What is the best intervention for a patient with brain metastases (cancer that has spread to the brain)?

From the Guidelines

For patients with brain metastasis, the best intervention is often stereotactic radiosurgery (SRS) for limited metastases (1-4 lesions), while whole brain radiation therapy (WBRT) plus memantine and hippocampal avoidance may be recommended for multiple or diffuse metastases, as supported by the most recent guidelines 1. The management of brain metastases is complex and depends on various factors including the number, size, and location of metastases, primary cancer type, patient's overall condition, and symptoms.

Key Considerations

• For patients with a favorable prognosis for survival and a single brain metastasis, treatment options include surgery with postoperative radiation, SRS alone, WBRT plus memantine and hippocampal avoidance, hypofractionated stereotactic radiotherapy, and discussion of systemic therapy in select patients 1.
• For patients with limited (two to four) metastases, treatment options include resection for large symptomatic lesion(s) plus postoperative radiotherapy, SRS for additional smaller lesions, SRS, hypofractionated stereotactic radiotherapy, or WBRT plus memantine and hippocampal avoidance for inoperable metastases 1.
• Systemic therapy options, such as the HER2CLIMB regimen of tucatinib plus capecitabine plus trastuzumab, may be offered to patients with HER2-positive metastatic breast cancer who have brain metastases without symptomatic mass effect and whose disease has progressed on one HER2-directed therapy for metastatic disease 1.

Treatment Goals

• The goal of treatment is to control intracranial disease while preserving neurological function and quality of life.
• Treatment selection is guided by a multidisciplinary approach involving neurosurgery, radiation oncology, and medical oncology.
• Supportive care with dexamethasone and anticonvulsants like levetiracetam may be added to manage cerebral edema and related symptoms, such as seizures. Some key points to consider when making a treatment decision include:
• The number and size of brain metastases
• The location of brain metastases
• The primary cancer type
• The patient's overall condition and symptoms
• The potential benefits and risks of each treatment option
• The importance of a multidisciplinary approach to treatment planning.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Brain Metastasis

• Surgical excision should be considered for patients with good performance status, minimal or no evidence of extracranial disease, and a surgically accessible single brain metastasis amenable to complete excision 2
• Postoperative whole-brain radiation therapy (WBRT) should be considered to reduce the risk of tumor recurrence for patients who have undergone resection of a single brain metastasis 2
• WBRT followed by stereotactic radiosurgery (SRS) boost should be considered as an alternative to surgical resection for patients with single brain metastasis 2
• SRS may be used to treat extensive brain metastases (>10-15 metastases), and clinical trials are currently comparing WBRT with SRS for extensive disease 3

Comparison of Treatment Options

• A meta-analysis of two trials found no statistically significant difference in overall survival between WBRT plus radiosurgery and WBRT alone groups, but patients with one brain metastasis had significantly longer median survival in the WBRT plus SRS group 4
• WBRT plus SRS showed improved survival in brain metastatic cancer patients with better prognostic factors, particularly when compared to WBRT only 5
• The combination of WBRT and SRS may improve survival and could be recommended selectively in patients with favorable prognostic factors 5

Considerations for Treatment

• The size and location of the metastasis determine the optimal approach, and no high-quality data are available regarding the choice of surgery versus radiosurgery for single brain metastasis 2
• WBRT is associated with toxicities, including neurocognitive impairment and leukoencephalopathy, and modern radiation technology may be able to reduce the morbidity of this therapy 6
• The optimal dose and fractionation schedule for WBRT is 3000 cGy in 10 fractions or 2000 cGy in 5 fractions, but the choice of fraction size is believed to be important to minimize long-term neurocognitive effects 2