Photo: Orlando Health
"There's a big change now, and that big change is that women with breast cancer brain metastases now have much better treatment options that are likely to result in far fewer side effects," says Naren Ramakrishna, co-director of the Brain and Spine Tumor Program at Orlando Health Cancer Institute.
Economic Backbone: Cancer Care
New therapies create better options when breast cancer spreads to the brain.
Brain metastases are a significant problem for women with breast cancer, particularly those with HER2+ breast cancer, an aggressive subtype that tends to grow and spread quickly. Up to half of the women with metastatic HER2+ breast cancer will end up with the cancer spreading to their brain — and until recently, treatment options were limited and caused severe side effects.
“Traditionally, the way that women were treated was using radiation to the entire brain, and it actually did save the lives of many women, but it was a feared form of treatment because after the radiation of the entire brain, typically any patient would have chronic fatigue and decreased neuro-cognitive function because of decreased short-term memory,” says Naren Ramakrishna, co-director of the Brain and Spine Tumor Program at Orlando Health Cancer Institute. “It would be something like really aging a person, aging their brain 10 or 20 years.”
But revolutionary changes in treatments over the last several years have “dramatically altered the options that are available to women in this situation and dramatically improve the outcomes for these women,” says Ramakrishna, who chaired a panel that created new treatment guidelines published in August by the American Society of Clinical Oncology.
The 40-page guidelines provide specific recommendations for a wide array of clinical scenarios — ranging from a patient who presents with a single brain metastases, to one with multiple tumors, to patients who’ve already exhausted first-line treatments and may need a second-or third-line therapy.
Among the most dramatic change in the guidelines is that a woman presenting with a relatively small and asymptomatic metastatic brain tumor can begin treatment with drug therapy alone and avoid radiation.
In situations where radiation is necessary, Ramakrishna says, the preference (if possible) is to avoid conventional whole-brain radiation and attempt instead to use radiosurgery, which is precisely targeted to each tumor and has far fewer side effects. When whole brain radiation can’t be avoided, he says, strategies can be employed to spare certain regions of the brain that are important to memory and learning. The “neuro-protectant” drug Namenda is also recommended to decrease the toxicity to the brain.
“There’s a big change now, and that big change is that women with breast cancer brain metastases now have much better treatment options that are likely to result in far fewer side effects,” Ramakrishna says. “These women are living longer and longer, and it’s incredibly important to maximize what we call performance status. It’s not just about survival. It’s about quality of life. We want to keep them functioning well, thinking well and having good energy levels.”