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).
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