Whole brain radiotherapy for the treatment of multiple brain metastases

Tsao MN, Lloyd N, Wong RKS, Chow E, Rakovitch E, Laperriere N

Published Online:

January 21, 2009

Radiotherapy is commonly used to treat patients with cancer that has spread to the brain. The aim of this review was to determine the effectiveness and adverse effects of whole brain radiotherapy (WBRT) alone or in combination with other treatments in adult patients with multiple brain metastases. Thirty trials involving 9415 participants were included following the update in 2007. There does not appear to be any additional benefit of altered WBRT dose schedules compared to standard doses. The use of chemotherapy or radiosensitizers in conjunction with WBRT has not yet been shown to confer any additional benefit.

Abstract (click to read)

Background:

This is an updated version of the original Cochrane review published in Issue 3, 2006. Brain radiotherapy is used to treat cancer participants who have brain metastases from various primary malignancies.

Objectives:

To assess the effectiveness and adverse effects of whole brain radiotherapy (WBRT) in adult participants with multiple metastases to the brain.

Search strategy:

In this updated review, we searched CENTRAL, MEDLINE, EMBASE, CANCERLIT, and CINAHL in May 2007.

Selection criteria:

Randomized controlled trials (RCTs) comparing whole brain radiotherapy (WBRT) either alone or with other treatments in adults with multiple metastases to the brain from any primary cancer. Trials of prophylactic WBRT were excluded as well as trials that dealt with surgery or WBRT, or both, for the treatment of single brain metastasis.

Data collection and analysis:

Two review authors independently assessed trial quality and abstracted information. Adverse effects information was also collected from the trials.

Main results:

Four new trials involving 1090 participants were added in this updated review. This updated review now includes a total of 30 trials involving 9415 participants.

Eight published reports (nine trials) showed no benefit of altered dose-fractionation schedules as compared to control fractionation (3000 cGy in 10 fractions) of WBRT for the probability of survival at six months. These studies also showed no difference in symptom control nor neurologic improvement among the different dose-fractionation schemes. The addition of radiosensitizers in six RCTs did not confer additional benefit to WBRT in either overall median survival times or brain tumour response rates. Three RCTs found no benefit in overall survival with the use of WBRT and radiosurgery boost as compared to WBRT alone for selected participants with multiple brain metastases (up to four brain metastases). Overall, there was a statistically significant improvement in local brain control favouring the whole brain radiotherapy and radiosurgery boost arm. Only one trial of radiosurgery boost with WBRT reported improved Karnofsky performance score outcome and improved ability to reduce dexamethasone dose. One RCT examined the use of WBRT and prednisone versus prednisone alone and produced inconclusive results.

Authors' conclusions:

The update has not changed the conclusions of this review: none of the RCTs with altered dose-fractionation schemes as compared to standard (3000 cGy in 10 fractions) found a benefit in terms of overall survival, neurologic function, or symptom control. The use of radiosensitisers or chemotherapy in conjunction with WBRT remains experimental. Radiosurgery boost with WBRT may improve local disease control in selected participants, although survival remains unchanged for participants with multiple brain metastases. The benefit of WBRT as compared to supportive care alone has not been studied in RCTs. It may be that supportive care alone, without WBRT, is appropriate for some participants, particularly those with advanced disease and poor performance status.

This record should be cited as:

Tsao MN, Lloyd N, Wong RKS, Chow E, Rakovitch E, Laperriere N. Whole brain radiotherapy for the treatment of multiple brain metastases. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003869. DOI: 10.1002/14651858.CD003869.pub2

Assessed as up to date:

November 12, 2007

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Primary Review Group:

Gynaecological Cancer Group

Health topics:

Cancer > Palliative and supportive care > Radiotherapy

Cancer > Neurological

Neurology > Cancer

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Whole brain radiotherapy for the treatment of multiple brain metastases

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