Re: LCD DL35236- Draft LCD for Stereotactic Radiation Therapy: Stereotactic
Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
Dear Dr. Hecker:
The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons
(CNS) appreciate the opportunity to comment on the proposed coverage policy entitled “Stereotactic
Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT),
DL 35236.”
Stereotactic radiosurgery is an increasingly important part of the neurosurgical treatment armamentarium
for brain metastasis patients. Recent publications have largely invalidated the number of metastasis as a
criterion for appropriate selection for SRS. In the most recent guidelines on SRS for brain metastasis
published by the American Society for Radiation Oncology (ASTRO), Tsao et al. write “[t]he maximum
number or total volume of brain metastases best treated with radiosurgery (or surgery) is unknown.
Randomized trials which have examined the use of radiosurgery, included selected patients with up to 4
brain metastases, while retrospective reports document use of radiosurgery that exceed 4 brain
metastases.” (Tsao et al., 2012). ASTRO noted that the literature supports the use of SRS as an initial
management for brain metastasis patients who exhibit good prognosis, an expected survival of 3 months
or more, and all brain metastases <= 3 to 4 cm (Tsao et al., 2012). In particular, SRS has been demonstrated to afford improved local control and neurocognition for multiple metastases patients (Tsao et al., 2012; Chang et al., 2009).
In a recent study of 251 brain metastases from MD Anderson, the authors concluded that “[t]he number of BM [brain metastasis] is not a strong predictor for clinical outcomes following initial SRS for newly diagnosed BM.” (Likhacheva et al., 2013). A study of 103 patients with >=5 brain metastases performed at Yale University demonstrated overall survival in patients with 5 or more brain metastases treated with radiosurgery alone was reasonable and compared well with controls (Raldow et al., 2013). Similar
findings have been observed in other studies (Salvetti et al., 2013; Rava et al., 2013).
…
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