New Treatment for Non-Small Cell Lung Cancer That Has Spread to the Brain?

In the future, patients with non-small cell lung cancer (NSCLC) that has spread to the brain may routinely undergo treatment that involves a combination of medications called immune checkpoint inhibitors (ICI) and a single, high dose of stereotactic radiation therapy. A multi-institutional study showed that the treatment is safe and does not increase the risk of what can be a serious complication ― radiation necrosis.

Lung cancer remains the leading cause of cancer death in the U.S., according to the American Cancer Society. And when it has spread to the brain, prognosis is typically poor. Approximately 85 percent of lung cancers are NSCLC, and in spite of treatment advances that are prolonging life and improving quality of life, there is no cure.

Manmeet Ahluwalia, M.D., MBA, FASCO, chief of medical oncology, chief scientific officer, deputy director and Fernandez Family Foundation Endowed Chair in Research at Miami Cancer Institute

“This study gives us hope that we are on the way to developing even better methods of caring for our patients,” says Manmeet Ahluwalia, M.D., MBA, FASCO, chief of medical oncology, chief scientific officer, deputy director and Fernandez Family Foundation Endowed Chair in Research at Baptist Health Miami Cancer Institute. “The key finding is that the combination of ICI and single fraction stereotactic radiosurgery does not increase the risk of radiation necrosis.”

Dr. Ahluwalia is the senior author of the study, titled “Immune Checkpoint Inhibition and Single Fraction Stereotactic Radiosurgery in Brain Metastases from Non-Small Cell Lung Cancer: An International Multicenter Study of 395 Patients.” The report, which included data from 11 institutions in four countries reviewed retrospectively, was recently published in the Journal of Neuro-Oncology.

Immune checkpoint inhibitors help the body’s own immune system fight cancer by blocking proteins that signal our T cells to “turn off” and ignore tumor cells. The drugs, being used more often for certain NSCLC patients, keep the signal “on” to allow cancer cells to be attacked.

In the past, doctors believed that the drugs should be halted, even when patients have a good response, if they experience radiation necrosis, a complication that can occur when healthy brain tissue is damaged or dies due to radiation exposure. Because immune checkpoint inhibitors spur the body’s immune cells to act, it was thought that the inflammation caused by radiation necrosis might put the immune system on heightened alert, causing it to destroy more healthy brain tissue.

Depending on the part of the brain affected by radiation necrosis, a patient may notice an increase in headaches and fatigue, neurological deficits such as problems with vision, speech or weakness in the limbs, behavior changes and a decline in cognitive functioning.

“Concurrent immune checkpoint inhibition and stereotactic radiosurgery do not appear to increase this risk,” says Dr. Ahluwalia. “That means that we may no longer need to interrupt therapy, which can negatively impact outcomes.”

The physician researchers also looked at other factors of radiation therapy that could raise the risk of radiation necrosis. “We did find a relationship between the volume of the brain area that is targeted during radiation and radiation necrosis,” he says. “Radiosurgical planning techniques should aim to minimize the area.” The work of the team is helping physicians develop new treatment guidelines. 

The just-published study is one of a number of clinical trials for patients with brain tumors underway at Miami Cancer Institute, according to Dr. Ahluwalia.