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01-08-2016 | Oncology | News | Article

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Stereotactic surgery sufficient for care of patients with one to three brain metastases

medwireNews: Stereotactic surgery (SRS) may be a good option for patients with one to three brain metastases, say researchers who believe monotherapy offers comparable overall survival to joint therapy with whole brain radiotherapy (WBRT) and greater preservation of cognition.

The results of the randomised clinical trial comparing SRS alone (20–24 Gy) or with WBRT (18–22 Gy plus 30 Gy WBRT in 12 fractions) in 213 patients with extracerebral solid tumours and brain metastases less than 3 cm in diameter are reported in JAMA.

The 63 patients given only SRS who were assessed at 3 months were significantly less likely to experience cognitive decline, as demonstrated on at least one of seven cognitive tests, than the 48 patients who were treated with SRS and WBRT, affecting 63.5% versus 91.7%.

This was replicated in patients who survived for at least 1 year, with cognitive deterioration at 3 months affecting 45.5% of 11 patients given SRS versus 94.1% of the 17 given combined therapy. The corresponding rate of cognitive deterioration at 1 year was 60.0% versus 94.4%, with a significant –34.4% difference.

SRS was also associated with a significantly higher quality of life (QOL) at 3 months, with a mean change from baseline on the Functional Assessment of Cancer Therapy–Brain scale of –0.1 versus –12.0 points. There was no difference, however, with regard to loss of functional independence between the groups at the 3-month checkpoint.

Patients given SRS alone had a shorter time to intracranial failure than those given SRS plus WBRT (hazard ratio=3.6) but overall survival was comparable at 10.4 months versus 7.4 months.

Lead author Paul Brown, from the Mayo Clinic in Rochester, Minnesota, USA, and team admit that the patients were aware of their assigned treatment and note that another potential study limitation is that the primary endpoint was cognitive decline after just 3 months, noting that “the results may reflect only a temporary and potentially reversible decrease in cognitive function and QOL”.

“However, because survival for the vast majority of patients with brain metastases is measured in months, many patients would have no opportunity to recover from the known toxic effects of WBRT”, they write.

“Even if some delayed recovery in cognition and QOL were to occur in a subpopulation of patients, the detrimental effects of WBRT would negatively affect the cognitive function and QOL of remaining survival in a significant majority of patients.”

Carey Anders, from University of North Carolina at Chapel Hill in the USA, and co-authors of a linked comment say that the debate between WBRT and SRS may be “resolved” for patients with one to three metastases but note that most patients do not fit the study characteristics.

“Thus, based on the robust findings from the current study and until proven otherwise, WBRT may still have an important role for treatment of patients who are not in this specific disease category”, they write.

And they caution that the “study results cannot be extrapolated to infer that SRS is the standard for patients with 4 or more metastases or that WBRT no longer has a role in the treatment of brain metastases.”

By Lynda Williams, Senior medwireNews Reporter 

medwireNews is an independent medical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2016