Best supportive care in patients with brain metastases and adverse prognostic factors: development of improved decision aids

Abstract

BSC is a reasonable choice in patients with limited life expectancy. After successful external validation of the selection criteria developed in this analysis, identification of patients who are unlikely to benefit from WBRT might be improved.

Stereotactic radiosurgery (SRS) for brain metastases: a systematic review

“…The major obstacle against the general adoption of combined SRS and WBRT is the fear of neurocognitive decline after WBRT. Patients with limited survival expectation because of progressive, uncontrollable extracranial disease should be managed with WBRT or best supportive care rather than SRS [85,86]. …”

External validation of a prognostic score predicting overall survival for patients with brain metastases based on extracranial factors

“…The role of extracranial factors such as performance status, extent of extracranial metastases or control of the primary tumor provided some additional valuable information about an individual’s prognosis [22]. A further refinement of the individual prognosis within the group of patients with very limited survival was possible after inclusion of such widely available and cheap biochemical surrogate parameters such as LDH and albumin [6].…”

Palliative radiotherapy at the end of life: A critical review

“…Various studies have evaluated the available prognostic instruments while seeking the optimal treatment of this patient group (Table 11). [66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81] Thus, the management of brain metastases has evolved significantly over the past 30 years, but challenges remain in the treatment of patients with brain metastases and poor prognosis. Although whole-brain radiotherapy may offer some clinical benefit, the extent of this benefit remains poorly defined, particularly in patients with short survival.…”

“…Comparison of existing prognostic instruments l Nine existing prognostic instruments were compared l Factors used to predict outcome were similar but not identical across these tools l Major misclassification rates varied from 2% to 39%, with 6 of the 9 instruments having misclassification rates >25% l The 2 instruments with the lowest misclassification rates have not yet been validated Nieder 2013 77 Retrospective analysis l A total of 124 patients with poor prognosis who received best supportive care, whole-brain radiotherapy, or stereotactic radiosurgery l Factors favoring best supportive care rather than radiotherapy included age 75 y, KPS 50, and uncontrolled primary tumor with extracranial metastases to at least 2 organs Craighead 2012 78 Population-based study, Alberta, Canada l A total of 568 poor-prognosis patients treated with whole-brain radiotherapy l Overall survival was 3 mo, with factors predicting poor prognosis including low KPS, advanced age, and a larger number of brain lesions Langley 2013 79 Ongoing prospective randomized trial l Randomization of poor-prognosis patients with non-small cell lung cancer metastasized to brain between best supportive care plus whole-brain radiotherapy vs best supportive care alone l Interim report suggests no improvement in overall survival or quality of life for patients treated with wholebrain radiotherapy Nieder 2013 80 Retrospective analysis l Patients with brain metastases, poor prognosis, and diagnoses other than non-small cell lung cancer l The addition of whole-brain radiotherapy did not add to median survival other than perhaps a slight amount in those with small cell lung cancer metastases KPS indicates Karnofsky performance score.…”