Whole brain radiation side effects? - 1245121

milajb
Posts:3

My husband (51) has been recently diagnosed with stage IV NSCLC. He is currently undergoing 10 radiation treatments (8 done 2 more to go) and has been taking it reasonably well with the main side effects being fatigue, nausea, and lost of apetite. Next week (Wed) he is starting with the whole brain radiation (WBR) for his brain mets (one dominant around 9mm and 3 more smaller then 5mm). I'm so worried about the WBR short term and long term side effects... it has been driving me crazy to be honest. Is it possible to treat all mets (4 of them) with stereotactic radio-surgery?
Do you have any good advise that would help us manage WBR's side effects? Any success stories, please share!
After the WBR he will start with Tarceva (since he tested EGFR positive) so I feel this may be the most critical phase in our battle.
I need to keep us both positive and strong.
Thanks for your help.

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Reply # - July 14, 2012, 02:56 PM

Dr West
Posts: 4735

It's possible to do stereotactic radiosurgery (SRS) for patients with more than 1-3 brain lesions, but with more than that, the risk of more is quite a bit higher, and WBR is really the standard approach and what I recommend to my patients with more than 3 brain metastases.

Here is a post about anticipated side effects with WBR/PCI:

http://cancergrace.org/radiation/2010/09/13/radiation-faq-what-side-eff…

I don't think there's anything specific to be done to minimize risk of side effects. The majority of patients really do fine, despite the horror stories that you may hear about online. Those alarmist stories are easily spread virally through internet communities, and while that is always possible, that is not anticipated. Moreover, the side effects of untreated or undertreated brain metastases is a real problem.

-Dr. West

Reply # - July 14, 2012, 07:14 PM

milajb
Posts: 3

Dr. West,
Thanks so much for your prompt response, I really appreciate it! I'm still having difficulties with ruling down Radio-surgery in favor of FBR if the number of lesions is 4 instead of 3, especially if there are some good odds that Tarceva may be able to clean the "micro lesions" that at this point are not visible and may not even be there.
Also, doing FBR means waiting almost two more weeks before my husband can start Tarceva treatment and to me this seems like long time. If a Radio-surgery is performed he may be able to start with Tarceva in few day.
If Tarceva doesn't work, is it possible to go back and only then perform FBR? What are the risk of this approach?
Many thanks for you kind help!
Mila

Reply # - July 14, 2012, 07:43 PM

Dr West
Posts: 4735

There is a little more of a risk of cognitive side effects if you do both stereotactic and whole brain radiation. I would have to say that a two week wait is really not likely to be a huge difference unless things are just spiraling into a crisis extremely quickly. In other words, I'm not inclined to have the tail wag the dog and overturn a treatment plan due to anxiety.

If you are really inclined to reverse the proposed plan, it would be more appropriate to discuss that directly with his physicians. I believe the proposed plan is very sensible based on what you've relayed thus far.

-Dr. West

Reply # - July 15, 2012, 08:44 AM

milajb
Posts: 3

Dear Dr. West,
Thanks so much for your advise and for being available online! You have no idea how much you are helping by generously taking time to answer questions online. My husband is in favor of WBR and feels strong to go through it. I will support his decision and will find a way to deal with my anxiety. I'm already feeling more positive about WBR and am hopping for the best.
One more question, what is the main reason for nor combining Tarceva and radiation at the same time?
many thanks!

Reply # - July 15, 2012, 09:54 AM

JimC
Posts: 2753

Hi milajb,

Dr. Weiss summarized the reason here:

"It's possible, but there is potential for sensitization. Tarceva has been studied as a radiosensitizer, so it could potentially increase both cell kill and side effects. I don't worry too much about giving it with very short course radiation like radiation to a bone met, but if the intent is curative or the field is larger, I tend to consider stopping it." - http://cancergrace.org/forums/index.php?topic=7588.msg55822#msg55822

And as Dr. West said in the same thread:

"My general inclination with regard to radiation and an oral EGFR inhibitor is to not overlap unless there's some pressing need. It's always a question of risk vs. benefit, and neither is really well defined here. Unless I feel that there is both a compelling reason to be doing local and systemic therapy and nothing to lose (we're pulling out all of the stops), I'd give these treatments sequentially". - http://cancergrace.org/forums/index.php?topic=7588.msg55860#msg55860

JimC
Forum Moderator

Reply # - July 15, 2012, 10:52 AM

marisa93
Posts: 215

milajb, I just wanted to say that I can completely understand and relate to your anxiety. I had those same fears about my husband's WBR but he did really well through it and after it. All the stuff you read and hear about WBR can be really scary and I only wish I had found this site before his WBR. Once here, I felt a lot more relaxed about it and felt that we really had done the best thing for him at the time. Sending best wishes for your husband and you.

Lisa

Reply # - July 15, 2012, 02:33 PM

Dr West
Posts: 4735

As I might have expected, Jim extracted the relevant info that really explains our current thinking about concurrent EGFR TKI therapy and whole brain radiation.

-Dr. West

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