Background: Data regarding the efficacy of adjuvant stereotactic radiosurgery (SRS) for resected brain metastases (BM) is often limited to patients completing SRS within a specified timeframe. We performed an intention-to-treat analysis to determine local recurrence (LR) for all BM patients referred for SRS.
Methods: We retrospectively identified resected BM patients referred for SRS between 2012 and 2018. Patients were divided based on delay to SRS into four categories: 1)≤4 weeks, 2) >4-8 weeks, 3) >8 weeks, and 4) never received. We investigated the relationship between delay to SRS and LR, local recurrence-free survival (LRFS), and overall survival, as well as the predictors of and reason for delays.
Results: In our cohort of 159 patients, median age was 64.0 years, 56.5% patients were female, median tumor diameter was 2.9 cm, and gross total resection was achieved in 83.0%. On intention-to-treat analysis, LR was 22.6%. Delays to SRS correlated with LR: 2.3% with SRS≤4 weeks postoperatively, 14.5% with SRS at >4-8 weeks (p=0.03), 48.5% with SRS at >8 weeks (p<0.001). No LR difference was observed with SRS delayed by >8 weeks, vs. never completed, 48.5% vs. 50.0% (p=0.91). 53 (33.3%) patients comprised these latter two categories. A similar relationship emerged between delay to SRS and LRFS (p<0.01). Non-small cell lung cancer pathology (p=0.04) and earlier year of treatment (p<0.01) were predictive of delays. Common reasons for delays included logistics, management of systemic disease, complications, or comorbidities.
Conclusion: A significant number of patients referred for SRS never receive it, or are treated with a delay >8 weeks, conferring equivalent LR risk. Accordingly, the actual efficacy of adjuvant SRS may need reassessment. Reasons for delays and mechanisms for reducing them are discussed. For patients likely to experience significant delays, other techniques, such as preoperative SRS or intraoperative brachytherapy, may be considered.