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. 2019 Feb 15;14(1):33.
doi: 10.1186/s13014-019-1237-9.

Management of patients with brain metastases from non-small cell lung cancer and adverse prognostic features: multi-national radiation treatment recommendations are heterogeneous

Carsten Nieder  1   2 , Matthias Guckenberger  3 , Laurie E Gaspar  4 , Chad G Rusthoven  4 , Dirk De Ruysscher  5 , Arjun Sahgal  6 , Timothy Nguyen  6 , Anca L Grosu  7 , Minesh P Mehta  8
Affiliations

Management of patients with brain metastases from non-small cell lung cancer and adverse prognostic features: multi-national radiation treatment recommendations are heterogeneous

Carsten Nieder et al. Radiat Oncol. .

Abstract

Background: Different management options exist for patients with brain metastases from non-small cell lung cancer (NSCLC), patients whose treatment with whole brain radiotherapy (WBRT) has become more controversial over the last decade. It is not trivial to find the optimal balance of over- versus undertreatment in these patients. Several recent trials, including the randomized QUARTZ trial now influence the decision to recommend or withhold WBRT for patients with unfavorable prognosis, and similarly, for favorable prognosis patients, the balance between radiosurgery alone or WBRT has become a nuanced decision. Additionally, the availability of intracranially active targeted agent for some subsets of these patients has added another layer of complexity to the decision-making.

Methods: A multinational consortium of expert radiation oncologists was established with the aim of compiling treatment recommendations for challenging scenarios, in this case the choice between optimal supportive care (SC), WBRT and other types of radiation therapy (RT). We distributed 17 cases to 7 radiation oncologists who were allowed to involve coworkers to provide their treatment recommendations. The cases differed in extra- and intracranial disease extent, histology, age and other prognostic factors. Expert recommendations were tabulated with the aim of providing guidance.

Results: Regarding willingness to include the 17 patients in the QUARTZ trial, the rates of trial inclusion were low (range 0/7 to 3/7). Experts not recommending trial inclusion provided their treatment recommendations. These suggestions differed widely for most of the patients. It was not uncommon to see 3 or 4 different recommendations. In general, few (0-2) recommended SC. Some kind of local treatment was suggested by the majority of experts for all 17 patients. Commonly, stereotactic single-fraction radiosurgery (SRS) or stereotactic fractionated radiotherapy (SFRT) were recommended by many experts, also for patients with 5-7 lesions. The highest proportion of recommendations towards WBRT in any patient was 3/7. It was also quite common for patients with multiple metastases of varying size that experts suggested combinations of resection, post-operative SRS/SFRT and SRS/SFRT to intact lesions. Despite recommending active treatment, experts were often willing to include the patients in a hypothetical protocol investigating radiotherapy utilization in the last 30 days of life (assessment of factors predicting early death).

Conclusions: WBRT was infrequently recommended. Even in patients with adverse prognostic features that raised the experts' awareness of an increased risk for futile treatment near the end of life, SRS/SFRT were more often recommended than optimal supportive care, unless a patient decided to forego active treatment.

Keywords: Brain metastases; Non-small cell lung cancer; Prognostic factors; Radiosurgery; Whole brain radiation therapy.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

We have read and understood the journal’s policy on disclosing conflicts of interest and declare the following. MM reports consulting relationships with Tocagen, Remedy, IBA, Varian, Oncoceutics, and Astra-Zeneca and serves on the DSMB for Monteris, as well as the Board of Directors of Oncoceutics; none of these are related to the topic of this manuscript. DDR: none related to the current manuscript. Outside the current manuscript: advisory board of Astra Zeneca, Bristol-Myers-Squibb, Roche/ Genentech, Merck/ Pfizer, Celgene, Noxxon, Mologen and has received investigator initiated grants from Bristol-Myers-Squibb, Boehringer Ingelheim and Astra-Zeneca. MG: none related to the current manuscript. Outside the current manuscript: advisory board of Astra Zeneca; research funding by Astra Zeneca and Varian. AS: Advisor/consultant with Abbvie, Merck, Roche and Varian (Medical Advisory Group), Elekta (Gamma Knife Icon). Ex officio Board Member: International Stereotactic Radiosurgery Society (ISRS). Past educational seminars with Elekta AB, Accuray Inc., Varian (CNS Teaching Faculty), BrainLAB, Medtronic Kyphon. Research grant with Elekta AB. Travel accommodations/expenses by Elekta, Varian, BrainLAB. Dr. Sahgal also belongs to the Elekta MR Linac Research Consortium, Elekta Spine, Oligometastases and Linac Based SRS Consortia. LEG is an advisor/consultant with AstraZeneca.

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