Introduction: Brain metastases (BM) have high mortality rates. Whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) are potential treatments, but SRS offers similar survival outcomes with less neurocognitive toxicity. This study compares national treatment patterns for SRS vs. WBRT.
Methods: We queried the National Cancer Database (NCDB) for adults (≥18 years) with BM treated with radiotherapy from 2004 to 2020, focusing on twelve common cancers. Patients were grouped by first-course radiotherapy (SRS or WBRT) confirmed by fraction numbers (SRS: 1-5, WBRT: 5-15). Multivariate logistic regression identified predictors of SRS use, adjusting for sociodemographic and clinical variables, with an interaction term for race/ethnicity and year to examine trends. A difference-in-differences analysis assessed Medicaid expansion’s impact on SRS receipt.
Results: Of 94,094 patients, 30,805 (27%) received SRS. From 2004 to 2020, SRS use rose from 8% to 53% (P < 0.001). Median age was 64. Multivariate analysis showed patients were more likely to receive SRS if diagnosed in 2012-2020 (OR=3.86 [3.71-4.02]), had prior chemotherapy (OR=1.17 [1.13-1.21]) or surgery (OR=2.26 [2.12-2.41]), or had specific primary cancers (colorectal, endometrial, kidney/bladder, lung, melanoma, thyroid) versus breast cancer (P < 0.001). In contrast, patients were less likely to receive SRS if they lived in regions of lower income (OR=0.88 [0.84-0.91]) or lower educational attainment (OR=0.88 [0.85-0.91]), had public (OR=0.86 [0.83-0.89]) versus private insurance, or were treated at non-academic centers (community, comprehensive community, or integrated network cancer programs) versus academic centers. (P < 0.001 for each). Black patients showed a modest increase in SRS use over time (OR=1.14 [1.00–1.29], p=0.049). Medicaid expansion had no significant effect on SRS use (aOR=0.99 [0.89–1.10]).
Conclusion : Disparities in SRS use persist among lower-income, publicly insured, and non-academic center patients. Black patients had a modest rise in SRS use, though Medicaid expansion alone did not increase access. Findings underscore the need to improve SRS access for underserved BM patients.
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