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Timing of Brain Radiotherapy for NSCLC With Brain Metastasis

By: Julia Fiederlein
Posted: Wednesday, November 18, 2020

Isabelle Monnet, MD, of the Centre Hospitalier Intercommunal de Créteil, France, and colleagues conducted a multicenter study to investigate whether upfront brain radiotherapy is superior to “at disease progression” brain radiotherapy in patients with advanced non–small cell lung cancer (NSCLC) and asymptomatic brain metastasis. The results of the phase III Metal2 trial, which were presented during the European Society for Medical Oncology (ESMO) Virtual Congress 2020 (Abstract 1306P), indicate that upfront brain radiotherapy is not mandatory in this patient population.  

Between January 2014 and January 2018, a total of 91 patients with advanced nonsquamous NSCLC and asymptomatic brain metastasis were randomly assigned in a 1:1 allocation ratio to undergo either upfront (n = 45) or “at disease progression” (n = 46) brain radiotherapy. Eligible patients were administered platin-pemetrexed and bevacizumab, followed by pemetrexed with or without bevacizumab as maintenance.

More patients in the upfront arm underwent brain radiotherapy than those in the “at disease progression” arm (87% vs. 20%; P < .001). According to the investigators, the duration of chemotherapy was 4 months in both arms. A second-line treatment (mainly docetaxel) was administered to 42.2% and 43.5% of the upfront and “at disease progression” arms, respectively.

The median progression-free survival (4.7 vs. 4.8 months), cerebral (27% vs. 13%; P = .064) and extracerebral (30% vs. 41%; P = .245) objective response rates, and median overall survival (8.5 vs. 8.3 months) did not seem to differ between the arms. There appeared to be a trend toward more grade 3 and 4 neutropenia in the “at disease progression” arm than the upfront arm (13% vs. 6%; P = .045); no other differences in toxicities were reported.  

“The significant difference in terms of proportion of brain radiotherapy performed in the two arms suggests that upfront brain radiotherapy is not mandatory in this situation,” the investigators concluded.

Disclosure: The study authors reported no conflicts of interest. 



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