Wednesday, October 19, 2011
NEJM presents a case of a man found to have a primary lung cancer and a solitary brain metastasis. The discussion regarding management of the patient is noteworthy, especially the possible role of surgery and a brief discussion regarding the use of tyrosine kinase inhibitors.
The palliative care consultant should be aware of the available case series which suggest that a minority of patients might have a longer survival than what is usually expected in patients with brain mets. (See Table 1 in the article.) In the case series, patients received aggressive surgical intervention for the brain met and aggressive attempt at locoregional control of the primary cancer.
The article provides some guidance for selection of appropriate patients for aggressive disease-based management. No particular quality of life outcomes are mentioned related to aggressive surgical management.
The bottom line dilemma: This is a scenario where multidisciplinary/multimodality management may give a small number of patients a chance at longer term survival. The approach may be worthwhile to some, but talking about prognosis on multiple levels (survival, anticipated quality of life/burden of procedures) is essential. I cannot remember encountering this scenario recently, but a palliative care consult would be appropriate in any patient with Stage IV lung cancer. It's possible that the complexities of therapy and communication surrounding prognosis may only increase the usefulness of palliative care in this scenario.