What outcomes are associated with stereotactic radiosurgery alone for small cell lung cancer brain metastases, and how do these results compare with the standard whole-brain radiotherapy approach?
In a cohort study of 710 patients with small cell lung cancer brain metastases who received first-line stereotactic radiosurgery, the median overall survival was 8.5 months, and the median time to central nervous system progression was 8.1 months. After controlling for multiple prognostic factors, whole-brain radiotherapy (vs stereotactic radiosurgery) was associated with superior time to central nervous system progression but offered no overall survival advantage.
This study provides a benchmark for stereotactic radiosurgery outcomes and suggests that this treatment alone is a potential option for select patients with small cell lung cancer.
Although stereotactic radiosurgery (SRS) is preferred for limited brain metastases from most histologies, whole-brain radiotherapy (WBRT) has remained the standard of care for patients with small cell lung cancer. Data on SRS are limited.
To characterize and compare first-line SRS outcomes (without prior WBRT or prophylactic cranial irradiation) with those of first-line WBRT.
Design, Setting, and Participants
FIRE-SCLC (First-line Radiosurgery for Small-Cell Lung Cancer) was a multicenter cohort study that analyzed SRS outcomes from 28 centers and a single-arm trial and compared these data with outcomes from a first-line WBRT cohort. Data were collected from October 26, 2017, to August 15, 2019, and analyzed from August 16, 2019, to November 6, 2019.
SRS and WBRT for small cell lung cancer brain metastases.
Main Outcomes and Measures
Overall survival, time to central nervous system progression (TTCP), and central nervous system (CNS) progression-free survival (PFS) after SRS were evaluated and compared with WBRT outcomes, with adjustment for performance status, number of brain metastases, synchronicity, age, sex, and treatment year in multivariable and propensity score–matched analyses.
In total, 710 patients (median [interquartile range] age, 68.5 [62-74] years; 531 men [74.8%]) who received SRS between 1994 and 2018 were analyzed. The median overall survival was 8.5 months, the median TTCP was 8.1 months, and the median CNS PFS was 5.0 months. When stratified by the number of brain metastases treated, the median overall survival was 11.0 months (95% CI, 8.9-13.4) for 1 lesion, 8.7 months (95% CI, 7.7-10.4) for 2 to 4 lesions, 8.0 months (95% CI, 6.4-9.6) for 5 to 10 lesions, and 5.5 months (95% CI, 4.3-7.6) for 11 or more lesions. Competing risk estimates were 7.0% (95% CI, 4.9%-9.2%) for local failures at 12 months and 41.6% (95% CI, 37.6%-45.7%) for distant CNS failures at 12 months. Leptomeningeal progression (46 of 425 patients [10.8%] with available data) and neurological mortality (80 of 647 patients [12.4%] with available data) were uncommon. On propensity score–matched analyses comparing SRS with WBRT, WBRT was associated with improved TTCP (hazard ratio, 0.38; 95% CI, 0.26-0.55; P < .001), without an improvement in overall survival (median, 6.5 months [95% CI, 5.5-8.0] for SRS vs 5.2 months [95% CI, 4.4-6.7] for WBRT; P = .003) or CNS PFS (median, 4.0 months for SRS vs 3.8 months for WBRT; P = .79). Multivariable analyses comparing SRS and WBRT, including subset analyses controlling for extracranial metastases and extracranial disease control status, demonstrated similar results.
Conclusions and Relevance
Results of this study suggest that the primary trade-offs associated with SRS without WBRT, including a shorter TTCP without a decrease in overall survival, are similar to those observed in settings in which SRS is already established.
Stereotactic radiosurgery (SRS) has become a well-established first-line therapy for limited brain metastases after multiple phase 3 randomized clinical trials of SRS with and without whole-brain radiotherapy (WBRT) collectively demonstrated no overall survival advantage with the addition of WBRT to SRS despite the superior central nervous system (CNS) control observed with WBRT.1-5 The absence of an overall survival advantage to justify the toxic effects of WBRT on cognitive function and quality of life1,4,6 made SRS alone the preferred treatment for limited brain metastases in most settings.7 However, patients with small cell lung cancer were excluded from the landmark randomized clinical trials2-5,8 that established SRS alone as a first-line strategy, making small cell lung cancer an exception where WBRT has remained the standard of care for limited and even solitary brain metastases.9 Historical reservations regarding SRS alone in small cell lung cancer have included concerns for short interval CNS progression that could potentially lead to a decrease in overall survival with WBRT omission, as well as the paucity of data on first-line SRS in this setting.10
In recent years, interest in the potential role of SRS in small cell lung cancer has been growing because of multiple factors, including the expanded use of surveillance brain magnetic resonance imaging (MRI), evolving controversies surrounding prophylactic cranial irradiation (PCI), integration of immunotherapy into management, and improvements in prognosis.9,11-14 These developments are expected to increase the identification of patients with small cell lung cancer and limited brain metastases who may be candidates for first-line SRS and to magnify survivorship considerations such as the long-term cognitive and quality-of-life advantages of avoiding early WBRT administration.15 In this context, a number of smaller studies, which have typically included a mix of both salvage and first-line SRS, and population-based analyses have been reported,16-19 and several clinical trials have been launched.20,21 Currently, however, the role of first-line SRS in contemporary small cell lung cancer management remains unclear.
This cohort study, First-line Radiosurgery for Small-Cell Lung Cancer (FIRE-SCLC), was a multicenter retrospective analysis of patients with small cell lung cancer brain metastases who were treated with SRS without prior PCI or WBRT. The analysis included a comparison of SRS outcomes with the outcomes from a cohort of patients treated with first-line WBRT. We hypothesized that SRS alone could deliver acceptable outcomes in clinical end points, such as overall survival, CNS control, and neurologic-specific mortality, and that the potential advantages in CNS control associated with WBRT would not translate into a decrease in overall survival with SRS alone, similar to other settings in which SRS is already well-established.1
The FIRE-SCLC retrospective cohort study included data from 28 centers in 6 countries (Japan, the US, Canada, Taiwan, Germany, and Switzerland) and 98 patients with small cell lung cancer who participated in the JLGK0901 prospective single-arm trial of SRS for 1 to 10 brain metastases from mixed histologies.22 The 28 participating centers obtained approval for the study from their respective institutional review boards, which granted informed consent exemptions because of the minimal risk of harm associated with analysis of deidentified data sets. The study was registered through the International Radiosurgery Research Foundation. Data for this study were collected from October 26, 2017, to August 15, 2019.
The primary analysis included patients with biopsy-confirmed small cell lung cancer who were treated with first-line SRS (without prior PCI or WBRT) for brain metastases. Stereotactic radiosurgery was described according to a consensus definition,23 and all platforms of SRS delivery were acceptable. After undergoing SRS, patients underwent follow up with clinical and radiographic surveillance per institutional standards. Data were collected on treatment center, treatment year, age, sex, Karnofsky Performance Status (KPS) score, presence of brain metastases at diagnosis, number of brain metastases treated, time until first CNS progression after SRS, type of first CNS progression (local, distant, or both), leptomeningeal progression, salvage therapy for CNS progression, vital status at reporting, neurological mortality, and duration of follow-up.
The primary objective of the analysis was to describe the clinical outcomes associated with first-line SRS without prior PCI or WBRT. Overall survival was defined as time from SRS to death and estimated using the Kaplan-Meier method, and comparisons were made using the log-rank test; the hazard ratio (HR) was modeled using Cox proportional hazards regression models. Time to CNS progression (TTCP) was defined as time from SRS to first CNS progression. Death was treated as a competing risk for TTCP; the cumulative incidence was examined, and the HR was estimated using the Fine-Gray method. Multivariable analyses of overall survival and TTCP were adjusted for treatment year (continuous), age (continuous), sex, region (Asia vs North America and Europe), KPS score (≤60, 70-80, 90-100),24 brain metastases at diagnosis (synchronous vs metachronous), and number of brain metastases (continuous). Subset analyses were performed with stratification by number of brain metastases (1, 2-4, 5-10, and ≥11 lesions), with established clinical relevance for SRS in other settings.7,22 Central nervous system control data were not available beyond the first CNS progression; cumulative incidence of local control and of distant CNS failures were estimated at 6 and 12 months; deaths or alternate forms of CNS progression (eg, distant failure in the setting of ongoing local control) were considered as competing risks. Local and distant failures were also calculated using the Kaplan-Meier method, with censoring of deaths and alternate forms of CNS progression. Central nervous system control outcomes were calculated on a per patient basis. Total rates of leptomeningeal progression, neurological mortality, and salvage therapies for brain metastases after SRS were described.
To compare SRS outcomes with contemporary WBRT outcomes, we acquired individual patient data from a large published data set of first-line WBRT for small cell lung cancer.25 The data elements in the WBRT cohort were the same as those in the SRS cohort, with the exception of unavailable data on CNS progression type (ie, local, distant, or both), leptomeningeal progression, salvage therapy, and neurological mortality; data on the number of brain metastases included 1, 2 to 4, and 5 or more.
The secondary objective of the analysis was to compare the SRS and WBRT cohort outcomes for overall survival, TTCP, and the composite end point of CNS progression-free survival (PFS). The CNS PFS was defined as time from SRS to either death or CNS progression and estimated using the Kaplan-Meier method. Multivariable comparisons were adjusted for KPS score, number of brain metastases, synchronicity, age, sex, and treatment year. Subset analyses were performed in patients with data on extracranial metastases outside of the thoracic tumor and regional lymph nodes (present vs absent) and extracranial disease control status (controlled [stable or responding] vs uncontrolled [progressive disease or treatment naive]).26 Because no differences in adjusted overall survival, TTCP, or CNS PFS were observed by region in the SRS cohort and all patients who received WBRT were treated in Germany, region was not included in the primary models comparing SRS and WBRT. Sensitivity analyses, including region in the multivariable models, returned similar results. Differences in overall survival, TTCP, and CNS PFS were also evaluated using propensity score–matched analyses (eMethods in the Supplement) accounting for KPS score, number of brain metastases, synchronicity, age, sex, and treatment year. In addition, semi–competing risk models were used to model the hazard of CNS progression, death without CNS progression, and death after a CNS progression event (eTable 6 in the supplement).27
All hypothesis tests were 2-sided and a P < .05 was considered statistically significant. Because of the hypothesis-generating nature of the comparative analyses, no corrections were made for multiple comparisons.28,29 All analyses were performed in R, version 3.5.2 (R Foundation for Statistical Computing), and SAS, version 9.4 (SAS Institute Inc), by the University of Colorado Cancer Center Biostatistics Core. Data analysis was conducted from August 16, 2019, to November 6, 2019.
Data were collected on 710 patients with small cell lung cancer brain metastases who were treated with first-line SRS without prior PCI or WBRT (Table 1). Patients were treated between 1994 and 2018, with 621 (87.5%) receiving treatment in the year 2000 or later (median [interquartile range (IQR)] treatment year, 2011 [2004-2014]). The median (IQR) patient age was 68.5 (62-74) years, and most patients were men (531 [74.8%]) and had a good performance status (437 [61.5%] had a KPS score ≥90). The median (IQR) number of brain metastases treated was 2.5 (1-6), and 540 (76.1%) were treated in Asia and 170 (23.9%) in North America and Europe. A complete list of participating centers is in eTable 1 in the Supplement.
At the time of analysis, 596 patients (83.9%) were deceased. The median overall survival after SRS was 8.5 months (95% CI, 7.9-9.5) (Figure 1A). When stratified by the number of brain metastases treated, the median overall survival was 11.0 months (95% CI, 8.9-13.4) for 1 lesion, 8.7 months (95% CI, 7.7-10.4) for 2 to 4 lesions, 8.0 months (95% CI, 6.4-9.6) for 5 to 10 lesions, and 5.5 months (95% CI, 4.3-7.6) for 11 or more lesions (P < .001) (Figure 1C). No significant differences in overall survival were observed after SRS for 2 to 4 vs 5 to 10 brain metastases (log-rank P = .30). As shown in Table 2, factors significantly associated with superior overall survival on multivariable analyses included better KPS scores, fewer brain metastases (continuous), synchronous brain metastases, younger age, female sex, and a more recent year of treatment. No significant differences in multivariable adjusted overall survival were observed by region (Asia vs North America and Europe).
We performed TTCP analyses for 456 patients with clinical follow-up data on CNS control. Of these patients, 406 (89.0%) had at least 1 follow-up brain MRI after SRS. The median TTCP was 8.1 months (95% CI, 7.1-9.4) (Figure 1B). When stratified by the number of brain metastases treated, the median TTCPs were 11.7 months (95% CI, 8.8-not reached) for 1 lesion, 6.8 months (95% CI, 5.7-8.3) for 2 to 4 lesions, 6.1 months (95% CI, 4.9-7.7) for 5 to 10 lesions, and 4.7 months (95% CI, 3.2-not reached) for 11 or more lesions (P < .001) (Figure 1D). On multivariable analysis, the number of brain metastases (continuous) was the only factor associated with TTCP (eTable 2 in the Supplement). Competing risk estimates for local failure were 4.1% (95% CI, 2.5%-5.7%) at 6 months and 7.0% (95% CI, 4.9%-9.2%) at 12 months, and distant CNS failure estimates were 28.0% (95% CI, 24.4%-31.7%) at 6 months and 41.6% (95% CI, 37.6%-45.7%) at 12 months. Kaplan-Meier estimates for local failure and distant failure are included in eTable 3 in the Supplement. The radiation necrosis rate (any grade) was 5.0%, and no treatment-related deaths were reported. After first-line SRS, 238 of 710 patients (33.5%) subsequently underwent salvage SRS and 114 patients (16.1%) underwent salvage WBRT. In patients with available data, leptomeningeal progression was reported in 46 of 425 patients (10.8%), and neurological mortality was considered possible or likely in 80 of 647 patients (12.4%).
Comparison of the SRS and WBRT Cohorts
In the WBRT data set, 219 patients were evaluable for overall survival and CNS control. Patients were treated with WBRT between 2003 and 2015 (median [IQR] treatment year, 2012 [2010-2014]). At the time of analysis, 206 patients (94.1%) were deceased and 101 patients (46.1%) had at least 1 follow-up brain MRI after WBRT. Baseline differences were found between the WBRT and SRS cohorts, with patients in the WBRT cohort displaying worse KPS score (≤60 score: 30.1% vs 7.2%), more brain metastases (≥5 metastases: 58.9% vs 32.0%), younger age (median [IQR] age: 62 [56.5-70.0] years vs 68.5 [62.0-74.0] years), more women (41.1% vs 25.2%), and treatment in more recent years (median [IQR] year: 2012 [2010-2014] vs 2011 [2004-2014]) (Table 3).
On unadjusted analysis, a significant difference in overall survival was found between the 2 cohorts, in favor of SRS vs WBRT (median, 8.5 months [95% CI, 7.9-9.5] vs 5.2 months [95% CI, 4.2-6.7]; P < .001) (Figure 2A), which persisted after multivariable adjustment (HR, 1.48 [95% CI, 1.21-1.80]; P < .001). On unadjusted analysis of TTCP, a significant difference was observed in favor of WBRT (median, 8.1 months (95% CI, 7.1-9.4) for SRS vs not reached for WBRT; P < .001) (Figure 2B), which persisted after multivariable adjustment (HR, 0.38 [95% CI, 0.28-0.52]; P < .001). On analyses of CNS PFS, unadjusted comparisons favored SRS vs WBRT (median, 5.0 months vs 3.8 months; P = .03) (eFigure 1A in the Supplement), but no differences were observed after multivariable adjustment (HR, 0.91 [95% CI, 0.74-1.11]; P = .35).
After propensity score matching, 187 patients in the SRS cohort and 187 patients in the WBRT cohort with balanced KPS scores, number of brain metastases, synchronicity, age, sex, and treatment year were analyzed for overall survival (Table 3). Overall survival outcomes in the matched data set were more similar than in the unmatched analyses but remained in favor of SRS vs WBRT (median, 6.5 months [95% CI, 5.5-8.0] vs 5.2 months [95% CI, 4.4-6.7]; P = .003) (Figure 2C). In the matched data set evaluating CNS control (eTable 4 in the Supplement), TTCP was improved with WBRT (median, 9.0 months [95% CI, 6.5-17.6] for SRS vs not reached for WBRT; HR, 0.38; 95% CI, 0.26-0.55; P < .001) (Figure 2D), whereas no differences were observed in CNS PFS (median, 4.0 months for SRS vs 3.8 months for WBRT; P = .79) (eFigure 1B in the Supplement).
Among the 524 patients (331 in the SRS cohort, and 193 in the WBRT cohort) with data on both extracranial metastases and extracranial disease control, multivariable analyses controlling for these factors found results similar to those of the overall analyses. Compared with WBRT, SRS was associated with favorable overall survival (HR, 1.94; 95% CI, 1.48-2.53; P < .001) and an inferior TTCP (HR, 0.33; 95% CI, 0.24-0.47; P < .001). Subset analyses by extracranial metastases and extracranial disease control status are displayed in eTables 7 and 8 in the Supplement.
On subset analyses, no significant differences in the association of treatment modality (SRS or WBRT) with overall survival were observed by age, sex, or number of brain metastases. Significant interactions between treatment modality and the covariables of KPS score, brain metastases at diagnosis, and treatment year were found, which suggested inferior outcomes after WBRT among patients with a KPS score of 60 or lower, synchronous brain metastases, and more recent years of treatment (all interaction P < .05) (eFigure 2A in the Supplement). Conversely, no significant interactions were observed between treatment modality and baseline patient characteristics for the end point of TTCP (eFigure 2B in the Supplement).
The FIRE-SCLC is a multicenter analysis of outcomes of 710 patients with small cell lung cancer brain metastases treated with first-line SRS. After SRS delivery, encouraging outcomes were observed, with a median overall survival of 8.5 months and TTCP of 8.1 months. The results were particularly impressive among patients with a single brain metastasis, with 11.0 months for median overall survival and 11.7 months for median TTCP. Concerning events that might be attributed to WBRT omission, such as neurological mortality (12.4%) and leptomeningeal progression (10.8%), were uncommon and their rates were not increased over those reported in other series of small cell lung cancer.19,30 Local failures after SRS were rare, with most of CNS progression occurring in the form of new lesions, similar to SRS in other settings.2,3,5,22 Among patients who received salvage therapy for CNS progression, 33.5% received salvage SRS and only 16.1% received salvage WBRT. Both overall survival and TTCP declined with continuous increases in brain metastases. However, similar to the JLGK0901 study,22 the present study observed no significant differences in overall survival or TTCP after SRS between patients with 2 to 4 lesions and those with 5 to 10 lesions.
In addition, we compared the SRS outcomes with individual patient data from a large cohort who received first-line WBRT. The median overall survival of 5.2 months in the WBRT cohort was similar to estimates from other large retrospective studies and prospective data of first-line WBRT.31,32 In this data set, TTCP was improved with WBRT (HR after multivariable adjustment, 0.38), which appears comparable to the CNS control advantages observed with WBRT for other histologies.1 However, similar to WBRT in other settings, the CNS control advantage with WBRT did not translate into an improvement in survival, as the observed overall survival outcomes remained in favor of SRS after adjustment for available prognostic factors. It is important to acknowledge the baseline differences between the SRS and WBRT treatment groups, including an increased number of brain metastases and the inferior KPS scores in the WBRT cohort (Table 3), as well as the observation that the overall survival outcomes became more similar after adjustment for baseline factors (median overall survival of 6.5 vs 5.2 months after propensity score matching). Although these retrospective data should not be used to conclude that overall survival is superior with SRS, the findings of this study suggest that the primary trade-offs associated with SRS without WBRT, including a shorter TTCP, are similar to other settings in which SRS alone is well established by multiple randomized clinical trials.1
Before this analysis, a number of smaller studies have reported outcomes after first-line SRS (eTable 9 in the Supplement).16,17,19,33-38 Serizawa et al18 compared first-line SRS in non–small cell lung cancer, where SRS is an established paradigm, with small cell lung cancer (n = 34). No statistically significant differences were observed in any end point between small cell lung cancer and non–small cell lung cancer, and the outcomes in the small cell lung cancer cohort were comparable to results of the present analysis (median overall survival, 9.1 months; 12-month local control, 94.5%; median time to new brain lesions, 6.9 months; and 12-month neurological mortality free survival, 86.5%). In a recent analysis of 293 patients with small cell lung cancer treated with SRS, the median overall survival was 7.5 months for 61 patients who received first-line SRS.33 Using the National Cancer Databases, Robin et al17 reported superior overall survival with SRS compared with WBRT (propensity score–matched overall survival, 10.9 months vs 7.6 months; P < .001). We included 98 patients with small cell lung cancer who participated in the prospective JLGK0901 study,22 and they demonstrated median overall survival (8.6 months) and TTCP (7.2 months) outcomes that were similar to the overall SRS cohort. Given the higher number of patients who received first-line SRS in Japan in this study, it is an important finding that no differences in adjusted overall survival or TTCP were observed by region in this analysis.
Strengths and Limitations
This study has several strengths, including the unprecedented size of the SRS cohort, participation from centers in 6 countries, a contemporary WBRT cohort with individual patient data for comparative analyses, and various analytical methods. These methods included competing risk modeling, semi–competing risk modeling, multivariable adjustment, and propensity score matching to control for multiple prognostic factors.
This study has several limitations as well. Given the retrospective design, all analyses were subject to confounding because of unquantified variables. Systemic therapy was not controlled for in this analysis, which has prognostic implications for both overall survival and CNS disease control in small cell lung cancer.10 To this end, the improved overall survival observed with synchronous brain metastases in this study could represent a surrogate for less systemic therapy exposure and the measurement of overall survival from an earlier point in the disease course. Volumetric assessments of CNS disease burden, cognitive function, and quality of life were unavailable for analysis. Patients in the WBRT cohort were treated at a large academic center in Germany and, although the overall survival was similar in this cohort to other large case series and prospective data,31,32 their outcomes may not be globally generalizable. Surveillance was dependent on institutional practices, and documented follow-up MRIs were more common in the SRS than in the WBRT cohort. The less frequent imaging after WBRT may reflect contemporaneous standards and practice patterns,39 but these differences could have increased the apparent CNS control advantage associated with WBRT. The absence of control data beyond the first CNS progression increases the uncertainty associated with local and distant control estimates. Beyond the number of lesions treated, we did not collect granular data on SRS dose and volume for technical analyses. Although it is reassuring that most patients treated with salvage radiation received salvage SRS rather than WBRT, the extent of CNS disease at recurrence was not characterized. In addition, analyses should be interpreted in the context of multiple comparisons without statistical adjustment, underscoring the importance of confirming the observed associations in future studies.28,29
In this large multicenter analysis, we believe that the outcomes of SRS for small cell lung cancer were encouraging overall and were particularly impressive for patients with a single brain metastasis. In addition, the trade-offs inherent to a first-line SRS approach without WBRT, including a shorter time to CNS progression without an associated decrease in overall survival, appear to be similar to those in other settings in which SRS is already well established. We believe that these data provide a benchmark for SRS outcomes and offer support to first-line SRS as a treatment option in carefully selected patients with small cell lung cancer.
Accepted for Publication: March 16, 2020.
Published Online: June 4, 2020. doi:10.1001/jamaoncol.2020.1271
Correction: This article was corrected on July 23, 2020, to add Dr Combs’ middle initial.
Corresponding author: Chad G. Rusthoven, MD, University of Colorado School of Medicine, Department of Radiation Oncology, 1665 Aurora Ct, Ste 1032, Mail Stop F706, Aurora, CO 80045 (Chad.Rusthoven@CUAnschutz.edu).
Author Contributions: Dr Rusthoven had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Rusthoven, Yamamoto, Bernhardt, Shuto, Grills, Sheehan, Cordeiro, Deibert, Combs, Rieken, Kavanagh, Robin.
Acquisition, analysis, or interpretation of data: Rusthoven, Yamamoto, Bernhardt, Smith, Gao, Serizawa, Yomo, Aiyama, Higuchi, Akabane, Sato, Niranjan, Faramand, Lunsford, McInerney, Tuanquin, Zacharia, Chiang, Singh, Yu, Braunstein, Mathieu, Touchette, Lee, Yang, Aizer, Cagney, Chan, Kondziolka, Bernstein, Silverman, Grills, Siddiqui, Yuan, Sheehan, Cordeiro, Nosaki, Seto, Deibert, Verma, Day, Halasz, Warnick, Trifiletti, Palmer, Attia, Li, Cifarelli, Brown, Vargo, Kessel, Rieken, Patel, Guckenberger, Andratschke, Kavanagh, Robin.
Drafting of the manuscript: Rusthoven, Bernhardt, Smith, Gao, Shuto, Seto, Deibert, Combs, Robin.
Critical revision of the manuscript for important intellectual content: Rusthoven, Yamamoto, Bernhardt, Smith, Gao, Serizawa, Yomo, Aiyama, Higuchi, Akabane, Sato, Niranjan, Faramand, Lunsford, McInerney, Tuanquin, Zacharia, Chiang, Singh, Yu, Braunstein, Mathieu, Touchette, Lee, Yang, Aizer, Cagney, Chan, Kondziolka, Bernstein, Silverman, Grills, Siddiqui, Yuan, Sheehan, Cordeiro, Nosaki, Seto, Deibert, Verma, Day, Halasz, Warnick, Trifiletti, Palmer, Attia, Li, Cifarelli, Brown, Vargo, Combs, Kessel, Rieken, Patel, Guckenberger, Andratschke, Kavanagh, Robin.
Statistical analysis: Rusthoven, Smith, Gao, Sato, Braunstein, Aizer, Grills, Cordeiro, Deibert, Day, Robin.
Obtained funding: Yamamoto, Patel.
Administrative, technical, or material support: Rusthoven, Yamamoto, Bernhardt, Serizawa, Shuto, Lunsford, McInerney, Tuanquin, Singh, Braunstein, Touchette, Lee, Chan, Bernstein, Grills, Yuan, Seto, Deibert, Day, Combs, Rieken, Kavanagh, Robin.
Supervision: Rusthoven, Yamamoto, Higuchi, Niranjan, Lunsford, McInerney, Cordeiro, Deibert, Trifiletti, Palmer, Combs, Kavanagh, Robin.
Conflict of Interest Disclosures: Dr Rusthoven reported receiving research funding from Takeda outside the submitted work as well as honoraria for educational talks from Genentech and AstraZeneca outside the submitted work. Dr Bernhardt reported receiving grants from Heidelberg University during the conduct of the study. Dr Lunsford reported receiving other from AB Elekta and Insightec during the conduct of the study. Dr McInerney reported receiving grants from Elekta outside the submitted work. Dr Zacharia reported receiving personal fees from NICO Corp and Medtronic outside the submitted work. Dr Yu reported receiving personal fees from Boston Scientific and Galera Pharmaceuticals outside the submitted work. Dr Aizer reported receiving grants from Varian Medical Systems outside the submitted work. Dr Chan reported receiving other from Monteris and Elekta outside the submitted work. Dr Kondziolka reported receiving grants from Brainlab outside the submitted work. Dr Seto reported receiving grants and personal fees from AstraZeneca, Chugai Pharmaceutical, Daiichi Sankyo, Eli Lilly Japan, Merck Sharp & Dohme, Nippon Boehringer Ingelheim, Novartis Pharma, Pfizer Japan, and Takeda Pharmaceutical; personal fees from Astellas Pharma, Bristol-Myers Squibb, Kyowa Hakko Kirin, Ono Pharmaceutical, Taiho Pharmaceutical, Thermo Fisher Scientific, and Precision Medicine Asia Co Ltd outside the submitted work; and grants from AbbVie, Bayer Yakuhin, Kissei Pharmaceutical, Loxo Oncology Inc, and Merck Serono. Dr Trifiletti reported receiving other from Novocure and Springer outside the submitted work. Dr Palmer reported receiving grants from Varian Medical Systems as well as personal fees from Depuy Synthes, Huron Consulting Group, and MORE Health Inc outside the submitted work. Dr Attia reported receiving personal fees from Novocure and AstraZeneca outside the submitted work. Dr Brown reported receiving personal fees from UpToDate outside the submitted work. Dr Vargo reported receiving other from Elsevier outside the submitted work. Dr Combs reported receiving personal fees and nonfinancial support from Roche, AstraZeneca, Medac, Dr Sennewald Medizintechnik, Elekta, Accuray, Bristol-Myers Squibb, Brainlab, Daiichi Sankyo, and Icotec outside the submitted work. Dr Rieken reported receiving grants and personal fees from AstraZeneca, Merck, Novocure, Pfizer, and Novartis outside the submitted work. No other disclosures were reported.
Funding/Support: This study was funded by grant P30CA046934 from the University of Colorado Cancer Center (Mr Smith and Dr Gao were partially supported by this grant).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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