Future of PCI: PCI vs MRI surveillance
Panelists discuss how the future of brain control in limited-stage small cell lung cancer may trend toward MRI surveillance rather than prophylactic cranial irradiation (PCI) given its toxicity and the availability of effective salvage stereotactic radiosurgery, though survival benefits from historical PCI trials and shared decision-making still support offering hippocampal-avoidant PCI with memantine until definitive data from trials like MAVERICK emerge.
EP: 1.PACIFIC Trials, DUART Trial, COAST Trial, and ADRIATIC Trial
EP: 2.LAURA Trial, SINDAS Trial, NORTHSTAR Trial, and LONESTAR Trial
EP: 3.Stage 1 – Increasing Pulmonologist Awareness About Radiation Oncology
EP: 4.Future of Stage III: Concurrent vs Sequential CRT
EP: 5.Future of PCI: PCI vs MRI surveillance
Future of PCI: PCI vs MRI surveillance
The debate addressed whether prophylactic cranial irradiation should remain standard practice for limited-stage small cell lung cancer or transition to MRI surveillance. Arguments against prophylactic cranial irradiation (PCI) emphasized its significant toxicities including fatigue, hair loss, and cognitive deficits that substantially impact quality of life. In the modern era, with immunotherapy demonstrating benefits regardless of PCI use in the ADRIATIC trial, the historical rationale may no longer apply. Most compellingly, stereotactic radiosurgery now offers effective salvage treatment for brain metastases detected early through surveillance, fundamentally changing the risk-benefit calculation from choosing between low-dose PCI now vs high-dose whole brain later, to choosing between no whole brain radiation with targeted stereotactic radiosurgery if needed.
Proponents of continuing PCI noted that randomized trials demonstrate both intracranial control and overall survival benefits, with approximately 5% absolute improvement in long-term survival. While innovations in systemic therapy may reduce this benefit somewhat, it remains clinically meaningful and should be discussed with patients through shared decision-making. Toxicity mitigation strategies including hippocampal avoidance and memantine can reduce cognitive effects. Patients who develop brain metastases after forgoing PCI face worse prognoses, and stereotactic radiosurgery or whole brain radiation at progression generally don’t prolong survival as effectively as preventing metastases initially.
The discussion emphasized patient-centered care through informed shared decision-making. Individual patient perspectives vary regarding the burden of frequent MRI surveillance causing anxiety vs accepting PCI toxicity risks. Current randomized trial data showing survival benefits should be presented to patients, along with limitations of that older data and ongoing trials like MAVERICK that may provide updated guidance. The vision for the future includes better biomarker-based risk stratification to identify which small cell lung cancer patients truly need PCI vs those at lower risk for multifocal brain metastases who could safely undergo surveillance. Until such personalized approaches exist, clinicians must present available evidence and help patients make informed decisions aligned with their values and preferences.
