Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique (IOT), INSERM U1030 Molecular Radiotherapy, Université Paris-Saclay, F-94805, Villejuif, France; Univ Paris Sud, Université Paris-Saclay, F-94270, Le Kremlin-Bicêtre, France.
Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre (MCRC), University of Manchester, Manchester, UK.
Eur J Cancer. 2018 Apr;93:37-46. doi: 10.1016/j.ejca.2018.01.067. Epub 2018 Feb 21.
Brain metastases (BM) are frequent in non-small cell lung cancer (NSCLC) patients, but there is a lack of evidence-based management of this patient group. We aimed to capture a snapshot of routine BM management in Europe to identify relevant research questions for future clinical trials.
An EORTC Lung Cancer Group (LCG) online survey containing questions on NSCLC BM screening and treatment was distributed between 16/02/17 and 15/06/17 to worldwide EORTC LCG members, and through several European scientific societies in the thoracic oncology field.
A total of 462 European physician responses (394 institutions) were analysed (radiation oncologist: 53% [n = 247], pulmonologist: 26% [n = 119], medical oncologist: 18% [n = 84]; 84% with >5 years' experience in NSCLC). Italy (18%, n = 85), Netherlands (15%, n = 68), UK (14%, n = 66), and France (12%, n = 55) contributed most. 393 physicians (85%) screened neurologically asymptomatic patients for BM at diagnosis (52% using magnetic resonance imaging). Most often screened patients were those with a driver mutation (MUT+; 51%, n = 234), stage III (63%, n = 289), and IV (43%, n = 199). 158 physicians (34%) used a prognostic classification to guide initial treatment decisions, and in 50%, lowest prognostic-score threshold to receive treatment differed between MUT+ and non-driver mutation (MUT-) patients. MUT+ patients with >4 BM were more likely to receive stereotactic radiosurgery (SRS) compared with MUT- (27% versus. 21%; p < 0.01). Most physicians (90%) had access to SRS. After single BM surgery, 50% systematically prescribed SRS or WBRT, and 45% only in case of incomplete resection. The preferred treatment in neurologically asymptomatic treatment-naive patients diagnosed with >5 BM was systemic treatment (79%). Of all, 45%/49% physicians stated that all tyrosine kinase inhibitors and immune checkpoint blockers were discontinued (timing varied) during SRS/WBRT, respectively. Drugs most often continued during SRS/WBRT were erlotinib (44%/40%), gefitinib (39%/34%), afatinib (29%/25%), crizotinib (33%/26%) and anti-PD-(L)-1 (28%/22%).
BM management is highly variable in Europe: screening is not uniform, prognostic classifications are not often used and MUT+ NSCLC patients generally receive more intensive local treatment. Prospective assessment of BM management in MUT+ NSCLC patients is required.
脑转移（BM）在非小细胞肺癌（NSCLC）患者中很常见，但缺乏针对这一患者群体的循证管理证据。我们旨在了解欧洲对 BM 的常规管理情况，以确定未来临床试验的相关研究问题。
EORTC 肺癌组（LCG）于 2017 年 2 月 16 日至 6 月 15 日之间通过在线调查的形式向全球范围内的 EORTC LCG 成员以及几家欧洲胸科肿瘤学领域的科学协会成员发放了一份包含 NSCLC BM 筛查和治疗相关问题的问卷。
共分析了 462 名欧洲医生的回复（来自 394 家机构）（放疗科医生：53%[n=247]，呼吸科医生：26%[n=119]，肿瘤内科医生：18%[n=84]；84%的医生有 5 年以上 NSCLC 治疗经验）。意大利（18%，n=85）、荷兰（15%，n=68）、英国（14%，n=66）和法国（12%，n=55）参与度较高。393 名医生（85%）对神经无症状的患者进行 BM 筛查（52%使用磁共振成像）。最常被筛查的患者是有驱动基因突变（MUT+；51%，n=234）、Ⅲ期（63%，n=289）和Ⅳ期（43%，n=199）的患者。158 名医生（34%）使用预后分类来指导初始治疗决策，在 50%的情况下，MUT+和非驱动突变（MUT-）患者的最低预后评分阈值存在差异。MUT+患者中，有 4 个以上 BM 的患者更有可能接受立体定向放射外科手术（SRS）治疗，而 MUT-患者为 27%（n=27）比 21%（n=21）（p<0.01）。大多数医生（90%）可以进行 SRS。在单发性 BM 手术后，50%的医生系统地进行 SRS 或全脑放疗（WBRT）治疗，45%仅在不完全切除的情况下进行。对于诊断为 5 个以上 BM 的神经无症状初治患者，首选治疗方法是全身治疗（79%）。所有医生中，45%/49%表示在 SRS/WBRT 期间分别停用了所有酪氨酸激酶抑制剂和免疫检查点抑制剂（时机不同）。SRS/WBRT 期间最常继续使用的药物是厄洛替尼（44%/40%）、吉非替尼（39%/34%）、阿法替尼（29%/25%）、克唑替尼（33%/26%）和抗 PD-（L）-1（28%/22%）。
欧洲对 BM 的管理差异很大：筛查并不统一，预后分类并不常用，MUT+NSCLC 患者通常接受更密集的局部治疗。需要对 MUT+NSCLC 患者的 BM 管理进行前瞻性评估。
