New guideline for treatment of brain metastases emphasizes key role of local therapies
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ASCO, in collaboration with the Society for Neuro-Oncology and American Society for Radiation Oncology, has issued a guideline that emphasizes the significance of local therapies for patients with symptomatic brain metastases.
The societies convened a panel of experts from neurosurgery, neurology, neuro-oncology, medical oncology and radiation oncology to develop the guidance, based on results of 32 randomized clinical trials published in 2008 or later that included data on treatment for brain metastases from nonhematologic solid tumors.
“During the past few decades, effective treatment of brain metastases has been limited to the use of surgery and various forms of radiotherapy, and prior guidelines were generated largely by experts in neurosurgery and radiation oncology,” Michael A. Vogelbaum, MD, PhD, chief of neurosurgery and program leader of the department of neuro-oncology at Moffitt Cancer Center, told Healio. “Recent advances in the development of targeted therapies and immunotherapies for cancers that have a propensity to spread to the brain led to the discovery that treatment with some of these agents can produce intracranial responses in some patients.”
Vogelbaum spoke with Healio about what prompted the creation of the guideline, published in Journal of Clinical Oncology, the key recommendations, and continuing challenges for this patient population.
Healio: What prompted this guideline?
Vogelbaum: Although the data indicating treatment with certain systemically administered agents can produce intracranial responses in some patients have been exciting, they also created the risk of a change in the approach to initial treatment without a clear understanding of the role of other modalities that have been shown to be highly effective in producing durable intracranial disease control. A multidisciplinary group of experts recognized the need for a more comprehensive set of guidelines that included all modalities — medical, surgical and radiation-based — to help ensure the highest quality of care of patients with brain metastases.
Healio: What are the key recommendations?
Vogelbaum: The single most important recommendation relates to the use of first-line medical therapy in patients who would otherwise be eligible for a localized therapy, such as surgery or radiosurgery. For asymptomatic patients who have brain metastasis from a cancer that is likely to be responsive to a systemically administered targeted therapy or immunotherapy, it may be appropriate to use medical therapy alone, although consultation with a multidisciplinary team that includes neuro-oncology, neurosurgery and/or radiation oncology is recommended. Patients with symptomatic brain metastases who are eligible for treatment with surgery and/or radiosurgery should be managed with those established treatments — potentially in combination with a systemically administered therapy — but the evidence does not currently support use of systemically administered therapy alone in this group of patients.
Healio: What topics do key secondary recommendations address?
Vogelbaum: Other recommendations focus on specific situations in which use of targeted therapies or immunotherapies is supported by emerging clinical trial data. Additionally, some surgery- and radiation therapy-specific recommendations largely build upon those made in previous specialty-specific guideline processes.
Healio: What are the continuing challenges for this patient population?
Vogelbaum: Multiple questions still need to be answered to optimize the treatment of patients with brain metastases. The most obvious relate to the best ways to sequence and/or combine modalities. We also need to obtain higher-quality data with randomized trials that establish the relative efficacy and durability of treatment with use of systemic therapies vs. localized therapies, such as radiosurgery. Finally, we need to more fully understand the neurocognitive impact of each treatment modality individually or in combination.
Reference:
Vogelbaum MA, et al. J Clin Oncol. 2022;doi:10.1200/JCO.21.02314.
For more information:
Michael A. Vogelbaum, MD, PhD, can be reached at Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612; email: michael.vogelbaum@moffitt.org.
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