The first 60 days: Brain metastases (secondary brain tumours)

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.

• SurgeonNamed in the standard of care for: Single large or symptomatic lesion, fit patient.
• Medical oncologistNamed in the standard of care for: Symptomatic oedema, Single large or symptomatic lesion, fit patient, Limited number of metastases, Many metastases or leptomeningeal spread and 3 more.
• Clinical oncologist (radiotherapy)Named in the standard of care for: Single large or symptomatic lesion, fit patient, Limited number of metastases, Many metastases or leptomeningeal spread, Melanoma.
• Palliative and supportive care teamNamed in the standard of care for: Symptomatic oedema, Many metastases or leptomeningeal spread.

A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.

Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.

1. 1.Limited number of metastasesNCCN Guidelines: Central Nervous System Cancers

   Stereotactic radiosurgery alone (Alliance N0574); whole-brain radiotherapy withheld because it worsens cognition without lengthening life.

   Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS)Gamma KnifeCyberKnife robotic radiosurgeryAlliance N0574 (NCCTG N0574)
2. 2.Symptomatic oedemaNCCN Guidelines: Central Nervous System Cancers

   Dexamethasone, tapered as quickly as symptoms allow; anticonvulsants only after a seizure.

   Dexamethasone
3. 3.Single large or symptomatic lesion, fit patientNCCN Guidelines: Central Nervous System Cancers

   Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy.

   Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS)
4. 4.Many metastases or leptomeningeal spreadNCCN Guidelines: Central Nervous System Cancers

   Hippocampal-avoidance whole-brain radiotherapy with memantine (NRG CC001) where whole-brain treatment is chosen; radiosurgery to many lesions in selected patients; best supportive care alone in poor-prognosis lung cancer (QUARTZ).

   Whole-brain radiotherapy (WBRT)NRG CC001QUARTZIMRT / IGRT (modern external beam)
5. 5.Driver-positive lung cancer, asymptomatic metastasesNCCN Guidelines: Central Nervous System Cancers

   Brain-penetrant targeted therapy first: osimertinib (EGFR), lorlatinib or alectinib (ALK); radiosurgery for progression.

   OsimertinibLorlatinibAlectinibCROWN
6. 6.HER2-positive breast cancerNCCN Guidelines: Central Nervous System Cancers

   Tucatinib with trastuzumab and capecitabine (HER2CLIMB) or trastuzumab deruxtecan (DESTINY-Breast12), with local therapy for symptomatic lesions.

   TucatinibTrastuzumab deruxtecanHER2CLIMBDESTINY-Breast12
7. 7.MelanomaNCCN Guidelines: Central Nervous System Cancers

   Nivolumab plus ipilimumab for asymptomatic metastases (CheckMate 204); dabrafenib plus trametinib for BRAF V600-mutant disease (COMBI-MB); radiosurgery for symptomatic or progressing lesions.

   NivolumabIpilimumabDabrafenib + trametinibStereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS)

Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.

Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.

• A Pivotal Phase II Clinical Trial of Utidelone Injection Plus Capecitabine in HER2-negative Breast Cancer Patients With Brain MetastasesPhase 2 · recruiting · NCT06764940A Pivotal Phase II Clinical Trial of Utidelone Injection (UTD1) Plus Capecitabine (CAP) in HER2-negative Breast Cancer Patients With Brain Metastases
• Efficacy and Safety of SPH4336 in Combination With Endocrine Therapy in Breast Cancer Patients With Brain Metastases.Phase 2 · recruiting · NCT05872347A Phase II Study of SPH4336 in Combination With Endocrine Therapy in HR-positive, HER2-negative Breast Cancer Patients With Brain Metastases.
• Phase 2b Imaging Study of RAD101 in Participants With Suspected Recurrent Brain MetastasesPhase 2 · active · NCT06777433An Open-Label, Single Dose, Single Arm, Multicenter Phase 2b Study to Establish the Imaging Performance of RAD101 Positron Emission Tomography (PET) in Participants With Suspected Recurrent Brain Metastases From Solid Tumors
• TY-9591 in the Patients With EGFR Mutations in Advanced NSCLC With Brain MetastasesPhase 2 · recruiting · NCT05948813A Phase II Study of TY-9591 Tablets in Patients With EGFR-Mutated Non-small Cell Lung Cancer With Brain Metastases
• Study of Abemaciclib and Elacestrant in Participants With Brain Metastasis Due to ER+/HER-2- Breast CancerPhase 1/2 · recruiting · NCT05386108An Open-label Multicenter Phase 1b-2 Study of Elacestrant in Combination With Abemaciclib in Women and Men With Brain Metastasis From Estrogen Receptor Positive, HER-2 Negative Breast Cancer

Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

• Free in oncologyFree testing, helplines, rides and lodging, second opinions and trial travel help, with who is eligible.
• Financial helpManufacturer programmes, national schemes and charities by country and product.
• Second opinionExpert centres for this cancer in your country and how referral works.

• Brain metastases (secondary brain tumours): the full pageBrain metastases are cancers that have spread to the brain from elsewhere, most often from the lung, breast or skin. Focused radiation aimed at each spot (radiosurgery) has largely replaced radiation to the whole brain, and for some cancers modern targeted drugs and immunotherapy reach the brain well enough to shrink the deposits on their own.
• One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
• Treatment sequencingWhich treatment tends to follow which, line by line.
• NavigatorStandard of care for your stage, what you have tried, and trials near you.