The brain game.

Top Line: Brain mets happen a lot in patients with locally-advanced non-small cell lung cancer (NSCLC), even more so as our systemic and local therapies stretch survival. 
The Study: So maybe we should be offering more aggressive prevention. The phase 3 RTOG 0214 randomized 340 patients with Stage III NSCLC who didn’t progress after initial definitive local therapy to [1] standard observation or [2] prophylactic cranial irradiation (PCI) with 2 Gy x 15. Sadly, accrual was only one-third of the target. The 2011 initial results demonstrated, to no real surprise, PCI decreases rates of brain mets but not overall or even disease-free survival. Now we have the long term results, again showing no “significant” difference in rates of overall survival at 10 years at 13 → 18% with PCI. Intriguingly, this may be more due to lack of power than lack of difference considering the hazard ratio of 0.8 was exactly as predicted. However, there did emerge a significant difference in disease-free survival from 8 → 13% with a continued benefit in rate of brain mets from 28 → 17%, continued mainly because there were no new brain mets after 5 years.
Bottom Line: There’s about as much evidence for PCI in NSCLC as SCLC, and it’s all probably moot in the era of MRI. | Sun, JAMA Oncol 2019


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