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Is stereotactic radiosurgery (SRS) a reasonable alternative to whole brain radiation (WBRT) for patients with “extensive” brain mets (i.e. 4 or more)? Just over 5 years ago, this question was a little more controversial than perhaps it seems today. In this phase 3 trial, patients with 4 or more non-melanoma BM were randomized to WBRT or SRS. Only 72 patients were enrolled over 7 years, which may be a clue that neither physicians nor patients had great interest in foregoing focal treatment on the flip of a coin. At 4 months, neurocognitive outcomes were actually better with SRS but significantly declined with WBRT. At the same time, local control was no different (100% SRS, 95.5% WBRT). Expectedly, median time to distant brain failure was significantly shorter after SRS (4.3 months) than after WBRT (18.1 months). TBL: This randomized trial confirms that SRS, even for patients with 4 or more brain mets, preserves neurocognitive function at the cost of additional focal treatment over time. | Li, ASTRO 2020


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