Brain metastases: the decisions you may face
7 treatment settings, 4 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Symptomatic oedema
Dexamethasone, tapered as quickly as symptoms allow; anticonvulsants only after a seizure.
Dexamethasone is a long-acting glucocorticoid steroid that kills lymphoid cancer cells directly, which is why it sits in nearly every myeloma regimen and in childhood leukaemia and lymphoma protocols. It is also the standard drug for preventing chemotherapy sickness and for brain swelling and spinal cord compression; high blood sugar, insomnia, muscle wasting and infection follow prolonged use.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.
- Is Dexamethasone the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (symptomatic oedema), which of the standard options do you recommend and why?Why: Guideline options include: Dexamethasone, tapered as quickly as symptoms allow; anticonvulsants only after a seizure.
- Am I a candidate for Dexamethasone, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
Single large or symptomatic lesion, fit patient
Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy.
A single very high dose, or a few doses, aimed at a small brain or spine target with millimetre precision, replacing whole-brain radiotherapy for most brain metastases.
- One to five sessions
- Spares healthy brain
- Treats targets surgery cannot reach
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Limited to small targets
- Radiation necrosis in a minority
- Needs precise imaging and immobilisation
- Is Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS) the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (single large or symptomatic lesion, fit patient), which of the standard options do you recommend and why?Why: Guideline options include: Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy.
Add these to your appointment list, or take the full question set for this cancer.
Limited number of metastases
Stereotactic radiosurgery alone (Alliance N0574); whole-brain radiotherapy withheld because it worsens cognition without lengthening life.
A single very high dose, or a few doses, aimed at a small brain or spine target with millimetre precision, replacing whole-brain radiotherapy for most brain metastases.
- One to five sessions
- Spares healthy brain
- Treats targets surgery cannot reach
The original radiosurgery machine: about two hundred cobalt-60 sources arranged in a shielded helmet whose beams cross at one point inside the brain, so a metastasis or benign tumour a few millimetres across receives a destructive dose in a single visit while the brain around it is spared.
- Sub-millimetre accuracy and steepest fall-off
- Many brain metastases in one session
- Decades of outcome data
A small accelerator on an industrial robot arm that aims hundreds of pencil-thin beams from any direction and follows the tumour as the patient breathes, so brain, spine, prostate, lung and pancreatic tumours can be treated in one to five sessions without a head frame.
- Frameless with real-time tracking of skull, spine and fiducials
- Follows breathing motion without gating
- Non-coplanar beams from almost any angle
- One to three brain metastases: stereotactic radiosurgery alone versus radiosurgery plus whole-brain radiotherapy
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- Cognitive deterioration at 3 months 63.5% (SRS alone) vs 91.7% (SRS plus WBRT); no survival difference.
Cognitive deterioration at 3 months (%): Radiosurgery alone 63.5 (n=111) vs Radiosurgery plus whole-brain radiotherapy 91.7 (n=102)
- Limited to small targets
- Radiation necrosis in a minority
- Needs precise imaging and immobilisation
- Intracranial targets only
- Cobalt sources decay and must be replaced
- Radioactive inventory, shielding and licensing
- Long sessions and low throughput
- Small fields only, not for large volumes
- Fiducial placement is invasive for soft-tissue targets
- Between Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS), Gamma Knife and CyberKnife robotic radiosurgery, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in Alliance N0574 (NCCTG N0574), and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (limited number of metastases), which of the standard options do you recommend and why?Why: Guideline options include: Stereotactic radiosurgery alone (Alliance N0574); whole-brain radiotherapy withheld because it worsens cognition without lengthening life.
- How do the results of Alliance N0574 (NCCTG N0574) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Many metastases or leptomeningeal spread
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).
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
- Brain metastases needing whole-brain radiotherapy: hippocampal-avoidance whole-brain radiotherapy plus memantine versus standard whole-brain radiotherapy plus memantine
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- Cognitive failure hazard ratio 0.74 with hippocampal avoidance; no difference in intracranial control or survival.
- Non-small-cell lung cancer with brain metastases unsuitable for surgery or radiosurgery: whole-brain radiotherapy plus supportive care versus supportive care alone
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- Quality-adjusted life-years 46.4 vs 41.7 days; overall survival 9.2 vs 8.5 weeks; no meaningful benefit from whole-brain radiotherapy.
Quality-adjusted life-years (QALY days): Optimal supportive care + WBRT 46.4 (n=269) vs Optimal supportive care alone 41.7 (n=269) · source
- Low-dose bath to normal tissue
- Motion management
- Is IMRT / IGRT (modern external beam) the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in NRG CC001 and QUARTZ, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (many metastases or leptomeningeal spread), which of the standard options do you recommend and why?Why: Guideline options include: 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).
- How do the results of NRG CC001 and QUARTZ apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Driver-positive lung cancer, asymptomatic metastases
Brain-penetrant targeted therapy first: osimertinib (EGFR), lorlatinib or alectinib (ALK); radiosurgery for progression.
Osimertinib (Tagrisso) is the standard pill for EGFR-mutant lung cancer, now also given after surgery and with chemotherapy or after chemoradiation.
An ALK inhibitor with the longest disease control ever recorded for a targeted lung cancer pill: 60% progression-free at five years.
Alectinib is a well-tolerated ALK pill, standard first line for years and, since 2024, the first targeted therapy given after surgery for ALK-positive lung cancer.
- Tests LorlatinibFirst-line ALK-positive advanced NSCLC: lorlatinib vs crizotinib
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- 5-year PFS 60% vs 8%, HR 0.19 (JCO 2024).
Progression-free survival at 5 years (BICR) (%): Lorlatinib 60 (n=149) vs Crizotinib 8 (n=147) · HR 0.19 · source
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Decreased appetite · FLAURA | 20% | 2.5% |
| Diarrhoea · FLAURA | 58% | 2.2% |
| Fatigue · FLAURA | 21% | 1.4% |
| Rash · FLAURA | 58% | 1.1% |
- Known QT prolongation. Avoid other QT-prolonging drugs where possible; check ECG and correct potassium and magnesium before and during treatment.
- No adjustment for mild or moderate impairment; not studied in severe.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Take with food; exposure roughly triples with a high-fat meal, and the trials dosed with food.
- Start at 450 mg twice daily in severe impairment (Child-Pugh C).
- Between Osimertinib, Lorlatinib and Alectinib, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in CROWN, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Osimertinib are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (driver-positive lung cancer, asymptomatic metastases), which of the standard options do you recommend and why?Why: Guideline options include: Brain-penetrant targeted therapy first: osimertinib (EGFR), lorlatinib or alectinib (ALK); radiosurgery for progression.
- Am I a candidate for Osimertinib, Lorlatinib, Alectinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CROWN apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
HER2-positive breast cancer
Tucatinib with trastuzumab and capecitabine (HER2CLIMB) or trastuzumab deruxtecan (DESTINY-Breast12), with local therapy for symptomatic lesions.
A HER2-selective pill that works in the brain, for HER2-positive breast cancer with brain metastases.
Trastuzumab deruxtecan (Enhertu) is the most successful ADC ever. It redefined HER2 by working in tumours with only tiny amounts of the protein, and in 2026 moved into early-stage breast cancer.
- Tests TucatinibHER2+ metastatic breast cancer after trastuzumab, pertuzumab, and T-DM1, including active brain metastases: tucatinib + trastuzumab + capecitabine vs placebo + trastuzumab + capecitabine
OS 21.9 vs 17.4 months, HR 0.66; CNS-PFS HR 0.32.
Progression-free survival (months): Tucatinib arm 7.8 (n=320) vs Placebo arm 5.6 (n=160) · HR 0.54 · source - Tests Trastuzumab deruxtecanHER2+ metastatic breast cancer with or without brain metastases: single-arm T-DXd
CNS ORR 71.7%; 12-month PFS 61.6% in brain-metastasis cohort.
- Reduce to 200 mg twice daily in severe impairment.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Neutropenia · DESTINY-Breast03/04; all-grade rates ≥20% per label | - | 18% |
| Nausea · DESTINY-Breast03/04; all-grade rates ≥20% per label | - | 7% |
| Anaemia · DESTINY-Breast03/04; all-grade rates ≥20% per label | - | 7% |
| Fatigue · DESTINY-Breast03/04; all-grade rates ≥20% per label | - | 6% |
- Interstitial lung disease in 10-15%: hold for any respiratory symptom and image; permanently discontinue for grade 2 or above. Moderately emetogenic: three-drug prophylaxis.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Between Tucatinib and Trastuzumab deruxtecan, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in HER2CLIMB and DESTINY-Breast12, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Trastuzumab deruxtecan are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (her2-positive breast cancer), which of the standard options do you recommend and why?Why: Guideline options include: Tucatinib with trastuzumab and capecitabine (HER2CLIMB) or trastuzumab deruxtecan (DESTINY-Breast12), with local therapy for symptomatic lesions.
- Am I a candidate for Tucatinib, Trastuzumab deruxtecan, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of HER2CLIMB and DESTINY-Breast12 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Melanoma
Nivolumab plus ipilimumab for asymptomatic metastases (CheckMate 204); dabrafenib plus trametinib for BRAF V600-mutant disease (COMBI-MB); radiosurgery for symptomatic or progressing lesions.
Nivolumab was the second PD-1 blocker and is often combined with ipilimumab. Long-term data show about half of advanced melanoma patients alive at 10 years on the combination.
Ipilimumab was the first checkpoint inhibitor (2011), and proved the immune system could be unleashed against cancer.
Dabrafenib plus trametinib is the BRAF-plus-MEK pill combination, approved for BRAF V600E lung cancer and, since 2022, for any solid tumour with that mutation.
A single very high dose, or a few doses, aimed at a small brain or spine target with millimetre precision, replacing whole-brain radiotherapy for most brain metastases.
- One to five sessions
- Spares healthy brain
- Treats targets surgery cannot reach
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Colitis with ipilimumab (1+3 mg/kg) · Monotherapy pooled unless stated | 25% | 14.4% |
| Hepatitis with ipilimumab · Monotherapy pooled unless stated | 15% | 13.4% |
| Colitis · Monotherapy pooled unless stated | 2.9% | 1.7% |
| Hepatitis · Monotherapy pooled unless stated | 1.8% | 1.5% |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Colitis (with nivolumab 1+3) · Nivolumab 1 mg/kg + ipilimumab 3 mg/kg, melanoma | 25% | 14.4% |
| Hepatitis (with nivolumab) · Nivolumab 1 mg/kg + ipilimumab 3 mg/kg, melanoma | 15% | 13.4% |
| Rash (with nivolumab) · Nivolumab 1 mg/kg + ipilimumab 3 mg/kg, melanoma | 28% | 4.8% |
| Adrenal insufficiency (with nivolumab) · Nivolumab 1 mg/kg + ipilimumab 3 mg/kg, melanoma | 8% | 2.6% |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Dabrafenib: take on an empty stomach. Trametinib: take on an empty stomach; both cause pyrexia.
- Limited to small targets
- Radiation necrosis in a minority
- Needs precise imaging and immobilisation
- Between Nivolumab, Ipilimumab, Dabrafenib + trametinib and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- Which side effects of Nivolumab or Ipilimumab are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (melanoma), which of the standard options do you recommend and why?Why: Guideline options include: Nivolumab plus ipilimumab for asymptomatic metastases (CheckMate 204); dabrafenib plus trametinib for BRAF V600-mutant disease (COMBI-MB); radiosurgery for symptomatic or progressing lesions.
- Am I a candidate for Nivolumab, Ipilimumab, Dabrafenib + trametinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.