Practice Patterns Related to Mitigation of Neurocognitive Decline in Patients Receiving Whole Brain Radiation Therapy

Whole brain radiation therapy (WBRT) is often used as an effective treatment for patients with brain metastasis, although it is also known to have deleterious cognitive effects. Multiple trials have identified strategies to help mitigate neurocognitive decline after WBRT, although there may be barriers to integrating these techniques into routine clinical practice. The aim of this study was to characterize national practice patterns related to neurocognitive preservation strategies used during WBRT.

We conducted an online survey of all American Society for Radiation Oncology-registered radiation oncologists (ROs), excluding trainees, regarding their practice patterns and attitudes toward employing memantine and hippocampal avoidance whole brain radiation therapy (HA-WBRT). Pearson χ² tests for categorical variables or Student t tests for continuous variables were used to assess associations between provider characteristics and prescribing of either memantine or HA. All statistical tests were 2-sided and a P value <.05 was considered statistically significant.

Among 4408 ROs invited to participate, 417 (9.5%) completed the survey. Among respondents, 79.6% reported having offered memantine, 72.7% HA-WBRT, and 63.1% both for any of their patients undergoing WBRT. Common reasons for not offering memantine included limitations of current evidence (35.3%) and concerns about adverse effects (22.4%). Common reasons for not offering HA-WBRT included resource-intensive treatment planning and treatment delay (43.9%) and concern about obtaining prior authorization (38.6%). ROs with fewer years in practice (mean 15.7 vs 23.4 years) were more likely to prescribe memantine (P < .001), whereas HA was more likely prescribed by central nervous system specialists (P < .001) and ROs in academic settings (P = .04).

Our survey suggests that the majority of respondents offer approaches for neurocognitive preservation during WBRT for their patients. Further efforts are needed to broaden education and reduce barriers among ROs to improve implementation of neurocognitive-sparing techniques in patients undergoing WBRT.