title: The Value of the History and Physical for Patients with Newly Diagnosed Brain Metastases Considering Radiosurgery.
abstract: BACKGROUND
  For patients with brain metastases, systemic disease burden has historically been accepted as a major determinant of overall survival (OS). However, less research has focused on specific history and physical findings made by clinicians and how such findings pertain to patient outcomes at a given time point. The aim of this study is to determine how the initial clinical assessment of patients with brain metastases, as part of the history and physical at the time of consultation, correlates to patient prognosis.
  
  
  METHODS
  We evaluated a prospective, multi-institutional database of 1523 brain metastases in 507 patients who were treated with radiosurgery (Gamma Knife or CyberKnife) from 2001 to 2014. Relevant history of present illness (HPI) and past medical history (PMH) variables included comorbidities, Eastern Cooperative Oncology Group (ECOG) performance status, and seizure history. Physical exam findings included a sensory exam, motor exam, and cognitive function. Univariate and multivariate Cox regression analyses were used to identify predictors of OS.
  
  
  RESULTS
  Two hundred ninety-four patients were included in the final analysis with a median OS of 10.8 months (95% CI, 7.8-13.7 months). On univariate analysis, significant HPI predictors of OS included age, primary diagnosis, performance status, extracranial metastases, systemic disease status, and history of surgery. Significant predictors of OS from the PMH included cardiac, vascular, and infectious comorbidities. On a physical exam, findings consistent with cognitive deficits were predictive of worse OS. However, motor deficits or changes in vision were not predictive of worse OS. In the multivariate Cox regression analysis, predictors of worse OS were primary diagnosis (p = 0.002), ECOG performance status (OR 1.73, p < 0.001), and presence of extracranial metastases (OR 1.22, p = 0.009).
  
  
  CONCLUSIONS
  Neurological deficits and systemic comorbidities noted at presentation are not associated with worse overall prognosis for patients with brain metastases undergoing radiosurgery. When encountering new patients with brain metastases, the most informative patient-related characteristics that determine prognosis remain performance status, primary diagnosis, and extent of extracranial disease.
authors.affiliation: Department of Radiation Medicine, Georgetown University Medical Center , Washington, DC , USA.
authors.forename: Ima
authors.initials: I
authors.lastname: Paydar
authors.affiliation: Department of Neurological Surgery, Mount Sinai Health System , New York, NY , USA.
authors.forename: Eric Karl
authors.initials: EK
authors.lastname: Oermann
authors.affiliation: Department of Radiation Oncology, Mount Sinai Health System , New York, NY , USA.
authors.forename: Miriam
authors.initials: M
authors.lastname: Knoll
authors.affiliation: Department of Radiation Oncology, Mount Sinai Health System , New York, NY , USA.
authors.forename: James
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Radiation Medicine, Georgetown University Medical Center , Washington, DC , USA.
authors.forename: Brian Timothy
authors.initials: BT
authors.lastname: Collins
authors.affiliation: Department of Neurological Surgery, The University of North Carolina at Chapel Hill , Chapel Hill, NC , USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Ewend
authors.affiliation: Department of Neurosurgery, New York University Langone Medical Center , New York, NY , USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Kondziolka
authors.affiliation: Department of Radiation Medicine, Georgetown University Medical Center , Washington, DC , USA.
authors.forename: Sean P
authors.initials: SP
authors.lastname: Collins
keywords: brain metastases; comorbidity; history and physical; neurological deficits; performance status; prognosis; radiosurgery