The first 60 days: Brain metastases (secondary brain tumours)
Brain 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. Below, week by week, is what OnCo's record of Brain metastases (secondary brain tumours) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
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.
Stereotactic radiosurgery alone (Alliance N0574); whole-brain radiotherapy withheld because it worsens cognition without lengthening life.
Dexamethasone, tapered as quickly as symptoms allow; anticonvulsants only after a seizure.
Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy.
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).
- 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.
Tucatinib with trastuzumab and capecitabine (HER2CLIMB) or trastuzumab deruxtecan (DESTINY-Breast12), with local therapy for symptomatic lesions.
Nivolumab plus ipilimumab for asymptomatic metastases (CheckMate 204); dabrafenib plus trametinib for BRAF V600-mutant disease (COMBI-MB); radiosurgery for symptomatic or progressing lesions.
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.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Primary tumour type and its driver, Number, size and location of lesions on contrast MRI, Graded prognostic assessment, Cerebrospinal fluid cytology and cell-free DNA for leptomeningeal disease, Distinguishing radionecrosis from progression), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Brain metastases from non-small cell lung cancer, Brain metastases from breast cancer, Brain metastases from melanoma.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Symptomatic oedema
- For my situation (symptomatic oedema), which of the standard options do you recommend and 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?Knowing the expected toxicities helps you plan work, family, and supportive care.
Single large or symptomatic lesion, fit patient
- For my situation (single large or symptomatic lesion, fit patient), which of the standard options do you recommend and why?Guideline options include: Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy.
Limited number of metastases
- For my situation (limited number of metastases), which of the standard options do you recommend and 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?Trial populations differ from individual patients; ask how closely you match.
Many metastases or leptomeningeal spread
- For my situation (many metastases or leptomeningeal spread), which of the standard options do you recommend and 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?Trial populations differ from individual patients; ask how closely you match.
Driver-positive lung cancer, asymptomatic metastases
- For my situation (driver-positive lung cancer, asymptomatic metastases), which of the standard options do you recommend and 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?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CROWN apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
HER2-positive breast cancer
- For my situation (her2-positive breast cancer), which of the standard options do you recommend and 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?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?Trial populations differ from individual patients; ask how closely you match.
Melanoma
- For my situation (melanoma), which of the standard options do you recommend and 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?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Trastuzumab deruxtecan, Tucatinib, Lorlatinib, Focused-ultrasound blood-brain barrier opening?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Trials still often exclude patients with brain metastases, so drug activity in the brain is learned late”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Leptomeningeal disease has no standard treatment and a survival of months”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- 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.
- HER2-positive brain metastases: Up to half of women with metastatic HER2-positive breast cancer develop brain metastases, because antibodies control the body but historically not the brain.
- Whole-brain radiotherapy (WBRT): Irradiating the entire brain, typically 30 Gy in 10 sessions, when metastases are too numerous or too widespread (leptomeningeal) for focused radiosurgery.
- Leptomeningeal disease: Cancer cells spreading in the fluid and membranes that bathe the brain and spinal cord, rather than as a solid lump.
- Stereotactic radiosurgery (SRS): A single high dose of radiation delivered to a brain tumour or metastasis by beams converging from all sides, so the target gets a destructive dose while the surrounding brain gets little; no scalpel is involved despite the name.
- Blood-brain barrier (BBB): The tight seal around brain blood vessels that keeps most drugs out, one of the two main reasons brain cancer is so hard to treat.
- Brain metastases (intracranial disease): Tumour deposits that have travelled to the brain from a cancer elsewhere, ten times more common than cancers that start in the brain, mostly from lung, breast, melanoma and kidney cancer.
Every term links to the glossary.