30-day mortality in patients treated for brain metastases: extracranial causes dominate

Abstract

Background Established prognostic models, such as the diagnosis-specific graded prognostic assessment, were not designed to specifically address very short survival. Therefore, a brain metastases-specific 30-day mortality model may be relevant. We hypothesized that in-depth evaluation of a carefully defined cohort with short survival, arbitrarily defined as a maximum of 3 months, may provide signals and insights, which facilitate the development of a 30-day mortality model. Methods Retrospective analysis (2011–2021) of patients treated for brain metastases with different approaches. Risk factors for 30-day mortality from radiosurgery or other primary treatment were evaluated. Results The cause of death was unrelated to brain metastases in 61%. Treatment-related death (grade 5 toxicity) did not occur. Completely unexpected death was not observed, e.g. accident, suicide or sudden cardiac death. Logistic regression analysis showed 9 factors associated with 30-day mortality (each assigned 3–6 points) and a point sum was calculated for each patient. The point sum ranged from 0 (no risk factors for death within 30 days present) to 30. The results can be grouped into 3 or 4 risk categories. Eighty-three percent of patients in the highest risk group (> 16 points) died within 30 days, and none survived for more than 2 months. However, many cases of 30-day mortality (more than half) occurred in intermediate risk categories. Conclusion Extracranial tumor progression was the prevailing cause of 30-day mortality and few, if any deaths could be considered relatively unexpected when looking at the complete oncological picture. We were able to develop a multifactorial prediction model. However, the model’s performance was not fully satisfactory and it is not routinely applicable at this point in time, because external validation is needed to confirm our hypothesis-generating findings.

Clinical Factors Associated With 30-Day Mortality Among Patients Undergoing Radiation Therapy for Brain Metastases

“… 6 , 7 , 17 , 18 , 19 In 1 recent study inclusive of 100 patients treated with radiation for brain metastases, extracranial disease progression (measured by blood test results and imaging) was a significant predictor for 30 DM. 16 Consistent with this observation, a lower KPS score and extracranial disease were associated with 30-DM in our analysis. These factors highlight the importance of evaluating a patient's intracranial disease in the context of their systemic progression and performance status.…”

“… 4 , 13 , 14 , 15 One recent study of patients with brain metastases from any primary site reported a 30-DM of 28%. 16 We observed a lower rate of 30-DM in our cohort, possibly owing to inclusion of those receiving SRS to limited intracranial metastases, representing a population with a better prognosis. The 30-DM rate for those receiving SRS was 7.7%, suggesting that patients are appropriately being selected for SRS at our center.…”

Early death after palliative radiation treatment: 30-, 35- and 40-day mortality data and statistically robust predictors

“…Furthermore, we had access to a broad set of baseline parameters and were therefore able to extend the knowledge provided by previous, otherwise similar studies. Patients with brain metastases, a small subgroup in the present study, might represent a special population, if treated to the brain [ 17 ] rather than skeletal metastases after previous brain-directed therapy. Our group’s previous work [ 17 ] resulted in different predictors of 30-day mortality after treatment for brain metastases (n = 100 patients) than those identified in the present bone metastases study, e.g., number of brain metastases and primary tumor control.…”

Utility of 30‐day mortality as a quality metric for palliative radiation treatment: A population‐based analysis from Queensland, Australia

“…While the recent meta-analysis by Kutzko et al 18 identified a 30 day mortality following PRT benchmark of 16%, given that several studies globally have reported 30-day mortality rates following PRT as low as 5-10% 24,25,30 we encourage individual RT centres throughout Australia and New Zealand to strive for as low a rate as possible taking into account each site's individual patient case mix, while being mindful of the potential for underutilisation or overutilisation of PRT based on the adopted benchmark.…”