The dosing and schedule of steroids isn’t exact, and the right answer is: enough but not too much. The response to the steroids is an important prognostic factor, as those who don’t respond well to the initial steroid dose are also less likely to respond to radiation therapy. Most oncologists use dexamethasone as the steroid of choice and usually give the first dose IV, especially if the patient is symptomatic. The dose is usually in the 4 to 16 mg per day range depending on the symptoms, the degree of cerebral edema, the number of lesions, etc.
More and more often, these patients are being discussed in multidisciplinary team meetings, to try to decide if they may be a candidate for neurosurgical intervention or stereotactic radiosurgery. The days are gone when brain metastasis was seen as a universal death sentence. Today, many of us know patients who are walking around a year and more after the event.