key historical misunderstandings hinder the research and treatment of brain metastases -
special article in neurosurgery calls for "new thinking and critical analysis" on cancers that spread brain
"false key historical ideas" hinder progress in research and treatment of patients with cancer metastasis to the brain, suggests a special article in the neurosurgery July issue, official journal of the Congress of neurological Surgeons .
Dr. Douglas Kondziolka NYU Langone Medical Center and co-authors identify issues that may be standing in the way of optimal clinical management for patients with cancer that has spread to the brain from other sites.
'All Brain metastases are created Equal' and Other Misconceptions
brain metastases are a significant problem in the treatment of cancer, but for which there are relatively few well-designed clinical trials. This partly reflects a point of view "often nihilistic", given that survival is relatively short for many patients with brain metastases.
But some key studies provide answers to some important questions about the benefits of specific treatments. In an era of rapid advances in cancer treatment, Dr. Kondziolka and colleagues point out five misconceptions in their opinion, must be overcome to advance the treatment of patients with brain metastases.
The first misconception is the assumption that "all histologies are created equal", this type of cancer does not matter once it has spread to the brain. Historically, studies have included any and all patients with brain metastases. But this may overlook important differences in brain metastases from different types and sites of the example of cancer, lung cancer, breast cancer or a malignant melanoma.
Similarly, there is no basis for the assumption that the number of brain metastases is the only factor determining the prognosis of patients. On the contrary, Dr. Kondziolka and coauthors believe that the focus should be on total tumor burden, including the size and number of metastases.
Similarly, some doctors hold the misconception that there is no such thing as a single metastasis that if one lesion is present, there must be others too. But this is contrary to the strong evidence that treatment of individual brain metastases may improve tumor control and patient survival.
Physicians may also believe that treatment by therapy of the brain around the radiation (WBRT) inevitably leads to a decline in cognitive (intellectual) function. Dr. Kondziolka and coauthors point out that, as with any treatment, the risks and benefits of WBRT should be considered for each patient. Studies are under way to clarify the cognitive effects of WBRT in order to balance the cognitive functioning with the tumor control.
Finally, there is an outdated assumption that since most brain metastases are symptomatic, there is no major benefit of screening tests for early detection. But with the increased use of MRI, metastases are now detected before they cause any symptoms. Previous studies of larger, symptomatic metastases may not apply to these smaller asymptomatic lesions.
"Especially in this era of medicine, more personalized one-size-fits-all thinking is inappropriate, especially for a wide and varied diagnostic entity as brain metastases," Dr. Kondziolka and coauthors write. Their article contains some recommendations for future brain metastases trials, including patient factors, such as the need for an official measure of cognitive function; and factors related to the tumor, such as studies focusing on a single type of tumor and considering the total tumor burden.
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