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Prophylactic cranial irradiation for patients with lung cancer
Péchoux, C.L., Sun, A., Slotman, B.J., (...), Belderbos, J., Gore, E.M.
THE LANCET Oncology, Volume 17, Issue 7, July 2016, Pages e277–e293
Commentary by Nir Peled
The practice of prophylactic cranial irradiation (PCI) is well established in limited SCLC and debated in extensive SCLC, while not recommended in NSCLC. Péchoux et al reviewed recently in The Lancet Oncology the literature to support this practice with a significant reduction of brain metastasis rate from ~50% to ~30% with a survival benefit of ~ 5% for 3 years in limited SCLC only. The survival benefit in extensive SCLC is still controversial. PCI has moderate cognitive cost which increases over time, therefore current studies focus on neuroprotection while under PCI.
It is important to note that PCI stands for "prophylactic" while it is not really prophylactic, rather treat un-detectable brain disease. The studies that lead to this practice are quite old without an appropriate brain imagine on the primary assessment (e.g. no brain imagine or only brain CT). As SCLC responses very well to radiation, the current urgent UNMET need is to perform a randomized study to re-assess the role of PCI in comparison to WBRT only when required upon frequent brain MRIs in SCLC. There is no doubt that we may see higher rate of brain metastasis, however we may avoid un-necessary brain radiation to 50% of the patients and a delayed diagnosis may not affect overall survival outcome.
Till this will be proven, the current practice should stay upon the evidence provided.