Treatment recommendations for patients with asymptomatic melanoma brain metastasis (MBM) vary by physicians’ specialties, according to a survey published in Radiotherapy and Oncology.
The experts surveyed did agree that radiotherapy (RT) and systemic therapy are appropriate in most clinical settings, but medical oncologists and clinical oncologists were more likely to recommend systemic therapy without RT in certain cases.
Researchers conducted this international survey to gain insight into current practice recommendations for patients with asymptomatic MBM.
The 268 survey respondents included radiation oncologists (58.4%), medical oncologists (20.2%), clinical oncologists (7.9%), and neurosurgeons (13.5%). Most practiced in the United States (44.6%), Canada (13.5%), Japan (7.9%), or Brazil (7.1%), and most were part of a multidisciplinary oncology team at an academic center.
The survey consisted of 6 multiple-choice questions about management of 3 patient scenarios. All hypothetical patients had newly diagnosed, asymptomatic MBM, an Eastern Cooperative Oncology Group performance status of 1 or 2, minimal extracranial disease, no metastasis in the brainstem, and no evidence of edema, leptomeningeal disease, or impeding herniation.
For BRAF-positive patients with 1 to 3 lesions measuring less than 2 cm in diameter, radiation oncologists and neurosurgeons less commonly recommended BRAF/MEK inhibitor therapy alone, compared with medical oncologists and clinical oncologists (P <.001).
Upfront surgery was the most common recommendation from all specialties for patients with 1 to 3 lesions when at least 1 measured greater than 2 cm. Still, in this scenario, radiation oncologists and neurosurgeons less commonly recommended BRAF/MEK inhibitors alone, compared with medical and clinical oncologists (P =.0018).
For patients with BRAF-negative MBM expected to receive immune checkpoint inhibitor (ICI) monotherapy, all specialties favored upfront RT. However, medical and clinical oncologists were more likely to recommend ICI monotherapy alone, compared with radiation oncologists and neurosurgeons.
The majority of both neurosurgeons and clinical oncologists recommended upfront surgery when at least 1 of 3 MBM lesions was larger than 2 cm. Medical and radiation oncologists, on the other hand, were more likely to recommend RT.
For patients with BRAF-negative MBM receiving combined ICI treatment (anti-PD1 and anti-CTLA4 agents), roughly half of the medical and clinical oncologists favored ICI treatment alone when all lesions measured less than 2 cm, though this was dependent upon the total number of lesions.
For patients with 1 to 3 lesions, with at least 1 measuring more than 2 cm, clinical oncologists and neurosurgeons were more likely to recommend upfront surgery, but radiation and medical oncologists were more likely to recommend RT. For patients with 4 to 9 or more than 9 lesions, with at least 1 measuring more than 2 cm, RT was the first choice for all specialties.
“To our knowledge, no previous survey has reported these real-world, specialty-specific practice patterns,” the researchers wrote. “While awaiting prospective data, the present findings demonstrate that, in most clinical scenarios, the most common upfront treatment recommendation for asymptomatic MBM is RT plus appropriate systemic therapy.”
Given the rapidly evolving field of MBM treatment, the researchers highlighted the need for a multidisciplinary approach to identify the most appropriate treatment for individual patients.
Jablonska PA, Fong CH, Kruser T, et al. Recommended first-line management of brain metastases from melanoma: A multicenter survey of clinical practice. Radiother Oncol. Published online February 1, 2022. doi:10.1016/j.radonc.2022.01.037