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Original Investigation
December 19, 2017

Effect of Tumor-Treating Fields Plus Maintenance Temozolomide vs Maintenance Temozolomide Alone on Survival in Patients With GlioblastomaA Randomized Clinical Trial

Author Affiliations
  • 1Lou and Jean MalnatiBrain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
  • 3University Hospital Zurich and University of Zurich, Zurich, Switzerland
  • 4Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, F-75013, Paris, France
  • 5Tel Aviv Medical Center, Tel Aviv, Israel
  • 6University of California, San Diego
  • 7Emory University, Atlanta, Georgia
  • 8Tel Aviv University, Tel Aviv, Israel
  • 9Geisinger Health System, Danville, Pennsylvania
  • 10Cleveland Clinic Foundation, Cleveland, Ohio
  • 11Baylor University Medical Center, Houston, Texas
  • 12Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
  • 13University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 14University of Texas Health Sciences Center at Houston
  • 15Tufts Medical Center, Boston, Massachusetts
  • 16Karolinska Hospital, Stockholm, Sweden
  • 17Washington University Barnes-Jewish Hospital, St Louis, Missouri
  • 18Moffitt Cancer Center, Tampa, Florida
  • 19University of Pennsylvania, Philadelphia
  • 20Novocure Ltd, Israel
  • 21Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea
  • 22Seoul National University, Seoul, Korea
  • 23Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 24Hospital Universitario de Bellvitge, Barcelona, Spain
  • 25Juravinski Cancer Centre, Hamilton, Ontario, Canada
JAMA. 2017;318(23):2306-2316. doi:10.1001/jama.2017.18718
Key Points

Question  Does the use of tumor-treating fields (TTFields), consisting of low-intensity, alternating electric fields delivered via transducer arrays applied to the scalp, when added to maintenance temozolomide chemotherapy, improve progression-free survival for patients with glioblastoma?

Findings  In this randomized clinical trial involving 695 patients with glioblastoma who had completed initial radiochemotherapy, median progression-free survival from randomization was 6.7 months in the TTFields plus temozolomide group and 4.0 months in the temozolomide-alone group (hazard ratio, 0.63), a significant difference.

Meaning  Among patients with glioblastoma, the addition of TTFields to maintenance temozolomide chemotherapy resulted in statistically significant improvement in survival. These results are consistent with those reported in a previous interim analysis.


Importance  Tumor-treating fields (TTFields) is an antimitotic treatment modality that interferes with glioblastoma cell division and organelle assembly by delivering low-intensity alternating electric fields to the tumor.

Objective  To investigate whether TTFields improves progression-free and overall survival of patients with glioblastoma, a fatal disease that commonly recurs at the initial tumor site or in the central nervous system.

Design, Setting, and Participants  In this randomized, open-label trial, 695 patients with glioblastoma whose tumor was resected or biopsied and had completed concomitant radiochemotherapy (median time from diagnosis to randomization, 3.8 months) were enrolled at 83 centers (July 2009-2014) and followed up through December 2016. A preliminary report from this trial was published in 2015; this report describes the final analysis.

Interventions  Patients were randomized 2:1 to TTFields plus maintenance temozolomide chemotherapy (n = 466) or temozolomide alone (n = 229). The TTFields, consisting of low-intensity, 200 kHz frequency, alternating electric fields, was delivered (≥ 18 hours/d) via 4 transducer arrays on the shaved scalp and connected to a portable device. Temozolomide was administered to both groups (150-200 mg/m2) for 5 days per 28-day cycle (6-12 cycles).

Main Outcomes and Measures  Progression-free survival (tested at α = .046). The secondary end point was overall survival (tested hierarchically at α = .048). Analyses were performed for the intent-to-treat population. Adverse events were compared by group.

Results  Of the 695 randomized patients (median age, 56 years; IQR, 48-63; 473 men [68%]), 637 (92%) completed the trial. Median progression-free survival from randomization was 6.7 months in the TTFields-temozolomide group and 4.0 months in the temozolomide-alone group (HR, 0.63; 95% CI, 0.52-0.76; P < .001). Median overall survival was 20.9 months in the TTFields-temozolomide group vs 16.0 months in the temozolomide-alone group (HR, 0.63; 95% CI, 0.53-0.76; P < .001). Systemic adverse event frequency was 48% in the TTFields-temozolomide group and 44% in the temozolomide-alone group. Mild to moderate skin toxicity underneath the transducer arrays occurred in 52% of patients who received TTFields-temozolomide vs no patients who received temozolomide alone.

Conclusions and Relevance  In the final analysis of this randomized clinical trial of patients with glioblastoma who had received standard radiochemotherapy, the addition of TTFields to maintenance temozolomide chemotherapy vs maintenance temozolomide alone, resulted in statistically significant improvement in progression-free survival and overall survival. These results are consistent with the previous interim analysis.

Trial Registration  clinicaltrials.gov Identifier: NCT00916409