Safety-Net Versus Private Hospital Setting for Brain Metastasis Patients Treated With Radiosurgery Alone: Disparities in Follow-Up Care and Outcomes

Abstract

Background: Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but requires adherence to frequently scheduled follow-up neuroimaging due to risk of distant brain metastasis. The effect of disparities in access to follow-up care on outcomes after SRS alone is unknown. Methods: This retrospective study included 153 brain metastasis patients treated consecutively with SRS alone from 2010 through 2016 at an academic medical center and a safety net hospital located in Los Angeles, California. Outcomes included neurologic symptoms, hospitalization, steroid use and dependency, salvage SRS, salvage whole brain radiotherapy (WBRT), salvage neurosurgery, and overall survival (OS). Results: Of 153 patients, 93 were private hospital patients and 60 were safety net hospital patients. Median follow-up time was 7.7 months. Safety net hospital patients received fewer follow-up neuroimaging studies (1.5 safety net, 3 private; p=0.008). In multivariable analysis, safety net hospital setting was a significant risk factor for salvage neurosurgery (HR 13.65, p<0.001), neurologic symptoms (HR 3.74, p=0.002), and hospitalization due to brain metastases (HR 6.25, p<0.001). More clinical visits were protective for hospitalization due to brain metastases (HR 0.75, p=0.002) while more neuroimaging studies were protective for death (HR 0.65, p<0.001). Conclusions: Safety net hospital patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and higher risk of neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery compared to private hospital patients. Clinicians should consider practice setting and patient access to follow-up care when deciding on the optimal strategy for treatment of brain metastases.