Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline
- Study type
- Clinical guideline
- Study name
- ASCO-SNO-ASTRO Brain Metastases 2022
- Design
- Clinical practice guideline based on a systematic literature review by an ASCO expert panel
- Sample size
- 32 randomised trials published from 2008 onwards
- Source
- JCO · 2022
In plain words
This guideline was written after reviewing 32 randomised trials and helps doctors choose the best treatment for a person whose cancer has spread to the brain (brain metastases). Depending on the number and size of the spots, whether there are symptoms and the person's general condition, surgery, radiosurgery (focused radiotherapy) or radiotherapy to the whole brain may be offered. The final decision should be made at a joint meeting of several specialists, weighing the possible benefits and harms for you.
Key points
Key guideline recommendations
- Grade of recommendation in the full guideline
Surgery is a reasonable option for patients with brain metastases. Patients with large tumours with mass effect are more likely to benefit than those with multiple brain metastases and/or uncontrolled systemic disease.
- Grade of recommendation in the full guideline
Patients with symptomatic brain metastases should receive local therapy regardless of the systemic therapy used.
- Grade of recommendation in the full guideline
For patients with asymptomatic brain metastases, local therapy should not be deferred unless deferral is specifically recommended in this guideline. The decision to defer local therapy should be based on a multidisciplinary discussion of the potential benefits and harms for the patient.
- Grade of recommendation in the full guideline
For patients with asymptomatic brain metastases without systemic therapy options, SRS alone should be offered to patients with one to four unresected brain metastases (excluding small-cell lung carcinoma). SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases. SRS, whole-brain radiotherapy or their combination are reasonable options for other patients.
- Grade of recommendation in the full guideline
Memantine and hippocampal avoidance should be offered to patients who receive whole-brain radiotherapy, have no hippocampal lesions and have an expected survival of 4 months or longer.
- Grade of recommendation in the full guideline
Patients with asymptomatic brain metastases and a Karnofsky performance status ≤ 50, or a Karnofsky score below 70 with no systemic therapy options, do not derive benefit from radiotherapy.
- Grade of recommendation in the full guideline
Several regimens are recommended for non-small-cell lung cancer, breast cancer and melanoma (regimen details in the full guideline).
Study population
Patients with brain metastases from solid tumours.
Endpoints
This is a clinical practice guideline and no specific primary or secondary endpoint is reported in the abstract. The aim of the guideline is to provide guidance to clinicians on the treatment of patients with brain metastases from solid tumours.
Safety and side effects
The abstract does not report grade ≥3 adverse events. The recommendations note only that memantine and hippocampal avoidance should be offered to patients receiving whole-brain radiotherapy who have no hippocampal lesions and an expected survival of 4 months or longer.
Clinical significance and place in guidelines
This joint ASCO, SNO and ASTRO guideline provides an evidence-based framework for choosing local therapy (surgery, SRS, whole-brain radiotherapy) and coordinating it with systemic therapy in brain metastases. It emphasises multidisciplinary decision-making, particularly about deferring local therapy in asymptomatic patients. For the exact status of its adoption in local protocols and the regimens recommended for non-small-cell lung cancer, breast cancer and melanoma, consult the full guideline and its erratum (J Clin Oncol 2022;40(12):1392).
Limitations
The abstract does not specifically report the guideline's limitations. The evidence base consists of randomised trials published from 2008 onwards. The grade of evidence and strength of each recommendation, and details of the systemic regimens, are given in the full guideline.
This summary was prepared by the editorial team from the published paper; the original paper is the final reference. Read the original abstract on PubMed.