Observation of Brain Metastases

Observation, in a medical context, typically refers to the careful monitoring of a patient's condition without active intervention, also known as, "watchful waiting." 

Brain metastases occur when cancer cells from a primary tumor, often in another part of the body, spread to the brain. However, approaches to managing brain metastases can vary based on several factors.

Factors in the decision to use observation as treatment can include the number and size of metastases, the primary cancer type, the patient's overall health, and the patient’s symptoms, if any.

The management of brain metastases is a complex and dynamic process that involves a multidisciplinary healthcare team that may comprise neurologists, oncologists, radiation oncologists, and neurosurgeons.

In this article, we'll explore the consideration of observation as treatment in the context of brain metastases. 

In certain situations, observation may be considered as part of the overall management plan for brain metastases. However, it is important to note that observation is not a standalone treatment, but rather a decision to monitor the patient's condition closely without immediate intervention. Some of these situations are discussed below:

• Small, asymptomatic lesions: Observation may be considered for small, asymptomatic brain metastases that are incidentally discovered during imaging studies for other reasons. In cases where the metastases are small and not causing neurological symptoms, the healthcare team might opt for a watch-and-wait approach.
• Limited number of lesions: If there are a limited number of brain metastases and they are manageable without causing significant symptoms, observation may be an option. The decision to observe is often influenced by the balance between the potential benefits of treatment and the potential risks and side effects of intervention.
• Primary cancer treatment response: If the primary cancer is well-controlled with treatment, and any brain metastases are stable or slow-growing, the healthcare team may choose observation. This decision is often made in conjunction with ongoing treatment for the primary cancer.
• Palliative care: For patients with advanced-stage cancer where the goal is palliative care rather than curative treatment, observation may be part of an overall supportive care plan.

A  patient’s general health and preferences also guide treatment decisions. The risks associated with aggressive treatments may outweigh the benefits, especially if a patient has other significant health issues. Patient preferences and values form key considerations on this journey.

Some patients may prefer a conservative approach, focusing on maintaining quality of life rather than aggressive treatments with potential side effects. Finally, the potential to access clinical trials with new treatment modalities might also influence the decision-making process. These decisions may be deeply personal and can be made in conjunction with a patient’s family and multidisciplinary team.

Observation is a valid strategy in certain scenarios, but as with all decisions,  there are challenges and uncertainties associated with this approach:

• Risk of progression: There is always a risk that observed lesions may progress, potentially leading to symptoms and necessitating intervention.
• Impact on quality of life: The choice between observation and active treatment involves a careful consideration of the potential impact on a patient's quality of life.

The survival rate for a person with untreated brain metastases can vary widely. Factors include the type of primary cancer, the number and size of metastases, and the overall health of the individual.

Without treatment, brain metastases can lead to neurological symptoms and complications that can significantly impact a person's quality of life, and ultimately result in death. In some cases, the progression of symptoms and decline in health can be relatively rapid.

Since prognosis for untreated brain metastases is generally poor, in the range of 1 to 2 months, intervention is typically recommended to manage symptoms, improve quality of life, and potentially extend a patient’s survival by many more months.

Treatments may include surgery, radiation therapy, chemotherapy, immunotherapy, or a combination of these, depending on a patient’s specific circumstances.

Supportive therapies aim to manage the symptoms and side effects of both the cancer itself and its treatment. These therapies play a vital role in improving the overall well-being of patients with brain metastases:

• Pain management
• Cognitive rehabilitation
• Symptom-specific therapies
• Psychosocial support
• Nutritional support

Palliative care focuses on improving the overall quality of life for individuals with serious illnesses, including those with brain metastases. It is not limited to end-of-life care but is an approach that can be integrated at any stage of the illness. Palliative care encompasses many types of assistance:

• Hospice care
• Symptom management
• End-of-life planning
• Spiritual and emotional support
• Family support

If someone is suspected of having brain metastases or has been diagnosed with brain metastases, it is crucial that they consult with a healthcare professional who can provide personalized information based on a patient’s specific cancer and health profile.

Researchers and clinicians share a hope that individuals with brain metastases will not only benefit from innovative treatments, but that they will also experience better comfort, support, and symptom control throughout their respective journey.

The collaborative efforts of healthcare professionals, researchers, and supportive care teams are essential in realizing this vision of hope, and in providing comprehensive care for those affected by brain metastases, as well as for their families.

• Observation is used only very specific situations, based on patient-specific circumstances.
• The survival rate of untreated brain metastases is considered poor.
• Supportive and palliative care can help a patient navigate the difficult journey that follows a diagnosis of brain metastases.

• American Association of Neurological Surgeons (AANS): Metastatic Brain Tumors
• National Cancer Institute (NCI): Brain Tumors
• National Brain Tumor Society: Signs & Symptoms
• CancerCare: Brain Cancer