As a service to our community, BTSS medical advisors have compiled a summary of Treatments for Gliomas which list treatments that are clinically available in Singapore, including clinical trials and helpful treatments that are available overseas. The efficacy, as well as the potential adverse side effects of these treatments, are also highlighted.
This Glioma Treatment Guide will be updated once in 6 months to provide current information to guide our BTSS members who are researching and deciding on alternative treatment options.
As the information provided herein is not intended as medical advice for your specific medical conditions, BTSS and our medical advisors shall not be responsible or be liable for any matter arising from your pursuit of the treatments mentioned. You should always consult a suitably qualified doctor to decide and pursue the best course of treatment for your unique condition.
NeuroOncology treatments for Glioma that are available in Singapore
| No. | Name of treatment | Line of treatment/Efficacy | Some known adverse effects | Applicable patient programme |
| 1 | Temozolomide | Standard first-line treatment/ may also be used in the recurrent setting. Survival benefit in the first-line setting when added to radiotherapy | Fatigue, hair loss, nausea, vomiting, constipation, suppression of immunity, low platelet, liver toxicity, loss of fertility | MAF plus, Singapore Cancer Society (please approach your doctor for more information) |
| 2 | Procarbazine, Lomustine, Vincristine | First-line treatment of oligodendrogliomas, Treatment in the recurrent setting | Fatigue, hair loss, nausea, vomiting, suppression of immunity, low platelet, liver toxicity, lung toxicity, loss of fertility, numbness | |
| 3 | Lomustine | Treatment in the recurrent setting | Fatigue, nausea, vomiting, suppression of immunity, low platelet, liver toxicity, lung toxicity, loss of fertility | |
| 4 | Bevacizumab (Avastin) | Mainly used in the recurrence setting, in the first-line setting under special circumstances | Hypertension, protein in the urine, blood clots, bleeding, wound healing issues | Roche ARISE program, Singapore Cancer Society (please approach your doctor for more information) |
| 5 | Tumor Treating Fields (TTF, Optune) | First-line treatment. May also be used in the recurrent setting. | Scalp irritation, headaches. | |
| 6 | Platinum-based regimens (Carboplatin) | Treatment in the recurrent setting | Fatigue, nausea, vomiting, suppression of immunity, low platelet count, renal toxicity, loss of fertility. | |
| 7 | Etoposide | Treatment in the recurrent setting | Fatigue, alopecia. nausea, vomiting, suppression of immunity, low platelet count. | |
| 8 | Larotrectinib | Presence of NTRK gene fusion tumours in recurrent setting | Fatigue, nausea, vomiting, anemia, suppression of immunity, liver toxicity. | |
| 9 | Dabrafenib/Cobimetinib | Presence of BRAF V600E activation mutation in recurrent setting | Hair loss, skin conditions, headache, constipation, joint aches, anemia, bleeding. | |
| 10 | Vemurafenib/Cobimetinib | Presence of BRAF V600E activation mutation in recurrent setting | ||
Clinical trials available in Singapore
| No. | Name of treatment | Rational of trial | Target population | Study site(s) |
| 1 | Pilot study for the optimisation of systemic therapy in recurrent glioblastoma multiforme | Testing patient-derived organoids against a panel of therapies used to treat recurrent GBM, in order to determine the combination which would be most efficacious for the individual patient at the point of relapse | GBM patients – patient-derived organoid is harvested at the time of first surgery or biopsy | NUH |
| 2 | Phase 1A Study of efficacy and safety of Ribociclib (LEE011) in combination with Topotecan and Tempzolomide (TOTEM) | To find the highest dose of test drug ribocicib (LEE011) that can be given safely to children with certain childhood cancers which have returned or worsened and cannot be cured by other standard treatment | Pediatric patients with relapsed or refractory neuroblastoma and other solid tumours | NUH, KKH |
Treatments for gliomas that may be helpful but not available in Singapore
| No. | Name of treatment | Efficacy | Some known adverse effects | Study site(s) |
| 1 | ONC201 | H3 K27M-mutant recurrent gliomas | Favourable toxicity profile | Please consult your oncologist for potential availability and clinical trials overseas |
Novel treatment and summary evaluation (Trials that are available outside Singapore, efficacy pending confirmation)
| No. | Name of treatment | Rational of trial | Target population |
| 1 | VAL083 | Oral chemotherapy which can overcome resistance associated with MGMT | MGMT unmethylated GBM patients |
| 2 | Immunotherapy, mainly vaccine therapies | – PVSRIPO (intratumoral delivery of recombinant poliovirus) – CMV-targeted vaccines – Personalised cancer vaccines | Mainly recurrent GBM populations |
RadioOncology treatments for Glioma that are available in Singapore
| No. | Different types of radiotherapy modality | Indications/ dose | Possible adverse effects | Applicable patient programme |
| 1 | Intensity modulated radiotherapy (IMRT) Allows shaping of the radiation dose around the target. This allows better coverage of the tumour target while reducing dose to the surrounding normal organs. IMRT can be delivered with or without daily image guidance (IGRT) depending on the level of precision required. | – High grade glioma (e.g. Glioblastoma, WHO grade 3 Astrocytomas ) : Standard dose RT (59.4 to 60Gy) with concurrent temozolomide, over ~6 weeks – Patients with high grade gliomas who are older in age or have lower functional status can be offered abbreviated RT 30 – 40Gy over ~ 2- 3 weeks, with or without concurrent temozolomide. – Low grade glioma : RT 50 – 54 Gy), over ~6 weeks, followed by chemotherapy (TMZ or PCV) | Short term : lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term : risk of radiation necrosis or pseudo-progression, possible cognitive changes, changes in vision/hearing (depending on location of tumour). Risk of radiation induced injury to the optic nerves or brainstem <5% Risk of secondary malignancies in patients who survive > 10 years. Estimated risk <1% every 10 years | MAF plus, Singapore Cancer Society (please approach your doctor for more information) |
| 2 | Volumetric modulated arc therapy (VMAT) A different form of IMRT. The main advantage is the delivery of radiation doses continuously, as the treatment gantry rotates around the patient. This usually results in a shorter time spent on the treatment couch. | – High grade glioma (e.g. Glioblastoma, WHO grade 3 Astrocytomas ) : Standard dose RT (59.4 to 60Gy) with concurrent temozolomide, over ~6 weeks – Patients with high grade gliomas who are older in age or have lower functional status can be offered abbreviated RT 30 – 40Gy over ~ 2- 3 weeks, with or without concurrent temozolomide. – Low grade glioma : RT 50 – 54 Gy), over ~6 weeks, followed by chemotherapy (TMZ or PCV) | Short term : lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term : risk of radiation necrosis or pseudo-progression, possible cognitive changes, changes in vision/hearing (depending on location of tumour). Risk of radiation induced injury to the optic nerves or brainstem <5% Risk of secondary malignancies in patients who survive > 10 years. Estimated risk <1% every 10 years | MAF plus, Singapore Cancer Society (please approach your doctor for more information) |
| 3 | Image Guided Radiotherapy (IGRT) Refers to the use of daily imaging to ensure that the tumour target is within the treatment volume. Most useful when anatomical changes are expected within the treatment volume or there are critical organs such as optic nerves in close proximity to the tumour target. | – High grade glioma (e.g. Glioblastoma, WHO grade 3 Astrocytomas ) : Standard dose RT (59.4 to 60Gy) with concurrent temozolomide, over ~6 weeks – Patients with high grade gliomas who are older in age or have lower functional status can be offered abbreviated RT 30 – 40Gy over ~ 2- 3 weeks, with or without concurrent temozolomide. – Low grade glioma : RT 50 – 54 Gy), over ~6 weeks, followed by chemotherapy (TMZ or PCV) | Short term : lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term : risk of radiation necrosis or pseudo-progression, possible cognitive changes, changes in vision/hearing (depending on location of tumour). Risk of radiation induced injury to the optic nerves or brainstem <5% Risk of secondary malignancies in patients who survive > 10 years. Estimated risk <1% every 10 years | MAF plus, Singapore Cancer Society (please approach your doctor for more information) |
| 4 | Tomotherapy A different form of IMRT. Tomotherapy incorporates daily imaging with delivery of radiation doses ‘slice by slice’, which can improve conformity. Useful in treating lengthy targets, for instance during craniospinal radiotherapy. | – High grade glioma (e.g. Glioblastoma, WHO grade 3 Astrocytomas ) : Standard dose RT (59.4 to 60Gy) with concurrent temozolomide, over ~6 weeks – Patients with high grade gliomas who are older in age or have lower functional status can be offered abbreviated RT 30 – 40Gy over ~ 2- 3 weeks, with or without concurrent temozolomide. – Low grade glioma : RT 50 – 54 Gy), over ~6 weeks, followed by chemotherapy (TMZ or PCV) | Short term : lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term : risk of radiation necrosis or pseudo-progression, possible cognitive changes, changes in vision/hearing (depending on location of tumour). Risk of radiation induced injury to the optic nerves or brainstem <5% Risk of secondary malignancies in patients who survive > 10 years. Estimated risk <1% every 10 years | MAF plus, Singapore Cancer Society (please approach your doctor for more information) |
| 5 | Stereotactic radiotherapy/ radiosurgery (SRT/ SRS) Stereotactic techniques allow delivery of radiotherapy doses with sub-millimetre precision. This improved precision is useful for treating smaller tumour targets as it allows for dose intensification (the delivery of larger radiotherapy doses per treatment fraction). The improved accuracy and reduced margins used can also be useful for sparing normal structures. | Useful in recurrent disease as part of re-irradiation. | In the re-irradiation setting, side effects can be very patient specific. Please consult your doctor for more information. | |
| 6 | Proton beam therapy (PBT) Proton beam therapy uses particles known as protons to treat tumours. Whereas x-rays inherently do not stop completely in the body and must traverse the patient before exiting, protons stop within the target volume. Hence, protons do not have an exit dose, which results in a lower integral dose to normal tissues beyond the target volume. In many circumstances, this inherent property of protons can be harnessed to improve the therapeutic ratio of radiotherapy, particularly in children and young adults. It is important to remember though, that for gliomas, there has been no proven survival advantage with proton therapy, although side effects may be reduced. | PBT is approved by Ministry of Health (MOH) for use in many paediatric central nervous system (CNS) conditions, including gliomas. For patients older than 25 years, PBT is only approved if it is delivered concurrently with chemotherapy. The doses used in proton beam therapy are similar to those used in x-ray radiotherapy. | Although the side effect profile is similar to conventional x-ray radiotherapy, the overall intensity is generally reduced due to sparing of normal tissues beyond the target volume. This is particularly true for low to moderate dose splash. The degree of benefit is dependent on factors such as proximity of organs-at-risk, dose, as well as tumour type. For instance, protons can be very helpful in reducing side effects when used for craniospinal radiotherapy. Please consult your doctor for more information. | Please consult your doctor to enquire about possible funding support for PBT. |
Treatments for gliomas that may be helpful but not available in Singapore
| No. | Name of treatment | Indications/ dose | Possible adverse effects | Applicable patient programme |
| 1 | Boron Neutron Capture Therapy (BNCT) In BNCT, boron is concentrated in tumours and not in normal tissue. When the area is irradiated with neutrons, it would interact with boron within tumours to cause localised radiation and destruction of tumours. Neutrons have minimal effect on normal tissue, in the absence of boron. | Generally, patients with newly diagnosed or recurrent high grade gliomas, who are unsuitable for standard treatment, and who are fit for overseas travels, can be considered for BNCT. Centres may have different criteria for accepting patients for BNCT, based on the countries’ and centres’ regulations and availability. | The most common side effect reported has been mild erythema of the skin over the irradiated area. This is usually self-limiting. | None at present. This treatment will be out of pocket. It is unlikely to get insurance coverage. At the same time, there is a need to factor in additional costs of travel, hotels etc. |
Neurosurgery for Glioma that are available in Singapore
| No. | Name of treatment | Efficacy | Some known adverse effects | Applicable patient programme |
| 1 | Awake surgery | Useful for gliomas in eloquent areas of the brain | ||
| 2 | Brain Mapping Surgery (with patient asleep) | For patients who cannot tolerate awake conditions or with severe deficits | ||
| 3 | Stereotactic biospy | Minimally invasive surgery to obtain tissue sample for histology | ||
| 4 | Use of intra- operative MRI for Glioma resection | Useful to ensure maximum safe removal of tumours. Used in conjunction with the other modalities – awake surgery |