(P118) Radiotherapeutic Care Within the Veterans Health Administration of US Veterans With Metastatic Cancer to the Brain: Part 2 Clinical Treatment Patterns

Alice V. Cheuk, MD, Ruchika Gutt, MD, Drew Moghanaki, MD, MPH, Michael Hagan, MD, PhD, Stephen Lutz, MD, Shruti Jolly, MD, Helen Fosmire, MD, Maria D. Kelly, MD, Lori Hoffman-Hogg, MS, RN, CNS, AOCN, Mitchell Anscher, MD, George A. Dawson, MD; US Veterans Healthcare Administration National Palliative Radiotherapy Taskforce

PURPOSE: Optimal radiation treatment (RT) for brain metastases must be individually tailored. Treatment guidelines by the American Society for Radiation Oncology (ASTRO) were used as the basis for a study of practice patterns among Veterans Health Administration (VHA) radiation oncologists (ROs). Radiotherapeutic interventions for three clinical scenarios were correlated with ASTRO guidelines.

METHODS: A survey was sent to all VHA ROs (n = 82). ROs were asked for treatment recommendations, which were analyzed by employment status, academic appointment, and years in practice.

SCENARIOS: (1) Uncontrolled non–small-cell lung cancer (NSCLC) with hemiplegia, > 10 brain metastases, Karnofsky performance status (KPS) 30, and life expectancy (LE) < 3 months. (2) Controlled NSCLC with hemiplegia, 4–6 brain metastases, KPS 70, and LE > 4 months. (3) New NSCLC without symptoms, 2 small brain lesions, KPS 90, and LE > 6 months.

Treatment options for scenarios 1 and 2 were: supportive care alone, steroids only, whole-brain RT (WBRT), and stereotactic radiosurgery (SRS). Options for scenario 3 were: resection with postoperative WBRT, SRS plus WBRT, SRS alone, and WBRT alone. ROs were asked to provide a WBRT dose fraction scheme for each selected case.

RESULTS: The survey response rate was 76%. Scenario 1: The majority (66%) of respondents chose WBRT, with 58% prescribing 3,000 cGy in 10 fractions and 42% delivering 2,000 cGy in 5 fractions. The others (34%) chose no intervention or steroids only. Full-time (FT) employees were more likely to choose WBRT (P < .001) compared with part-time (PT) employees and contractors. Those with an academic appointment and greater number of years in practice (P < .001) also chose WBRT more frequently. Scenario 2: Nearly all (98%) ROs recommended WBRT; 3,000 cGy in 10 fractions was the most common fractionation. There was an association with having an academic appointment, being an FT employee, being in practice less than 5 years, and choosing WBRT (P < .001). Scenario 3: FT employees (64%) and those with academic appointments were more likely to choose SRS alone (P < .001) compared with others. ROs in practice for 6–20 years preferred to do SRS with WBRT (P < .001).

CONCLUSIONS: ROs in practice less than 5 years, with academic appointments, or with an FT status had statistically significant associations with WBRT/SRS choice. In poor-prognosis patients, consideration of best supportive care measures is done, and short-course RT is often recommended. For patients with good KPS and limited small brain metastases, SRS with or without WBRT is recommended by most practitioners in accordance with ASTRO guidelines.

Proceedings of the 97th Annual Meeting of the American Radium Society - americanradiumsociety.org