Reevaluating the Management of Patients with Brain Metastases

In a recent article published in Neurosurgery, Douglas Kondziolka, M.D., and colleagues1 present a “call to arms” for the medical community to take a fresh look at how patients with metastatic brain cancer are managed. This provocative article examines common “historical misconceptions” that continue to impact the day-to-day care patients receive:

  1. All metastatic tumors to the brain behave similarly. The histology, or cancer cell type of origin, has recently been demonstrated to have a significant impact on outcome. In the past, studies grouped all tumor types together (lung, breast, melanoma, etc.) and did not adequately differentiate one specific histology from another. This tumor-specific variable is critical in generating treatment decisions tailored to the individual patient.
  2. More than one metastatic tumor to the brain confers a worse outcome. Dr. Kondziolka et al. point out that this general statement might not always be the case. Several recent studies show that patients with multiple brain metastases can often have the same outcome as patients with a single brain tumor when a patient-specific, individualized treatment strategy is implemented.
  3. “There is no such thing as a single brain metastasis”. People often think that if an MRI shows one brain metastasis, then there must be multiple other tumors too small to be detected by MRI. The result of this thinking often leads to prophylactic radiation in the form of whole brain radiation therapy in the hopes of addressing tumors we assume are present without MRI evidence. In some instances, this approach leads to future problems with thinking and memory, a result of the long-term impact of radiation. This potential complication can sometimes be avoided if a more focused treatment strategy, such as gamma knife radiosurgery, is used to treat only the MRI-visible tumors at first detection.
  4. “Screening” MRI scans of the brain. Currently, most physicians do not routinely perform brain imaging unless a patient develops headaches, seizures and/or neurological deficits. This remains appropriate and is in line with current guidelines. However, many centers are beginning to perform screening MRI scans in the hopes of finding smaller brain metastases before they become symptomatic or large. Specifically, when the primary tumor histology demonstrates a predilection for brain metastases, several researchers feel that early detection and subsequent prevention of brain tumor progression is important to overall survival and best quality of life.

At The Valley Hospital’s Gamma Knife Center, our own data has also demonstrated superior outcomes when compared to previously published data from major academic centers utilizing universal protocols based on some of the concepts discussed above. Our independent findings strongly support the use of focused, individualized treatment strategies for all appropriate patients with any number of brain metastases. (Our presentation, “Community Cancer Center Experience using Gamma Knife Perfexion Radiosurgery as Stand-Alone and Adjuvant Treatment for Recursive Partitioning Analysis Class I and II Patient with Brain Metastases,” will be available at the Congress of Neurological Surgeons international conference in Boston, Mass., this fall.)

In my opinion, this report is both timely and in line with the current way of thinking at the Gamma Knife Center. Since we opened in November 2011, we have always focused on generating a patient-specific, individualized plan for every one of our patients with metastatic brain cancer. We believe—and have demonstrated—that focused, individualized care offers the best prognosis and quality of life to our patients suffering from metastatic cancer to the brain.

If you or someone you care about is considering treatment for brain metastases, please contact a center that will take the time to design a comprehensive, patient-specific, individualized plan before initiating therapy. Appropriate centers must have experience with gamma knife radiosurgery (or a similar stereotactic radiosurgery technology) to provide the best treatment options for you or your loved one.

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