Whole brain radiotherapy for the treatment of multiple brain metastases

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Whole brain radiotherapy for the treatment of multiple brain metastases

Updated
Authors: 
Tsao MN, Xu W, Wong RKS, Lloyd N, Laperriere N, Sahgal A, Rakovitch E, Chow E

The issue
A large proportion of people with cancer will receive a diagnosis of the spread of cancer (metastases) to the brain. Radiotherapy is commonly used to treat brain metastases.

The aim of the review
We conducted this review to determine the effectiveness and adverse effects of whole brain radiotherapy (WBRT) given alone or in combination with other treatments to adults with multiple brain metastases.

What are the main findings?
This review includes 54 published trials involving 11,898 participants.

Data show no apparent additional benefit of altered WBRT dose schedules compared with standard dose schedules.

Use of other treatments such as chemotherapy, radiosensitisers, and molecular targeted agents in conjunction with WBRT has not yet been shown to be of benefit.

Radiosurgery boost with WBRT does not improve survival among selected people with multiple brain metastases. WBRT when added to radiosurgery improves local and distant brain control. However, neurocognitive outcomes are better for selected people treated with radiosurgery alone as compared with WBRT and radiosurgery.

For selected individuals with metastatic non-small-cell lung cancer to brain, survival may not be better with WBRT and optimal supportive care than with optimal supportive care alone.

Quality of the evidence
Studies have provided evidence of moderate to high certainty.

What are the conclusions?
Altered higher biological WBRT dose-fractionation schemes, as reported in randomised trials, did not confer benefit for overall survival, neurological function, or symptom control compared with standard treatment (3000 cGy in 10 daily fractions, or 2000 cGy in 4 or 5 daily fractions). However, overall survival and neurological function were worse for lower biological WBRT dose-fractionation schemes than for standard dose schedules.

The addition of WBRT to radiosurgery improved local and distant brain control (i.e. absence of new intracranial lesions at the site or outside of treated lesions after treatment) among selected people with brain metastases, but investigators reported worse cognitive outcomes and no differences in overall survival.

Selected people with multiple brain metastases from non-small-cell lung cancer may show no difference in overall survival when optimal supportive care is given and WBRT is omitted.

Use of other treatments (radiosensitisers, chemotherapy, or molecular targeted agents) in conjunction with WBRT remains experimental.

Additional trials are needed to evaluate strategies to protect cognitive decline associated with WBRT. As well, future trials should examine people with brain metastases with focus on prognostic features and tumour characteristics.

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