For many people with lung cancer, the disease doesn’t stay confined to the lungs. Up to half of patients with non-small cell lung cancer, and as many as 80 percent of patients with small cell lung cancer, develop brain metastases throughout the course of their illness. These diagnoses can significantly affect quality of life, treatment options, and long-term outcomes.
At Duke Cancer Institute (DCI), Laura Alder, MD, deputy director of medical oncology for the Duke Center for Brain and Spine Metastasis, is working to change how patients with brain metastases are represented in clinical research and, ultimately, how they are treated.
Alder’s clinical and research career centers on two closely related priorities: lung cancer and brain metastases. After completing her fellowship at Duke, she joined the faculty and became deeply involved in multidisciplinary efforts to improve care for patients whose cancer has spread to the brain or spine.
“Brain metastases have a huge impact on a patient’s trajectory,” Alder said. “They affect quality of life, treatment decisions, and outcomes in very meaningful ways.”
Clinical trials often represent the most promising treatment option for patients with advanced cancer, offering access to therapies that are not yet widely available. However, Alder notes that trial eligibility criteria have traditionally been narrow.
“There’s been a longstanding concern that patients with brain metastases wouldn’t do well on clinical trials or could confound the results,” Alder said. “As a result, many trials exclude these patients entirely.”
To address this gap, Alder collaborated with a multidisciplinary group of researchers on a publication focused on improving clinical trial inclusion for patients with lung cancer and brain metastases. The work, published recently in Lung Cancer, builds on decades of research led by Paul Sperduto, MD, PhD, adjunct professor in the Duke Department of Radiation Oncology, who developed the Graded Prognostic Assessment (GPA).
The GPA is a validated tool used to estimate survival in patients with brain metastases by accounting for factors such as age, performance status, disease burden, and tumor biology. For non-small cell lung cancer, the tool incorporates modern biomarkers, including genetic driver mutations, which can influence response to targeted immunotherapies.
Paired with the eligibility quotient (EQ), which helps estimate conditional survival, these tools paint a more accurate and individualized picture of prognosis, one that challenges outdated assumptions.
“What we see is that many of these patients actually have very good overall survival,” Alder said. “Our therapies are better, more precise, and more effective than ever before.”
Alder said advances in imaging, MRI surveillance, and radiation techniques, such as stereotactic radiosurgery (SRS), also make it possible to closely monitor and manage brain metastases during treatment. These innovations further support the safe inclusion of these patients in trials.
At Duke, efforts to improve clinical trial inclusivity extend beyond a single publication. Through the Duke Center for Brain and Spine Metastasis, clinicians and researchers regularly collaborate with pharmaceutical partners, advocate at national conferences, and engage in ongoing dialogue with industry leaders.
“This has been a mission for many of us for years,” Alder said. “At every meeting, every podium, we’re making the case that these patients need to be included because that’s where the unmet need is.”
Encouragingly, progress is being made. National organizations such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), along with the U.S. Food and Drug Administration (FDA), have increasingly emphasized the importance of broader eligibility criteria in cancer trials.
Alder hopes the framework outlined in the publication will be used prospectively in future trials, helping demonstrate that inclusion of patients with brain metastases is both safe and beneficial.
“Our patients are living longer than ever before,” she says. “They deserve clinical trials that reflect the reality of their disease and give us the data we need to keep making progress.”
