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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?
6 Answers
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Radiation Oncology · Michigan Healthcare Professionals, PC
Answered on

Agree, YES! But, can I elaborate? :)

No evidence has ever indicated any benefit more than local/elsewhere brain control for WBRT. The addition of WBRT to surgery didn't change overall survival, and enough retrospective data indicates cognitive side effects. Patchell's trial used 50.4 Gy in 1.8 Gy fra...

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Radiation Oncology · Veterans Administration Hospital, Jackson,MS
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I agree in priniciple SRS is best whenever possible. However the treatment is for palliation.

1. Coming back for retreatment is not good palliation.

2. Is all of the memory decline due to WBRT or the combination? 67% with SRS alone is in itself significant.

3. The median survival in both groups is i...

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Radiation Oncology · University of Colorado School of Medicine
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To me, the decision about SRS with/without whole brain radiation still has to be discussed with the patient. I think most patients want just SRS (and it is reasonable) but I am not really sure that they understand why that is a reasonable decision. And for some patients WBRT is the right choice for ...

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Radiation Oncology · Michigan Healthcare Professionals, PC
Answered on

Choosing Wisely states: "Don’t routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases".

I don't think Choosing Wisely made a blanket policy at all, and I don't think anyone is suggesting that. The question above was "Is the recommendation pract...

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Radiation Oncology · NYU Langone Medical Center
Answered on

YES

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Radiation Oncology · University of Washington School of Medicine
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I agree with Laurie. I always discuss the pro and cons of WBRT +/- SRS and SRS alone. Sunnybrook Odette Cancer Centre and my previous center (UH Cleveland Med Ctr/ Case Western Reserve U) completed a small patient preference study which was presented at ESTRO. Most pts picked SRS. Hopefully, it will...

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