New tools improve care for cancers that spread to the brain

Ambitious efforts at UVA Cancer Center to improve care delivered to patients with cancer that has spread to the brain have yielded important insights and tools that can benefit other hospitals, a new publication reports.

The tools include the first set of metrics to assess care provided for these secondary tumors, known as brain metastasis. The UVA team says its findings will help doctors and patients make better-informed treatment decisions, enhance the care of brain metastases, and enable hospitals to improve the coordination and effectiveness of their interdisciplinary treatment programs.

“The proposed set of measurements serves as the framework to gauge the performance of multidisciplinary programs, with the goal of providing optimal consistent and coordinated care to patients with brain metastasis,” said Camilo E. Fadul, MD, a neuro-oncologist at UVA Health and UVA Cancer Center.

Brain metastases are the most common tumors affecting the central nervous system. Although any type of cancer can spread to the brain, the most frequent are lung cancer, breast cancer and melanoma.

As patients with cancer are living longer, the frequency of brain metastasis is on the rise. So doctors are seeking to personalize treatment from a menu of options that include surgery, radiation (either targeted stereotactic radiosurgery or whole brain radiation), chemotherapy, targeted oral therapies and immunotherapy. Because of the complexity of treatment decisions and the need to provide safe and consistent patient-centered care, UVA takes an interdisciplinary approach, which brings together providers with expertise in radiation oncology, neuro-oncology, medical oncology, neurosurgery and palliative care.

While developing this program, the UVA group led by Dr. Fadul identified relevant outcome measurements to inform treatment decisions, evaluate the care process and implement interventions that will improve value. They tested the measurements by looking at hundreds of patients’ data to identify strategies that will improve outcomes, and they reviewed every detail of UVA’s care for patients, beginning with their brain metastasis diagnosis and ending with the patients’ discharge.

They identified relevant outcome measurements for patients receiving brain metastases directed treatment by looking at survival – specifically, survival more than 90 days after the important milestones of diagnosis, surgery, stereotactic radiosurgery and whole-brain radiation therapy. Other measurements examined processes that may translate in better outcomes, such as whether patients had advance directives outlining the type of care they wish to receive documented in their electronic medical record, if they had palliative care consultation and if the drug memantine, which may protect cognitive function from possible radiation injury, was prescribed to patients receiving whole-brain radiation therapy.

“The proposed set of performance measurements serves as the foundation for improving healthcare delivery, for characterizing the structure, processes and functions of the optimal interdisciplinary teams, and for filling the gap associated with disparities in the quality of the care and outcomes after diagnosis of brain metastases,” Dr. Fadul said.

He noted the measurements need to incorporate the input and perspective from patients and caregivers — what are called “patient-reported outcomes.” In addition, the metrics have to be refined and validated by other experts in the field. Several projects are already underway to build upon these results and further improve the care provided to patients with brain metastasis at UVA.

“Identification of areas for quality improvement, sharing among hospitals of data and strategies that improve outcomes, and development of consistent treatment guidelines based on continuous performance measurements, like the ones we proposed, will enhance the quality and value of the care provided to the growing population of patients afflicted with brain metastasis,” Dr. Fadul said.

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The findings have been published in the scientific journal JCO Oncology Practice. The group contributing to this work consisted of Julio Silvestre, Tracey Gosse, Paul Read, Ryan Gentzler, Benjamin Purow, Ashok Asthagiri, Elizabeth Gaughan, Patrick M. Dillon, James M. Larner, Roger T. Anderson, Jason P. Sheehan and Camilo E. Fadul. A full list of the authors’ disclosures is included in the paper.

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