So we have established a strong backbone. We know that this is really the standard of care. From the CATON subset analysis we show that basically regardless of the presence of poor prognostic factors, there is absolutely no predicted effect of those poor prognosticators. So even patients that have molecular markers associated with poor outcome, they still benefit from the addition of 12 cycles of adjuvant chemotherapy...
So we have established a strong backbone. We know that this is really the standard of care. From the CATON subset analysis we show that basically regardless of the presence of poor prognostic factors, there is absolutely no predicted effect of those poor prognosticators. So even patients that have molecular markers associated with poor outcome, they still benefit from the addition of 12 cycles of adjuvant chemotherapy. The question is now how you position your treatments. We know that there is an IDH inhibitor. There are several IDH inhibitors in development. There is one now registered for use in grade 2 gliomas. CATON was on grade 3 gliomas. So the role of the IDH inhibitors in grade 3 gliomas has not been established. And there are currently several trials going to explore this. The backbone for treatment will for the coming period be radiation therapy plus chemotherapy, those 12 adjuvant cycles. And I would expect that several trials will try to find ways of adding the IDH inhibitors somewhere either prior or after, as maintenance treatment, after this backbone of radiation therapy and chemotherapy. What I would think though is important is that there is a subgroup of patients with actually a good outcome, even with grade 3 histology. I think upfront trials with IDH inhibitors should be tried there. There is a subset of patients that can be selected in which I think it is safe to have an upfront approach with an IDH inhibitor trying to postpone radiation therapy and chemotherapy. Because although it is effective, we also know that it is associated with adverse events in terms of fatigue, on the long term, memory disturbances, attention deficits. So it’s important to postpone radiation therapy and chemotherapy.
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