Health Service Focus

Treating the patient as a whole - not just the cancer

Source: NHE Nov/Dec 19 

Puneet Plaha, consultant neuro-oncology surgeon at GenesisCare, as well as chair of the tumour section of the Society of British Neurological Surgeons.

The incidence of brain metastasis – cancer that has spread to the brain from another part of the body – is increasing. The key reasons are; the better - and early - use of brain MRI (magnetic resonance imaging) and improved systemic treatment of the extracranial primary cancer, meaning patients will survive long enough for the cancer to spread to the brain.

Conventional radiotherapy treatments for a brain metastasis involves whole brain radiotherapy (WBRT), however, this often leads to cognitive deterioration, with limited benefit in terms of overall survival. Up to 30 percent of cancer patients are likely to develop a brain metastasis. The challenge, therefore, for treatment providers is to design a service that balances the need to treat the cancer versus the desire to improve patient quality of life. A holistic, whole patient centric approach to treatment is required.

Stereotactic radiosurgery (SRS) is an innovation - often described as non-invasive brain-sparing surgery – that has transformed the treatment of brain metastases in the last decade. It delivers precisely-focused radiation beams in a single (SRS) treatment or a few short treatments (known as stereotactic radiotherapy, or SRT). This highly advanced approach permits the maximum conformal dose to ensure ablation (destruction) of tumour cells while minimising the dose to the surrounding unaffected brain. The aim is to destroy the tumour and achieve permanent local control, whilst preserving important brain function.

Initially, SRS was used in combination with WBRT, but recently the role of SRS on its own in the management of brain metastasis has been widely researched. The results are promising. Although WBRT with SRS does result in less frequent intracranial metastasis progression than SRS alone, numerous studies have failed to show any significant difference in overall survival rates between the two approaches. However, the evidence is clear that SRS alone benefits in significantly less decline in cognitive deterioration, along with better quality of life (QoL).

The overriding question then is whether metastasis progression in the brain is more detrimental to a patient’s wellbeing than the potential deterioration of cognitive function and quality of life associated with WBRT. This has directed a move away from WBRT and SRS is now replacing conventional WBRT as procedure of choice for solitary and/or multiple brain metastasis and also some other primary brain tumours which respond to SRS.

However, SRS is not appropriate for every cancer type - small-cell lung metastasis is one example where WBRT remains the gold standard radiotherapy treatment. For this reason, there has also been considerable research and innovation focusing on eloquent brain-area sparing techniques that play a role in preserving quality of life, often used alongside surgery.

Whatever the treatment pathway, there is invariably a need for active surveillance and imaging such as MRI. NICE guidance on treatment of brain metastasis acknowledges that whilst frequent hospital visits for scanning appointments is reassuring to some, it may cause anxiety for others. Add to this the natural distress and uncertainty of living with the disease. A neuro-oncological service needs to fully embrace the wider role of the multi-disciplinary team to streamline care plans and provide support and intervention where possible, including wellbeing services, to enable patients and families to retain control over decisions and get the best possible life outcome.

At GenesisCare we have a well set-up multidisciplinary team of oncologists, neurosurgeons, neuro radiologists and advanced brain imaging experts. They review every case and plan a treatment pathway in consultation with the patient as part of a shared decision-making approach. It recognises that every patient is unique and treatments need to be tailored to individual needs.

In summary, brain metastasis account for the majority of intracranial malignancies. As disease progresses there will often be some cognitive deterioration, but the challenge is to slow the disease without accelerating deterioration – preserving quality of life for as long as possible. SRS currently offers an optimum solution for many patients if used as part of a wider approach that treats the whole patient, not just their cancer.