CNS: QUARTZ and WBRT in NSCLC metastases

Why A is correct

The QUARTZ trial found no difference in overall survival or quality-adjusted life-years between whole-brain radiotherapy plus optimal supportive care and optimal supportive care alone in NSCLC patients with brain metastases unsuitable for surgery or radiosurgery. NICE NG99 (recommendation 1.7.8) advises against whole-brain radiotherapy in such patients with KPS under 70. Optimal supportive care including dexamethasone is therefore the most appropriate option.

And why the others are not

• BIncorrect: WBRT provided little additional clinically significant benefit in QUARTZ and is advised against by NICE in this group.
• CIncorrect: an alternative WBRT schedule does not overcome the lack of survival or quality-of-life benefit shown in QUARTZ.
• DIncorrect: the lesions are explicitly unsuitable for stereotactic radiosurgery.
• EIncorrect: hippocampal-sparing WBRT addresses cognitive toxicity but does not change the absence of benefit in this poor-performance-status NSCLC population.

Source QUARTZ — whole-brain radiotherapy versus optimal supportive care in NSCLC brain metastases — Mulvenna P, Nankivell M, Barton R, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): a phase 3, non-inferiority, randomised trial. Lancet. 2016;388(10055):2004-2014.