Irrational fear of whole‐brain radiotherapy: Are we doing our patients a disservice?

Abstract

A previously healthy woman aged 64 years presents with persistent cough has a left hilar mass identified. Biopsy reveals adenocarcinoma without epidermal growth factor receptor mutation or anaplastic lymphoma kinase translocation. A right adrenal gland metastasis is identified on a positron emission tomography scan. Screening brain magnetic resonance imaging reveals multiple, enhancing masses consistent with metastatic disease. Over 40 areas of abnormal enhancement are noted within both cerebral hemispheres and the cerebellum (Fig. 1A,B). The largest of these is in the right parasagittal occipital lobe measuring 1.3 cm, and this lesion is associated with moderate vasogenic edema. Despite the volume of intracranial metastases, she remains asymptomatic. She meets with her medical oncologist to review the results of the magnetic resonance imaging scan, and there is some discussion regarding whole-brain radiotherapy (WBRT) and the potential risks of cognitive decline with WBRT. Two days later, the patient reviews care options with a radiation oncologist. The radiation oncologist recommends WBRT in conjunction with memantine to decrease her risk of cognitive decline. 1 At the mention of WBRT, the patient's hands begin to tremble and she starts to cry. On the basis of her reading on the Internet and her conversations with her medical oncologist, she refuses to consider WBRT because of fears of cognitive deterioration after this treatment. She ends the visit by informing the medical care team that she will only consider either supportive care or systemic therapy. Patient Decision MakingOverwhelmed by the complexity of medical decision making, patients often seek easily accessible resources, such as the Internet and their trusted clinician's personal biases, as a means to simplify their choices. The Internet has become a frequent source of medical information for patients, replacing traditional media sources. In 2016, 87% of the US population used the Internet, and 80% of those Internet users searched online for health information. 2 A recent survey-based analysis of 457 patients observed a correlation between the extent of online health information utilization and patients' strategies for medical decision making. 3 Specifically, the more patients searched online for their medical problems, the more likely they were to change their medical decision based on the online health information. In the setting of WBRT for brain metastases, a simple Internet search reveals several webpages mentioning the cognitive effects of WBRT, which have been demonstrated primarily in the setting of limited brain metastases. Extrapolation of these findings to the setting of high-risk brain metastases represents not only a distortion of published evidence but may lead to inferior treatment approaches, as discussed below.Given the potential distortion of online health information, the role of the clinician in guiding patients' understanding and use of online health information becomes critical to the process of medical decision making. However,...

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