Brain metastases: still an 'orphan' disease?

The diagnosis of brain metastases from systemic cancer has been associated with a poor prognosis. In fact, most chemotherapy clinical trials exclude patients with metastatic disease. In the past, clinical and basic research activity in this area has been only moderate. Recent developments in clinical trial design, as evidenced by recursive partitioning analysis and complemented by new treatment strategies in neurosurgery and radiotherapy, suggest a change in attitude and approach to the management of brain metastases. The role of chemotherapy will require more focused investigation, but recent advances in our understanding of the biology of brain metastases suggest that the next generation of chemotherapy treatments will involve targeting specific pathways of metastatic disease.