Optimizing Patient Experience and Resource Allocation for Asymptomatic Brain Metastases via an Expedited, Multidisciplinary Outpatient Workflow

Introduction: The diagnosis of brain metastasis (BrM) is a source of clinical concern, and even asymptomatic lesions often lead to emergency room and urgent care center referrals, at experienced cancer centers and beyond. With the advent of multidisciplinary brain metastasis programs including outpatient triage pathways, we hypothesize that timely and appropriate care can be delivered on an outpatient basis (OP), with reduced time and financial toxicity and equivalent efficacy to patients relative to urgent/inpatient pathways (UIP). We sought to quantify patient burden and 6-month tumor control upon referral to UIP/OP.

Methods: Patients referred to specialty CNS care for asymptomatic brain metastases (ABrM) at an NCI-designated Cancer Center with a Multidisciplinary Brain Metastasis Program managed via UIP and OP were identified via retrospective chart review. Scans, encounters, time to local interventions (including radiotherapy [SRS, WBRT] or neurosurgical procedures including resection, LITT and/or biopsy), and survival data were collected. Tumor control and radiation necrosis were evaluated using RANO-BM criteria.

Results: One-hundred seven patients with AbrM were identified. Fifty-one were referred to OP and 56 via UIP. Both groups had similar mean preoperative disease-specific graded prognostic assessments and subsequent treatments. Patients managed via UIP had larger dominant BrM (3.1cm vs 2.1 cm, p< 0.0001), decreased time from consult to therapy (8.0 days vs 13.2 days, p=0.0039) and more in-person interaction with the healthcare system (7.6 Days vs 3.6 Days, p< 0.0001). Outpatient and UIP pathways demonstrated similar 6-month local control (95% vs 95%, p=1) and OS (84% vs 73%, p=0.23).

Conclusion : Patients managed through an integrated outpatient pathway attained similar outcomes with reduced time toxicity to patients managed through urgent/inpatient pathways. These data support the management of people with asymptomatic brain metastases where possible as outpatients through the clinic to lessen patient burden while preserving clinical outcomes.