Clinical and economic outcomes of patients with brain metastases based on symptoms: An argument for routine brain screening of those treated with upfront radiosurgery

Abstract

BACKGROUND:Insurers have started to deny reimbursement for routine brain surveillance with magnetic resonance imaging (MRI) after stereotactic radiosurgery (SRS) for brain metastases in favor of symptom-prompted imaging. The authors investigated the clinical and economic impact of symptomatic versus asymptomatic metastases and related these findings to the use of routine brain surveillance. METHODS: Between January 2000 and December 2010, 442 patients underwent upfront SRS for brain metastases. In total, 127 asymptomatic patients and 315 symptomatic patients were included. Medical records were used to determine the presenting symptoms, distant and local brain failure, retreatment, and need for hospital and rehabilitative care. Cost-of-care estimates were based on Medicare payment rates as of January 2013. RESULTS: Symptomatic patients had an increased hazard for all-cause mortality (hazard ratio, 1.448) and were more likely to experience neurologic death (42% vs 20%; P <.0001). Relative to asymptomatic patients, symptomatic patients required more craniotomies (43% vs 5%; P <.0001), had more prolonged hospitalization (2 vs 0 days; P <.0001), were more likely to have Radiation Therapy Oncology Group grade 3 and 4 post-treatment symptoms (24% vs 5%; P <.0001), and required $11,957 more on average to manage per patient. Accounting for all-cause mortality rates and the probability of diagnosis at each follow-up period, the authors estimated that insurers would save an average $1326 per patient by covering routine surveillance MRI after SRS to detect asymptomatic metastases. CONCLUSIONS: Patients who presented with symptomatic brain metastases had worse clinical outcomes and cost more to manage than asymptomatic patients. The current findings argue that routine brain surveillance after radiosurgery has clinical benefits and reduces the cost of care. Cancer 2014;120:433-41.

Prediction of new brain metastases after radiosurgery: validation and analysis of performance of a multi-institutional nomogram

“…Other factors including local failure risk, life expectancy, leptomeningeal involvement, current cognitive function and practitioner bias contribute to this decision. Despite these other factors, DBF is an endpoint that significantly affects the cost of future care as it can lead to multiple salvage treatments given its prevalence and the cost of multiple SRS procedures [1, 2]. The use of salvage WBRT after SRS ranged from 5 to 20% amongst the SRS centers in the current study, suggesting that the standards for use of WBRT vary amongst institutions.…”

“…SRS is approximately four-fold more expensive than whole brain radiotherapy (WBRT) but has been proven to be more cost-effective in selected patient populations [2, 3]. While the use of upfront WBRT may mitigate the likelihood of DBF [4], it is associated with toxicities such as fatigue [5] and cognitive decline [6].…”

Whole Brain Radiotherapy-Based Combined Modality Treatment of Brain Metastases from Non-Small Cell Lung Cancer: A Retrospective Analysis of Prognostic Factors

“…Post-contrast MRI was capable of detecting asymptomatic metastatic brain lesions that were missed on contrast-enhanced CT in lung cancer patients, and can be regarded as superior to contrast-enhanced CT in diagnosing occult brain metastases [12,13,14]. Yokoi et al [33] reported median survival times of 10 months for CT-detected brain metastases and 17 months for MRI-detected brain metastases. Patients who presented with symptomatic brain metastases had worse clinical outcomes as compared to those without symptoms.…”

Impact of Radiosurgical Management of Geriatric Patients With Brain Metastases: Clinical and Quality of Life Outcomes

“…This improvement has been due to a combination of improved systemic therapies 18,19 , improved brain-directed therapies 20 , and earlier detection of metastases 21 . It is unclear, however, whether geriatric oncology patients face a bias with regards to the use of aggressive treatment for brain metastases.…”