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Guidelines for the treatment of patients with brain metastases is moving from whole brain radiation therapy to less toxic treatment options to potentially improve care and increase survival.
Recently released guidelines for the treatment of brain metastases may improve care and survival in these patients by providing evidence-based information on best treatments and outcomes.
These guidelines, prepared by an expert panel from the American Society of Clinical Oncology (ASCO), implement many of the advances in brain metastases care that have been made over the last few decades. This includes a shift from whole-brain radiation therapy and steroids for all patients to a more selective approach to care with targeted chemotherapies, immunotherapies and localized radiation.
“What these guidelines highlight … is how far away we’ve moved from ‘one-size-fits-all’ therapy, which usually meant whole brain therapy, to more effective and less toxic therapy personalized to the patient’s symptoms, brain imaging and underlying cancer type,” said Dr. David Schiff, the Harrison Distinguished Teaching Professor of Neurology, Neurological Surgery and Medicine and co-director of the Neuro-Oncology Center at the University of Virginia in Charlottesville, in an interview with CURE®.
Schiff, who was co-chair of the ASCO panel that prepared the guidelines, believes that this guidance may improve and even extend the lives of patients with brain metastases, although it may somewhat complicate the decision-making process.
“When I started in the field, development of brain metastases typically resulted in immediate referral to a radiation oncologist,” he said. “Now, medical oncologists may reach out initially to neurosurgeons for consideration of radiosurgery or resection, or even consider trying systemic therapy as a first. Nonetheless, experts are in agreement that patients benefit from decision-making input from all these subspecialists.”
Not only can patients benefit from these guidelines, but subspecialists can also rely on this document to help guide their patients in the best manner.
“The consensus among expert subspecialists reflected in these new guidelines means that subspecialists from any of these disciplines in the community can rely upon these guidelines as a general roadmap on patient management and know what types of therapies or referrals should be considered,” Schiff added.
Advancements Over the Last Two Decades
Twenty years ago, the majority of patients with brain metastases were treated with whole brain radiation, during which radiation is applied to the entire brain (versus a targeted approach) to kill tumor cells.
“This usually didn’t control the tumors for more than a few months, and in patients who were fortunate enough to be long-term survivors, many had cognitive problems including memory and concentration difficulties,” Schiff recalled. “Now, we’ve learned that patients with only a few brain metastases can be treated with high-dose local therapy (called radiosurgery), which is better at providing long-term control of metastases and doesn’t carry the risk of cognitive toxicity.”
Over the last few decades, oncologists have learned improved strategies with radiation, many of which are highlighted in the recent guidelines.
“We’ve learned that following surgical removal of a brain metastases that localized radiation can help ‘sterilize’ the borders to decrease local recurrence,” Schiff explained. “When patients have too many metastases for radiosurgery to be feasible, whole brain radiation’s side effects can be reduced by blocking out brain structures crucial for memory (so-called hippocampal-avoidant whole brain radiation) and administering the brain-protective medicine memantine.”
Lately the brain metastases space has been opening up to the potential of tactics to avoid radiation and surgery altogether.
“We are starting to see strong evidence that in some cases, new medicines and immunotherapies can control brain metastases, sparing patients (from) radiation, radiosurgery and surgery,” Schiff said.
The Future of Brain Metastases Treatment
The medicines that are starting to show promise in treating patients with brain metastases may provide a glimpse into what this space may be headed in the next two decades, if not sooner.
“We are going to see many new medicines approved for cancer,” Schiff explained. “Some of these will be tested for effectiveness in treating brain metastases, and I am optimistic some will be effective. In particular, we are seeing that immunotherapy can be effective in small brain metastases from some common tumors like lung cancer and melanoma. I expect our immunotherapy armamentarium to grow with success against brain metastases in more and more situations.”
Schiff anticipates that advances in this space will lead to further updates in the guidelines.
“My great hope is that rapid advances will make our guidelines outdated in the near future to patients’ benefit,” he said.
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