Real-world clinical practice patterns in the surgical management of low-grade astrocytomas: An analysis of Surveillance, Epidemiology, and End Results (SEER) and the National Cancer Database (NCDB) databases

Introduction Despite evidence supporting the benefit of early surgical treatment of low-grade gliomas, the “watchful waiting” approach remains commonly practiced. Here, we examined the real-world pattern of surgical recommendations on early versus delayed surgical biopsies for low-grade gliomas. Methods Low-grade astrocytoma (A2), anaplastic astrocytoma (A3), and glioblastoma patients who underwent biopsies for histologic diagnosis were identified in the SEER (2004–2019) and NCDB (2010–2020). The early biopsy (EB) cohort was defined as patients receiving a recommendation for biopsy on initial presentation. Patients receiving initial recommendations against surgery were placed in the “watchful waiting”/delayed biopsy (DB) cohort. Demographic, clinical characteristics, and survival outcomes of these cohorts were evaluated. Results In both the SEER and the NCDB, A2 patients were more likely to receive a DB recommendation than glioblastoma patients after adjusting for pertinent covariates (SEER: aOR = 1.77, p < 0.001; NCDB: aOR = 1.88, p < 0.001). Compared to glioblastoma patients, the odds of receiving DB recommendations were also significantly higher in A3 patients (SEER: aOR = 1.78, p < 0.001; NCDB: aOR = 1.97, p < 0.001). Variables associated with DB for both low-grade glioma and anaplastic astrocytoma patients included: advanced age, deep cortical/infratentorial location, and smaller tumor size. In the multivariable models accounting for survival-pertinent variables (including age, tumor location, tumor size, and other covariates), DB patients showed a higher hazard ratio of death relative to EB patients for A2 (SEER: aHR = 1.15, p = 0.039; NCDB: aHR = 1.23, p = 0.006) and A3 (SEER: aHR = 1.53, p < 0.001; NCDB: aHR = 1.44, p < 0.001). In both SEER and NCDB, all findings remain robust after accounting for dehydrogenase ( IDH ) mutation status. Conclusion Patients with low-grade or anaplastic astrocytoma are nearly twice as likely to receive a recommendation for delayed biopsy and “watchful waiting”. This practice should be considered in light of the clinical availability of IDH inhibitors and surgical technologies that improve the safety of stereotactic needle biopsies.