A Randomized Controlled Study Of Neurocognitive Outcomes In Patients With Five Or More Brain Metastases Treated With Radiosurgery Or Whole-Brain Radiotherapy
试验速览
- 阶段
- 不适用
- 状态
- 撤回
- 试验地点
- 2
- 主要终点
- To compare the relative change in neurocognitive outcomes (change in oNCF z-score) between baseline and 6 months for surviving patients in upfront WBRT vs. SRS treatment groups.
研究概览
简要总结
This is randomized study of neurocognitive outcomes in patients with five or more brain metastases treated with stereotactic radiosurgery (SRS), specifically the Gamma Knife (GK) system, or whole-brain radiation therapy (WBRT). The primary aim of this study is to compare the change in neurocognitive function outcome between baseline and 6 months in WBRT versus SRS treatment groups.
详细描述
This is randomized controlled study of neurocognitive outcomes in patients with five or more brain metastases treated with stereotactic radiosurgery (SRS), specifically the Gamma Knife (GK) system, or whole-brain radiation therapy (WBRT). The goal of the study is to enroll 120 patients with at least five (≥5) newly-diagnosed brain metastases from non-melanoma, except melanoma patients with BRAF V600E B-Raf protein mutation, primary cancers with the largest intracranial tumor volume ≤10 cc, ≤15 cc total tumor volume, absence of leptomeningeal disease on MRI, and Karnofsky performance status (KPS) score ≥70 (unless due to intracranial disease), and KPS expected to improve to ≥70 with treatment.
All study participants will undergo standard, pre-treatment clinical evaluations that include: complete clinical/neurologic exam, performance status assessment, systemic staging, and diagnostic MRI of the brain. The baseline neurocognitive function (NCF) will be assessed by a short (20-30 minute) online test battery that can be completed by patients at home. All study participants will be randomized to receive radiosurgical or whole-brain radiation treatment for their brain metastases. All patients will have treatment response assessments every 10-12 weeks consisting of a clinical/neurologic exam, performance status evaluation, disease re-staging (if indicated), and diagnostic MRI of the brain. If progressive disease is identified (radiographic progression of treated lesions or new brain lesions), the patients will be considered for "salvage" therapy which will primarily consist of SRS, WBRT, surgery±brachytherapy or best supportive care (e.g. steroids only). The preferred salvage therapy will be SRS provided that the re-treatment criteria are met. The NCF follow-up will start 2 weeks after completion of the initial SRS treatment and will repeat at 2-week intervals, irrespective of any salvage therapy that may be indicated. All study participants will be followed until death or withdrawal from the study.
The primary aim of this study is to compare the change in neurocognitive outcome between baseline and 6 months for surviving patients in upfront WBRT versus SRS treatment groups. The primary study endpoint is neurocognitive function as measured by a significant change in online neurocognitive function (oNCF) z-score from baseline to 6 months. The outcomes will be compared after initial treatment and then repeatedly in follow-up, and will include the impact of salvage SRS treatments. This approach will allow us to assess the relative impact on neurocognitive outcomes of repeat SRS treatments to sites of new brain metastases.
Since SRS and WBRT are two very different forms of treatment (single high-dose treatment vs. multiple low-dose treatments) with markedly different target volumes, it is expected that local control rates will also be markedly different. This, in turn, will impact salvage therapies and associated costs. This study will evaluate local control rates and overall intracranial disease control at 3, 6, 9, and 12 months as a function of initial treatment cohort (SRS vs. WBRT). We also expect significant differences between the treatment groups in patient and caregiver reported quality of life (QoL) measures.
It is also expected that the SRS cohort will require multiple SRS treatments over the course of the study since, unlike WBRT, the treatments target only gross brain metastases and do not address microscopic (clinically undetectable) disease. Conversely, WBRT is expected to result in inferior control rates of gross metastatic disease, increasing the likelihood of subsequent SRS or other salvage therapy. For these reasons, we will track the actual costs of treatments over the course of the study, including the need for supportive care and the ability of patients to continue to work in their previous occupation.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Pathologically (histologically or cytologically) proven diagnosis of a non-hematopoietic malignancy other than small cell lung cancer and germ cell malignancy within 5 years of registration. If the original histologic proof of malignancy is greater than 5 years, then pathological confirmation is required (e.g. from extra- or intra-cranial disease).
- •If an open biopsy is performed, the patient must be at least one week post biopsy. This requirement does not apply to patients who undergo stereotactic biopsies.
- •Patients with ≥5 measurable brain metastases on a diagnostic-quality contrast-enhanced magnetic resonance imaging (MRI) obtained within 30 days prior to registration.
- •Patients with ≤10 cc largest tumor volume, and ≤15 cc total tumor volume.
- •History/physical examination within 30 days prior to registration.
- •Age ≥18 years.
- •Karnofsky performance status ≥70 (RTOG recursive partitioning analysis (RPA) Class I & II).
- •Minimum pre-treatment oNCF score ≥
- •Patients must provide study-specific informed consent prior to study entry.
- •Women of child-bearing age must have a negative, quantitative serum pregnancy test ≤14 days prior to study entry, or have a documented reason why such a test is not necessary (e.g. history of tubal ligation).
- •Patients must be able to speak and read English fluently (required for the use of online NCF testing).
- •Patients must demonstrate basic computer literacy skills and have access to an internet terminal (required for the use of online NCF testing).
排除标准
- •Clinical (e.g. multiple new cranial nerve deficits in the absence of obvious radiographic disease to explain symptoms) or radiographic evidence of leptomeningeal disease.
- •Patients with measurable brain metastasis(es) resulting from small cell lung cancer and/or germ cell malignancy.
- •No documentation of prior cytotoxic or other therapy for malignancy if such therapy was previously received. Note: This does not apply to patients with synchronous metastases at initial diagnosis.
- •Contraindication to MR imaging, such as implanted metal devices or foreign bodies, severe claustrophobia, or contraindications to contrast agent administration.
- •Estimated glomerular filtration rate (eGFR) <60 within 6 weeks prior to registration. • Prior radiation therapy to the brain. • Severe, active co-morbidity, defined as follows:
- •Unstable angina, and/or congestive heart failure requiring hospitalization within the last 6 months.
- •Transmural myocardial infarction within the last 6 months. - Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration.
- •Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects.
- •Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization, or precluding study therapy at the time of registration.
- •Uncontrolled, clinically significant cardiac arrhythmias. - Radiologic or clinical evidence of hydrocephalus, or history of previously treated hydrocephalus.
- •Women of childbearing potential and male participants who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the radiation treatment involved in this study is potentially teratogenic
结局指标
主要结局
To compare the relative change in neurocognitive outcomes (change in oNCF z-score) between baseline and 6 months for surviving patients in upfront WBRT vs. SRS treatment groups.
时间窗: Every 3 months for 12 months
All participants will be asked to complete: 1. Online brain function testing: Complete a short 20-minute online brain function (cognitive) assessment every 2 weeks (twice per month, at least 10-14 days apart). 2. Quality of Life Questionnaire: Complete a self-reported (if patient) and caregiver quality of life questionnaires every 10-12 weeks (2.5-3 months). These questionnaires take approximately 15-20 minutes to complete and can be done online or in clinic during follow-up visits.
次要结局
- To estimate consistency and change in z-scores for oNCF assessments over all study endpoints in surviving patients treated with upfront whole brain radiation therapy (WBRT) vs. stereotactic radiosurgery (SRS).(Every 10-12 months)
- To compare the relative change in neurocognitive outcomes (change in oNCF z-score) between baseline and 12 months for surviving patients in upfront WBRT vs. SRS treatment groups.(Every 10-12 weeks for 12 months after treatment)
- To compare the relative impact of initial therapy on patients' quality of life (QoL) as measured by caregiver assessments(Every 10-12 months)
- To compare proportions of patients in the two treatment groups that require salvage therapy as a function of systemic disease control (controlled vs. uncontrolled).(3, 6, 9, and 12 months)
- To compare the overall survival between patients in upfront whole brain radiation therapy (WBRT) vs. stereotactic radiosurgery (SRS) treatment groups(baseline to study completion)