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Evidence summaries

Whole Brain Radiotherapy for the Treatment of Newly Diagnosed Multiple Brain Metastases

Altered dose-fractionating schemes compared to conventional dose-fractionating appear to bring no benefit in terms of survival, tumour control or symptom control. However, addition of whole brain radiotherapy to radiosurgery appears to improve local and distant brain control in selected people with brain metastases, but with worse neurocognitive outcomes and no differences in overall survival. Level of evidence: "B"

Summary

A Cochrane review [Abstract] 1 included 54 trials with a total of 11 898 patients to assess the effectiveness of whole brain radiotherapy (WBRT) in patients with multiple metastases to the brain.

Lower biological WBRT doses vs. control fractionation (3 trials, n=705):The HR for overall survival (OS) with lower biological WBRT doses as compared with control (3000 cGy in 10 daily fractions) was 1.21 (95% CI 1.04 to 1.40; p = 0.01) in favour of control. The HR for neurological function improvement (NFI) was 1.74 (95% CI 1.06 to 2.84; p = 0.03) in favour of control.

Higher biological WBRT doses vs. control (4 trials, n=846):The HR for OS with higher biological WBRT doses as compared with control (3000 cGy in 10 daily fractions) was 0.97 (95% CI 0.83 to 1.12; p = 0.65). The HR for NFI was 1.14 (95% CI 0.92 to 1.42; p = 0.23).

WBRT and radiosensitisers vs. WBRT alone: The addition of radiosensitizers to WBRT did not confer additional benefit to WBRT in either the OS times (HR 1.05, 95% CI 0.99 to 1.12; 8 trials, n=2546) or brain tumour response rates (HR 0.84, 95% CI 0.63 to 1.11; 6 trials, n=847).

WBRT and radiosurgery boost vs. WBRT alone (2 trials, n=358): There was no benefit in OS (HR 0.61, 95% CI 0.27 to 1.39). For overall brain control at one year, the HR was 0.39 (95% CI 0.25 to 0.60; p < 0.0001) favouring the WBRT and radiosurgery boost group.

Radiosurgery alone vs. WBRT and radiosurgery: The HR for local brain control was 2.73 (95% CI 1.87 to 3.99; p < 0.00001; 4 trials, n=602), favouring the addition of WBRT to radiosurgery. The HR for distant brain control was 2.34 (95% CI 1.73 to 3.18; p < 0.00001; 4 trials, n=602) favouring WBRT and radiosurgery. The HR for OS was 1.00 (95% CI 0.80 to 1.25; p = 0.99; 3 trials, n=403). Two trials reported worse neurocognitive outcomes and one trial reported worse quality of life outcomes when WBRT was added to radiosurgery.

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in primary cancer diagnoses).

Clinical comments

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Date of latest search:

    References

    • Tsao MN, Xu W, Wong RK et al. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev 2018;1():CD003869. [PubMed]

Primary/Secondary Keywords