Abstract
Stereotactic radiosurgery is frequently used, either alone or together with whole-brain radiation therapy to treat brain metastases from solid tumors. Certain experts and radiation oncology groups have proposed replacing whole-brain radiation therapy with stereotactic radiosurgery alone for the management of brain metastases. Although randomized trials have favored adding whole-brain radiation therapy to stereotactic radiosurgery for most end points, a recent meta-analysis demonstrated a survival disadvantage for patients treated with whole-brain radiation therapy and stereotactic radiosurgery compared with patients treated with stereotactic radiosurgery alone. However the apparent detrimental effect of adding whole-brain radiation therapy to stereotactic radiosurgery reported in this meta-analysis may be the result of inhomogeneous distribution of the patients with respect to tumor histologies, molecular histologic subtypes, and extracranial tumor stages between the groups rather than a real effect. Unfortunately, soon after this meta-analysis was published, even as an abstract, use of whole-brain radiation therapy in managing brain metastases has become controversial among radiation oncologists. The American Society of Radiation Oncology recently recommended, in their “Choose Wisely” campaign, against routinely adding whole-brain radiation therapy to stereotactic radiosurgery to treat brain metastases. However, this situation creates conflict for radiation oncologists who believe that there are enough high level of evidence for the effectiveness of whole-brain radiation therapy in the treatment of brain metastases.
Highlights
The recent meta-analysis of Sahgal et al [5, 6] has dissuaded many radiation oncologists against routinely adding wholebrain radiation therapy (WBRT) to SRS for patients with 1 to 4 brain metastases, and have concluded that such addition is detrimental with respect to survival, especially for patients younger than 50 years of age
Sahgal et al acknowledge that further research and prospective data are required because their findings are based on subgroup analysis and are hypothesis generating, they presented the data to the world as if the survival advantage observed in patients younger than 50 years of age was the result of treatment of brain metastases with SRS-alone, and the avoidance of detrimental effects of WBRT addition with respect to health related quality of life, and neurocognitive functions [5, 6, 16]
Before considering WBRT as detrimental to patients with brain metastases, we should question the validity of the data in the recent meta-analysis
Summary
For patients with brain metastases, stereotactic radiosurgery (SRS) has become an increasingly available treatment, especially as the range of stereotactic treatment technologies progresses. Wholebrain radiation therapy (WBRT) has been used to treat brain metastases together with SRS, a recent trend promotes the use of SRS-alone. This trend is mainly based on the adverse effect of WBRT on neurocognitive functioning and quality of life scores. The data in this area is controversial and may not be reliable due to early evaluation of these end points after WBRT with a limited number of patients [1,2,3,4]
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