Brain metastases: a role of conventional chemotherapy?

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Published: 17 May 2017
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Dr Peter Mohr - Elbe Klinikum Buxtehude, Germany

Dr Mohr speaks with ecancer at EADO 2017 about the suitability of chemotherapy for brain metastases of skin cancer.

He notes ongoing research into combining chemotherapy with immunotherapy, and in the adjuvant setting, but ultimately chemotherapeutics offer no survival benefit.

This does mean that patients with brain metastases may be more readily considered eligible for trials of new agents, but Dr Mohr cautions against any further use of chemotherapy beyond last-line and salvage efforts.

ecancer's filming has been kindly supported by Amgen through the ECMS Foundation. ecancer is editorially independent and there is no influence over content.

I’m going to have a presentation on brain metastases and chemotherapy. As you know, there have been a lot of different drugs introduced now in this field. We do not have very much data about immune therapy and about targeted therapy we do have a little bit more. All the trials coming from chemotherapy are very early on trials with not very much impact.

So what can we say? We have a remission rate of around 5% to maybe 10% with fotemustine and also with temozolomide, those drugs that are partially licensed, temozolomide in most countries and fotemustine in some countries. But they have never shown to show an overall survival benefit so it’s actually a last line therapy of the days today. There are some trials going on in combination with immune therapy for fotemustine and ipilimumab which showed some promising phase II data but this is ongoing now in a phase III trial. There are also some data about the combination of whole brain irradiation and chemotherapy and we have to state that there is absolutely no beneficial situation combining these two different options. So basically last line therapy or maybe no therapy at all, maybe only salvage therapy and chemotherapy will not play a role in the future for metastatic melanoma in the brain.

Are you looking at the timing of chemotherapy in a combination setting?

There will be a trial on adjuvant chemotherapy at ASCO for brain metastases but it’s too early to talk about that now so you’ve got to wait a couple of weeks but look out for that one. There is a little bit of data maybe in regards of chemotherapy that chemotherapy could prevent brain metastases but it’s very weak evidence. Since we don’t apply chemotherapy in order to treat brain mets it’s also not applicable in order to prevent brain mets and we have much better and stronger drugs coming up in combinations. The main issue is that up front we should now include patients with brain mets in our trials when we deliver new combinations because, after all, they are not all doing so badly. So we have to pick the right patients in order to get the drugs to the patients with brain metastases more early than now.

Will this help in making treatments more available in developing countries?

I would say no, rather save the money and buy for fewer patients something that is worthwhile doing. Because also for metastatic melanoma we have not managed to show survival benefits with just chemotherapy, it was just the only thing that we had but no survival benefits. Rather for today, although if it’s hard, no therapy instead of giving a chemotherapy that is not working. For these developing countries we need to find a way in order to deliver the drugs to them like we do in HIV for the third world countries to make it more feasible for patients to have access to these drugs.