Drs. Ben Solomon, Leora Horn, & Jack West discuss whether the data highlighting cognitive deficits from whole brain radiation therapy (WBRT) for patients with brain metastases should change our recommendations for prophylactic cranial irradiation (PCI).
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Dr. West: What about patients with extensive stage small cell lung cancer who don’t have brain metastases, and complete four or six cycles of chemotherapy, and still have a good performance status? We’ve seen conflicting results on the potential value of prophylactic cranial irradiation — some suggesting a significant survival benefit, some even suggesting harm, and a greater concern, I would say, throughout cancer, and certainly lung cancer, about cognitive side effects of brain radiation. So, where does that leave you in terms of what you say to a patient who’s finishing first line therapy and still has a good performance status; Leora?
Dr. Horn: So, I do talk to patients about the data being fairly controversial. In my clinical experience, the patients who don’t get PCI — many of them do end up with brain metastases at some point.
Dr. West: It’s very common in small cell.
Dr. Horn: Yeah, and so I tell them it may delay it, or if it’s not something you want to do, we don’t have to do it at this point. But, I do worry about those patients that we’re not doing PCI [for] anymore, because the Japanese studies suggested, you know, maybe we shouldn’t.
Dr. Solomon: Yeah, so one of the things that I’ve wondered about that Japanese study, which might make it different from the Slotman study, was the Japanese patients had pretty rigorous imaging of their brain, even prior to entry onto the study, so that study, to my recollection, gave PCI to patients who didn’t have brain metastases, and I wonder whether that might be an explanation for the differences seen. So, again, we have the discussion about PCI with the concerns about neurocognitive effects, but I wonder whether an alternative in someone who doesn’t want to have PCI is to have a policy of CNS imaging — but that’s not yet supported by data, but it might be something to think about.