Advice with brain mets after 10 years Afatinib-Tagrisso

Hello everyone,

I'm seeking advice as my wife (51) and I navigate a tough treatment decision in her cancer journey. We are incredibly grateful to be nearing 10 years since her diagnosis of stage 4 NSCLC, which had several brain metastases.

Since her diagnosis, she underwent full brain radiotherapy in 2014 and began treatment with Afatinib (exon 19 mutation), responding well for 2 years before progressing. She then switched to Tagrisso, which has kept her lung disease stable for nearly 8 years, with great quality of life apart from the typical side effects. However, an MRI in early 2023 revealed brain progression, leading to the surgical removal of a 20 mm lesion. Unfortunately, 8 months after the operation, the MRI showed new growth in the same area, so they did targeted radiotherapy, which worked well and “killed” the lesions. However, almost 10 months after the last radiotherapy, the MRI showed further progression, with a new +10 mm lesion that developed rapidly (in less than 3 months).

Doctors have told us this is not a good scenario and have presented two difficult options: 1) further targeted radiotherapy followed by another brain surgery, which may only achieve partial removal of the lesion, or 2) systemic chemotherapy and immunotherapy while continuing Tagrisso, which remains effective in the rest of her body. My wife understandably hesitates about surgery, but we worry that chemotherapy and immunotherapy alone might not be effective, especially since she hasn’t used traditional chemotherapy yet, and we are also concerned about the blood-brain barrier.

She is also afraid of possible sequelae since her first brain surgery 18 months ago provoked her walking instability and hearing loss in one ear. We’re also uncertain if choosing one option could limit our ability to pursue the other later. We know the near future appears unpromising, but we want to keep fighting and are desperate to make the best decision. If anyone has insights, suggestions, or knows of any cutting-edge treatments or alternatives that could help us, we’d be deeply grateful.