Research question:

The aim of the present investigation is

to assess the benefit of treatment with single-session stereotactic radiosurgery (SRS) with linear accelerators or cobalt-60-gamma radiation sources (also in combination with surgical resection) versus treatment with microsurgical resection (also in combination with whole brain radiation therapy, WBRT) or WBRT

in each case in patients with one or a few brain metastases requiring treatment. The focus of the assessment was on patient-relevant outcomes.

Conclusion:

A total of 7 randomized controlled trials (RCTs) were included in the present assessment. These were assigned to 2 different comparisons, depending on the control intervention investigated.

For the comparison of single-session SRS versus microsurgical resection (Comparison 1), a treatment-inherent advantage of SRS with regard to length of hospital stay was found. However, due to the risk of publication bias of a relevant magnitude, no conclusion regarding a greater benefit or harm of either treatment option could be drawn for this comparison across outcomes. Nor could valid conclusions be drawn regarding a comparable benefit of SRS.

Due to the intervention-specific differences in invasiveness and length of hospital stay, the present results suggest that single-session SRS in patients with one or a few brain metastases may have the potential to be a necessary treatment alternative to resection. The prospects of success of a testing study for this comparison must be considered very low due to the known recruitment problems.

For the comparison of single-session SRS versus WBRT (Comparison 2), data from a total of 6 randomized trials could be used, of which 1 had a high and 5 had a moderate qualitative certainty of results across outcomes. In terms of all-cause mortality, across studies, overall the data provide no hint of a greater benefit or harm of any of the treatment options. In addition, the available results do not suggest with sufficient certainty that SRS provides at least comparable overall survival versus WBRT. With regard to memory performance as a subcomponent of cognitive function, there was a hint of a greater benefit of SRS, but not for other components of cognitive function, such as speech fluency or executive functions. For the outcomes of activities of daily living, adverse events and treatment-related complications, and health-related quality of life, there was no hint of a greater benefit or harm of any of the treatment options. For the outcome of neurological function, no usable data were identified. Beyond the results reported in the studies, single-session SRS has treatment-inherent advantages over WBRT in terms of repeatable application of the intervention and in terms of treatment-related burden. Thus, a hint of a greater benefit of SRS can be also be derived for the comparison of single-session SRS versus WBRT in the overall assessment across outcomes.

Publisher

Institute for Quality and Efficiency in Health Care

Topic

Stereotactic radiosurgery for treatment of patients with brain metastases

Commissioning agency

Federal Joint Committee

Commission awarded on

5 November 2020

Internal Commission No.

N20-04

Address of publisher

This report was prepared in collaboration with external experts.

The responsibility for the contents of the report lies solely with IQWiG.

According to §139b (3) No. 2 of Social Code Book (SGB) V, Statutory Health Insurance, external experts who are involved in the Institute’s research commissions must disclose “all connections to interest groups and contract organizations, particularly in the pharmaceutical and medical devices industries, including details on the type and amount of any remuneration received”. The Institute received the completed Form for disclosure of potential conflicts of interest from each external expert. The information provided was reviewed by a Committee of the Institute specifically established to assess conflicts of interests. The information on conflicts of interest provided by the external experts and external reviewers is presented in Chapter A8 of the full report. No conflicts of interest were detected that could endanger professional independence with regard to the work on the present commission.

External experts

• Jan Boström, Gamma Knife Centre of the University Hospital Knappschaftskrankenhaus (Miners’ Guild Hospital) Bochum, Bochum, Germany.
• Roland Goldbrunner, Neurosurgery Centre, University Hospital Cologne, Cologne, Germany

IQWiG thanks the external experts for their collaboration in the project.

IQWiG employees

• Christoph Mosch
• Wolfram Groß
• Thomas Jakubeit
• Mattea Patt
• Nadine Reinhardt
• Stefan Sauerland
• Wiebke Sieben
• Dorothea Sow