An article published Online First and in the November edition of The Lancet Oncology reviews the treatments for patients with brain tumors. The current method is stereotactic radiosurgery (SRS), which is a technique for administering narrowly focused beams of irradiation to the brain in a very precise manner. This is done with or without whole-brain radiotherapy (WBRT). However, to date it has been unclear whether addition of WBRT outweighed the risks. The article is the work of Dr Eric L Chang, of The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA, and colleagues. The authors conclude that patients given WBRT are at greater risk of decline in learning and memory function. They recommend that SRS plus close clinical monitoring be the standard initial treatment.
Between 2001 and 2007, patients with one to three newly diagnosed brain metastases were randomly assigned to SRS plus WBRT (28 patients) or SRS alone (30 patients), in this randomised controlled trial. The primary endpoint was neurocognitive function. This can be objectively measured as a significant deterioration (5-point drop compared with baseline) in an assessment called the Hopkins Verbal Learning Test-Revised (HVLT-R) total recall at four months.
After these 58 patients were recruited, the trial was stopped. The reason was that there was a high probability of 96 percent that patients randomly assigned to receive SRS plus WBRT were significantly more likely to show a decline in learning and memory function at four months, than were patients assigned to receive SRS alone.
Results indicated that patients randomly assigned to SRS plus WBRT were more likely to show a significant drop in HVLT-R total recall at four months than were patients randomly assigned to SRS alone (52 percent compared to 24 percent, respectively). This was despite the fact that patients in the SRS alone group showed a higher overall brain tumour recurrence rate than did those patients in the SRS plus WBRT group. This finding remained clear at the six-month follow-up. At four months, there were four deaths (13 percent) in the group that received SRS alone, and eight deaths (29 percent) in the group that received SRS plus WBRT. Also, 73 percent of patients in the SRS plus WBRT group were free from recurrence after one year, compared with 27 percent of patients who received SRS alone. However, regardless of this difference in recurrence, the authors advise against WBRT because it causes more of decline in brain function. If tumors recur, they could be successfully managed with surgery if detected early through regular monitoring. This causes much less decline in brain function than is seen in those patients receiving WBRT upfront.
The authors explain: “Applicability of the findings is dependent on the willingness of patients and their physicians to adhere to a schedule of close monitoring, having consistent access to high-quality MRI, having access to a neurosurgical team willing and able to perform salvage resections when indicated, and applying strict physics quality-assurance procedures for SRS.”
They write in conclusion: “This study provides level 1 evidence to support the use of SRS alone in the initial management of patients newly diagnosed with one to three brain metastases. We recommend that initial SRS alone combined with close clinical monitoring should be the preferred treatment strategy for such patients.”
“Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial”
Eric L Chang, Jeffrey S Wefel, Kenneth R Hess, Pamela K Allen, Frederick F Lang, David G Kornguth, Rebecca B Arbuckle, J Michael Swint, Almon S Shiu, Moshe H Maor, Christina A Meyers
DOI: 10.1016/S1470-2045(09)70263-3
Written by Stephanie Brunner (B.A.)