title: Decision analysis of stereotactic radiation surgery versus stereotactic radiation surgery and whole-brain radiation therapy for 1 to 3 brain metastases.
abstract: OBJECTIVE
  Although whole-brain radiation therapy (WBRT) is effective for controlling intracranial disease, it is also associated with neurocognitive side effects. It is unclear whether a theoretically improved quality of life after stereotactic radiation surgery (SRS) alone relative to that after SRS with adjuvant WBRT would justify the omission of WBRT, given the higher risk of intracranial failure. This study compares SRS alone with SRS and WBRT, to evaluate the theoretical benefits of intracranial tumor control with adjuvant WBRT against its possible side effects, using quality-adjusted life expectancy (QALE) as a primary endpoint.
  
  
  METHODS
  A Markov decision analysis model was used to compare QALE in a cohort of patients with 1 to 3 brain metastases and Karnofsky performance status of at least 70. Patients were treated with SRS alone or with SRS immediately followed by WBRT. Patients treated with SRS alone underwent surveillance magnetic resonance imaging and received salvage WBRT if they developed intracranial relapse. All patients whose cancer relapsed after WBRT underwent simulation as dying of intracranial progression. Model parameters were estimated from published literature.
  
  
  RESULTS
  Treatment with SRS yielded 6.2 quality-adjusted life months (QALMs). The addition of initial WBRT reduced QALE by 1.2 QALMs. On one-way sensitivity analysis, the model was sensitive only to a single parameter, the utility associated with the state of no evidence of disease after SRS alone. At values greater than 0.51, SRS alone was preferred.
  
  
  CONCLUSIONS
  In general, SRS alone is suggested to have improved quality of life in patients with 1 to 3 brain metastases compared to SRS and immediate WBRT. Our results suggest that immediate treatment with WBRT after SRS can be reserved for patients who would have a poor performance status regardless of treatment. These findings are stable under a wide range of assumptions.
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut. Electronic address: nataniel.lester-coll@yale.edu.
authors.forename: Nataniel H
authors.initials: NH
authors.lastname: Lester-Coll
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Arie P
authors.initials: AP
authors.lastname: Dosoretz
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Comprehensive Cancer Center, and Yale University School of Medicine, New Haven, Connecticut.
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
mesh_terms: D001932:Brain Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery*; D016371:Cranial Irradiation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D003661:Decision Support Techniques; D006801:Humans; D017567:Karnofsky Performance Status; D008390:Markov Chains; D009364:Neoplasm Recurrence, Local / Q000401:mortality; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D016634:Radiosurgery / Q000379:methods* / Q000401:mortality; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects / Q000379:methods; D012680:Sensitivity and Specificity