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Background There is growing evidence supporting the need for a short time delay before starting radiotherapy (RT) treatment post-surgery for most optimal responses. The timing of RT initiation and effects on outcomes have been evaluated in a variety of malignancies, but the relationship remains to be well established for brain metastasis. Methods Retrospective study of 176 patients (aged 18 to 89 years) with brain metastases at a single institution (03/2009 to 08/2018) who received RT following surgical resection. Time interval (≤ 22 days and > 22 days) from surgical resection to initiation of RT and any potential impact on patient outcomes were assessed. Results Patients who underwent RT > 22 days after surgical resection had a decreased risk for all-cause mortality of 47.2% (95% CI 8.60, 69.5%). Additionally, waiting > 40 days for RT after surgical resection more than doubled the risk of tumor progression; adjusted hazard ratio 2.02 (95% CI 1.12, 3.64). Conclusions Findings indicate that a short interval delay (> 22 days) following surgical resection is required before RT initiation for optimal treatment effects in brain metastasis. Our timing of RT post-surgical resection data add definition to current heterogeneity in RT timing, which is especially important for standardized clinical trial design and patient outcomes.

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