Several EGFR- and ALK-TKIs have demonstrated CNS penetration, so do we add SRS for upfront brain metastases from EGFR- or ALK-mutated non-small cell lung cancer? Absent randomized data, here is a discussion of the tradeoffs based on retrospective comparative data. Those being “up-front SRS was associated with superior local control and time to CNS progression at the cost of increased treatment-related toxic effects in a minority of patients.” Practically speaking, deferral of SRS for subcentimeter asymptomatic brain mets in favor of short interval imaging surveillance probably makes sense in most cases of systemic therapy-naive disease. | Pike, JAMA Oncol 2025
