Aim

To evaluate international patterns of practice for the management of metastatic disease to the brain.

Materials and methods

An online international practice survey was conducted from April to June 2010. Most of the survey questions were based on common management issues for which optimal management using level 1 evidence was lacking. The survey consisted of three sections: respondent demographics, 13 general questions regarding surgery, whole brain radiotherapy (WBRT) and radiosurgery and 13 questions related to specific scenarios.

Results

In total, 445 individuals responded to the survey over a 3 month period. Ninety per cent of respondents worked in a hospital-based setting. Ninety-three per cent of respondents were radiation oncologists. Thirty-seven per cent worked in an academic setting. Only three of 26 survey questions generated at least 70% agreement for a favoured response. Eighty-eight per cent of respondents chose comfort measures only for patients with multiple brain metastases who have been previously treated with WBRT and who now present 6 months later with two to four brain metastases (all less than 4 cm in size) with uncontrolled extracranial disease and bedridden state. Seventy-eight per cent of respondents would use WBRT alone for initial treatment in patients with two to four brain metastases (all less than 4 cm in size), with active, uncontrolled extracranial disease and a Karnofsky performance status of 70. Seventy-eight per cent of respondents chose surgical resection for an enlarging single brain metastasis that has been previously treated with radiosurgery. The enlarging single brain metastasis is in a surgically accessible site and is now symptomatic. The patient has controlled extracranial disease, good performance status and magnetic resonance spectroscopy was not diagnostic.

Conclusions

There is a lack of uniform agreement for many common management issues (not well answered by level 1 evidence) in patients with metastatic disease to the brain.