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Spine Radiosurgery in the Management of Renal Cell Carcinoma Metastases

Neil K. Taunk, Daniel E. Spratt, Mark Bilsky, and Yoshiya Yamada

Renal cell carcinoma (RCC) presents an interesting challenge in radiation oncology. Improved systemic therapy has significantly prolonged survival. Modern imaging has allowed practitioners to effectively identify patients with oligometastatic disease. Conventionally fractionated radiation therapy is a first-line treatment option for palliation of bone metastases, including the spine, but has limited efficacy and durability. Conventional treatment may not be sufficient in metastatic RCC because of the disease's relative radioresistance. Improved technology, including custom immobilization and on-board treatment imaging, has allowed ultra-high-dose radiation therapy, or stereotactic radiosurgery (SRS), to effectively treat metastatic disease in the spine. Safety and efficacy have already been established for intracranial disease and data are emerging for extracranial metastasis. Spine SRS offers local control rates and durable pain improvement in up to 90% of patients. Many series have already reported its effectiveness, and prospective multi-institutional trials are underway. Spine SRS should be strongly considered in select patients with refractory or oligometastatic disease.

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Real-World Use of Hypofractionated Radiotherapy for Primary CNS Tumors in the Elderly, and Implications on Medicare Spending

Kathryn R. Tringale, Andrew Lin, Alexandra M. Miller, Atif Khan, Linda Chen, Melissa Zinovoy, Yoshiya Yamada, Yao Yu, Luke R.G. Pike, and Brandon S. Imber

Background: For elderly patients with high-grade gliomas, 3-week hypofractionated radiotherapy (HFRT) is noninferior to standard long-course radiotherapy (LCRT). We analyzed real-world utilization of HFRT with and without systemic therapy in Medicare beneficiaries treated with RT for primary central nervous system (CNS) tumors using Centers for Medicare & Medicaid Services data. Methods: Radiation modality, year, age (65–74, 75–84, or ≥85 years), and site of care (freestanding vs hospital-affiliated) were evaluated. Utilization of HFRT (11–20 fractions) versus LCRT (21–30 or 31–40 fractions) and systemic therapy was evaluated by multivariable logistic regression. Medicare spending over the 90-day episode after RT planning initiation was analyzed using multivariable linear regression. Results: From 2015 to 2019, a total of 10,702 RT courses (ie, episodes) were included (28% HFRT; 65% of patients aged 65–74 years). A considerable minority died within 90 days of RT planning initiation (n=1,251; 12%), and 765 (61%) of those received HFRT. HFRT utilization increased (24% in 2015 to 31% in 2019; odds ratio [OR], 1.2 per year; 95% CI, 1.1–1.2) and was associated with older age (≥85 vs 65–74 years; OR, 6.8; 95% CI, 5.5–8.4), death within 90 days of RT planning initiation (OR, 5.0; 95% CI, 4.4–5.8), hospital-affiliated sites (OR, 1.4; 95% CI, 1.3–1.6), conventional external-beam RT (vs intensity-modulated RT; OR, 2.7; 95% CI, 2.3–3.1), and no systemic therapy (OR, 1.2; 95% CI, 1.1–1.3; P<.001 for all). Increasing use of HFRT was concentrated in hospital-affiliated sites (P=.002 for interaction). Most patients (69%) received systemic therapy with no differences by site of care (P=.12). Systemic therapy utilization increased (67% in 2015 to 71% in 2019; OR, 1.1 per year; 95% CI, 1.0–1.1) and was less likely for older patients, patients who died within 90 days of RT planning initiation, those who received conventional external-beam RT, and those who received HFRT. HFRT significantly reduced spending compared with LCRT (adjusted β for LCRT = +$8,649; 95% CI, $8,544–$8,755), whereas spending modestly increased with systemic therapy (adjusted β for systemic therapy = +$270; 95% CI, $176–$365). Conclusions: Although most Medicare beneficiaries received LCRT for primary brain tumors, HFRT utilization increased in hospital-affiliated centers. Despite high-level evidence for elderly patients, discrepancy in HFRT implementation by site of care persists. Further investigation is needed to understand why patients with short survival may still receive LCRT, because this has major quality-of-life and Medicare spending implications.