Trials and added programs usually have to be joined during the gap, because vaccine manufacturing takes weeks and the first doses follow radiotherapy.
Step 1: surgery
The goal is maximal safe resection: removing as much enhancing tumor as possible without damaging function. Surgeons use navigation, awake mapping for tumors near speech or movement areas, and fluorescent dyes (5-ALA) that make tumor glow under blue light. Extent of resection is confirmed on an MRI within 72 hours. Gross total resection improves survival; when the tumor sits in critical areas, a partial resection or biopsy is the safe choice, and the rest of the pathway is unchanged. Tissue from surgery is what every molecular test, trial and vaccine depends on, so ask that it be stored.
Step 2: chemoradiation
About three to six weeks after surgery, radiotherapy begins: 60 Gy in 30 daily sessions over six weeks, Monday to Friday, each lasting minutes. Temozolomide is taken every day during radiotherapy at 75 mg per square metre of body surface, including weekends. Common effects are fatigue, hair loss in the treated area, nausea controlled by anti-emetics, and a drop in blood counts checked weekly. Patients over about 70 or with poor performance status may be offered a shorter three-week course of radiotherapy, with or without temozolomide depending on MGMT status.
- 1Radiotherapy30 sessions, Monday to Friday, 60 Gy in total
- 2Daily temozolomideA low dose every day of the six weeks, weekends included
- 3Maintenance cyclesSix 28-day cycles: five days of higher-dose temozolomide, then a break
Schematic calendar. Elderly or frail patients may receive a shorter three-week course.
Step 3: maintenance temozolomide
After a four-week break, temozolomide restarts at 150 to 200 mg per square metre for five days of every 28-day cycle, for six cycles. Blood counts are checked before each cycle. Some centers extend to twelve cycles; the evidence for going beyond six is weak. An MRI is done after chemoradiation and then every two to three months. Scans in the first three months can show "pseudoprogression", a treatment effect that mimics growth and settles on its own; this is why one worrying scan is rarely acted on alone.
Step 4: tumor-treating fields
TTFields (Optune) deliver alternating electric fields through adhesive arrays on the shaved scalp, worn at least 18 hours a day during maintenance temozolomide. In the EF-14 randomized trial, adding TTFields increased median survival from 16.0 to 20.9 months. It is approved in the United States, Europe, Japan and China, but availability and reimbursement vary, and the device demands commitment from the patient and family. Ask whether it is offered where you are treated.
- 1Arrays on the scalpFour adhesive patches deliver a low-intensity alternating electric field through the skull.
- 2Fields alternate directionThe field switches direction about 200,000 times a second, invisible and painless.
- 3Dividing cells are disruptedTumor cells trying to divide are pulled apart as the field changes; resting brain cells are largely unaffected.
Schematic. Worn at least 18 hours a day during maintenance temozolomide.
Where added treatments fit
Clinical trials and authorized programs, including vaccine programs like ours, slot into this sequence rather than replacing it. Most require enrollment before or at the start of chemoradiation, because vaccine manufacturing takes weeks and the first doses are usually timed after radiotherapy, when the immune system has recovered. This is why the decision has to be made in the gap after surgery. Some programs also accept patients after chemoradiation or at recurrence; the timing differs and should be asked about explicitly.
What the standard pathway achieves
In the original 2005 trial, the median survival with chemoradiation was 14.6 months and the two-year survival 27 percent; with TTFields added, median survival in the 2017 trial was 20.9 months. Patients with MGMT-methylated tumors, complete resections, younger age and good performance status do better than these medians; others do worse. These numbers are the benchmark against which any added treatment should be judged. See how to read treatment numbers.
| Treatment | Median overall survival, months | Source |
|---|---|---|
| Radiotherapy alone (2005 trial) | 12.1 | Stupp 2005 |
| Radiotherapy + temozolomide (2005 trial) | 14.6 | Stupp 2005 |
| Temozolomide maintenance alone (2017 trial, control arm) | 16.0 | EF-14, 2017 |
| Temozolomide + TTFields (2017 trial) | 20.9 | EF-14, 2017 |
Months, newly diagnosed glioblastoma. Two different trials a decade apart; populations differ.
Questions families ask
Can I skip temozolomide if my tumor is MGMT-unmethylated?
Guidelines still recommend it for fit patients, because the trial showed a smaller but real benefit, and because trials of alternatives have not shown anything better. In elderly patients the decision is individualized.
Is proton therapy better than standard radiotherapy for glioblastoma?
No survival advantage has been shown. Protons can reduce dose to healthy brain and are sometimes used in younger patients, but photon radiotherapy remains standard.
How soon after radiotherapy can a vaccine be given?
It depends on the program. Many give the first dose two to four weeks after radiotherapy ends, when blood counts recover; the vaccine is manufactured during radiotherapy so that it is ready.
Related guides
- Newly diagnosed glioblastoma: what to do in the first two weeks
- Recurrent glioblastoma: the options after standard treatment
- Dendritic-cell and mRNA vaccines for glioblastoma: how they work and what is proven
Sources
- Stupp R, et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. NEJM 2005 doi.org
- Stupp R, et al. Effect of tumor-treating fields plus maintenance temozolomide vs maintenance temozolomide alone on survival in glioblastoma (EF-14). JAMA 2017 doi.org
- NCCN Guidelines for Patients: Brain Cancer, Gliomas (2026) nccn.org
Considering treatment in China?
Send the patient's records for a remote review. A coordinator confirms receipt within one business day; the multidisciplinary team's report and a written estimate follow in about a week, before any decision or payment.