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Radiation FAQ: What side effects can I expect from Whole Brain Radiation (WBR)/Prophylactic Cranial Irradiation (PCI)?

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The following content is offered by the moderators and is adapted from text that appears in several different posts and discussion threads on this topic.

Side effects can be somewhat variable, but most seem to tolerate it pretty well. Hair loss does not occur in every patient and does not occur to the same degree in the patients that experience this. There is also the sensation that people get “ear stuffiness”, and this probably results from some of the ear wax becoming “drier” than pre treatment. There are a few people who experience some nausea after just 1 or 2 treatments. The good news is that this nausea seems to disappear and not return during the remaining treatments.

The most common complaint is tiredness/fatigue. This is, of course, difficult to assess, because it is such an individual complaint and might be an effect of previous treatments, or treatments received after WBR.

With regard to late effects, most patients seem to function at a normal level more than a year or two out from treatment. The scientific studies of the incidence of cognitive or functional impairment are very difficult to interpret because of all the other variables that come into play. For example, in one study of patients that had not been treated with WBR yet, the incidence of cognitive impairment was just as high as another series reported after the patients had been treated with WBR. The other factors that might have something to do with explaining cognitive decline include general aging, the underlying cancer process, the presence of brain metastases (meaning the existence of clinical or subclinical spread of cancer to the brain), the effect of chemotherapy received before or after the WBR, and other possible factors (strokes, etc).

Unfortunately, there are rare patients who simply don’t tolerate brain radiation very well. For some of these patients, we need to simply quit the radiation altogether. There are also rare patients who simply don’t recover very well after treatment, and the effects of fatigue can be long lasting in this group.

Another way of assessing tolerability has been from reviewing work on prophylactic cranial irradiation (PCI). This work has generally shown it to be quite well tolerated, with the main side effects being headache in just over 40% of patients, nausea and/or vomiting in about 1/3, and a smaller proportion of around 10% or less with fatigue. Skin reactions like a local burn were rarely seen as well. About 2% of the total getting PCI in a pivotal study experienced long-term significant headaches or neurologic problems, the big fears about brain radiation.

Commentary from faculty (opinion): …my opinion is that fears about WBR leading to dementia are really overstated and that the fear of it exceeds the true risk, even if it’s not risk-free. Yes, the risk is generally understood to be higher in older patients, who have fewer compensatory neurologic pathways and a lower threshold to exhibit cognitive problems, and I would be judicious about WBR and would prefer gamma knife for one or a few lesions. But dementia is far from inevitable, and the vast majority of my patients who have received WBR have also done well and exhibited either no cognitive deficits or ones subtle enough that they may perceive a change, but they wouldn’t be obvious to anyone around them, and far from becoming oblivious and unable to ambulate. Plus, having brain metastases not managed effectively isn’t a picnic either in terms of the problems this can cause.

For further discussion, visit:
Whole brain radiation immediate side-effects
Whole brain RT/Prophylactic Cranial Radiation
Prophylactic Cranial Irradiation (PCI) for ED-SCLC
Discussion: What about WBR for 71 year old?


16 Responses to Radiation FAQ: What side effects can I expect from Whole Brain Radiation (WBR)/Prophylactic Cranial Irradiation (PCI)?

  • rancherswifecw says:

    I had read that Advasin along with this PCI would help a lot of the cognitive problems out Andersons of AZ. Our Dr has never mentioned this

  • Dr West says:

    This is still an open question, but it was discussed in the presentation Q&A by Dr. Minesh Mehta: Here’s the link to the podcast of the webinar he did on radiation for prevention and treatment of brain mets:

    http://cancergrace.org/radiation/2011/04/29/dr-minesh-mehta-radiation-oncologist-on-prevention-treatment-of-brain-metastases/

    Here’s the podcast of the Q&A session that followed, including discussion of Avastin and other possible avenues to reduce cognitive deficits with brain radiation:

    http://cancergrace.org/radiation/2011/05/04/qa-session-with-dr-minesh-mehta-covering-prevention-and-management-of-brain-metastases/

    -Dr West

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  • laya d. says:

    Can nausea/vomitting rear its ugly head a week or two after WBR treatment has completed?

    Laya

  • Dr Loiselle says:

    Hi Laya -

    Yes indeed, for certain nausea and fatigue can catch up with a patient the week or two after treatment. Particularly the first week out. Once out 2-3 weeks I would expect short terms side effects to really be diminishing, and by one month, recovery from any such symptoms.

    When it does cause nausea, a short course of low dose dexamethasone can really help (in addition to all of the other tricks and medications known well to the forum)…

    Hope that helps.

    -Dr. Loiselle

  • laya d. says:

    Thank you. . .

    Laya

  • richardry says:

    Dr.West and Dr.Loiselle

    Is it normal to have low temperature fever (99.3 to 99.6F) 60 days after WBR? My wife (ALK on Xalkori ten months,age 40) has fever already 3 days, and not feel bad though, I am painc at the fever. She also felt thorn pain art the back of ear after Last week brain MRI.
    this lasted a week.

    Thanks very much for reply.

  • richardry says:

    Dr.West and Dr.Loiselle

    Is it normal to have low temperature fever (99.3 to 99.6F) 60 days after WBR? My wife (ALK on Xalkori ten months,age 40) has fever already 3 days, and not feel bad though, I am painc at the fever. She also felt thorn pain art the back of ear after Last week brain MRI.
    this lasted a week.

    Thanks very much for reply

  • Dr West says:

    Not normal, but I suppose possible. I would just say that this temperature is actually not significantly elevated and isn’t associated with an increased risk of serious infection or other complications. It’s only very slightly above normal, and I could envision this possibly happening after WBR.

    As for that thorn pain sensation, I wonder if it might be something called L’hermitte’s sign, which is classically defined as an “electrical sensation” that can occur when someone who has had radiation in the neck region bends their neck forward. It might not be that but something related, but that isn’t a dangerous problem — just an annoying side effect people can have after radiation.

    -Dr. West

  • richardry says:

    Dr.West

    Thanks very much for your reply. Her pain has gone, but continue to have low fever 98.8F every evening (she used to be 97.7F during the day). It is somewhat strange. Is it possible that the radiation cause the cancer cell dying, the the body tried to expell them by circulation?

    Another important question, I belive patients had WBR used to have recurrence after a while. I saw the news of AP26113 would penetrate into brain (at dosage of 180mg) and LDK378 also have the ablility with higher dosage (800mg?). Is it wise to request clinic trial to use AP26113 to replace Xalkori? My understanding is that the brain met cancer cell is treated by radiation, plus strong drug which penetrate into brain might eradicate them instead of dormant? Otherwise, the cancer cell might gradually come alive.

    But I am seeing doctor usually not prefer trial if patient is in maintain status. My concerning is that the cancer will come back anytime when the resistance occurs.

  • Dr West says:

    A textbook normal temperature is 98.6F, and it varies by up to a degree up or down over the course of the day. Whether you say that her normal temperature is 97.7F or not, there is nothing remotely pathological about having a temperature of 98.8F. In truth, that is not a low fever, but a very normal temperature.

    I can’t say whether AP26113 would be effective in the brain, now LDK378. I just don’t think there’s enough known about this to do more than wildly speculate, which I’m not inclined to do without any real evidence to address these questions.

    Good luck.

    -Dr. West

  • richardry says:

    Dr.West,

    Thanks very much for your kind and prompt reply.

    Understand it is not right time to decide if a trial drug would be solution, but Xalkori failed at wide range brain metastatics is really fatal to patients. I do not know what to do next.

    Again appreciated.

  • richardry says:

    Dr.West

    I saw some people has succesful story on PD1 drug. I am looking at this as well, amoung the antibody PD1 and YERVOY, which is better for NSCLC with ALK mutation? I knew PD1 would be newer than YERVOY, I am somewhat worried about the side effect of intestine perforation issue ,even if it has longer practice exambles.

  • richardry says:

    I meant YERVOY intestine perfoation danger.

  • Dr West says:

    I don’t think there is ANY information specifically on people with an ALK rearrangement. Yervoy (ipilimumab) definitely has side effect challenges, and while anti-PD1 therapy isn’t without some risk, it’s not been as troubled by a frequent challenge of problematic side effects as Yervoy.

    -Dr. West

  • wierwilles3 says:

    This thread has been helpful to me. Thank you for the information on WBR, as I am facing a decision. I was told yesterday that I have AT LEAST 6 brain mets, so it seems from your opinion, and that of my oncologist and radiation oncologists that WBR is the only real option.

    Sharon

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