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I would like to get some opinions or experience on NSCLC brain mets treatment strategy. Is it always a better practice trying to eliminate all tumors in brain with available treatment options, WBRT or new medication (like AP26113)? Or it is good enough to just control brain mets, so that I get less treatment and side effects, radiation or medication. If I hit progression later, does it make a big difference for the available treatment and outcome at that time between the two strategies?
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Reply # - November 11, 2013, 04:46 PM
Reply To: Brain mets treatment strategy
If someone has multiple brain metastases, we generally favor dealing with this proactively, since developing complications can lead to a worsening performance status and significant complications quickly. Whole brain radiation therapy (WBRT) is still the most reliable approach and standard of care in this setting. If someone has small, asymptomatic brain metastases and a cancer with a known signficant probability of response, such as someone with an EGFR mutation starting an oral EGFR inhibitor, I'll consider a trial of the systemic therapy, with an understanding that any hint of decline would lead me to favor a very rapid transition to initiation of WBRT. Practically, this has meant having the patient meet with a radiation oncologist and pursue a "window of opportunity" trial of other therapy only if they also feel it's reasonable and are able to jump in and start WBRT quickly as needed.
I think that focal therapy such as stereotactic radiosurgery for multiple brain lesions is often over-used and doesn't make sense when there are more than a handful of lesions in the brain, as the rest of the brain is at extremely high risk for progression and very, very often demonstrates new, growing lesions later.
-Dr. West