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PubMed This is a summary of 22 peer-reviewed journal articles Updated
Oncology

The Standard of Care for Glioblastoma

At a Glance

The standard of care for glioblastoma typically begins with surgery to safely remove as much tumor as possible. This is followed by the Stupp Protocol, which combines daily radiation and temozolomide chemotherapy, and often includes wearing a Tumor Treating Fields device to slow tumor growth.

Once a diagnosis is confirmed, your medical team will move quickly to implement a treatment plan. For glioblastoma, there is a clear, evidence-based sequence of therapies known as the Standard of Care (SOC). While this plan is aggressive, it is designed to attack the tumor from multiple angles simultaneously.

The Foundation: Surgical Resection

The first step is almost always surgery. The goal of the neurosurgeon is to achieve a maximal safe resection—removing as much of the tumor as possible without damaging areas of the brain that control speech, movement, or vision [1][2].

  • Gross Total Resection (GTR): This means the surgeon was able to remove all of the visible tumor on the post-operative MRI scan. GTR is strongly associated with improved survival and better long-term outcomes [3][4].
  • Subtotal Resection (STR): If the tumor is in a sensitive area, the surgeon may only remove a portion of it. While not as ideal as GTR, removing a significant amount of the tumor can still relieve pressure and help subsequent treatments work better [5][6].

Note: After surgery, there is typically a 3-to-4 week waiting period to allow your surgical wound to heal fully before starting radiation. While this wait can induce severe anxiety, it is a standard and necessary period to ensure the scalp is strong enough to withstand radiation treatment.

The Stupp Protocol

Named after the researcher who pioneered it, the Stupp Protocol has been the gold standard for over two decades for patients typically under age 65 [7][8]. It consists of two main phases:

  1. Phase 1: Concurrent Chemoradiation: For six weeks, you will receive daily radiation therapy (Monday through Friday) while taking a daily pill of the chemotherapy drug temozolomide (TMZ) [7][9].
  2. Phase 2: Adjuvant (Maintenance) Chemotherapy: After a short break following radiation, you will begin “adjuvant” therapy. This typically involves taking a higher dose of temozolomide for five days every 28 days, for a total of six cycles [7][8].

Physical Realities and Side Effects: The Stupp Protocol is intense. Common physical side effects include profound fatigue, localized hair loss (from radiation), nausea, and constipation (often from anti-nausea medications). Temozolomide can also lower your blood counts, meaning you may be immunocompromised and require regular blood tests. Your doctor will provide anti-nausea and supportive medications to help manage these issues.

The Fourth Modality: Tumor Treating Fields (TTFields)

In recent years, a fourth treatment pillar has been added to the standard of care: Tumor Treating Fields (TTFields). This therapy uses a portable device called Optune® that delivers low-intensity electric fields through arrays (patches) placed on the scalp [10].

  • How it works: These electric fields disrupt the ability of cancer cells to divide and multiply [11].
  • The evidence: Clinical trials have shown that adding TTFields to maintenance temozolomide significantly improves both overall survival and quality of life [12][13].
  • Compliance and Lifestyle Impact: The benefit of TTFields is directly related to wearing it for at least 75% of the day (about 18 hours). It is important to know that using this device requires regularly shaving your head to ensure the arrays stick properly to the scalp. You will also need to carry the device’s portable battery pack with you as you go about your day [14][15].

Modifications for Elderly or Frail Patients

Because the standard Stupp Protocol can be physically demanding, doctors often tailor the plan for patients over 65 or those with other health concerns (frailty) [16][17].

  • Hypofractionated Radiation: Instead of a 6-week course, your doctor may recommend a 1- to 3-week course of “short-course” radiation. This delivers higher daily doses but in fewer sessions, making it much easier to tolerate without losing significant efficacy [18][19].
  • MGMT-Based Decisions: For elderly patients, the MGMT status of the tumor is critical. If the tumor is “unmethylated” (meaning it is resistant to chemotherapy), your doctor might recommend radiation alone to avoid the side effects of drugs that may not be effective [20][21]. Conversely, for “methylated” tumors, adding temozolomide to short-course radiation provides a clear survival benefit [20][22].

Common questions in this guide

What is a maximal safe resection in glioblastoma surgery?
Maximal safe resection means the neurosurgeon removes as much of the visible tumor as possible without damaging healthy brain tissue that controls vital functions like speech, movement, or vision. Removing all visible tumor is called a gross total resection.
What is the Stupp Protocol for glioblastoma?
The Stupp Protocol is the standard initial treatment plan for many glioblastoma patients. It involves six weeks of daily radiation therapy combined with a chemotherapy pill called temozolomide, followed by several months of maintenance temozolomide at a higher dose.
How do Tumor Treating Fields work?
Tumor Treating Fields (TTFields) use a portable device called Optune that delivers low-intensity electric fields to the brain through patches placed on a shaved scalp. These continuous electric fields disrupt the cancer cells' ability to divide and multiply.
Why is my MGMT status important for my treatment plan?
Your tumor's MGMT methylation status helps doctors predict how well it will respond to the chemotherapy drug temozolomide. For elderly patients with unmethylated tumors, doctors may recommend radiation alone to avoid side effects from a drug that may not be effective.
Are there different treatment options for older glioblastoma patients?
Yes, older or frail patients often receive a modified plan called hypofractionated radiation. This involves higher daily doses of radiation over a shorter period, usually one to three weeks, which is often easier to tolerate while still being effective.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Am I a candidate for 'gross total resection,' or is the tumor located too close to functional areas of my brain?
  2. 2.Given my age and health, would you recommend the standard 6-week radiation course or a shorter 'hypofractionated' course?
  3. 3.Based on my MGMT status, how much benefit should I expect from adding temozolomide to my radiation therapy?
  4. 4.When is the best time for me to start using Tumor Treating Fields (TTFields), and what lifestyle adjustments will I need to make for it?
  5. 5.What support services and medications will be provided to help me manage the side effects of concurrent chemotherapy and radiation?
  6. 6.Am I a candidate for clinical trials before starting the standard radiation/chemo?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

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This page explains the standard of care treatments for glioblastoma for educational purposes. Your neuro-oncology team is the best source for determining your specific medical treatment plan.

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