Elsevier

Practical Radiation Oncology

Volume 12, Issue 4, July–August 2022, Pages 265-282
Practical Radiation Oncology

Clinical Practice Guideline
Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline

https://doi.org/10.1016/j.prro.2022.02.003Get rights and content

Abstract

Purpose

This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity.

Methods

The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.

Results

Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system–active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended.

Conclusions

The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.

Section snippets

Preamble

As the leading organization in radiation oncology, the American Society for Radiation Oncology (ASTRO) is dedicated to improving quality of care and patient outcomes. A cornerstone of this goal is the development and dissemination of clinical practice guidelines based on systematic methods to evaluate and classify evidence, combined with a focus on patient-centric care and shared decision making. ASTRO develops and publishes guidelines without commercial support, and members volunteer their

Task force composition

The task force consisted of a multidisciplinary team of radiation, medical, and neurosurgical oncologists; a radiation oncology resident; a medical physicist; and a patient representative. This guideline was developed in collaboration with the American Association of Neurological Surgeons/Congress of Neurological Surgeons, ASCO, and SNO, who provided representatives and peer reviewers.

Document review and approval

The guideline was reviewed by 20 official peer reviewers (Appendix E1, Supplementary Materials) and revised

KQ 1: Indications for SRS alone for patients with intact brain metastases (Table 3)

See evidence tables in Appendix E3 (Supplementary Materials) for the data supporting the recommendations for KQ1.

What are the indications for SRS alone for patients with intact brain metastases?

Progression of intracranial metastases can lead to neurologic morbidity and death. WBRT remained the standard of care for decades, but the development of SRS allowed treatment of limited brain metastases alone, often in a single fraction, while largely sparing surrounding brain. Initially, neither the risks of omitting treatment of grossly uninvolved brain nor the exact benefits of

Conclusions and Future Directions

In the decade since the previous ASTRO brain metastasis guideline,3 there has been a tremendous evolution in the management of this patient population. Novel RT techniques such as HA-WBRT have been developed that improve the therapeutic ratio, SRS has a more predominant role, and newer systemic agents have demonstrated unprecedented CNS activity. Treatment and management decisions (Figs. 1 and 2) depend on multiple factors (eg, number of brain metastases, brain metastasis size, and performance

Acknowledgments

We are grateful to the AHRQ evidence-based practice center that performed the systematic review of the evidence, and to the Patient-Centered Outcomes Research Institute for funding the systematic review. The task force also appreciates the data abstraction assistance provided by Madeera Kathpal, DO, and Amber Retzlaff, MD. The task force thanks the peer reviewers for their comments and time spent reviewing the guideline. See Appendix E1 in Supplementary Materials for their names and disclosures.

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    Sources of support: Guideline development was funded by the American Society for Radiation Oncology and the systematic evidence review was funded by the Patient-Centered Outcomes Research Institute.

    Disclosures: All task force members’ disclosure statements were reviewed before being invited and were shared with other task force members throughout the guideline's development. Those disclosures are published within this guideline. Where potential conflicts were detected, remedial measures to address them were taken.

    Paul Brown (chair): Novocure (unpaid trial leadership position), Stuart Burri: Novocure (consultant-DSMB); Vinai Gondi (vice chair): Novocure (unpaid trial leadership position), NRG Oncology (National Cancer Institute-sponsored research), Radiation Oncology Consultants (partnership), UpToDate (honoraria); Rupesh Kotecha: Accuray, Brainlab, and Elekta (honoraria, travel), AstraZeneca, Blue Earth Diagnostics, Exelixis, GT Medical Technologies, and Medtronic (all research), and Viewray (honoraria, research), Novocure (advisory board, speaker's bureau, consultant, research, travel); Jing Li: Bristol-Myers Squibb and Medtronic (research), Montaris (honoraria-ended 8/30/21); Michelle Kim: Blue Earth Diagnostics (research), International Journal of Radiation Oncology • Biology • Physics (editor); Seema Nagpal (Society for Neurological Oncology Representative): Agios, Berg Health, Inovio, and Pharmabcine (all research), Biocept (consultant, research), Novocure and Seattle Genetics (consultant), National Comprehensive Cancer Network (CNS committee); American Radium Society (CNS-AUC committee); Chad Rusthoven: Merck (research), National Comprehensive Cancer Network (CNS and SCLC committees), Takeda (research), SURVIVEit (nonprofit-board member-family member); John Suh: Neutron Therapeutics, Novocure, and Phillips (all advisory board); Wolfgang Tomé: Accuray (advisory board, consultant), Archeus (advisory board), Chrysalis (research), Varian (research, honoraria, travel), WI Alumni Research Foundation (patent/royalty); Tony Wang: Abbvie (research, travel), Cancer Panels (consultant), Doximity (stock), Elekta (consultant, honoraria), Genentech and RTOG Foundation (research), Iylon Precision Oncology (consultant), Merck (research), Novocure (advisory board, consultant), Varian (research), Wolters Kluwer (honoraria); Mateo Ziu (AANS/CNS representative): Medtronic (research). Glenn Bauman, Lisa Bradfield, Alvin Cabrera (Guideline Subcommittee representative), Lianne Kraemer, Danielle Cunningham, Bree Eaton, Jona Hattangadi-Gluth, and Alexandra Zimmer (American Society of Clinical Oncology representative) reported no disclosures.

    Disclaimer and Adherence: American Society for Radiation Oncology (ASTRO) guidelines present scientific, health, and safety information and may reflect scientific or medical opinion. They are available to ASTRO members and the public for educational and informational purposes only. Commercial use of any content in this guideline without the prior written consent of ASTRO is strictly prohibited.

    Adherence to this guideline does not ensure successful treatment in every situation. This guideline should not be deemed inclusive of all proper methods of care or of all factors influencing the treatment decision, nor is it intended to be exclusive of other methods reasonably directed to obtaining the same results. The physician must make the ultimate judgment regarding therapy considering all circumstances presented by the patient. ASTRO assumes no liability for the information, conclusions, and findings contained in its guidelines. This guideline cannot be assumed to apply to the use of these interventions performed in the context of clinical trials. This guideline is based on information available at the time the task force conducted its research and discussions on this topic. There may be new developments that are not reflected in this guideline and that may, over time, be a basis for ASTRO to revisit and update the guideline.

    Noted—An online CME test for this article can be taken at https://academy.astro.org.

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