We read with interest the Position Paper by Aldape and colleagues (Aldape, K. et al. Challenges to curing primary brain tumours. Nat. Rev. Clin. Oncol. https://doi.org/10.1038/s41571-019-0177-5 (2019))1 on the challenges and future approaches to curing patients with primary brain tumours. We congratulate Cancer Research UK (CRUK) on convening this group of expert clinicians and scientists, and we applaud the authors’ elegant synthesis of multiple complex issues. However, we note that among the disciplines represented by the 26 authors of this article, expertise in radiation oncology is conspicuously absent. The authors assert that CRUK “convened an international panel of brain cancer researchers with interests in neurobiology, preclinical tumour modelling, genomics, pharmacology, drug discovery and/or development, neuropathology, neurosurgery, imaging, radiotherapy and medical oncology, with the task of identifying the most important challenges that must be overcome if we are to eventually be in the position to cure all patients with a brain tumour”1. Aside from radiation oncology, all of the neuro-oncological subspecialties listed above were represented.
Beyond issues of author representation, radiotherapy is only discussed in the context of efforts to reduce the dose of radiation or to eliminate radiotherapy entirely from the treatment of patients with certain disease characteristics. Even in clinical situations in which attempts to reduce the radiation dose have failed (such as medulloblastoma)2,3, the authors contend that this is a function of an historical “inadequate understanding of medulloblastoma biology”1. Without noting the central conclusion of these studies2,3 (the importance of adequate irradiation of the neuraxis in patients with medulloblastoma), the authors proceed to discuss why several previous attempts at radiation dose reduction failed and why future efforts will (hypothetically) succeed.
What should already be known to the panel, as well as to members of the broader neuro-oncology community, is that radiotherapy is an integral component of the treatment of brain malignancies. Radiotherapy confers survival advantages to patients with glioblastoma4,5, medulloblastoma2,3, germ cell tumours6,7, ependymoma8 and others9. This cost-effective and accessible treatment modality has proven efficacy in the adjuvant setting2,3,4,5,8, as well as in the definitive setting6,7, as a first-line treatment2,3,4,5,6,7,8 or after prior lines of therapy10. Neuro-radiation oncology has witnessed a burgeoning of new techniques, technologies and strategies that will better optimize the therapeutic ratio. For example, stereotactic radiosurgery (SRS) is an increasingly widely used non-operative modality and has provided excellent outcomes with mild toxicities for patients with primary or metastatic intracranial neoplasms11. Similarly, proton beam therapy (PBT) offers the potential to minimize late-onset toxicities while preserving disease-related outcomes; this promise is increasingly being realized as clinical data on PBT continue to mature12,13. Furthermore, multidisciplinary efforts to find synergies between the effects of radiotherapy and novel systemic therapies are ongoing; these collaborative undertakings might translate into more meaningful improvements in survival outcomes14. Current and future studies also aim to tailor the delivery of radiotherapy by molecular profile and couple this with high-precision technologies designed to individualize both target volume and dose15.
In this sense, the authors of the CRUK position paper1 are absolutely correct: the neuro-oncology community must meet the challenges of treating primary brain tumours with robust research efforts across all boundaries: across disciplines; across geographical borders; across the academia–industry divide; and across the bench-to-bedside spectrum of research. Ensuring that all neuro-oncology disciplines, including radiation oncology, are given a voice as we rise to meet these challenges is imperative to engage in truly collaborative research.
There is a reply to this Correspondence by Aldape, K. et al. Nat. Rev. Clin. Oncol. https://doi.org/10.1038/s41571-019-0236-y (2019).
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Ludmir, E.B., Mahajan, A., Ahern, V. et al. Assembling the brain trust: the multidisciplinary imperative in neuro-oncology. Nat Rev Clin Oncol 16, 521–522 (2019). https://doi.org/10.1038/s41571-019-0235-z
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DOI: https://doi.org/10.1038/s41571-019-0235-z