AS MANY AS ONE IN 10 PEOPLE with cancer in the U.S. will develop brain metastases, defined as cancer that has spread to the brain from other parts of the body. While in the past, people with brain metastases often died within months, survival has greatly improved thanks to treatment advances in the past two decades. Survival still varies widely depending on the primary cancer diagnosis, but many with brain metastases now live for years.
In light of treatment improvements and a growing list of options, the American Society of Clinical Oncology (ASCO) convened an expert panel, including neurosurgeons, neurologists, neurooncologists, medical oncologists and radiation oncologists, to systematically review the evidence and provide guidance for doctors treating those living with brain metastases. The guidelines published Feb. 10, 2022, in the Journal of Clinical Oncology, which cover topics such as when surgery or radiation in various forms is needed, are based on a review of studies published from January 2008 to April 2020 together with the clinical experience of the contributors.
Cancer Today spoke with neurologist David Schiff, co-chair of the ASCO panel and co-director of the UVA Cancer Center’s Neuro-Oncology Center in Charlottesville, Virginia, about what this guidance means for people with brain metastases.
CT: Why was it the right time to conduct a thorough review of the evidence and develop these new guidelines?
SCHIFF: There have been vast changes in management of brain metastases over the last 15 years, especially in terms of the role of various forms of radiation delivery and chemotherapy. Moreover, there was no existing comprehensive set of guidelines. … With the multiplicity of potential treatments, [including] surgery, laser interstitial thermal therapy, stereotactic radiosurgery, whole brain radiotherapy, targeted therapies and immunotherapy, it is hard even for specialists to keep up with treatment options and their relative benefits. These guidelines provide a roadmap to making rational treatment decisions.
CT: What are some of the key recommendations in these new guidelines?
SCHIFF: The guidelines emphasize the importance of local therapies—surgery or stereotactic radiosurgery—when feasible for symptomatic brain metastases [cases where the tumors affect brain function] and lay out when these modalities are feasible. They highlight situations in which local therapy or whole brain radiotherapy can be deferred in place of chemotherapy, targeted therapy or immunotherapy depending on tumor histology and molecular features.
CT: What do the guidelines mean for those living with brain metastases?
SCHIFF: All the recommendations are based upon published clinical studies. As such, none of the recommendations is practice changing. What the recommendations do is to bring together in one place a comprehensive, carefully vetted set of guidelines that physicians from all the disciplines involved in treating patients with solid tumors can rely upon to chart a treatment path for an individual patient with cancer [that has spread to the brain].
With the rapid advances over the last 20 years in brain metastasis management from well-designed clinical trials, decision-making for patients has become more complicated. When I started in the field, development of brain metastases typically resulted in immediate referral to a radiation oncologist. Now, medical oncologists may reach out initially to neurosurgeons for consideration of radiosurgery or resection, or even consider trying systemic therapy as a first step. Nonetheless, experts agree that patients benefit from decision-making input from all these subspecialists. It’s hard for subspecialists like medical oncologists to keep up with all the advances in radiation oncology and neurosurgery, and vice versa; thus, having all the relevant studies distilled into a single document is incredibly helpful. The consensus among expert subspecialists reflected in these new guidelines means that subspecialists from any of these disciplines in the community can rely upon these guidelines as a general roadmap on patient management and know what types of therapies or referrals should be considered.
Historically, patients with brain metastases were usually treated with whole brain radiation therapy. This wasn’t usually terribly effective, and a substantial portion of patients experienced fatigue [and] memory and concentration problems from this treatment. The carefully done studies summarized in these guidelines have resulted in better control of brain metastases with less cognitive toxicity. More effective and safer treatment is a win for the patient.
CT: What should patients know and perhaps consider asking their doctors about the new guidelines?
SCHIFF: I think patients with brain metastases could ask the doctor making a treatment recommendation how that recommendation aligns with the guidelines. [They might also ask] whether their recommendation has been discussed with the other relevant specialists, [including] a neurosurgeon, medical or neuro-oncologist, and radiation oncologist. The guidelines emphasize the importance of multidisciplinary physician input, in addition to patient involvement, in developing a treatment plan for brain metastases.