The best sequence of treatment strategies has been identified for patients with epidermal growth factor receptor (EGFR)-mutant lung cancer and brain metastases, according to an article published in the Journal of Clinical Oncology.
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Approximately 10% of lung cancers in the US contain EGFR-gene mutations. In the event of brain metastases observed at diagnosis before the patient has undergone EGFR-targeted drug therapy, whether doctors should administer EGFR-tyrosine kinase inhibitors (TKIs) first, or if they should begin with whole-brain radiotherapy or stereotactic radiosurgery followed by EGFR-TKIs, has been a topic for debate.
Researchers led by Brian Kavanagh, MD, MPH, FASTRO, professor and chair of Radiation Oncology, University of Colorado Cancer Center, conducted a retrospective, multi-institutional analysis to determine the optimal treatment sequence for patients with EGFR-mutant NSCLC who developed brain metastases and had not received prior EGFR-TKI treatment. A total of 351 patients were sampled from six institutions who were treated with 1 of 3 therapy sequences: stereotactic radiosurgery followed by EGFR-TKI, whole-brain radiotherapy followed by EGFR-TKI, or EGFR-TKI followed by stereotactic radiosurgery or whole-brain radiotherapy. Overall survival (OS) and progression-free survival (PFS) were measured from the date of brain metastases diagnosis.
Results of the study showed stereotactic radiosurgery followed by EGFR-TKI resulted in the longest OS for the patients. Median OS times for the stereotactic radiosurgery followed by EGFR-TKI (n = 100), whole-brain radiotherapy followed by EGFR-TKI (n = 120), and EGFR-TKI followed by stereotactic radiosurgery or whole-brain radiotherapy (n = 131) cohorts were 46, 30, and 25 months, respectively (P < .001).
Researchers concluded that the findings of their non-randomized study need to be validated with a multi-institutional randomized trial of stereotactic radiosurgery followed by EGFR-TKI versus EGFR-TKI followed by stereotactic radiosurgery.
"Ultimately, it is possible that there is some middle path that is best," said Dr Kavanagh. He explained, “We suspect that some patients with very tiny tumors in the brain… can probably be safely watched closely for a while, and maybe we only need to treat them with radiosurgery when the tumors grow to a somewhat larger size.” Plans for a study to address this question are currently underway.
