Stereotactic Radiotherapy vs. Whole Brain Radiation Therapy in EGFR Mutated NSCLC: Results and Reflections from the Prematurely Closed Phase III HYBRID Trial

• Published in: International journal of radiation oncology, biology, physics Vol. 120; no. 2; p. e294
• Main Authors: Zeng, M., Verma, V., Luo, X.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.10.2024
• ISSN: 0360-3016
• DOI: 10.1016/j.ijrobp.2024.07.653

All known randomized trials of stereotactic radiotherapy (SRT) versus whole brain radiotherapy (WBRT) for brain metastases (BMs) comprise mixed histologies. The phase III HYBRID trial (NCT02882984) attempted to evaluate non-inferiority of SRT vs. WBRT specifically for EGFR-mutated non-small cell lung cancer (EGFRm NSCLC) BMs. Inclusion criteria were ≤5 BMs (any size) from treatment-naïve EGFRm NSCLC. All patients started a first-generation tyrosine kinase inhibitor on the first day of WBRT (37.5Gy/15 fractions) or SRT (25-40 Gy/5 fractions per tumor volume). The primary endpoint was 18-month intracranial progression-free survival (iPFS; intention-to-treat). The trial (commenced in June 2015) was closed in April 2021 after screening 208 patients but enrolling 85 (n = 41 WBRT, n = 44 SRT; median follow-up 31 and 36 months, respectively). Respectively, 9.5% vs. 10.2% of patients experienced intracranial progression at 18 months, and median iPFS was 21.4 vs. 22.3 months (P>0.05 for all). The SRT arm experienced higher overall survival and cognitive preservation (P<0.05 for all). The most notable reason for low enrollment was patients not wishing to risk neurocognitive decline from WBRT. Although this phase III trial was underpowered, there was no evidence that SRT yielded outcome detriments compared to WBRT for EGFRm NSCLC BMs. Lessons from prematurely closed trials are valuable, as they often provide important experiential perspectives for investigators designing/executing future trials. In the current era, randomized trials involving WBRT without cognitive sparing measures may be at high risk of under accrual; however, trials of molecular-/biologically-stratified patients are highly recommended as “individualized medicine/oncology” continues to expand.