Survival and quality of life after first-time diagnosis of brain metastases: a multicenter, prospective, observational study

Olav Erich Yri; Guro Lindviksmoen Astrup; Astrid Telhaug Karlsson; Rene van Helvoirt; Marianne Jensen Hjermstad; Kristin Moksnes Husby; Jon Håvard Loge; Jo-Åsmund Lund; Tonje Lundeby; Ørnulf Paulsen; Eva Skovlund; Marius-Ioan Taran; Rebecca Rootwelt Winther; Nina Aass; Stein Kaasa

doi:10.1016/j.lanepe.2024.101181

Survival and quality of life after first-time diagnosis of brain metastases: a multicenter, prospective, observational study

Lancet Reg Health Eur. 2024 Dec 19:49:101181. doi: 10.1016/j.lanepe.2024.101181. eCollection 2025 Feb.

Authors

Olav Erich Yri^{1

2}, Guro Lindviksmoen Astrup^{1

2}, Astrid Telhaug Karlsson^{1

2}, Rene van Helvoirt³, Marianne Jensen Hjermstad^{1

2}, Kristin Moksnes Husby⁴, Jon Håvard Loge^{1

2}, Jo-Åsmund Lund^{5

6}, Tonje Lundeby^{1

2}, Ørnulf Paulsen^{2

7}, Eva Skovlund⁸, Marius-Ioan Taran⁹, Rebecca Rootwelt Winther^{1

2}, Nina Aass^{1

2}, Stein Kaasa^{1

2}

Affiliations

¹ Department of Oncology, Oslo University Hospital, PO Box 4950 Nydalen, Oslo, 0424, Norway.
² European Palliative Care Research Centre (PRC), Institute for Clinical Medicine, PO Box 1171, Blindern, Oslo, 0318, Norway.
³ Department of Oncology, Sorlandet Hospital Trust, PO Box 416 Lundsiden, Kristiansand, 4604, Norway.
⁴ Department of Surgery, Vestre Viken Hospital Trust, PO Box 800, Drammen, 3004, Norway.
⁵ Clinic for Cancer Treatment and Rehabilitation, Møre and Romsdal Hospital Trust, PO Box 1600, Ålesund, 6026, Norway.
⁶ Department of Health Sciences, Faculty of Medicine and Health Services, Norwegian University of Science and Technology, PO Box 1517, Ålesund, 6025, Norway.
⁷ Department of Oncology and Hematology, Telemark Hospital Trust, PO Box 2900 Kjørbekk, Skien, 3710, Norway.
⁸ Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), PO Box 8905, Trondheim, 7491, Norway.
⁹ Department of Oncology and Hematology, Vestfold Hospital Trust, PO Box 2168, Tønsberg, 3103, Norway.

Abstract

Background: A major concern in anticancer treatment (ACT) of brain metastases (BM) is exposing patients with short expected survival to treatments that negatively impact on quality of life (QoL). Such futile ACT at the end of life is time-consuming and burdensome for patients and their families and entails unnecessary healthcare costs. Refraining from ACT is challenging for both physicians and patients. This study aimed to provide real-life data on survival after BM diagnosis and patient reported outcomes (PROs) after ACT to identify risk factors for futile treatment and to support BM treatment decisions.

Methods: This multi-center, prospective, observational study recruited consecutive patients with first-time BM from November 2017 to March 2021. Patients were followed until death or study end (October 1st, 2023). Clinical factors associated with survival were analyzed by the Cox' proportional hazards model. Changes in PROs after BM treatment were described according to Eastern Cooperative Oncology Group (ECOG) performance status, survival, and treatment groups.

Findings: For the total cohort (N = 912), median overall survival (mOS) after BM diagnosis was 5.9 months (95% confidence interval [CI] 5.2-6.7). ECOG 2-4, uncontrolled extracranial metastases, and ≥5 BM were associated with short survival. In patients treated with radiotherapy, survival for patients with ECOG 2 and those with ECOG 3-4 was similar and particularly short for the whole brain radiotherapy (WBRT) group (ECOG 2: 2.9 months [95% CI 2.3-3.5]; ECOG 3-4: 2.1 [1.5-2.7]). Patients surviving <6 months after BM diagnosis reported worse QoL scores two months after ACT; patients surviving >6 months reported stable scores over time.

Interpretation: Patients with ECOG 2-4, especially those with uncontrolled extracranial metastases and ≥5 BM, are at risk for futile ACT. BM treatment guidelines should strongly caution against ACT to patients with expected survival <6 months and specifically advise against WBRT.

Funding: The South-Eastern Norway Regional Health Authority; The Norwegian Cancer Society.

Keywords: Anticancer treatment; Brain metastases; Futile treatment; Radiotherapy; Treatment decisions.