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The Making of Medicine

Improving Care for Cancers That Spread to the Brain

Our David Schiff, MD, has helped lead the development of important new guidelines that will improve care for brain metastases -- cancers that spread to the brain.

The new guidelines reflect the dramatic advances Dr. Schiff has witnessed in his career: “When I started in this field 30 years ago, the average survival with brain metastases was four months, and most patients died from the brain disease," he told me. "With improvements in therapies, fewer than one-quarter of patients die from the brain metastases, and some patients live years or are even cured.”

Not only are patients living longer, they're living better, thanks to highly targeted radiation techniques, targeted chemotherapies and new immunotherapies, he noted.

To draft the new guidelines, the American Society of Clinical Oncology (ASCO) assembled a blue-blue ribbon panel that consisted of Dr. Schiff and other top experts, as well as a patient representative. The panel did a deep dive into the medical literature to determine the practices and treatment options that lead to the best patient outcomes.

The resulting document covers everything from when surgery is appropriate to when and what type of radiation should be used, as well as when medication alone is the best option.

The guidelines emphasize the importance of local therapies (surgery or stereotactic radiosurgery) for symptomatic brain metastases and outline when these are possible. The guidelines also highlight situations in which local therapy or whole brain radiotherapy can be deferred in place of chemotherapy, targeted therapy or immunotherapy -- this depends on the type of tumor and its molecular features.

The guidelines also describe how, in many cases, doctors can avoid the cognitive toxicity of whole brain radiotherapy by using either stereotactic radiosurgery or hippocampal-avoidant whole brain radiotherapy with a drug, memantine.

The new document will serve as an important roadmap for many different care providers, Dr. Schiff says. And that will help ensure patients get the best care possible.

“Patients with brain metastases may initially see a neurosurgeon, radiation or medical oncologist. The rigorous analysis underpinning these guidelines will provide each subspecialist a comprehensive picture of the treatment options appropriate for a given patient,” he said. “The result will allow patients the optimal personalized approach to maximize long-term control of brain metastases with good functional outcome.”

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