btlaw123
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Posts:45
I have read a lot of articles and comments in this site and others, I am still not sure if WBR is a treatment of choice more for Small cell lung cancer but not for NSCLC mets to the brain. I am under the impression that WBRT is not so effective for non small cell lung cancer in the brain. Any advice?
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Reply # - January 12, 2014, 11:32 AM
Reply To: Is WBR only good for SCLC but not for NSCLC?
WBRT is absolutely an effective treatment for brain mets in the setting of NSCLC, and it's really the appropriate treatment for someone with more than a few brain metastases from NSCLC. However, cognitive side effects can possibly occur, and this wasn't a major issue when patients with brain mets rarely lived beyond a few months. But now that more and more patients are living beyond a few months, there's more concern about this, although this is also amplified by a rather extreme propagation of stories of worst case scenarios that are definition the rare exception and not the rule. It's also abetted by the economics of stereotactic radiosurgery (gamma knife, cyber knife), which are an incentive for radiation oncologists, particularly because the people who don't undergo WBRT are at high risk for future brain metastases (i.e., more business), whereas those who undergo WBRT have much, much higher rates of longer-term control in the brain.
SCLC is characterized by a higher risk for brain metastases, so much so that it's really hard to realistically envision that one or a few brain metastases appear in isolation. SCLC is so likely to be accompanied by multifocal brain metastases that a lower dose WBRT approach, prophylactic cranial irradiation (PCI) is the recommended standard of care for patients who respond to initial treatment for SCLC, even if they don't have evidence of brain metastases, and it's associated with a survival benefit.
I should say that the discussion of WBRT is a combination of evidence and our own perspective/bias. I have a bit of a chip on my shoulder about over-use of SRS well beyond where it's clearly appropriate, because I think that is somewhat market-driven for profit and capitalizes on subordinating evidence to emotion in patients -- like over-use of PET/CT, it's easy to nudge patients to the more expensive new technology that is more profitable for the institution but bleeds societal resources.
-Dr. West
Reply # - January 12, 2014, 04:53 PM
Reply To: Is WBR only good for SCLC but not for NSCLC?
Thank you Dr. West again for providing the information.
Admittedly, there might be some of "own perspective/bias" inserted, these are still important factors to consider. However, in a large HMO setting, where the core infrastructure of clinical and therapeutic equipment are already established and in placed, the economic consideration might not be as important.
Just wondering if there are much research studies on recurrence rate in the use of local SRS alone after surgical resection of a single solitary met to the brain and its potential toxicities due to a higher single fraction dosage of radiation?
Reply # - January 12, 2014, 08:40 PM
Reply To: Is WBR only good for SCLC but not for NSCLC?
No, I don't believe there have been significant issues with later side effects from SRS, given how limited the scope of the treatment field is.
-Dr. West
Reply # - January 13, 2014, 04:24 PM
Reply To: Is WBR only good for SCLC but not for NSCLC?
SRS or gamma knife is a great treatment option when used in the ideal setting. However, I agree with Dr West regarding the occasional potential for 'misaligned incentives' with SRS/gamma knife procedures. The maximium gamma-knifes for a single patient I have heard of is 32 separate procedures, before ultimately coming to get whole-brain radiation.
At that time in 2012, Medicare paid ~$8,100 per Gamma Knife treatment. So that single patient basically generated >$259,200 in practice revenue for his local radiation oncologist, enough to buy a brand-new Maserati or Ferrari.
The other factor is that SRS procedures still have an entry/exit dose of radiation, and so can still have adverse effects like radiation necrosis. It depends on the context and location of the brain mets as well. Ultimately it can be a difficult decision to make in those patients with 3-5 brain mets, and there is no perfectly accepted answer.