Overall survival after initial radiotherapy for brain metastases; a population based study of 2140 patients with non-small cell lung cancer

Overall Survival after Radiotherapy for Brain Metastases According to ECOG Status-A Prospective Study of 294 NSCLC Patients

Up to 40% of non-smallcell lung cancer (NSCLC) patients develop brain metastases (BMs). The potential benefits of radiotherapy (RT) in patients with poor performance status (PS) are questionable, with considerable risk for futile treatment. We analyzed overall survival after initial radiotherapy in NSCLC patients with BMs, focusing on the relationship between PS and survival after RT. This study reports a prospective observational study including consecutive 294 NSCLC patients with first-time BMs. Overall survival (OS) was calculated from the start of RT to death or last follow-up (1 June 2023). Overall, in the 294 included patients (median age 69 years), the median OS was 4.6 months; 2.5 months after WBRT (n = 141), and 7.5 months after SRT (n = 153). After WBRT, mOS was equally poor for patients with ECOG 2 (1.9 months) and ECOG 3-4 (1.2 months). After SRT, mOS for patients with ECOG 2 was 4.1 months; for ECOG 3 patients, mOS was 4 1.6 months. For NSCLC patients with ECOG 2 diagnosed with BMs who are not candidates for surgery or SRT, WBRT should be questioned due to short survival.

Utilisation of radiotherapy in lung cancer: A scoping narrative literature review with a focus on the introduction of evidence-based therapeutic approaches in Europe

Background and purpose

The aim of this study was to review the published studies on the utilisation of radiotherapy in lung cancer (both small and non-small cell lung cancer, SCLC and NSCLC) patients in European countries with a population-based perspective.

Material and methods

A literature search since January 2000 until December 2022 was carried out. Only English-published papers were included, and only European data was considered. PRISMA guidelines were followed. A scoping narrative review was undertaken due to the hetereogeneity of the published papers.

Results

38 papers were included in the analysis, with the majority from the Netherlands (52.6%) and the UK (18.4%). Large variability is observed in the reported radiotherapy utilisation, around 40% for NSCLC in general and between 26 and 42% in stage I NSCLC. Stereotactic body radiotherapy (SBRT) shows a wide range of utilisation across countries and over time, from 8 to 63%. Similary, in stage III lung cancer, chemoradiotherapy (CRT) utilisation varied considerably (11-70%). Eleven studies compared radiotherapy utilisation between older and younger age-groups, showing that younger patients receive more CRT, while the opposite applies for SBRT. An widespreadlack of data on relevant covariates such as comorbidty and health-services related variables is observed.

Conclusion

The actual utilisation of radiotherapy for lung cancer reported in patterns-of-care studies (POCs) is notably lower than the evidence-based optimal utilisation. Important variability is observed by country, time period, stage at diagnosis and age. A wider use of POCs should be promoted to improve our knowledge on the actual application of evidence-based treatment recommendations.

Effect of EGFR-TKIs combined with craniocerebral radiotherapy on the prognosis of EGFR-mutant lung adenocarcinoma patients with brain metastasis: A propensity-score matched analysis

Background and Purpose

Epidermal growth factor receptor (EGFR)-mutant lung cancers are associated with a high risk of developing brain metastases (BM). Craniocerebral radiotherapy is a cornerstone for the treatment of BM, and EGFR-TKIs act on craniocerebral metastases". However, whether EGFR-TKIs combined with craniocerebral radiotherapy can further increase the efficacy and improve the prognosis of patients is unclear. This study aimed to evaluate the difference in efficacy between targeted-therapy alone and targeted-therapy combined with radiotherapy in EGFR-mutant lung adenocarcinoma patients with BM.

Materials and Methods

A total of 291 patients with advanced non-small cell lung cancer (NSCLC) and EGFR mutations were enrolled in this retrospective cohort study. Propensity score matching (PSM) was conducted using a nearest-neighbor algorithm (1:1) to adjust for demographic and clinical covariates. Patients were divided into two groups: EGFR-TKIs alone and EGFR-TKIs combined with craniocerebral radiotherapy. Intracranial progression-free survival (iPFS) and overall survival (OS) were calculated. Kaplan-Meier analysis was used to compare iPFS and OS between the two groups. Brain radiotherapy included WBRT, local radiotherapy, and WBRT+Boost.

Results

The median age at diagnosis was 54 years (range: 28-81 years). Most patients were female (55.9%) and non-smokers (75.5%). Fifty-one pairs of patients were matched using PSM. The median iPFS for EGFR-TKIs alone (n=37) and EGFR-TKIs+craniocerebral radiotherapy (n=24) was 8.9 and 14.7 months, respectively. The median OS for EGFR-TKIs alone (n=52) and EGFR-TKIs+craniocerebral radiotherapy (n=52) was 32.1 and 45.3 months, respectively.

Conclusion

In EGFR-mutant lung adenocarcinoma patients with BM, targeted therapy combined with craniocerebral radiotherapy is an optimal treatment.

Re-Whole Brain Radiotherapy May Be One of the Treatment Choices for Symptomatic Brain Metastases Patients

Generally, patients with multiple brain metastases receive whole brain radiotherapy (WBRT). Although, more than 60% of patients show complete or partial responses, many experience recurrence. Therefore, some institutions consider re-WBRT administration; however, there is insufficient information regarding this. Therefore, we aimed to review re-WBRT administration among these patients. Although most patients did not live longer than 12 months, symptomatic improvement was sometimes observed, with tolerable acute toxicities. Therefore, re-WBRT may be a treatment option for patients with symptomatic recurrence of brain metastases. However, physicians should consider this treatment cautiously because there is insufficient data on late toxicity, including radiation necrosis, owing to poor prognosis. A better prognostic factor for survival following radiotherapy administration may be the time interval of > 9 months between the first WBRT and re-WBRT, but there is no evidence supporting that higher doses lead to prolonged survival, symptom improvement, and tumor control. Therefore, 20 Gy in 10 fractions or 18 Gy in five fractions may be a reasonable treatment method within the tolerable total biological effective dose 2 ≤ 150 Gy, considering the biologically effective dose for tumors and normal tissues.

Real-world analysis of different intracranial radiation therapies in non-small cell lung cancer patients with 1–4 brain metastases

Purpose

Stereotactic radiosurgery (SRS) has become a standard approach for the treatment of patients with few metastatic brain lesions. However, the optimal treatment approach for the use radiotherapy in the treatment of non-small cell lung cancer (NSCLC) patients with brain metastases (BMs) remain unclear. This study aimed to compare the survival outcomes and intracranial local control in NSCLC patients with 1–4 BMs who are treated with SRS using linear accelerators (LINAC-SRS), whole-brain radiotherapy (WBRT), or WBRT plus radiotherapy boost (WBRT + RTB).

Materials and methods

We retrospectively analyzed 156 NSCLC patients with 1–4 BMs who received LINAC-SRS, WBRT, and WBRT + RTB. The median overall survival (OS), intracranial progression-free survival (iPFS), and distant brain failure-free survival (DBF-FS) and related prognostic factors were analyzed.

Results

The median follow-up period was 31.6 months. The median OS times in the LINAC-SRS, WBRT, and WBRT + RTB groups were not reached, 33.3 months and 27.9 months, respectively. The difference in survival rate was non-significant (P = 0.909). The 2-year iPFS and DBF-FS rates in the LINAC-SRS, WBRT and WBRT + RTB groups were 51.6% and 37.5%; 42.0% and 50.4%; and 51.1% and 56.1%, respectively. There was no significant difference in 2-year iPFS or DBF-FS among the three groups (P = 0.572 for iPFS, P = 0.628 for DBF-FS). Multivariate analysis showed that the independent adverse prognostic factors for OS, iPFS, and DBF-FS were neurological symptoms, recursive partitioning analysis (RPA) class, and targeted therapy.

Conclusion

LINAC-SRS did not result in significantly superior survival times or intracranial local control compared to WBRT or WBRT + RTB in the treatment of NSCLC patients with 1–4 BMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10083-8.

Evaluation of Whole Brain Radiotherapy among Lung Cancer Patients with Brain Metastases in Relation to Health Care Level and Survival

Whole-brain radiotherapy (WBRT) as a treatment for brain metastases has been questioned over the last years. This study aimed to evaluate health care levels and survival after WBRT in a cohort of lung cancer patients with brain metastases receiving WBRT in Stockholm, Sweden, from 2008 to 2019 (n = 384). If the patients were able to come home again was estimated using logistic regression and odds ratios (OR) and survival by using Cox regression. The median age in the cohort was 65.6 years, the median survival following WBRT was 2.4 months (interquartile range (IQR) 1.2–6.2 months), and 84 (22%) patients were not able to come home after treatment. Significantly more males could come home again after WBRT compared to women (OR = 0.37, 95%CI 0.20–0.68). Patients with performance status scores WHO 3–4 had a median survival of 1.0 months, hazard ratio (HR) = 4.69 (95%CI 3.31–6.64) versus WHO score 0–1. Patients admitted to a palliative ward before WBRT had a median survival of 0.85 months, HR = 2.26 (95%CI 1.53–3.34) versus being at home. In conclusion, patients treated with WBRT had a short median survival and 20% could not be discharged from the hospital following treatment. Significantly more women did not come home again.