Abstract
Background
Stereotactic radiosurgery (SRS) has emerged as an important modality for the treatment of intracranial metastases. There are currently few established guidelines delineating indications for SRS use and fewer still regarding plan evaluation in the treatment of multiple brain metastases.
Methods
An 18 question electronic survey was distributed to radiation oncologists at National Cancer Institute (NCI) designated cancer centers in the USA (60). Centers without radiation oncologists were excluded. Physicians who indicated that they do not prescribe SRS were excluded from the remaining survey questions. Sign test and Chi-square test were used to determine if responses differed significantly from random distribution.
Results
One hundred sixteen of the 697 radiation oncologists surveyed completed the questionnaire, representing 51 institutions. Sixty-two percent reported treating patients with brain metastases using SRS. Radiation oncologists prescribing SRS most commonly treat CNS (66.2%) and lung (49.3%) malignancies. SRS was used more frequently for < 10 brain metastases (73.7%; p < 0.0001) and whole brain radiation therapy (WBRT) for > 10 brain metastases (82.5%; p < 0.0001). The maximum number of lesions physicians were willing to treat with SRS without WBRT was 1–4 (40.4%) and 5–10 (42.4%) (p < 0.0001 compared to 11–15, 16–20 and no limit). The most important criteria for choosing SRS or WBRT were number of lesions (p < 0.0001) and performance status (p = 0.016). The most common margin for SRS was 0 mm (49.1%; p = 0.0021). The most common dose constraints other than critical structure was conformity index (84.2%) and brain V12 (61.4%). The LINAC was the most common treatment modality (54.4%) and mono-isocenter technique for multiple brain metastases was commonly used (43.9%; p = 0.23). Most departments do not have a policy for brain metastases treatment (64.9%; p = 0.024).
Conclusions
This is one of the first national surveys assessing the use of SRS for brain metastases in clinical practice. These data highlight some clinical considerations for physicians treating brain metastases with SRS.
Similar content being viewed by others
References
Mehta MP, Tsao MN, Whelan TJ, Morris DE, Hayman JA, Flickinger JC, Mills M, Rogers CL, Souhami L (2005) The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 63(1):37–46. https://doi.org/10.1016/j.ijrobp.2005.05.023 [published Online First: 2005/08/23]
Shonka N, Venur VA, Ahluwalia MS (2017) Targeted treatment of brain metastases. Curr Neurol Neurosci Rep 17(4):37. https://doi.org/10.1007/s11910-017-0741-2
Patchell RA, Tibbs PA, Regine WF et al (1998) Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 280(17):1485–1489 [published Online First: 1998/11/11]
Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, Markesbery WR, Macdonald JS, Young B (1990) A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322(8):494–500. https://doi.org/10.1056/NEJM199002223220802 [published Online First: 1990/02/22]
Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, Arbuckle RB, Swint JM, Shiu AS, Maor MH, Meyers CA (2009) Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol 10(11):1037–1044. https://doi.org/10.1016/S1470-2045(09)70263-3
Lippitz B, Lindquist C, Paddick I, Peterson D, O’Neill K, Beaney R (2014) Stereotactic radiosurgery in the treatment of brain metastases: the current evidence. Cancer Treat Rev 40(1):48–59. https://doi.org/10.1016/j.ctrv.2013.05.002
Tsao MN, Rades D, Wirth A, Lo SS, Danielson BL, Gaspar LE, Sperduto PW, Vogelbaum MA, Radawski JD, Wang JZ, Gillin MT, Mohideen N, Hahn CA, Chang EL (2012) Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): an American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol 2(3):210–225. https://doi.org/10.1016/j.prro.2011.12.004
Gaspar LE, Mehta MP, Patchell RA, Burri SH, Robinson PD, Morris RE, Ammirati M, Andrews DW, Asher AL, Cobbs CS, Kondziolka D, Linskey ME, Loeffler JS, McDermott M, Mikkelsen T, Olson JJ, Paleologos NA, Ryken TC, Kalkanis SN (2010) The role of whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neuro-Oncol 96(1):17–32. https://doi.org/10.1007/s11060-009-0060-9
Kalkanis SN, Kondziolka D, Gaspar LE, Burri SH, Asher AL, Cobbs CS, Ammirati M, Robinson PD, Andrews DW, Loeffler JS, McDermott M, Mehta MP, Mikkelsen T, Olson JJ, Paleologos NA, Patchell RA, Ryken TC, Linskey ME (2010) The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neuro-Oncol 96(1):33–43. https://doi.org/10.1007/s11060-009-0061-8
Mehta MP, Paleologos NA, Mikkelsen T, Robinson PD, Ammirati M, Andrews DW, Asher AL, Burri SH, Cobbs CS, Gaspar LE, Kondziolka D, Linskey ME, Loeffler JS, McDermott M, Olson JJ, Patchell RA, Ryken TC, Kalkanis SN (2010) The role of chemotherapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neuro-Oncol 96(1):71–83. https://doi.org/10.1007/s11060-009-0062-7
Linskey ME, Andrews DW, Asher AL, Burri SH, Kondziolka D, Robinson PD, Ammirati M, Cobbs CS, Gaspar LE, Loeffler JS, McDermott M, Mehta MP, Mikkelsen T, Olson JJ, Paleologos NA, Patchell RA, Ryken TC, Kalkanis SN (2010) The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neuro-Oncol 96(1):45–68. https://doi.org/10.1007/s11060-009-0073-4
ASTRO (2014) ChoosingWisely. ASTRO releases second list of five radiation oncology treatments to question, as part of national Choosing Wisely campaign. Choosing Wisely
Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, Kenjyo M, Oya N, Hirota S, Shioura H, Kunieda E, Inomata T, Hayakawa K, Katoh N, Kobashi G (2006) Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 295(21):2483–2491. https://doi.org/10.1001/jama.295.21.2483 [published Online First: 2006/06/08]
Kocher M, Soffietti R, Abacioglu U, Villà S, Fauchon F, Baumert BG, Fariselli L, Tzuk-Shina T, Kortmann RD, Carrie C, Hassel MB, Kouri M, Valeinis E, van den Berge D, Collette S, Collette L, Mueller RP (2011) Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol 29(2):134–141. https://doi.org/10.1200/JCO.2010.30.1655
Yamamoto M, Serizawa T, Shuto T, Akabane A, Higuchi Y, Kawagishi J, Yamanaka K, Sato Y, Jokura H, Yomo S, Nagano O, Kenai H, Moriki A, Suzuki S, Kida Y, Iwai Y, Hayashi M, Onishi H, Gondo M, Sato M, Akimitsu T, Kubo K, Kikuchi Y, Shibasaki T, Goto T, Takanashi M, Mori Y, Takakura K, Saeki N, Kunieda E, Aoyama H, Momoshima S, Tsuchiya K (2014) Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol 15(4):387–395. https://doi.org/10.1016/S1470-2045(14)70061-0
Rava P, Leonard K, Sioshansi S, Curran B, Wazer DE, Cosgrove GR, Norén G, Hepel JT (2013) Survival among patients with 10 or more brain metastases treated with stereotactic radiosurgery. J Neurosurg 119(2):457–462. https://doi.org/10.3171/2013.4.JNS121751
Yamamoto M, Kawabe T, Sato Y et al (2014) Stereotactic radiosurgery for patients with multiple brain metastases: a case-matched study comparing treatment results for patients with 2-9 versus 10 or more tumors. J Neurosurg 121(Suppl):16–25. https://doi.org/10.3171/2014.8.GKS141421
Shield BCB (2016) Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) POLICY NUMBER A60110
Nabors LB, Portnow J, Ammirati M, Brem H, Brown P, Butowski N, Chamberlain MC, DeAngelis LM, Fenstermaker RA, Friedman A, Gilbert MR, Hattangadi-Gluth J, Hesser D, Holdhoff M, Junck L, Lawson R, Loeffler JS, Moots PL, Mrugala MM, Newton HB, Raizer JJ, Recht L, Shonka N, Shrieve DC, Sills AK Jr, Swinnen LJ, Tran D, Tran N, Vrionis FD, Wen PY, McMillian NR, Ho M (2014) Central nervous system cancers, version 2.2014. Featured updates to the NCCN guidelines. J Natl Compr Cancer Netw 12(11):1517–1523
Knisely JP, Yamamoto M, Gross CP et al (2010) Radiosurgery alone for 5 or more brain metastases: expert opinion survey. J Neurosurg 113(Suppl):84–89. https://doi.org/10.3171/2010.8.GKS10999
Sandler KA, Shaverdian N, Cook RR, Kishan AU, King CR, Yang I, Steinberg ML, Lee P (2017) Treatment trends for patients with brain metastases: does practice reflect the data? Cancer 123(12):2274–2282. https://doi.org/10.1002/cncr.30607
Soliman H, Das S, Larson DA, Sahgal A (2016) Stereotactic radiosurgery (SRS) in the modern management of patients with brain metastases. Oncotarget 7(11):12318–12330. https://doi.org/10.18632/oncotarget.7131
Minniti G, Clarke E, Lanzetta G, Osti M, Trasimeni G, Bozzao A, Romano A, Enrici R (2011) Stereotactic radiosurgery for brain metastases: analysis of outcome and risk of brain radionecrosis. Radiat Oncol 6:48. https://doi.org/10.1186/1748-717X-6-48
Keeter SKC, Dimock M, Best J, Craighill P (2006) Gauging the impact of growing nonresponse on estimates from a national RDD telephone survey. Public Opin Q 70:759–779
Holbrook A, Krosnick J, Pfent A (2008) The causes and consequences of response rates in surveys by the news media and government contractor survey research firms. In: Lepkowki JM, Tucker C, Brick JM et al (eds) Advances in telephone survey methodology. Wiley, Hoboken, pp 499–500
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Funding
E.S.B. received an F30 Ruth Kirschstein MD-PhD Fellowship Award (CA180500).
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent
For this type of study, formal consent is not required. This is approved by our institutional IRB.
Rights and permissions
About this article
Cite this article
Blomain, E.S., Kim, H., Garg, S. et al. Stereotactic radiosurgery practice patterns for brain metastases in the United States: a national survey. J Radiat Oncol 7, 241–246 (2018). https://doi.org/10.1007/s13566-018-0353-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13566-018-0353-8