Dr. Goldberg on Treatment Strategies for CNS Metastases

Sarah B. Goldberg, MD, MPH
Published: Tuesday, Feb 05, 2019



Sarah B. Goldberg, MD, MPH, an assistant professor of medicine at the Yale School of Medicine and Yale Cancer Center, discusses treatment strategies for patients with non–small cell lung cancer (NSCLC) who develop central nervous system (CNS) metastases.

Osimertinib (Tagrisso), the standard frontline therapy for patients with EGFR-positive NSCLC, is a very good CNS penetrant, with patients demonstrating high response rates and disease control in the brain and body, Goldberg says. In these cases, Goldberg says she would hold off on giving brain radiation, especially if patients are asymptomatic and their lesions are small and are in areas that are not particularly concerning. Instead, she would treat these patients with an EGFR TKI alone.

When there is progression in the brain alone and the body is still controlled, Goldberg says she would consider the use of radiation with the continuation of treatment on an EGFR inhibitor. This strategy is based largely on data from early retrospective studies examining earlier generations of targeted therapies, but she feels it’s a very reasonable approach.

In the case of ALK-positive patients, there are several available targeted therapies, and even if a patient progresses on 1 of these drugs, a different, next-generation ALK inhibitor could still effectively control CNS metastases, she adds.
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Sarah B. Goldberg, MD, MPH, an assistant professor of medicine at the Yale School of Medicine and Yale Cancer Center, discusses treatment strategies for patients with non–small cell lung cancer (NSCLC) who develop central nervous system (CNS) metastases.

Osimertinib (Tagrisso), the standard frontline therapy for patients with EGFR-positive NSCLC, is a very good CNS penetrant, with patients demonstrating high response rates and disease control in the brain and body, Goldberg says. In these cases, Goldberg says she would hold off on giving brain radiation, especially if patients are asymptomatic and their lesions are small and are in areas that are not particularly concerning. Instead, she would treat these patients with an EGFR TKI alone.

When there is progression in the brain alone and the body is still controlled, Goldberg says she would consider the use of radiation with the continuation of treatment on an EGFR inhibitor. This strategy is based largely on data from early retrospective studies examining earlier generations of targeted therapies, but she feels it’s a very reasonable approach.

In the case of ALK-positive patients, there are several available targeted therapies, and even if a patient progresses on 1 of these drugs, a different, next-generation ALK inhibitor could still effectively control CNS metastases, she adds.



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Online CME Activities
TitleExpiration DateCME Credits
Year in Review™: Reflecting on Recent Evidence With an Eye to the Future of Lung Cancer ManagementMar 30, 20191.5
Online Medical Crossfire®: 5th Annual Miami Lung Cancer ConferenceMay 30, 20196.5
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