What are the options to manage lung cancer that has spread to the brain?
What are the options to manage lung cancer that has spread to the brain?
When lung cancer has spread to the brain, this is called brain metastasis. Deposits of cancer in the brain are common and the risk is highest for patients with advanced non-small cell lung cancer (stage IV), adenocarcinoma subtypes and small cell lung cancer subtypes. As doctors are increasingly looking for brain metastasis (by MRI or CT scanning), more brain deposits are detected before symptoms (such as headache, weakness in an arm or leg, trouble talking, difficulty coordinating hands or feet, seizures or memory problems) develop.
Treatment options and how to decide on the best treatment
Even if brain deposits are detected, there are many treatment options available. This includes:
- local options such as surgery or radiotherapy and
- systemic options such as targeted therapies, chemotherapy and immunotherapy
It is also possible to treat any associated swelling next to the deposits using steroids and seizures may be controlled by anti-epileptic medication.
The management of brain deposits is usually discussed by a team of doctors that includes a medical oncologist, radiation oncologist, neurologist, neurosurgeon and radiologist where the best treatment plan is personalised for each individual based on symptoms, number, size and location of the deposits.
Local therapies
Local treatment is usually chosen if a) the deposits are causing symptoms, b) it is large or c) if medication is unlikely to control the disease. This includes stereotactic radiotherapy (focused, high dose, precise radiotherapy that causes fewer memory problems) most suitable for patients with a limited number of brain deposits that are small in size. The other option is whole-brain radiotherapy which delivers a lower dose of radiotherapy to a wider area.
Surgery to remove the deposits is usually reserved for patients with large brain deposits that cause symptoms. Often stereotactic radiotherapy is also given after surgery to improve disease control and reduce the risk of recurrence.
Systemic therapies
Systemic therapy is usually chosen for patients with smaller brain metastases that do not cause symptoms with specific biomarkers (such as EGFR, ALK and ROS1) where the treating medication can reach the brain through the bloodstream. Newer drugs that target specific biomarkers can be very effective with more than a 70% chance of reducing the size and number of brain deposits with a long-lasting effect [1].
Immunotherapy given alone or with chemotherapy is the standard treatment for patients without the option for biomarker-targeted therapies with a 30-45% chance of reducing the size and number of brain deposits.
Follow-up
It is important to have regular scans to screen for the re-growth of brain deposits for patients treated with systemic treatment and/or if there are a number of further treatment options to offer.
Supportive care
All patients with brain deposits should receive supportive care, and it is the optimum management for patients in poor physical condition when no biomarker-targeted options are available (targeted therapies can work in patients in poor physical condition). Optimal supportive care (with steroids, and painkillers) has been shown to provide a longer and better quality of life compared to local treatments such as whole-brain radiotherapy [2].
Conclusion
Over the last few years, many new treatments and options have become available for patients with brain deposits. The best treatment plan will be formulated for each patient by their dedicated multidisciplinary tumor board.
October 2022
Professor Lizza Hendriks does not have any disclosures for this article.
References
[1] Alvarez-Breckenridge C, Remon J, Piña Y, Nieblas-Bedolla E, Forsyth P, Hendriks L, Brastianos PK. Emerging Systemic Treatment Perspectives on Brain Metastases: Moving Toward a Better Outlook for Patients. Am Soc Clin Oncol Educ Book. 2022 Apr;42:1-19. doi: 10.1200/EDBK_352320.
[2]Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, Moore B, Brisbane I, Ardron D, Holt T, Morgan S, Lee C, Waite K, Bayman N, Pugh C, Sydes B, Stephens R, Parmar MK, Langley RE. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet. 2016 Oct 22;388(10055):2004-2014. doi: 10.1016/S0140-6736(16)30825-X. Epub 2016 Sep 4.