Abstract
For patients with brain metastases, systemic disease burden has historically been accepted as a major determinant of overall survival (OS). However, less research has focused on specific history and physical findings made by clinicians and how such findings pertain to patient outcomes at a given time point. The aim of this study is to determine how the initial clinical assessment of patients with brain metastases, as part of the history and physical at the time of consultation, correlates to patient prognosis. We evaluated a prospective, multi-institutional database of 1523 brain metastases in 507 patients who were treated with radiosurgery (Gamma Knife or CyberKnife) from 2001 to 2014. Relevant history of present illness (HPI) and past medical history (PMH) variables included comorbidities, Eastern Cooperative Oncology Group (ECOG) performance status, and seizure history. Physical exam findings included a sensory exam, motor exam, and cognitive function. Univariate and multivariate Cox regression analyses were used to identify predictors of OS. Two hundred ninety-four patients were included in the final analysis with a median OS of 10.8 months (95% CI, 7.8-13.7 months). On univariate analysis, significant HPI predictors of OS included age, primary diagnosis, performance status, extracranial metastases, systemic disease status, and history of surgery. Significant predictors of OS from the PMH included cardiac, vascular, and infectious comorbidities. On a physical exam, findings consistent with cognitive deficits were predictive of worse OS. However, motor deficits or changes in vision were not predictive of worse OS. In the multivariate Cox regression analysis, predictors of worse OS were primary diagnosis (p = 0.002), ECOG performance status (OR 1.73, p < 0.001), and presence of extracranial metastases (OR 1.22, p = 0.009). Neurological deficits and systemic comorbidities noted at presentation are not associated with worse overall prognosis for patients with brain metastases undergoing radiosurgery. When encountering new patients with brain metastases, the most informative patient-related characteristics that determine prognosis remain performance status, primary diagnosis, and extent of extracranial disease.
Highlights
For patients with brain metastases undergoing radiation treatment, patient-specific variables such as performance status and extracranial disease burden are commonly used to prognosticate overall survival (OS)
In an analysis of patients included in three Radiation Therapy Oncology Group (RTOG) studies undergoing whole brain fractionated radiotherapy, neurological function was included as a potential prognostic factor in the regression analysis [1]
The RTOG recursive partitioning analysis (RPA), which enrolled patients as early as 1979, did not include patients treated with radiosurgery, and, its results may not be generalizable to patients with intracranial metastases treated with radiosurgery alone
Summary
For patients with brain metastases undergoing radiation treatment, patient-specific variables such as performance status and extracranial disease burden are commonly used to prognosticate overall survival (OS). Other prognostic indices published in the more modern era were based on analyses of patients treated with either whole brain radiation therapy (WBRT) [2, 3], stereotactic radiosurgery [4, 5], or either one of these modalities [6,7,8]. These indices did not evaluate neurological function as a potential prognostic indicator; it was not included in the resulting scoring systems. The aim of this study is to determine how the initial clinical assessment of patients with brain metastases, as part of the history and physical at the time of consultation, correlates to patient prognosis
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