Is ASTRO's recommendation to avoid whole brain radiotherapy following SRS for limited brain metastases practical for patients treated in the community setting?  

The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases."  It includes assertions that whole brain radiotherapy leads to diminished quality of life.  This flies in the face of traditional teaching based on Patchell's studies and others since them.  Moreover, the arguments in favor of improved quality of life for those not receiving whole brain radiotherapy do not take into account the fractionation used, and it could be very legitimately argued that having to go for repeated sessions of Gamma Knife or other radiosurgical treatments do not equate to optimal quality of life either.  The assertions made also fail to acknowledge the decrement in a patient's quality of life due to new metastases, and fail to acknowledge the improved quality of life associated with local control in the whole brain.  To the best of my knowledge, there has not been a randomized controlled trial that somehow disproved the original assertions by Patchell's works, nor has there been clear evidence of superiority to the repeated SRS-only approach vs. the SRS +WBRT approach described in papers since Patchell's (which used surgery, not SRS).  It makes sense that larger centers with intracranial SRS capabilities would endorse inclusion of this on the Choosing Wisely list, but for the average patient, treated in a community setting, is there truly sufficient evidence in the literature for ASTRO to make its assertion?



Answer from: Radiation Oncologist at Community Practice

Answer from: Radiation Oncologist at Community Practice
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Radiation Oncologist at Generations Radiotherapy and Oncology PC
I could not be more enthusiastic in my agreement w...
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Answer from: Radiation Oncologist at Academic Institution

Answer from: Radiation Oncologist at Community Practice
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Radiation Oncologist at Generations Radiotherapy and Oncology PC
I agree with your last paragraph, @Simul Parikh, b...
Radiation Oncologist at Banner MD Anderson Cancer Center
Agreed!
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Answer from: Radiation Oncologist at Academic Institution

Answer from: Radiation Oncologist at Academic Institution