George A. Dawson, MD, Shruti Jolly, MD, Helen Fosmire, MD, Maria Kelly, MD, Stephen Lutz, MD, Micheal Hagan, MD, PhD, Ruchika Gutt, MD, Drew Moghanaki, MD, MPH, Lori Hoffman-Hogg, MS, RN, CNS, AOCN, Mitchell Ancher, MD, Alice Cheuk, MD; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force
Metastatic cancer to the brain is estimated to occur in 170,000 Americans annually. Of them, over 600 cases occur in US veterans. Management of brain metastases is complex. Prognostic scoring criteria and evidence-based guidelines have been developed by societies, including the American Society of Radiation Oncology (ASTRO), to provide guidance in the care of patients with metastatic brain cancer. Patterns of care among Veterans Health Administration radiation oncologists (VHA ROs) in the treatment of brain metastases are not known.
METHOD: An electronic survey was sent to all (82) VHA ROs at 38 active VHA radiation oncology centers. Follow-up phone calls were made to nonresponders. The survey inquired about supportive measures, including the number of brain metastases consults seen per year, steroid usage and dosing, use of the Radiotherapy Oncology Group (RTOG)-recursive partitioning analysis (RPA) or diagnosis-specific graded prognostic assessment (GPA) prognostic score, onsite availability of stereotactic radiosurgery (SRS), and demographics. Additional information about VHA ROs regarding their employment status, years in practice, and academic appointments was also obtained.
RESULTS: A total of 62 of 82 VHA ROs responded to the questionnaire (76%). Most respondents had academic appointments (70%). Most respondents (79%) received more than 10 consults annually. A total of 89% only used steroids in the setting of neurological changes or edema, while ~10% always used steroids for brain metastases. Prognostic scores for brain metastases were used routinely by only 42% of VHA ROs. The RTOG-RPA classification was used the most (73%). Physicians in practice for less than 5 years (P = .024) and full-time employees (P < .001) were more likely to use prognostic scoring. Also, 69% of surveyed sites referred to another VA or VA-contracted facility for SRS services when required (31% + SRS onsite).
The most common dexamethasone dose was 16 mg/day, used by 54% of the respondents.
CONCLUSIONS: Veterans with brain metastases treated at VHA radiation oncology centers receive appropriate care. Still, the use of prognostic indices in treatment decision-making is statistically significantly more likely in cases treated by recent training program graduates. Given the relatively recent development of these scoring systems, educational efforts need to be devoted to increasing their use in the clinic.
Proceedings of the 97th Annual Meeting of the American Radium Society — americanradiumsociety.org