Optimizing treatment of brain metastases in an era of novel systemic treatments: a single center consecutive series

Abstract

Background: The multidisciplinary management of patients with brain metastases consists of surgical resection, radiation treatment and systemic treatment. Tailoring and timing these treatment modalities is challenging. This study presents real-world data from consecutively treated patients and assesses the impact of all treatment strategies and their relation with survival. The aim is to provide new insights to improve multidisciplinary decisions towards individualized treatment strategies in patients with brain metastases.

Methods: A retrospective consecutive cohort study was performed. Patients with brain metastases were included between June 2018 and May 2020. Brain metastases of small cell lung carcinoma were excluded. Overall survival was analyzed in multivariable models.

Results: 676 patients were included in the study, 596 (88%) received radiotherapy, 41 (6%) awaited the effect of newly started or switched systemic treatment and 39 (6%) received best supportive care. Overall survival in the stereotactic radiotherapy group was 14 months (IQR 5-32) and 32 months (IQR 11-43) in patients who started or switched systemic treatment and initially did not receive radiotherapy. In patients with brain metastases without options for local or systemic treatment best supportive care was provided, these patients had an overall survival of 0 months (IQR 0-1). Options for systemic treatment, Karnofsky Performance Score ≥ 70 and breast cancer were prognostic for a longer overall survival, while progressive extracranial metastases and whole-brain-radiotherapy were prognostic for shorter overall survival.

Conclusions: Assessing prognosis in light of systemic treatment options is crucial after the diagnosis of brain metastasis for the consideration of radiotherapy versus best supportive care.

Keywords: Brain metastases; Radiotherapy; Systemic treatment.

Fig. 1

Study design. Of the 65 patients excluded between step 2 and 3 55 had a session of RT for BM before in the course of their disease, and 10 had an incomplete follow-up

Fig. 2

Kaplan-Meier Curves for Overall Survival according to remaining options for systemic treatment. A Individual groups of different options for systemic treatment. Median OS for the group receiving the first ST was 17 months (95% CI 13–20); median OS in the group that continued ST was 19 months (95% CI 7–31); median OS in the group that switched ST was 11 months (95% CI 9–13); median OS in the group that received no ST bur had options was 16 months (95% CI 11–21); median OS in the group that had no options for ST was 2 months (95% CI 1–3). B All patients receiving systemic treatment, or having options for it, versus patients without options for systemic treatment. Median OS for group 1 was 14 months (95% CI 12–16); median OS for group 2 was 2 months (95% CI 1–3)