A major concern in anticancer treatment (ACT) of brain metastases (BM) is exposing patients with short expected survival to treatments that negatively impact on quality of life (QoL). Such futile ACT at the end of life is time-consuming and burdensome for patients and their families and entails unnecessary healthcare costs. Refraining from ACT is challenging for both physicians and patients. This study aimed to provide real-life data on survival after BM diagnosis and patient reported outcomes (PROs) after ACT to identify risk factors for futile treatment and to support BM treatment decisions. This multi-center, prospective, observational study recruited consecutive patients with first-time BM from November 2017 to March 2021. Patients were followed until death or study end (October 1st, 2023). Clinical factors associated with survival were analyzed by the Cox’ proportional hazards model. Changes in PROs after BM treatment were described according to Eastern Cooperative Oncology Group (ECOG) performance status, survival, and treatment groups. For the total cohort (N = 912), median overall survival (mOS) after BM diagnosis was 5.9 months (95% confidence interval [CI] 5.2–6.7). ECOG 2–4, uncontrolled extracranial metastases, and ≥5 BM were associated with short survival. In patients treated with radiotherapy, survival for patients with ECOG 2 and those with ECOG 3–4 was similar and particularly short for the whole brain radiotherapy (WBRT) group (ECOG 2: 2.9 months [95% CI 2.3–3.5]; ECOG 3–4: 2.1 [1.5–2.7]). Patients surviving 6 months reported stable scores over time. Patients with ECOG 2–4, especially those with uncontrolled extracranial metastases and ≥5 BM, are at risk for futile ACT. BM treatment guidelines should strongly caution against ACT to patients with expected survival <6 months and specifically advise against WBRT. The 10.13039/501100006095 South-Eastern Norway Regional Health Authority ; The 10.13039/100008730 Norwegian Cancer Society .

Managing cancer-related pain remains a major clinical challenge, particularly in the context of increasing concerns around opioid use. The World Health Organization's Analgesic Ladder, a widely used framework for cancer pain management, is being re-evaluated-especially the second step involving weak opioids such as codeine and tramadol. Evidence suggests these offer limited benefit and more side effects compared to initiating treatment with strong opioids. As cancer care advances, more patients live longer with chronic pain, requiring a tailored, multimodal approach. Meanwhile, the global opioid crisis has led to heightened regulatory scrutiny, making prescribers more cautious and potentially contributing to the under-treatment of pain. Long-term opioid use is also associated with risks including cognitive impairment, opioid-induced hyperalgesia, and endocrine dysfunction. This review examines the ongoing relevance and limitations of the WHO ladder, highlights the challenges of opioid toxicity, and advocates for a personalised, multidisciplinary strategy to deliver safe, effective, and compassionate cancer pain relief.

Surgical resection of brain metastases (BM) improves overall survival (OS) in selected patients. Selecting those patients likely to benefit from surgery is challenging. The Graded Prognostic Assess...

Brain metastases (BM) occur in about 30% of all patients with non-small cell lung cancer (NSCLC). BM treatment guidelines recommend more frequent use of stereotactic radiotherapy (SRT). Overall, st...

To analyse the use of radiotherapy (RT) and factors affecting overall survival (OS) after RT in breast cancer patients with brain metastases. Breast cancer patients treated from 2008 to 2018 with whole brain RT (WBRT) or stereotactic radiosurgery (SRS) at a large regional cancer referral center were identified from the hospital's RT register. Clinical variables were extracted from medical records. OS was calculated from date of first RT until death or last follow up. Potential factors affecting OS were analyzed. 255 females with WBRT (n = 206) or SRS (n = 49) as first RT were included. An increased use of initial SRS was observed in the second half of the study period. The most common WBRT fractionation regimen was 3 Gy × 10. SRS was most often single fractions; 18 or 25 Gy between 2009 and 2016, while fractionated SRS was mostly used in 2017 and 2018. Median OS in the WBRT group was 6 months (CI 1-73) relative to 23 (CI 0-78) in the SRS group. Age, performance status, initial RT technique, extracranial disease, brain metastasis surgery, number of brain metastases and DS-GPA score had significant impact on OS. Only ECOG 0 and brain metastasis surgery were associated with superior OS in multivariate analysis. WBRT was the most frequent primary RT. An increased use of initial SRS was observed in the second half of the study period. Only ECOG 0 and brain metastasis surgery were associated with superior OS in multivariate analysis.

Up to 40% of non-smallcell lung cancer (NSCLC) patients develop brain metastases (BMs). The potential benefits of radiotherapy (RT) in patients with poor performance status (PS) are questionable, with considerable risk for futile treatment. We analyzed overall survival after initial radiotherapy in NSCLC patients with BMs, focusing on the relationship between PS and survival after RT. This study reports a prospective observational study including consecutive 294 NSCLC patients with first-time BMs. Overall survival (OS) was calculated from the start of RT to death or last follow-up (1 June 2023). Overall, in the 294 included patients (median age 69 years), the median OS was 4.6 months; 2.5 months after WBRT (n = 141), and 7.5 months after SRT (n = 153). After WBRT, mOS was equally poor for patients with ECOG 2 (1.9 months) and ECOG 3–4 (1.2 months). After SRT, mOS for patients with ECOG 2 was 4.1 months; for ECOG 3 patients, mOS was 4 1.6 months. For NSCLC patients with ECOG 2 diagnosed with BMs who are not candidates for surgery or SRT, WBRT should be questioned due to short survival.