An interdisciplinary consensus on the management of brain metastases in patients with renal cell carcinoma.

Brain metastases are a challenging manifestation of renal cell carcinoma. We have a limited understanding of brain metastasis tumor and immune biology, drivers of resistance to systemic treatment, and their overall poor prognosis. Current data support a multimodal treatment strategy with radiation treatment and/or surgery. Nonetheless, the optimal approach for the management of brain metastases from renal cell carcinoma remains unclear. To improve patient care, the authors sought to standardize practical management strategies. They performed an unstructured literature review and elaborated on the current management strategies through an international group of experts from different disciplines assembled via the network of the International Kidney Cancer Coalition. Experts from different disciplines were administered a survey to answer questions related to current challenges and unmet patient needs. On the basis of the integrated approach of literature review and survey study results, the authors built algorithms for the management of single and multiple brain metastases in patients with renal cell carcinoma. The literature review, consensus statements, and algorithms presented in this report can serve as a framework guiding treatment decisions for patients. CA Cancer J Clin. 2022;72:454-489.

Evolution of the prevalence of pre-residency peer-reviewed publications among incoming junior residents.

Pre-residency peer-reviewed publications (PRP) have been associated with subsequent resident choice of academic versus private practice career. The evolution of PRP prevalence among radiation oncology resident classes has yet to be examined. A list of radiation oncology residents from the graduating classes of 2016 and 2022 were obtained, and PRP was compiled as the number of publications a resident had listed in PubMed as of the end of the calendar year of residency application. Statistical analysis was conducted using Fisher's exact test. Analysis of 163 residents from the 2016 class compared with 195 from the 2022 class revealed that the proportion of residents with zero PRP decreased from 46.6% to 23.6% between the 2016 to 2022 classes (p<0.0001), while that of residents with one PRP increased from 17.8% to 19.0% (p>0.05) and with at least two PRP increased from 35.6% to 57.4% (p<0.0001). Residents with a PhD were more likely to have at least two PRP in each class (p<0.0001). As with the class of 2016, there remained no significant difference in PRP by gender for the class of 2022. Over the past six years, PRP has become more prevalent among incoming radiation oncology residents. Residents in the class of 2016 were 180% less likely than the class of 2022 to have at least one PRP, and 60% less likely to have at least two PRP. These findings are indicative of the increasing pressure on medical students to enter residency with a publication background.

Navigator-assisted hypofractionation (NAVAH) to address radiation therapy access disparities facing African-Americans with breast cancer.

Background: African-Americans have the highest overall cancer death rate and shortest survival time of any racial or ethnic group in the United States. The most common cancer studied in African-American radiation therapy (RT) access disparities research is breast cancer. The goal of this study is to evaluate the impact of patient navigation on RT access for African-American breast cancer patients. Material and methods: This study is a prospective survey-based evaluation of the impact of patient navigation on access to hypofractionated RT and financial toxicity in African-American breast cancer patients. The impact of patient navigation on RT access will be collated and analyzed from survey results pre-RT versus post-RT as well as for patients with versus without receipt of patient navigation. The validated COST-Functional Assessment of Chronic Illness Therapy score will be used to compare hypofractionation versus standard fractionated RT financial toxicity for patients with early-stage breast cancer who have received lumpectomy. Conclusion: This is the first study to investigate the impact of patient navigation on reducing RT access disparities facing African-American breast cancer patients. The natural progression of this work will be to expand this model to include additional breast cancer populations most vulnerable to suffering RT access disparities (Native American, Hispanic American, Appalachian) within the United States.

A National Cancer Database analysis of the patterns of care for meningeal melanocytoma.

Aim: To evaluate demographics, treatment patterns, radiotherapy utilization and patient outcomes in meningeal melanocytomas. Materials & methods: The National Cancer Database was queried for meningeal melanocytomas diagnosed in 2002-2016. The effects of demographic, clinical and treatment variables were determined via Kaplan-Meier log-rank and Cox regression analyses. Results: The median and 5-year overall survival were 57.46 months and 48%, respectively. Patients earning ≥$48K showed improved survival (p = 0.0319). Radiotherapy and chemotherapy were utilized in 37.7 and 9% of patients, respectively. Conclusion: Income significantly affected survival. Surgery remains the mainstay approach. Radiotherapy was delivered in more than one-third of patients but did not impact survival. However, further analyses were limited by poor treatment modality information in the database.

Lay abstract Aim: To assess the impact of demographic, clinical and treatment factors on survival in patients with meningeal melanocytomas. Materials & methods: Biostatistical analyses were conducted on patients diagnosed with meningeal melanocytomas between 2002 and 2016 using data from the National Cancer Database. Results: The median and 5-year survival rate were 57.46 months and 48%, respectively. Patients with incomes ≥$48K showed improved survival (p = 0.0319). Radiotherapy and chemotherapy were administered in 37.7 and 9% of patients, respectively. Conclusion: Income was a critical factor in increasing patient survival. Surgery serves as the primary means for treatment, while radiotherapy and chemotherapy remain underutilized.

Impact of hospital volume on mortality for brain metastases treated with radiation.

BACKGROUND: The impact of hospital volume on cancer patient survival has been demonstrated in the surgical literature, but sparsely for patients receiving radiation therapy (RT). This analysis addresses the impact of hospital volume on patients receiving RT for the most common central nervous system tumor: brain metastases. MATERIALS AND METHODS: Analysis was conducted using the National Cancer Database (NCDB) from 2010-2015 for patients with metastatic brain disease from lung cancer, breast cancer, and colorectal cancer requiring RT. Hospital volume was stratified as high-volume (≥ 12 brain RT/year), moderate (5-11 RT/year), and low (< 5 RT/year). The effect of hospital volume on overall survival was assessed using a multivariable Cox regression model. RESULTS: A total of 18,841 patients [9479 (50.3%) men, 9362 (49.7%) women; median age 64 years] met the inclusion criteria. 16.7% were treated at high-volume hospitals, 36.5% at moderate-volume, and the remaining 46.8% at low-volume centers. Multivariable analysis revealed that mortality was significantly improved in high-volume centers (HR: 0.95, p = 0.039) compared with low-volume centers after accounting for multiple demographics including age, sex, race, insurance status, income, facility type, Charlson-Deyo score and receipt of palliative care. CONCLUSION: Hospitals performing 12 or more brain RT procedures per year have significantly improved survival in brain metastases patients receiving radiation as compared to lower volume hospitals. This finding, independent of additional demographics, indicates that the increased experience associated with increased volume may improve survival in this patient population.

Impact of the American Tax Payer Relief Act on stereotactic radiosurgery utilization in the United States.

INTRODUCTION: Single-fraction stereotactic radiosurgery (SRS) is delivered predominantly via two modalities: Gamma Knife, and linear accelerator (LINAC). Implementation of the American Tax Payer Relief Act (ATRA) in 2013 represented the first time limitations specifically targeting SRS reimbursement were introduced into federal law. The subsequent impact of the ATRA on SRS utilization in the United States (US) has yet to be examined. METHODS: The National Cancer Database from 2010-2016 identified brain metastases patients from non-small cell lung cancer throughout the US having undergone SRS. Utilization between GKRS and LINAC was assessed before (2010-2012), during (2013-2014) and after (2015-2016) ATRA implementation. RESULTS: In 2013, there was a substantial decrease of LINAC SRS in favor of GKRS in non-academic centers. Over the 3-year span immediately preceding ATRA implementation, 39% of all eligible SRS cases received LINAC. There was a modest decrease in LINAC utilization over the 2 years immediately following ATRA implementation (35%), followed by an increase over the next two years (40%). SRS modality showed differences over the three time periods (unadjusted, p = 0.043), primarily in non-academic centers (unadjusted, p = 0.003). CONCLUSIONS: ATRA implementation in 2013 caused an initial spike in Gamma Knife SRS utilization, followed by a decline to rates similar to the years before implementation. These findings indicate that the ATRA provision mandating Medicare reduction of outpatient payment rates for Gamma Knife to be equivalent with those of LINAC SRS had a significant short-term impact on the radiosurgical treatment of metastatic brain disease throughout the US, serving as a reminder of the importance/impact of public policy on treatment modality utilization by physicians and hospitals.

Analysis of pre-residency research productivity, dual degree status, and gender distribution of underrepresented minorities among a current United States radiation oncology junior resident class.

BACKGROUND: Among the most competitive medical subspecialties, representation of underrepresented minorities (African-American race and/or Hispanic ethnicity) among resident trainees has historically been low compared to their United States Census general population representation. Research productivity and dual degree status may impact residency applicant competitiveness. To date, such an analysis has yet to be performed in Radiation Oncology. METHODS: A list of radiation oncology residents from the graduating class of 2022 was obtained through internet searches. Demographics included were gender and dual degree status. Research productivity was calculated using the number of pre-residency peer-reviewed publications (PRP). Fisher's exact test was used for statistical analysis. RESULTS: Of the 179 residents evaluated from the 2022 class, eleven (6.1%) were underrepresented minorities. Compared to the remainder of the class, underrepresented minorities had a lower proportion of men (63.6% versus 69.3%), a higher proportion of dual degrees (45.5% versus 28.6%), and a lower proportion of MD-PhD degrees (9.1% versus 17.2%). Underrepresented minorities had a higher proportion of residents with at least two PRP (72.7% versus 57.1%) and a lower proportion of residents with no PRP (18.2% versus 24.4%). None of these differences reached statistical significance (p > 0.05). CONCLUSION: Underrepresented minorities were comparable to the remainder of their Radiation Oncology resident class regarding gender distribution, dual degrees status, and likelihood of having at least two peer-reviewed publications cited in PubMed during the calendar year of residency application. Further studies will be needed to determine how these findings translate into future scholarly activity and post-graduate career choice.

Use of the g-index for assessment of citation-based scholarly activity of United States radiation oncology residents and subsequent choice of academic versus private practice career.

INTRODUCTION: The Hirsch index (h-index) evaluates citation-based scholarly activity, but has limited ability to acknowledge those publishing a smaller number of manuscripts with exceedingly high citations. The g-index addresses this limitation by assessing the largest number of manuscripts (g) by an author cited at least (g × g) times, but has yet to be applied to radiation oncology resident productivity. METHODS: A list of recent radiation oncology resident graduates (comprising 86% of the 2016 graduating class) and their post-residency career choice was compiled. The Scopus bibliometric citation database was searched to collect and calculate g-index data for each resident. RESULTS: The mean g-index score for all resident graduates was 7.16. Residents with a PhD had significantly higher g-index scores (11.97 versus 5.80; p < 0.01), while there was no statistically significant difference in g-index scores between male and female residents. Residents choosing academic careers had higher g-index scores than those choosing private practice (9.47 versus 4.99; p < 0.01). Programs graduating at least three residents produced significantly higher g-index scores/resident than those graduating two residents, and while comprising only 25% of programs and 45% of residents, produced 60% of academic careers (p < 0.02). CONCLUSION: Radiation oncology resident graduates published on average a minimum of seven manuscripts cited at least 49 times. PhD-degree graduates had significantly higher g-index scores, as did residents choosing academic over private practice careers. There was no significant gender-related difference in g-index score regardless of career choice. The majority of academic careers are produced from programs graduating at least three residents.

Application of tumor treating fields for newly diagnosed glioblastoma: understanding of nationwide practice patterns.

BACKGROUND: Tumor treating fields (TTF) harness magnetic fields to induce apoptosis in targeted regions. A 2015 landmark randomized phase III trial of newly diagnosed glioblastoma (GBM) patients demonstrated TTF + temozolomide to be superior to temozolomide alone. Given these results, we sought to assess practice patterns of providers in TTF utilization for GBM. METHODS: A survey was administered to practices in the United States self-identifying as specializing in radiation oncology, medical oncology, neuro-oncology, neurosurgery, and/or neurology. Responses were collected anonymously; analysis was performed using Fisher's exact test. RESULTS: A total of 106 providers responded; a minority (36%) were in private practice. Regarding case volume, 82% treated at least six high-grade gliomas/year. The provider most commonly certified to offer TTF therapy to GBM patients was the neuro-oncologist (40%), followed by the radiation oncologist (34%); 31% reported no TTF-certified physician in their practice. TTF users were more likely to have high volume, and be aware of TTF inclusion in National Comprehensive Cancer Network (NCCN) guidelines (p < 0.05). CONCLUSIONS: More than 80% of TTF for GBM in the United States is performed by groups who treat at least six high-grade gliomas per year; unfortunately more than 30% were in practices bereft of anyone certified to offer TTF therapy. These results indicate that there remains fertile soil for TTF therapy nationwide to be introduced into practices for GBM treatment. Providers seeking to refer newly diagnosed GBM patients for TTF should seek out practices with TTF user-associated characteristics to ensure optimal access for their patients.

Treatment of young adults with Philadelphia-negative acute lymphoblastic leukemia and lymphoblastic lymphoma: Hyper-CVAD vs. pediatric-inspired regimens.

For young adults with acute lymphoblastic leukemia, pediatric-based regimens are likely to provide the following when compared to hyper-CVAD regimens: better disease control, less hospitalization time, diminished acute toxicities, decreased financial cost, more quality-adjusted life years, and fewer adverse late effects, such as infertility, myelodysplasia, and second malignant neoplasms. There are also reasons to expect less cardiac and cognitive dysfunction after pediatric regimens. The improved quality and quantity of life associated with pediatric regimens renders them preferable to hyper-CVAD regimens for the treatment of Philadelphia-negative B-precursor or T-cell acute lymphoblastic leukemia and lymphoblastic lymphoma in young adults.

On thin ice: barriers to adoption of surveillance for patients with stage I testicular seminoma. Survey of US radiation oncologists.

PURPOSE: Most men with stage I testicular seminoma are cured with surgery alone, which is a preferred strategy per national guidelines. The current pattern of practice among US radiation oncologists (ROs) is unknown. MATERIALS AND METHODS: We surveyed practicing US ROs via an online questionnaire. Respondent's characteristics, self-rated knowledge, perceived patient compliance rates with observation were analyzed for association with treatment recommendations. RESULTS: We received 353 responses from ROs, of whom 23% considered themselves experts. A vast majority (84%) recommend observation as a default strategy, however this rate drops to 3% if the patient is believed to be noncompliant. 33% of respondents believe that survival is jeopardized in case of disease recurrence, and among these respondents only 5% support observation. 22% of respondents over-estimate the likelihood of noncompliance with observation to be in the 50-80% range. Responders with a higher perceived noncompliance rate are more likely to recommend adjuvant therapy (Fisher's exact p<0.01). Only 7% of respondents recommend observation for stage IS seminoma and 45% administer adjuvant RT in patients with elevated pre-orchiectomy alpha-fetal protein levels. CONCLUSIONS: Many US ROs over-estimate the likelihood that stage I testicular seminoma patients will be noncompliant with surveillance and incorrectly believe that overall survival is jeopardized if disease recurs on surveillance. Observation is quickly dismissed for patients who are not deemed to be compliant with observation, and is generally not accepted for patients with stage IS disease. There is clearly an opportunity for improved physician education on evidence-based management of stage I testicular seminoma.

A novel component from citrus, ginger, and mushroom family exhibits antitumor activity on human meningioma cells through suppressing the Wnt/ß-catenin signaling pathway.

Recurrent meningiomas constitute an uncommon but significant problem after standard (surgery and radiation) therapy failure. Current chemotherapies (hydroxyurea, RU-486, and interferon-α) are only of marginal benefit. There is an urgent need for more effective treatments for meningioma patients who have failed surgery and radiation therapy. Limonin, Tangeritin, Zerumbone, 6-Gingerol, Ganoderic Acid A, and Ganoderic Acid DM are some of the plant derivatives that have anti-tumorgenic properties and cause cell death in meningioma cells in vitro. Due to its ease of administration, long-term tolerability, and low incidence of long-term side effects, we explored its potential as a therapeutic agent against meningiomas by examining their efficacy in vitro against meningioma cells. Treatment effects were assessed using MTT assay, Western blot analysis, caspases assay, and DNA fragmentation assay. Results indicated that treatments of IOMM-Lee and CH157MN meningioma cells with Limonin, Tangeritin, Zerumbone, 6-Gingerol, Ganoderic Acid A, and Ganoderic Acid DM induced apoptosis with enhanced phosphorylation of glycogen synthase kinase 3 ß (GSK3ß) via inhibition of the Wnt5/ß-catenin pathway. These drugs did not induce apoptosis in normal human neurons. Other events in apoptosis included downregulation of tetraspanin protein (TSPAN12), survival proteins (Bcl-XL and Mcl-1), and overexpression apoptotic factors (Bax and caspase-3). These results provide preliminary strong evidence that medicinal plants containing Limonin, Tangeritin, 6-Gingerol, Zerumbone, Ganoderic Acid A, and Ganoderic Acid DM can be applied to high-grade meningiomas as a therapeutic agent, and suggests that further in vivo studies are necessary to explore its potential as a therapeutic agent against malignant meningiomas.

A Multidisciplinary Central Nervous System Clinic Model for Radiation Oncology and Neurosurgery (RADIANS): three-year experience with brain and skull base lesions in a community hospital setting.

BACKGROUND: Subspecialty, multidisciplinary care within community hospital settings are limited and remains a challenge. Improving outcomes for central nervous system (CNS) disease rely on integrated subspecialty care between radiation oncology (RadOnc) and neurosurgery (NS). Three-year experience with simultaneous patient evaluation with RadOnc and NS physicians in a community hospital-based CNS clinic model (RADIANS) for brain and skull base lesions (BSBL) are reported. METHODS: Clinical and demographic data were prospectively collected for patients evaluated in RADIANS. Surveys administered and three-year data reviewed. Descriptive statistics reported as mean and percentages for patient characteristics, diagnosis, treatment and outcomes. RESULTS: Sixty-seven patients with confirmed BSBL were evaluated between August 2016 and August 2019. Mean age and distance traveled was 61.0 years and 66.5 miles, respectively. Female (N.=39, 58.2%) and male (N.=28, 41.8%) patients had mean Patient Satisfaction Score of 4.77 (0-5 Scale, where 5 is very satisfied; 26 respondents). Forty-three patients had malignant disease (28 brain mets; six with both brain/spine; nine with primary brain), and 24 had benign disease. Post-evaluation treatment: radiation therapy (RT) only (N.=16), neurosurgery (NS) only (N.=12), both RT and NS (N.=15), and no RT/NS intervention (N.=24). Fractionated stereotactic radiosurgery was most common RT delivered; craniotomy with tumor resection was most common NS performed. Treatment outcomes: local control in 33 of 38 (86.8%); radiation necrosis in one of 31 (3.2%). CONCLUSIONS: The multidisciplinary community hospital-based CNS clinic continues its high patient approval at extended follow-up. Results demonstrate the clinic serves as a regional referral center where patients with BSBL with varying degrees of co-morbidities, systemic disease status, and oncologic staging can be treated with evidence-based treatment modalities yielding high rates of local control and low rates of grade 3 and 4 radiation-induced toxicity, while having access to on-going clinical trials.

Risk Factors for Radiotherapy Failure in the Treatment of Spinal Metastases.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To build a predictive model for risk factors for failure of radiation therapy, hypothesizing a higher SINS would correlate with failure. METHODS: Patients with spinal metastasis being treated with radiation at a tertiary care academic center between September 2014 and October 2018 were identified. The primary outcome measure was radiation therapy failure as defined by persistent pain, need for re-irradiation, or surgical intervention. Risk factors were primary tumor type, Karnofsky and ECOG scores, time to treatment, biologically effective dose (BED) calculations using α/ß ratio = 10, and radiation modality. A logistic regression was used to construct a prediction model for radiation therapy failure. RESULTS: One hundred and seventy patients were included. Median follow up was 91.5 days. Forty-three patients failed radiation therapy. Of those patients, 10 required repeat radiation and 7 underwent surgery. Thirty-six patients reported no pain relief, including some that required re-irradiation and surgery. Total SINS score for those who failed reduction therapy was <7 for 27 patients (62.8%), between 7-12 for 14 patients (32.6%), and >12 for 2 patients (4.6%). In the final prediction model, BED (OR .451 for BED > 43 compared to BED ≤ 43; P = .174), Karnofksy score (OR .736 for every 10 unit increase in Karnofksy score; P = .008), and gender (OR 2.147 for male compared to female; P = .053) are associated with risk of radiation failure (AUC .695). A statistically significant association between SINS score and radiation therapy failure was not found. CONCLUSIONS: In the multivariable model, BED ≤ 43, lower Karnofksy score, and male gender are predictive for radiotherapy failure. SINS score was among the candidate risk factors included in multivariable model building procedure, but it was not selected in the final model. LEVEL OF EVIDENCE: Prognostic level III.

Academic patterns of practice regarding CT simulation scans and radiology review.

OBJECTIVE: Currently, there are no consensus guidelines about handling incidental radiological findings on radiotherapy planning CT simulation scans. Retrospective studies analyzing incidental findings on CT simulations show a small, but not insignificant, rate of both oncologic and non-oncologic findings. These findings may have medico-legal, financial, and clinical implications. Given a lack of guidelines, we obtained a formal survey of multiple academic institutions to evaluate how CT simulations are handled in regard to incidental findings. METHODS: A formal survey was developed consisting of 12 questions related to institutional practices regarding CT simulation scans. From 7/18/21 to 8/27/21 and 5/6/22 to 5/24/22, the survey was administered electronically by REDCap to key personnel at Academic Radiation Oncology Programs identified through the American Society for Radiation Oncology (ASTRO) with inclusion criteria including an active ACGME approved Radiation Oncology residency program. RESULTS: In total, 88 academic radiation oncology programs were surveyed with total of 45 responses (51%). 1 out of 45 departments who responded has formal guidelines regarding workup of incidental findings. There is variability about sending CT simulation scans for official radiology review if an incidental finding is identified. CONCLUSIONS: Based on a measurable rate of incidental findings on radiotherapy planning CT simulations and their possible implications, our survey illustrates a likely need for consensus recommendations for handling such findings to improve patient care and safety.

Geriatric patient outcomes in a multidisciplinary central nervous system community hospital clinic for radiation oncology and neurosurgery (RADIANS).

INTRODUCTION: Management of older adult patients with central nervous system (CNS) cancers requires a patient-centric, multidisciplinary approach. Assessment of neurosurgical and radiation treatment outcomes can assist in establishing guidelines for this patient population. We previously reported on the RADIANS clinic, a novel community hospital-based multidisciplinary clinic (MDC) for CNS cancer care, providing simultaneous radiation oncology and neurosurgery evaluation in a same-day, single-setting clinic. We now provide a focused analysis of our older adult patient population and recommendations for triage and standardization of care. METHODS: Consecutive older adult patients (age ≥ 65) evaluated at the RADIANS clinic for CNS disease were identified and retrospectively reviewed. Observed 30-day neurosurgical outcomes were compared to predicted outcomes determined by the American College of Physicians NSQIP Surgical Risk Calculator. One-sample binomial exact tests were used to evaluate binary outcome measures. A two-sample t-test was used to evaluate the length of hospital stay. Brier Scores were calculated to assess the deviation between predicted probabilities and observed outcomes for binary outcome measures. Overall survival at 90 days was reported. RESULTS: Fifty-six older adult patients with malignant (42/56) and benign (14/56) CNS disease were evaluated. Mean distance traveled for multidisciplinary evaluation at the RADIANS clinic was 43.4 miles. There was no incidence of radiation-induced toxicity. Mean length of hospital stay for RADIANS patients was significantly shorter by about 1.5 to 3.5 days (95% CI). There was no statistically significant difference for other outcome measures, however, Brier Scores demonstrated that NSQIP was not a good predictive tool for any or serious complications, UTI, venous thromboembolism, return to OR, readmission, or death in our cohort. Local tumor control rate and progression-free survival at 90 days were 97.4% and 76.9%, respectively. CONCLUSIONS: This is the first report of CNS disease outcomes in older adult patients evaluated by radiation oncology and neurosurgery at a community hospital-based MDC. We observed minimal adverse radiation outcomes and high tumor control in our cohort. Findings show significantly shorter postoperative hospital stay for patients evaluated and managed at the RADIANS clinic.

Increase in mastectomies performed in patients in the community setting undergoing MRI.

This study is designed to determine whether the use of magnetic resonance imaging (MRI) leads to an increased number of unnecessary mastectomies in breast cancer patients in the community setting. This is a retrospective study of the records of 178 patients from the local offices of three community physicians. The medical records of patients over the age of 18 with breast cancer who underwent both MRI and mammogram imaging were reviewed. MRI detected more lesions than mammogram; however, these lesions were not cancerous. The lesions detected by mammogram correlated more with pathologic lesions. Of the 59 patients who underwent mastectomies, 78% had MRI and 22% did not have the imaging. Of the 100 patients who had both MRI and mammogram, 48% underwent lumpectomy and 46% had mastectomy. More patients who had both imaging modalities underwent mastectomies compared to those who had mammogram alone. The addition of MRI evaluation in patients with breast cancer is related to increased unnecessary mastectomies.

Cost-Effectiveness of Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy in Treating Brain Metastases.

Single-fraction stereotactic radiosurgery (SRS) is a highly used tool in managing brain metastases, alongside its multifraction counterpart - stereotactic body radiation therapy (SBRT). These radiation therapy techniques have been associated with excellent clinical outcomes, such as decreased local recurrence, increased survival, and improved palliative effects. However, present literature concerning the cost-effectiveness of these techniques remain scarce. Based on the current procedure terminology codes involving services provided during radiation consultation, treatment, and follow-up in our institution, 3-fraction SBRT with a 3-dimensional plan and intensity modulated radiation therapy cost 27% and 17% more than SRS, respectively. A 32% and 34% price increase can, respectively, be seen in 5-fraction SBRT with 3-dimensional plan and intensity modulated radiation therapy delivery sessions relative to 3-fraction SBRT administration. Cost savings between these procedures were associated with the radiation therapy delivery sessions instead of the treatment planning process. These analyses indicate that SRS appears to be a less expensive and time-intensive option than SBRT in our institution. However, additional comparative analyses regarding SRS and SBRT are needed to explore the clinical and financial benefits of these radiation therapy techniques.