International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: BrainImportance of the mini-mental status examination in the treatment of patients with brain metastases: a report from the radiation therapy oncology group protocol 91-04☆
Introduction
Radiation therapy remains the standard treatment for patients with brain metastases, especially those with multiple lesions. Various reports have generally identified age of the patient at the time of treatment as the single most important prognostic factor, although good performance status, absence of systemic disease, complete resection performed, and location of the primary site (such as breast or lung) have also been associated with increased survival. Recently, the Radiation Therapy Oncology Group (RTOG) completed a Phase III comparison of accelerated fractionation (AF) or accelerated hyperfractionation (AH) in the treatment of patients with central nervous system (CNS) metastases. Additional information on the value of performance status as identified by a Mini-Mental Status Examination (MMSE) or Karnofsky Performance Status (KPS) was obtained in these patients and its importance, relative to outcome, is reported here.
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Methods and materials
From 1991 to 1995, the RTOG conducted Protocol 91-04. This was a Phase III trial in patients with known CNS metastasis. Prior to initiating patient entry, all participating institutions submitted the protocol design and consent form to their Institutional Review Board for approval. Informed consent was obtained from all patients. Eligibility requirements included proof of an underlying primary tumor with a measurable brain lesion (or lesions) by CT or MRI. Additionally, a KPS of at least 70 and
Results
This study accrued a total of 445 patients between October of 1991 and September of 1995. Sixteen patients were either ineligible or not analyzable: 9 were ineligible, 1 canceled, 2 were awaiting submission of appropriate forms, and 4 had no on-study forms. Two hundred twenty-four patients received accelerated fractionation. For this analysis, all patients had to be eligible according to the protocol guidelines and have treatment and survival data. Patients without pretreatment MMSE were also
Discussion
Multiple other studies have demonstrated the poor outcome usually expected in patients with CNS metastasis. Previous RTOG studies have explored a series of different fractionation schedules. The initial experience utilizing various accelerated-fractionation regimens was summarized by Borgelt et al. (4). Four treatment regimens consisting of 40 Gy in 4 weeks, 40 Gy in 3 weeks, 30 Gy in 3 weeks, or 30 Gy in 2 weeks were reviewed. The overall response to treatment was equivalent among all of the
Conclusions
Long-term survival of selected patients with CNS metastases is 17% at 1 year and 5% at 2 years after treatment with 30 Gy in 10 fractions in 2 weeks. Studies attempting to improve upon these results through the use of radiosensitizers, radioprotectors, or stereotactic radiosurgery are currently ongoing.
Although gender and age may be predictors of survival, KPS and MMSE are also highly correlated with outcome.
MMSE and primary site remain important determinants of time until death from CNS
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This paper was supported by grants CA21661 and Ca32115 from the National Cancer Institute and from funding through Pharmacyclics Inc. Its contents are solely the responsibility of the authors and do not necessarily represent the views of the National Cancer Institute or Pharmacyclics Inc.