ASTRO updates guideline on radiation therapy for brain metastases
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American Society for Radiation Oncology has issued a guideline on use of radiation therapy to treat patients with brain metastases.
“This evidence review and guideline were developed in order to update prior ASTRO guidance that was 10 years old,” Vinai Gondi, MD, vice chair of the guideline task force and director of research and education at Northwestern Medicine Cancer Center and Proton Center in Chicago, told Healio. “The guideline also reflects recent developments in the management of patients with brain metastases, including advanced radiotherapy techniques such as stereotactic radiosurgery and hippocampal avoidance whole-brain radiation therapy to reduce side effects of radiotherapy, emerging central nervous system-active systemic therapies such as targeted therapies and immunotherapy as alternatives or adjuncts to radiotherapy, and more detailed tools to estimate patient survival such as the graded prognostic assessment.”
Healio spoke with co-chairs of the guideline panel about the key recommendations in the guideline, published in Practical Radiation Oncology, and why they are needed.
Rationale for new guideline
In December, ASCO, Society for Neuro-Oncology (SNO) and ASTRO published a joint guideline on the treatment of brain metastases, including general recommendations on the use of radiotherapy for patients with brain metastases.
“ASTRO recognized a need for more detailed recommendations that would address specifics of radiotherapy dose, fractionation and approach, sequence of surgery, and radiotherapy and radionecrosis,” Paul D. Brown, MD, chair of the guideline task force and professor of radiation oncology at Mayo Clinic in Rochester, Minnesota, told Healio. “Thus, ASTRO convened a multidisciplinary team of radiation, medical and neurosurgical oncologists, a radiation oncology resident, a medical physicist, and a patient representative to develop this guideline in collaboration with American Association of Neurological Surgeons/Congress of Neurological Surgeons, ASCO and SNO, who provided representatives and peer reviewers.”
Key recommendations
The guideline specifically addresses patient selection, radiation therapy planning and delivery techniques to manage unresected and resected brain metastases and offers treatment algorithms for limited brain metastases and extensive brain metastases.
“There is a focus on advanced radiotherapy techniques, such as stereotactic radiosurgery and hippocampal avoidance whole-brain radiation therapy, that improve control of brain metastases and lead to fewer side effects and better quality-of-life outcomes,” Brown said.
Key recommendations for unresected brain metastases include:
Stereotactic radiosurgery for patients with one to four brain metastases and ECOG performance status of 0 to 2. Stereotactic radiosurgery is conditionally recommended for those with five to 10 brain metastases and reasonable performance status, and a multidisciplinary discussion with neurosurgery is recommended to consider surgical resection for patients with tumors exerting mass effect and/or larger size.
Upfront local therapy for patients with symptomatic brain metastases, and multidisciplinary and patient-centered decision-making for patients with asymptomatic brain metastases who are eligible for CNS-directed systemic therapy, to assess whether local therapy may be safely deferred.
Whole-brain radiation therapy as primary treatment for patients with favorable prognosis brain metastases who are ineligible for surgery and/or stereotactic radiosurgery. Hippocampal avoidance is suggested to preserve memory function and memantine is recommended to delay neurocognitive decline; however, routine adjuvant whole-brain radiation therapy combined with stereotactic radiosurgery is not recommended.
Whole-brain radiation therapy may not improve outcomes compared with supportive care alone among patients with poor prognoses and brain metastases, according to the guideline. Palliative care or hospice or short-course whole-brain radiation therapy are reasonable options for symptomatic brain metastases, it states.
The guideline further states that patients’ total tumor volume, tumor location, age and extracranial disease status should also be considered during patient-centered decision-making.
For patients with resected brain metastases:
Radiation therapy following resection of brain metastases is recommended to improve intracranial control, and postoperative stereotactic radiosurgery is recommended vs. whole-brain radiation therapy for those with limited brain metastases after resection to preserve neurocognitive function and quality of life.
Stereotactic radiosurgery before resection is conditionally recommended as a potential alternative to postoperative stereotactic radiosurgery.
Looking ahead
“Advances in radiotherapy, medical therapy and neurosurgical resection have not only significantly widened the breadth of treatment options available to patients with brain metastases, but also amplified the importance of remaining abreast of these treatment advances in order to ensure a patient-centered decision-making process by a multidisciplinary team,” Gondi said. “The ASTRO guidelines are meant to be helpful to the entire radiation oncology team, as well as collaborating oncology specialists outside radiation oncology, in complementing the recently published ASCO-SNO-ASTRO guidelines for brain metastasis management and providing the framework for multidisciplinary, patient-centered decision-making.”
For more information:
Paul D. Brown, MD, can be reached at brown.paul@mayo.edu.
Vinai Gondi, MD, can be reached at vinai.gondi@nm.org.
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