Can we assumed regarding these SRS treatments, that although long term survival is not affected, quality of life is probably favorably affected if fewer people are developing fewer brain lesions with SRS? Is quality of life at least benefited?

I’d also be curious to know the statistics between cause of death between the 2 SRS VS WBRT (whether the primary malignancy caused the ultimate demise or a distance malignancy was the primary cause of death.)

It seems counter-intuitive that if we are stopping brain lesions from developing, some at quite remarkable rates, that we are not gaining any survival benefit.

What could be the reasons for this? Perhaps brain metastases are not as significant to overall survival as we may think, maybe because growth and disease progression from the primary malignancies will ultimately outpace outpace the brain mets?

Jim

dadawg001

Jim,

Yes, quality of life does tend to be better if people don’t develop seizures and unsteadiness with walking, and headaches and vision changes. Quality of life isn’t often included in clinical trials, not as often as we’d like to see it, because it’s expensive and it’s one more thing that patients need to do, and researchers are trying to balance between getting as much information as possible and imposing on patients and staff as little as possible.

With regard to the reason why controlling disease it the brain, you identified the problem, which is that there are two “compartments” to deal with: one is the brain, and the other is the rest of the body. It’s hard to get an overall survival benefit from controlling the brain when disease is still progressing outside of the brain. That’s also a large part of why there historically hadn’t been as much concern about long-term, maximal treatment in the brain: it wasn’t necessary to definitively treat the brain if the cancer in the chest or elsewhere was now going to control the overall tempo of the disease. Now that we have added some more therapies for treating lung cancer outside of the brain (survival benefits seen in previously treated patients with SCLC or NSCLC, for instance), and we’ve seen that translate to modestly better overall survivals for many patients with lung cancer, just getting a hold on the cancer in the brain may no longer be good enough.

-Dr. West

Dr West

Dr. West,
My wife was treated with stereotactic and WBR and did extremely well. I beleve the disease in her brain was “cured” to the extent that’s possible. It was one of the most effective treatments she had…I’m wondering why sterotactic radiation isn’t used more for liver lesions caused by metastatic nsclc.
Thanks.
Bill

bwarfel

Bill,

You can radiate the whole brain to dramatically reduce the risk of any new lesions developing in the brain, but you can’t radiate the whole body to reduce the risk of new lesions developing outside of the brain. The issue is that there is not usually a benefit to focusing treatment on a specific area in metastatic disease, when the problem is a whole body one. Often, by the time you treat one area effectively, a new area develops a problem. For this reason, we generally do radiation or surgery for metastatic disease only in unusual settings where there is a local problem caused by the metastasis, like pain or an impending fracture of a bony lesion, or potential neurologic symptoms from a brain metastasis, or compression of an airway from bulky disease in the chest. So our focus is a whole body treatment like chemo or targeted therapies (tarceva, avastin, etc.) for a whole body problem of metastatic disease.

The other practical issue is that stereotactic radiosurgery for the brain can be reliably delivered to a target area by securing the skull in a stable frame that keeps the head and the brain lesion inside from moving. Because of that, the very focused radiation can go to the target lesion without missing part of it, and without hitting much of the surrouding area. In contrast, there isn’t a “body frame” to keep the rest of the body from moving, and the organs move some with breathing, etc. So if there is any movement of the target lesion and you’re doing a single radiation treatment, you can miss the target and hit surrounding tissue instead. There is some work being done at ways to give targeted radiation to the body, and the “cyber knife” approach is doing this, but it’s much less well established than stereotactic radiosurgery for brain metastases.

-Dr. West

Dr. West

Dr. West,

My mother has stage 4 NSCLC with 3 lymph nodes in chest involved and 3 brain mets. She has recieved WBR, Lung radiation, chemo and now we are waiting for scans in April. Assuming everything is “stable” would it be unreasonable to try SRS for the brain mets? My mom is determinded to fight despite the doctors calling it all “pallative”. At what point and whose decision is it to be curative treatment or pallative? Thank you so very much for this wonderful site!! I appreciate all your work.

Regards, Christi

2mmama

Christi,

SRS is certainly a strong consideration for any residual disease as a “boost” if any of those lesions remains after the treatment she’s received. That’s commonly done.

I think the question of how long to treat is an important and pretty personal decision, but really the difference of treatment being in a curative or palliative treatment setting is largely determined by stage. For stage IV disease with several brain metastases, I think there are increasing numbers of patients with survival that goes out far longer than we previously would have expected, but the question is whether it makes sense to pursue excessively toxic treatments that won’t end up helping. Adding chest radiation to chemo for stage III NSCLC is a significant burden of side effects, and people can even die from that. It’s much more justifiable if you can realistically shoot for a prize of a cure at the end. With several brain metastases, I would consider it really far more likely that at least concurrent chemo and radiation would add heaps of added toxicity without an obvious gain. Sequential radiation may or may not add anything, but it would likly not be as harsh.

I certainly appreciate the desire of patients to be a “fighter”. I’ve just seen many courageous, stoic fighters do less well than we’d have wanted, not because they didn’t fight hard enough, but because it wasn’t a fair fight.

-Dr. West

Dr. West

Dr. West,

I realize you most likely leave these decisions to the radiation oncologist and neurosurgeon, but why (in general) would surgical resection be chosen over SRS in single brain mets? My mom had a single tumor (”golf-ball sized”) in her cerebellum as a result of her adenocarcinoma. Cyberknife was considered, but ultimately they decided on traditional surgery, followed by WBR. There were significant complications - she suffered nerve damage to her right side and became fairly debilitated. And recently she developed meningeal carcinomatosis as a result of the cells escaping into the CSF during surgery. So with all the potential for complications, wouldn’t the non-invasive choice be tried first? If SRS is tried first and is found to be unsuccessful, can it be repeated or can surgery then be done? I know every situation is different and this isn’t your area of expertise, but I’d appreciate your thoughts. Thank you.

John 11

Larger tumors may be better treated by surgery than SRS, and there are certainly some locations that are better for SRS, and perhaps others that can be reached better with surgery. As you suggest, I would really defer to my radiation oncology and neurosurgery colleagues about the best approach, but in general we’ve seen a move to much, much more SRS as it becomes more readily available. I’d need to get a radiation oncologist and neurosurgeon to comment on the situations in which you’d clearly favor one approach over another. I’m getting a radiation oncologist involved. A neurosurgeon will be a little harder to come by. I rarely see them hanging around looking bored and trying to find something new to work on.

-Dr. West

Dr. West