Stereotactic radiosurgery can result in less cognitive deterioration in certain patients

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Among patients with one to three brain metastases, the use of stereotactic radiosurgery alone, compared with stereotactic radiosurgery combined with whole brain radiotherapy, resulted in less cognitive deterioration at three months, according to a study published in JAMA.

Paul D Brown (Mayo Clinic, Rochester, USA) and colleagues conducted a study in which 213 patients with one to three brain metastases were randomly assigned to receive stereotactic radiosurgery alone (n=111) or stereotactic radiosurgery plus whole brain radiotherapy (n=102). The study was conducted at 34 institutions in North America; average patient age was 61 years. The primary outcome measured for the study was cognitive deterioration among patients who completed assessments at study entry and three months. Other measured outcomes included quality of life, functional independence, long-term cognitive status, and overall survival.

The researchers found that there was less cognitive deterioration at 3 months after stereotactic radiosurgery alone (40/63 patients, 64%) than when combined with whole brain radiotherapy (44/48 patients, 92%). Quality of life was higher at three months with stereotactic radiosurgery alone, including overall quality of life. There was no significant difference in functional independence at three months between the treatment groups. Median overall survival was 10.4 months for stereotactic radiosurgery alone and 7.4 months for stereotactic radiosurgery plus whole brain radiotherapy. For long-term survivors, the incidence of cognitive deterioration was less after stereotactic radiosurgery alone at three months and at 12 months.

“In the absence of a difference in overall survival, these findings suggest that for patients with one to three brain metastases amenable to radiosurgery, stereotactic radiosurgery alone may be a preferred strategy,” the authors write.

“The debate between whole brain radiotherapy and stereotactic radiosurgery has been resolved for the specific type of patient (with one to three metastases) who enrolled in the current study, and there is little role for whole brain radiotherapy for these patients,” write Carey K Anders, of the University of North Carolina at Chapel Hill, USA, and colleagues in an accompanying editorial. “However, both treatment modes have a valid position in clinical practice, because many patients do not precisely fit the characteristics for study entry. Thus, based on the robust findings from the current study and until proven otherwise, whole brain radiotherapy may still have an important role for treatment of patients who are not in this specific disease category (i.e., one to three brain metastases). However, the study results cannot be extrapolated to infer that stereotactic radiosurgery is the standard for patients with four or more metastases or that whole brain radiotherapy no longer has a role in the treatment of brain metastases.”