For patients who have been diagnosed with cancer that has spread to the brain from other parts of the body, there are more and more reasons to be hopeful. These types of tumors are increasingly being met with powerful, targeted treatments designed to eliminate them entirely, with truly promising results.
The dedicated doctors and scientists at Memorial Sloan Kettering Cancer Center (MSK) have been at the forefront of many of these life-changing breakthroughs, championing innovative new approaches to treatment that are transforming the journey for patients with brain metastases. What was once considered an insurmountable challenge is now being met with renewed optimism and real, meaningful progress.
“The mindset surrounding patients with these tumors has changed dramatically,” says MSK neurosurgeon Nelson Moss, MD. “It used to be that these patients were so sick that it was time to focus on end-of-life care. But today, this is no longer the case. Survival for these patients has greatly improved, and that’s because cancer treatments overall have improved so much.”
Are brain metastases becoming more common?
Experts believe the incidence of brain metastases is increasing, in part because improved treatments are helping people with cancer live longer, giving tumors more time to potentially spread to the brain.
Better imaging technologies may also be detecting brain metastases that previously would have gone undiagnosed.
Between 20% and 40% of people with cancer will eventually develop brain metastases, depending on what type of cancer they have.
What types of cancer are most likely to spread to the brain?
Some cancers are more prone to spreading to the brain than others. The three most common types are:
- Lung cancer
- Breast cancer
- Melanoma
Other cancers that may less frequently spread to the brain include kidney cancer and colon cancer.
What are the treatments for brain metastases?
Most patients with brain metastases receive a combination of treatments to bring their cancer under control.
Radiation therapy
Radiation therapy is often the main treatment for brain metastases. There are two main types, and doctors choose according to which will best control the cancer and minimize the side effects of radiation, which can include cognitive impairment.
- Stereotactic radiosurgery (SRS) is the most common type of radiation given for brain metastases. This noninvasive, image-guided therapy allows for the delivery of high-dose radiation to small areas while sparing surrounding healthy structures. It is often completed in one to five sessions.
- Whole-brain radiation. Less frequently, patients may be given whole-brain radiation, which treats a larger area of the brain.
“In cases where we think other treatments are likely to be effective, we may hold off on giving radiation therapy,” says radiation oncologist Brandon Imber, MD, MA. “This spares patients the side effects of radiation for as long as possible.”
Systemic therapies
The good news is that the targeted therapies that are increasingly being used to treat a patient’s primary cancer will often work just as well against brain metastases — meaning patients may already have an effective treatment option.
“Most older chemotherapies were not able to cross the blood-brain barrier, but many of these newer therapies are able to penetrate the brain,” says MSK neurologist and neuro-oncologist Joshua Budhu, MD, MS, MPH. The blood-brain barrier is a highly selective protective shield surrounding the brain that, while designed to keep harmful substances out, can unfortunately also block many cancer-fighting drugs from reaching their target.
“These new drugs can be quite effective at shrinking or eliminating tumors that have spread from another organ to the brain,” he adds. This includes drugs that target common cancer mutations in genes like EGFR and BRAF.
In cases where melanoma has spread to the brain, a combination of the immunotherapy drugs nivolumab (Opdivo®) and ipilimumab (Yervoy®) can be very effective at shrinking brain metastases. This treatment works even better when it’s combined with SRS. “I have many patients who have received this treatment who are more than a decade out from treatment and still doing well,” Dr. Imber says.
Relief from side effects
You may also receive medications to help manage seizures, a common symptom of brain metastases, as well as the swelling in the brain that can result from other treatments.
Surgical techniques
Surgery for brain metastases is less common than it is for primary brain cancers. That’s because in many instances, patients have multiple small tumors. But there are some cases where surgery may be appropriate, especially if a tumor is large and causing symptoms.
“We also have a growing toolkit of other things we can try as surgeons, including laser ablation,” Dr. Moss says. “This technique, which heats tumors from the inside out as a way to kill cancer cells, can be very effective. It is delivered through the skin, making it much less invasive than brain surgery and requiring only a tiny incision.”
Who cares for people with brain metastases at MSK?
If you have metastatic brain tumors, you will be seen by many experts on MSK’s brain tumor team, including radiation oncologists, surgeons, and neuro-oncologists. These doctors work closely with each other to coordinate your care and to minimize the number of appointments you may need.
In many cases, patients with brain metastases can see their doctors by telemedicine, reducing the number of trips they need to make to the clinic.
Patients with brain metastases continue to see their main oncologist, who will have the broadest view of their overall health and cancer history. Your primary oncologist will be best positioned to help you and your family understand the big picture and make informed decisions about treatment goals and options.
Why should I go to a comprehensive cancer center like MSK for treatment?
At MSK, everyone who treats patients with brain metastases works together as part of a team. Every patient has a personalized treatment plan created just for them based on the details of their cancer as well as their personal priorities.
“In addition to talking about how to best treat a patient’s tumors, we also always focus on their quality of life as well as their life expectancy,” Dr. Budhu says. “Every treatment we give can cause side effects, including cognitive and memory issues. So it’s important to weigh the potential benefits against the patient’s priorities and what is most important to them.”
“I always try to have frank discussions with my patients about the pros and cons of each treatment,” Dr. Imber adds. “It’s not my job to tell patients what they should do, but to lay out the factors that might support or go against a particular treatment. Part of the art of doing this is working with each patient individually to figure out what matters most to them.”
Are there clinical trials for patients with brain metastases?
Yes. MSK has a number of trials studying ways to better treat patients with brain metastases. These include studies focused on how patients may benefit from targeted therapies.
There are also several trials looking at ways to improve radiation therapy. This includes a study investigating the benefits of brachytherapy — a procedure in which small radioactive seeds are implanted in the brain during surgery. The hope is that these seeds will destroy cancer that comes back after radiation therapy.
“It’s important for patients to know that in many cases, brain progression is not the end,” Dr. Moss concludes. “All the members of the multidisciplinary brain cancer program see our role as protecting the brain and protecting a patient’s neurologic function and quality of life as much as possible.”
Key Takeaways
- Brain metastases are increasingly treatable, with improved cancer therapies dramatically changing the outlook for patients who previously may have been directed toward end-of-life care.
- The three most common cancers to spread to the brain are lung cancer, breast cancer, and melanoma.
- Treatment options for brain metastases have expanded significantly and now include stereotactic radiosurgery, targeted systemic therapies that can cross the blood-brain barrier, immunotherapy, and minimally invasive surgical techniques like laser ablation.
- Comprehensive cancer centers like MSK take a personalized, multidisciplinary approach to treating brain metastases, carefully weighing each patient’s treatment options against their quality of life, priorities, and overall health.
Dr. Budhu is a Nicholls-Biondi Diversity Clinical Scientist Faculty Scholar.
