Radiosurgery, cost-effectiveness, gold standards, the scientific method, cavalier cowboys, and the cost of hope

Estimating Survival in Melanoma Patients With Brain Metastases: An Update of the Graded Prognostic Assessment for Melanoma Using Molecular Markers (Melanoma-molGPA)

PURPOSE

To update the Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) for a markedly heterogeneous patient population, patients with melanoma and brain metastases, using a larger, more current cohort, including molecular markers.

METHODS

The original Melanoma-GPA is based on data from 483 patients whose conditions were diagnosed between 1985 and 2005. This is a multi-institutional retrospective database analysis of 823 melanoma patients with newly diagnosed brain metastases from January 1, 2006, to December 31, 2015. Multivariable analyses identified significant prognostic factors, which were weighted and included in the updated index (Melanoma-molGPA). Multiple Cox regression was used to select and weight prognostic factors in proportion to their hazard ratios to design the updated Melanoma-molGPA in which scores of 4.0 and 0.0 are associated with the best and worst prognoses, as with all of the diagnosis-specific GPA indices. Log-rank tests were used to compare adjacent classes.

RESULTS

There were 5 significant prognostic factors for survival (age, Karnofsky performance status [KPS], extracranial metastases [ECM], number of brain metastases, and BRAF status), whereas only KPS and the number of brain metastases were significant in the original Melanoma-GPA. Median survival improved from 6.7 to 9.8 months between the 2 treatment eras, and the median survival times for patients with Melanoma-molGPA of 0 to 1.0, 1.5 to 2.0, 2.5 to 3.0, and 3.5 to 4.0 were 4.9, 8.3, 15.8, and 34.1 months (P<.0001 between each adjacent group).

CONCLUSIONS

Survival and our ability to estimate survival in melanoma patients with brain metastases has improved significantly. The updated Melanoma-molGPA, a user-friendly tool to estimate survival, will facilitate clinical decision making regarding whether and which treatment is appropriate and will also be useful for stratification of future clinical trials. To further simplify use, a free online/smart phone app is available at brainmetgpa.com.

Increased survival with the combination of stereotactic radiosurgery and gefitinib for non-small cell lung cancer brain metastasis patients: a nationwide study in Taiwan

PURPOSE

Whole brain irradiation (WBRT) either with or without resection has historically been the treatment for brain metastases from non-small cell lung cancer (NSCLC). The effect of gamma knife (GK) radiosurgery, chemotherapy, or the combination remains incompletely defined. In this study, we assessed the outcome of brain metastases from non-small cell lung cancer treated by WBRT followed by GK, gefitinib, or the combination of GK and gefitinib.

MATERIAL AND METHODS

We retrieved the records of NSCLC patients with brain metastases from the National Health Insurance Research Database (NHIRD) of Taiwan from 2004 to 2010. WBRT either with or without resection was the first line treatment for nearly all patients. The decision to add GK and/or gefitinib treatment was at the discretion of the treating physician and based upon a patient's medical records and imaging data. These patients were classified into four groups including WBRT, WBRT + gefitinib, WBRT + GK, WBRT + gefitinib + GK. These data was evaluated for difference in survival and factors that portended an extended survival from the time of brain metastasis diagnosis.

RESULTS

Of the 60194 patients with newly diagnosed NSCLC, 23874 (39.6 %) developed brain metastases. The distribution of patients for the groups was WBRT for 20241, WBRT + gefitinib for 3379, WBRT + GK for 155, and WBRT+ gefitinib + GK for 99 patients. The median survival for the time of brain metastasis diagnosis for WBRT, WBRT+ gefitinib, WBRT+ GK, WBRT+ gefitinib + GK groups was 0.53, 1.01, 1.46, and 2.25 years, respectively (p < 0.0001). The hazard ratio (95 % CI) for survival was 1, 0.56, 0.43, and 0.40, respectively (p < 0.001). The adjusted hazard ratio (95 % CI) by age, sex and Charlson comorbidity index (CCI) was 1, 0.73, 0.49, and 0.42, respectively (p < 0.001).

CONCLUSION

Patients with brain metastases from NSCLC receiving GK or gefitinib demonstrated extended survival. The improved survival seen with GK and gefitinib suggests a survival benefit in selected patients receiving the combined treatment. Further Phase II study should be conducted to assessment these influence.

Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States

PURPOSE

The indications for treatment of brain metastases from non-small cell lung cancer (NSCLC) with stereotactic radiosurgery (SRS) remain controversial. We studied patterns, predictors, and cost of SRS use in elderly patients with NSCLC.

METHODS AND MATERIALS

Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients with NSCLC who were diagnosed with brain metastases between 2000 and 2007. Our cohort included patients treated with radiation therapy and not surgical resection as initial treatment for brain metastases.

RESULTS

We identified 7684 patients treated with radiation therapy within 2 months after brain metastases diagnosis, of whom 469 (6.1%) cases had billing codes for SRS. Annual SRS use increased from 3.0% in 2000 to 8.2% in 2005 and varied from 3.4% to 12.5% by specific SEER registry site. After controlling for clinical and sociodemographic characteristics, we found SRS use was significantly associated with increasing year of diagnosis, specific SEER registry, higher socioeconomic status, admission to a teaching hospital, no history of participation in low-income state buy-in programs (a proxy for Medicaid eligibility), no extracranial metastases, and longer intervals from NSCLC diagnosis. The average cost per patient associated with radiation therapy was 2.19 times greater for those who received SRS than for those who did not.

CONCLUSIONS

The use of SRS in patients with metastatic NSCLC increased almost 3-fold from 2000 to 2005. In addition, we found significant variations in SRS use across SEER registries and socioeconomic quartiles. National practice patterns in this study suggested both a lack of consensus and an overall limited use of the approach among elderly patients before 2008.

[Stereotaxic brain radiosurgery in Hungary 1991-2009]

Stereotaxic brain radiosurgery as a non-invasive type of local treatment appeared as a therapeutic approach of intracranial lesions in the middle of the last century. Originally it was developed for treating functional disorders but with the evolution of their medication the clinical need increasingly turned to treating pathomorphological intracerebral target volumes. A review of the indication's historical changes and the installation, methods, results and perspectives of Hungarian brain radiosurgery are presented. During the above mentioned period 2565 patient have been treated in five institutes of Hungary: 52% for brain metastases, 29.5% for benignomas, 12% for arteriovenous malformations, 6% for primary malignant brain tumors and 0.5% for functional disorders. Local tumor control of 86% and median survivals among patients with metastasis of 24 months in RPA class 1, 8.5 months in RPA 2 and 3.4 months in RPA 3 were reported. These results are comparable with those in the literature. Hopefully with a change in the therapeutic approach and better organization of patients' management, stereotaxic brain radiosurgery will be integrated into everyday routine in Hungary.

Role of Stereotactic Radiosurgery in the Treatment of Brain Metastases

Stereotactic radiosurgery (SRS) is a highly conformal form of radiation therapy designed to deliver a high dose in a single treatment to the target volume while sparing adjacent normal tissues. Its role in the treatment of brain metastases continues to be defined, but the recently reported RTOG 95-08 trial demonstrated a survival benefit with the addition of SRS to whole-brain radiation therapy in select patients with a single brain metastasis, as well as a local control and palliative benefit in select patients with 1 to 3 brain metastases. The authors review the role of SRS in the treatment of brain metastases and discuss the use of SRS with or without whole-brain radiation therapy, optimal dose of SRS, SRS delivery methods, and selection of appropriate patients for SRS.

Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial

BACKGROUND

Brain metastases occur in up to 40% of all patients with systemic cancer. We aimed to assess whether stereotactic radiosurgery provided any therapeutic benefit in a randomised multi-institutional trial directed by the Radiation Therapy Oncology Group (RTOG).

METHODS

Patients with one to three newly diagnosed brain metastases were randomly allocated either whole brain radiation therapy (WBRT) or WBRT followed by stereotactic radiosurgery boost. Patients were stratified by number of metastases and status of extracranial disease. Primary outcome was survival; secondary outcomes were tumour response and local rates, overall intracranial recurrence rates, cause of death, and performance measurements.

FINDINGS

From January, 1996, to June, 2001, we enrolled 333 patients from 55 participating RTOG institutions--167 were assigned WBRT and stereotactic radiosurgery and 164 were allocated WBRT alone. Univariate analysis showed that there was a survival advantage in the WBRT and stereotactic radiosurgery group for patients with a single brain metastasis (median survival time 6.5 vs 4.9 months, p=0.0393). Patients in the stereotactic surgery group were more likely to have a stable or improved Karnofsky Performance Status (KPS) score at 6 months' follow-up than were patients allocated WBRT alone (43% vs 27%, respectively; p=0.03). By multivariate analysis, survival improved in patients with an RPA class 1 (p<0.0001) or a favourable histological status (p=0.0121).

INTERPRETATION

WBRT and stereotactic boost treatment improved functional autonomy (KPS) for all patients and survival for patients with a single unresectable brain metastasis. WBRT and stereotactic radiosurgery should, therefore, be standard treatment for patients with a single unresectable brain metastasis and considered for patients with two or three brain metastases.

Practice parameters for the management of single brain metastasis

Object

In January 1998 the Guidelines and Outcomes Committee of the American Association of Neurological Surgeons (AANS) issued a charge for the development of evidence-based practice parameters focusing on the treatment of patients with single metastasis to the brain. The charge was imposed in response to the significant controversy surrounding questions relating to the optimal management strategies for patients with single brain metastasis.

Methods

A team consisting of physicians from the AANS, the American Academy of Neurology, and the American Association of Therapeutic Radiation Oncology convened and the literature was reviewed. Methodically drawing from the best of Class I, II, and III levels of available evidence, authors sought to determine how the literature addressed and disposed of the question of the optimal management for an adult with a known history of cancer and a single meta-static brain lesion. Framing the question in this specific manner allowed researchers to focus directly on treatment issues, without having to consider diagnostic issues.

Conclusions

The results of the evidence-based analysis demonstrated that there was insufficient information to establish standards of care. Data from the literature does, however, support a guideline stating that surgical resection accompanied by whole brain radiation therapy is associated with the best survival rate. Additional lower-quality evidence supports an option for management with radiosurgery.

[Radiosurgery of single brain metastasis without combined total cerebral irradiation. Results of a consecutive series of 12 cases]

PURPOSE

To evaluate the usefulness of radiosurgery without whole brain irradiation for a solitary brain metastasis.

PATIENTS AND METHODS

Between December 1994 and November 1996, 12 patients were treated for a single brain metastasis by radiosurgery alone. Median age was 53, and 10 patients had a Karnofsky performance status above 70. Half the patients had active extracranial disease at the time of radiosurgery. Stereotactic radiosurgery delivered a single dose of 20 Gy (specified at the isocenter with a 70% isodose reference curve). Evaluation of results was performed according to local control, survival, evolution of performance status, as well as evolution of neurologic symptoms.

RESULTS

No patient had immediate toxicity. One month later, ten patients showed improvement in their neurologic impairments, and none had progression of the cerebral lesion according to CT scan evaluation (diminution for seven patients, and stabilization for five). Local control rate was 58%, and median time to failure was 4 months. The overall median survival time was 10 months. Three patients were alive, with good performance status, and six died following cerebral progression.

CONCLUSION

These poor results in terms of local control are in favor of supplementary whole brain irradiation, except for particular cases.

[Could the evaluation of the cost of complications be a worthwhile means to improve radiotherapy?]

At the present time, the current improvement of technical and dosimetric aspects of radiation oncology has to be evaluated in terms of potential benefit for the patient and the society. For this last point of view, specially designed economic analyses must be performed in order to justify the number of resources involved by these technical improvements. If the question is how the current technical procedures could reduce the risk of undesirable side-effects, the response cannot be immediately drawn from the literature. This paper emphasizes the possibility to evaluate the role of side-effects as endpoints of economic analyses when using special models in medical decision making such as Markov's. Only few oncologic situations are reliable to properly analyze the relationship between sophisticated radiation techniques and the incidence of post-radiation complications. These situations should be selected when prospective economic analyses are planned in the field of radiation therapy.

[Radiotherapy in stereotactic conditions (radiosurgery) in malignant brain tumors: clinical research]

We have looked for trials which are in progress in the field of stereotactic radiotherapy (radiosurgery) of malignant brain tumors. Most randomized trials are conducted by the Radiation Therapy Oncology Group (RTOG) or the European Organization for Research and Treatment of Cancer (EORTC) and assess the role of radiosurgery in treatment of high grade glioma and brain metastasis.

[Radiosurgery of brain metastasis]

Radiosurgery has recently provided an alternative to conventional therapy for the treatment of brain metastases. This non-invasive technique delivers a single large fraction of ionizing radiation to a well-defined small intracranial target as brain metastases. After a computerized tomography (CT) with stereotactic frame in place for tumor localization, a dosimetric study was performed. The sharp dose gradient of radiation reduces the dose to the surrounding normal structures at a minimal level (> 10%). The prescribed dose at the periphery of the lesion varies from 8 to 27 Gy with a combined whole brain irradiation and from 20 to 35 Gy without any irradiation. Radiosurgery has been reported to be highly efficacious with a local control rate of 86% (not increased size without local recurrence). Brain metastases from melanoma and renal carcinoma are usually resistant to conventional irradiation and are highly sensitive with this technique. The morbidity is very low with a symptomatic edema rate of 5-10% at 2 years, resolved with corticosteroids. A radiation necrosis has been reported in less than 5% of cases. The patients with a good performance status, without any extracranial metastasis and with a solitary brain metastases have presented the best survival rate. New brain metastases have occurred in 20 to 30% of the cases during the follow-up. Eleven to 25% of patients died from their intracranial disease and the others from the extracranial evolution of the cancer. The median survival was still poor, ranging from 8 to 12 months. Radiosurgery is a good choice for surgically inaccessible and recurrent tumors. It represents an alternative to the neurosurgery with or without whole brain irradiation, taking into account different prognostic factors and morbidity rate. The local control and the survival rates without neurologic symptom should be considered the major endpoints of different ongoing randomized studies for evaluating the role of the radiosurgery.

Surgical treatment of metastatic brain tumors

Key elements in the modern surgical treatment of metastatic brain tumors are a firm grasp of criteria for selection of proper surgical candidates and a thorough grounding in the surgical approaches to, and the anatomy of, cerebral metastases. It is important to realize that the presence of multiple or recurrent brain metastases does not automatically contraindicate surgery because in properly selected patients, resection of multiple metastases or reoperation for recurrent metastases can extend survival and enhance the quality of life. Appropriate treatment of metastatic brain tumors frequently requires the judicious use of modalities such as open craniotomy, whole brain radiotherapy, and stereotactic radiosurgery. In order to assure the best outcome of patients with cerebral metastases, it is necessary to have an awareness of how these modalities can best complement one another and to apply them accordingly.

Whole brain radiotherapy in the treatment of metastatic brain tumors

Previous prospective and retrospective trials have failed to demonstrate the best treatment approach for patients with brain metastases. As a result, fractionated whole brain radiotherapy (WBRT) has been the mainstay of treatment for several decades. However, with improved surgical techniques and the advent of radiosurgical procedures to treat single and multiple metastases, the continued value of WBRT is in question. This is particularly true in the treatment of a favorable patient subset where the risks of long-term morbidity need to be addressed. This article reviews the trials of the Radiation Therapy Oncology Group (RTOG) and other select radiotherapy brain metastases trials, and compares their morbidities and outcomes to surgical and radiosurgical techniques. It is unfortunate that the inherent selection bias in most retrospective studies makes comparisons difficult. Therefore, to better understand the roles of WBRT, surgery, and radiosurgery in the treatment of brain metastases, additional randomized studies need to be conducted on homogeneous patient groups.