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Brar K, Taslimi S, Ellenbogen Y, Deng J, Hou W, Moraes FY, Glantz M, Zacharia BE, Tan A, Ahluwalia MS, Khasraw M, Zadeh G, Mansouri A. Comparative Efficacy of Treatments for Brain Metastases from Non-Small Cell Lung Cancer without an EGFR-Mutation/ALK-Rearrangement: A Systematic Review and Network Meta-Analysis. World Neurosurg 2021; 158:e87-e102. [PMID: 34688937 DOI: 10.1016/j.wneu.2021.10.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION As many as 30% of patients with non-small cell lung cancer (NSCLC) will develop brain metastases (BMs) over the course of their illness. Here, we quantitatively compare the efficacy of the various emerging regimens for NSCLC BMs without a definitive targetable epidermal growth factor receptor mutation/ALK rearrangement. METHODS We searched MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CENTRAL, and references of key studies for randomized controlled trials (RCTs) published from inception until June 2020. Comparative RCTs that included ≥10 patients were included. We used a frequentist fixed or random-effects model for network meta-analysis. The outcomes of interest included intracranial progression-free survival (iPFS), overall survival (OS), and overall progression-free survival. RESULTS In total, 18 studies representing 17 trials (n = 2726 patients) were identified. Immune checkpoint inhibitor regimens showed significant improvement in OS compared with chemotherapy alone, including pembrolizumab and chemotherapy (6 studies, hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.21-0.62), atezolizumab alone (HR 0.54, 95% CI 0.33-0.89), and nivolumab and ipilimumab (HR 0.64, 95% CI 0.42-0.97). An improvement in overall PFS was seen with use of pembrolizumab and chemotherapy compared with chemotherapy alone (3 studies, HR 0.42, 95% CI 0.26-0.68). Studies evaluating checkpoint inhibitors did not report iPFS data, and we did not find improvement in iPFS or OS with the addition of any chemotherapy regimen to whole-brain radiation therapy. CONCLUSIONS In this network meta-analysis, we demonstrate the promising survival benefit with use of checkpoint inhibitor-based regimens in NSCLC BMs without a targetable epidermal growth factor receptor mutation/ALK rearrangement. Moving forward, large-scale BM-focused RCTs are necessary to establish the iPFS benefit of immune checkpoint inhibitor-based immunotherapy in this patient population.
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Affiliation(s)
- Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Yosef Ellenbogen
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Winston Hou
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Fabio Y Moraes
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Aaron Tan
- Division of Medical Oncology, National Cancer Center Singapore, Singapore
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA.
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Brain metastases in patients with oncogenic-driven non-small cell lung cancer: Pros and cons for early radiotherapy. Cancer Treat Rev 2021; 100:102291. [PMID: 34587557 DOI: 10.1016/j.ctrv.2021.102291] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 01/01/2023]
Abstract
Non-small cell lung cancer (NSCLC) with oncogenic driver mutations such as EGFR or ALK has a high predilection for brain metastases (BMs) compared to unselected patients. Historically, whole brain radiotherapy (WBRT) was adopted widely for patients with BM. More recently, stereotactic radiosurgery (SRS) has become a standard approach for patients with 1 - 4 metastatic brain lesions. However, data on overall survival benefit with WBRT/SRS compared to target agents are conflicting, with a significant compromise of loss of neurocognitive function. Newer target agents with improved CNS efficacy have challenged the use of early radiotherapy in NSCLC patients with oncogenic driver mutations. Optimal treatment approach and timing of radiotherapy remain unclear, especially under the various clinical contexts. The purpose of this review is to summarize the available data on the possible benefits and risks of early radiotherapy for oncogenic-driven NSCLC patients with brain metastases. Clinical decisions should consider both intracranial efficacy and patient quality of life, given that patients are surviving long enough to experience the long-term consequences of radiation therapy.
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Zhao B, Wang Y, Wang Y, Chen W, Zhou L, Liu PH, Kong Z, Dai C, Wang Y, Ma W. Efficacy and safety of therapies for EGFR-mutant non-small cell lung cancer with brain metastasis: an evidence-based Bayesian network pooled study of multivariable survival analyses. Aging (Albany NY) 2020; 12:14244-14270. [PMID: 32669477 PMCID: PMC7425486 DOI: 10.18632/aging.103455] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
Preferable treatments for epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) with brain metastasis are elusive. The study intended to estimate the relative efficacy and safety of systemic therapies. Clinical trials about therapies for EGFR-mutant, brain-metastatic NSCLC were identified. Progression-free survival (PFS) and overall survival (OS) were analysed using random effects Bayesian network meta-analyses (NMAs) on the hazard ratio (HR)-scale. Nomogram and Kaplan-Meier plots based on clinical or individual factors are displayed using data obtained from the Surveillance Epidemiology and End Results (SEER) database. Third-generation EGFR- tyrosine kinase inhibitors (EGFR-TKI) (osimertinib), EGFR-TKIs + stereotactic radiosurgery (SRS)/whole brain radiotherapy (WBRT) (gefitinib/erlotinib + SRS/WBRT), and EGFR-TKIs (erlotinib) + anti-vascular endothelial growth factor receptor (anti-VEGFR) (bevacizumab) achieved superior PFS (HR: 0.30 (0.15-0.59); HR: 0.47 (0.31-0.72); HR: 0.50 (0.21-1.21) vs. deferring SRS/WBRT) and acceptability; EGFR-TKIs + SRS/WBRT was top ranking (vs. others) for OS followed by third-generation EGFR-TKI. In the dataset cohort of 1173 brain-metastatic NSCLC patients, the 6-month, 1-year, and 3-year survival rates were 59.8%, 41.3%, and 5.6%, respectively. Race and origin, and year of diagnosis were independent predictors of OS. Survival curves showed that the OS of patients varied significantly by histology and race. Third-generation EGFR-TKI and EGFR-TKIs + SRS/WBRT are more effective and potentially acceptable for EGFR-mutant NSCLC with brain metastases balancing OS and PFS. Surgeries without adjuvant therapies cannot significantly improve the OS of brain-metastatic NSCLC patients. The study highlights importance of osimertinib in these patients and provide a reference for clinical treatments.
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Affiliation(s)
- Binghao Zhao
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yuekun Wang
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yaning Wang
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenlin Chen
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lizhou Zhou
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Peng Hao Liu
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ziren Kong
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Congxin Dai
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yu Wang
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenbin Ma
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Ponce S, Bruna J, Juan O, López R, Navarro A, Ortega AL, Puente J, Verger E, Bartolomé A, Nadal E. Multidisciplinary expert opinion on the treatment consensus for patients with EGFR mutated NSCLC with brain metastases. Crit Rev Oncol Hematol 2019; 138:190-206. [PMID: 31092376 DOI: 10.1016/j.critrevonc.2019.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/09/2019] [Accepted: 03/26/2019] [Indexed: 12/14/2022] Open
Abstract
The presence of an epidermal growth factor receptor (EGFR) mutation is associated with higher incidence of brain metastases in patients with non-small cell lung cancer (NSCLC); however, patients with synchronous brain metastases at diagnosis have generally been excluded from clinical trials. As there is limited clinical evidence for managing this patient population, a multidisciplinary group of Spanish medical and radiation oncologists, and neuro-oncologist with expertise treating brain metastases in lung cancer patients met with the aim of reaching and developing an expert opinion consensus on the management of patients with EGFR mutated NSCLC with brain metastases. This consensus contains 26 recommendations and 20 conclusion statements across 21 questions in 7 areas, as well as a first-line treatment algorithm.
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Affiliation(s)
- Santiago Ponce
- Lung Cancer Clinical Research Unit, Hospital Universitario 12 de Octubre, Av. Cordoba, s/n, 28041 Madrid, Spain.
| | - Jordi Bruna
- Neuro-Oncology Unit, Bellvitge University Hospital-ICO, Carrer de la Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain; Clinical Research in Solid Tumors (CReST) and Neuro-Oncology Group. Oncobell, IDIBELL, Avda Gran Via 199-203, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Oscar Juan
- Medical Oncology Service, Hospital Universitario y Politécnico La Fe, Valencia, Avda. de Fernando Abril Martorell, nº 106, 46026, Valencia, Spain.
| | - Rafael López
- Medical Oncology Unit. Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, 47003, Valladolid, Spain.
| | - Alejandro Navarro
- Medical Oncology. Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
| | - Ana Laura Ortega
- Oncology Research Unit, Complejo Hospitalario de Jaén, Av. del Ejército Español, 10, 23007, Jaén, Spain.
| | - Javier Puente
- GU, Thoracic and Melanoma Cancer Unit, Medical Oncology Department, Assistant Professor of Medicine, Complutense University. Hospital Clinico Universitario San Carlos, Calle del Prof Martín Lagos, s/n, 28040, Madrid, Spain.
| | - Eugènia Verger
- Radiation Oncology Department, Hospital Clínic de Barcelona, Carrer de Villarroel, 170, 08036, Barcelona, Spain.
| | - Adela Bartolomé
- Radiotherapy Oncology Department. Hospital Universitario 12 de Octubre, Av. Cordoba, s/n, 28041, Madrid, Spain.
| | - Ernest Nadal
- Clinical Research in Solid Tumors (CReST) and Neuro-Oncology Group. Oncobell, IDIBELL, Avda Gran Via 199-203, 08907, L'Hospitalet de Llobregat, Barcelona, Spain; Thoracic Oncology Unit, Department of Medical Oncology, Catalan Institute of Oncology. Avda Gran Via 199-203, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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