RTOG 0933 results published in JCO

[Gfunk6]

http://m.jco.ascopubs.org/content/32/34/3789.full

Bottom line: Hippocampal avoidance whole brain radiation therapy appears to spare neuro cognitive functioning just as well as stereotactic radiosurgery alone. However, a phase 3 trial is required to validate this approach formally. To that end, they are proposing a trial using prophylactic cranial irradiation using a standard opposed tangent approach versus a hippocampal avoidance approach.

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[Neuronix]

Anyone using hippocampal sparing off protocol? Does insurance cover it?

Anyone using memantine? I've been using memantine for whole brain cases in patients with good performance status since that was positive in a phase III trial for prevention of neurocognitive decline (http://neuro-oncology.oxfordjournals.org/content/15/10/1429.abstract). Most of my faculty seem to be against it, and I've had to fight tooth and nail to get it covered by insurance. A lot of pharmacies don't carry it either. These issues dramatically increase the hassle factor of a whole brain case.

 

[medgator]

http://m.jco.ascopubs.org/content/32/34/3789.full

Bottom line: Hippocampal avoidance whole brain radiation therapy appears to spare neuro cognitive functioning just as well as stereotactic radiosurgery alone. However, a phase 3 trial is required to validate this approach formally. To that end, they are proposing a trial using prophylactic cranial irradiation using a standard opposed tangent approach versus a hippocampal avoidance approach.

Bottom line, I think there is a push for srs upfront alone in younger/good ps pts. Where I see this to be most applicable is with pci.

Not currently doing this or memantine in practice currently. Phase 3 data definitely is there for memantine though

 

[ramsesthenice]

We have been doing memantine and I havn't had any trouble with insurance. The bigger problem has just been getting patients interested in it. Not too many really want it which I found a little surprising.

I pretty much agree with Gator. I do SRS without whole brain whenever I can for younger/good patients. That is our whole departments practice. I am having a really hard time getting excited about HSWBRT except for maybe in PCI.

 

[OTN]

I use both memantine and HSWBRT for all my patients with decent life expectancy (decent extracranial tumor burden, basically) and have been very happy with the results. I've only had trouble with insurance once or twice for HSWBRT and have never had a problem getting memantine approved. I have had some issues with dose escalation with memantine- lots of dizziness, etc.

Frankly, I didn't feel as if I needed to wait for a Phase III trial to implement HSWBRT. There's a fantastic amount of pre-clinical data backing up the hypothesis, and the data to me was very convincing. While I've only been doing it for a year, and obviously my data is anecdotal, my whole brain patients have done very well after HSWBRT.

I still use SRS whenever I can and withhold whole brain RT for as long as possible, naturally.

 

[radiaterMike]

I think routine use of hswbrt won't and shouldn't be covered. Perhaps in selected patients (perhaps breast cancer and alk+ nsclc) one could advocate for its use. I think the rtog trial was well done and appropriately analyzed and reported, but there are enough issues with it to not consider hswbrt standard of care (check out editorials by Suh and chamberlain). Phase iii studies are forthcoming. My big concern is that for younger patients (ie not eligible for Medicare ) insurance coverage may be denied even if on an nrg study. I guess we'll see. Otn I am surprised you are getting this covered for your patients.

 

[RadRadRad]

I use memantine or HSWBRT for most of my patients with good PS. Have had no insurance issues with either.

As a side note, I've had 2 patients with significant neurocognitive decline after standard WBRT who subsequently had dramatic improvements to initiation of memantine 1-2 months post WBRT. My experience with memantine has been better than expected based on the RCT results (which seemed modest)

 

[SneakyBooger]

I agree HA-WBRT data is strong, but insurance won't pay for it.

 

[seper]

I would guess at 1 month after WBRT you see reversible fatigue/apathy, rather than cognitive decline, which occurs > 3 months out and is not reversible.

I use memantine or HSWBRT for most of my patients with good PS. Have had no insurance issues with either.

As a side note, I've had 2 patients with significant neurocognitive decline after standard WBRT who subsequently had dramatic improvements to initiation of memantine 1-2 months post WBRT. My experience with memantine has been better than expected based on the RCT results (which seemed modest)