brain tumours.

A team of radiologists, neurosurgeons, oncologists, nurses, physicists and pathologists are using detailed MRI scans and highly targeted radiotherapy before surgery with the aim of reducing the likelihood of tumours growing back quickly, thereby helping patients live longer.

Currently, brain tumour patients around the world have surgery first, then radiotherapy, then chemotherapy. Even with such an intensive treatment course, fewer than 10% of those with glioblastomas, a fast-growing and aggressive brain cancer on which the trial focused, live for more than five years, according to experts.

Brain tumours are notoriously difficult to treat. Treatment options have not improved significantly in decades. And despite extensive research and hundreds of trials, the standard treatment sequence of surgery first, followed by radiotherapy and chemotherapy, has never been challenged.

Now the team behind the trial, at the Christie NHS foundation trust in Manchester, are planning to overturn the standard medical practice in the hope of improving outcomes for brain tumour patients.

“This study is an important and significant milestone in brain cancer research, and the culmination of 10 years’ work for me,” said Dr Gerben Borst, a radiation oncologist at the Christie and a senior lecturer at the University of Manchester, who is leading the team of specialists running the trial.

“The order of radiotherapy and surgery should be challenged, and this could be the breakthrough we have been working towards for decades.”

The trial – codenamed POBIG (PreOperative Brain Irradiation in Glioblastoma) – is at an early stage. However, Borst said the results so far had been “very encouraging”.

While surgery will always be “essential” for patients with brain tumours, Borst explained, some tiny cancer cells are always left behind after an operation. That is because of the sensitive nature of operating in such a delicate area of the body.

“Remnant tumour cells remain growing, potentially even more aggressively post-surgery in the recovery period, before the patient is given the standard course of radiotherapy,” said Borst. “Therefore, better strategies are desperately needed to target all tumour cells at an earlier stage.

“As a tumour is likely to respond better to radiotherapy before the operation, we hope, by giving highly targeted radiotherapy before surgery, to stop the tumour from growing back so quickly to improve outcomes and extend lives.”

Patients in the trial have an MRI scan to help the surgeons best estimate where remnant cells are most likely to be left after they operate. A single dose of radiation is aimed precisely at that area. Patients then have surgery followed by radiotherapy and chemotherapy, as is standard practice.

“For patients who are not in a medical emergency and need to undergo immediate surgery, we know that the outcomes are not affected as long as surgery is done within a couple of weeks,” said Borst. “This allows us to apply a treatment that targets all the tumour cells that are inevitably left behind after the surgery at an earlier stage.”

“Crucially, we don’t irradiate the whole tumour, only the part where the neurosurgeon believes the remnants will be left behind.”

Joel Rush is one of the first patients to join the trial. “The doctors explained the reasons for using radiotherapy before surgery – made absolute sense – so I was very happy to participate in the trial,” said Rush, a director of a digital marketing agency he co-founded with his wife, Tracey.

The 45-year-old, a father of two from Denton, Greater Manchester, was diagnosed with a glioblastoma – a grade 4 brain tumour – after experiencing severe headaches and pain last October.

“I love learning, so if I can help others like Dr Borst and his team gain knowledge which can help others like me, that can only be a good thing,” Rush added. “It’s still early days but I hope this early intervention will benefit me in the long term.”

Borst said: “We are very pleased with how Joel has responded to this treatment and the result so far is very encouraging. We are hopeful this technique could improve outcomes for all patients like Joel in the future.”

Graham Norton, the interim chief executive officer of The Brain Tumour Charity, which helped design the trial with another charity, Brainstrust, said: “New treatment options for those diagnosed with a brain tumour are essential and this innovative study has the potential to offer more options for those with a newly diagnosed glioblastoma.

“Treatments for glioblastoma have not improved significantly in the last 15 years and it is therefore vital that we keep looking for kinder treatments that would help those with this devastating diagnosis live longer, better lives.

“We look forward to further updates from this trial as advances in treatments could change the lives of people newly diagnosed with a glioblastoma. Brain tumours are unforgiving and, with 33 people diagnosed every day, they wreak havoc on people’s lives all too often.”

Experts seeking to improve outcomes for other cancers are trying similar strategies. Research reported by the Guardian earlier this month found that giving bowel cancer patients chemotherapy before surgery cut the risk of it coming back by 28%.

Borst would like to inspire others to challenge the status quo. “I really hope that our study motivates and encourages others to join our efforts in seeking more effective and personalised treatment strategies to be applied before surgery.”

• This article was amended on 2 February 2023 to clarify that the figure of fewer than 10% of brain cancer patients living for more than five years applied specifically to those with glioblastoma, on which the trial focused.