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Purpose: Minority cancer patients receive more aggressive care near death. This may indicate low quality end-of-life (EOL) care if discordant with patient preferences. We investigated preferred potential place of death and preferences regarding use of mechanical ventilation in a cohort of Texas cancer patients.Methods: A population-based convenience sample of recently diagnosed cancer patients from the Texas Cancer Registry was surveyed using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about preferences regarding location of death and mechanical ventilation were the outcome measures of this investigation. Inverse probability weighting analysis was used to construct multivariable logistic regression examining the associations of covariates. Results: Of 1460 respondents, a majority (82%) preferred to die at home compared to 8% who preferred dying at the hospital. In total 25% of respondents expressed a preference for undergoing mechanical ventilation at the EOL. Adjusted analysis showed increased preference among Black (OR=1.81; 95% CI: 1.19-2.73) and other non-white, non-Hispanic race individuals (OR=3.53; 95% CI: 1.99-6.27) for dying at a hospital. Males, married individuals, those of higher education and poor self-reported health showed significantly higher preference for dying at home. Minority respondents of all non-white races were more likely to prefer mechanical ventilation at the EOL as were individuals who lived with another person at home. Conclusion: Minority cancer patients were more likely to express preferences coinciding with aggressive EOL care including dying at the hospital and utilizing mechanical ventilation. These findings were independent of other sociodemographic characteristics, including decisional self-efficacy.

Spine stereotactic radiosurgery (SSRS) offers high rates of local control in a critical anatomic area by delivering precise, ablative doses of radiation for treatment of spine metastases. However, the dose tolerance of the spinal cord (SC) after SSRS with relation to radiation myelopathy (RM) is not well-described.We reviewed patients who underwent single fraction, de novo SSRS from 2012-2017 and received12 Gy Dmax to the SC, defined using MRI-CT fusion without PRV expansion. The standard SC constraint was D0.01cc ≤ 12 Gy. Local control was estimated with the Kaplan-Meier method. Bayesian analysis was used to compute posterior probabilities for RM.A total of 146 SSRS treatments among 132 patients were included. The median SC Dmax was 12.6 Gy (range, 12.1-17.1 Gy). The SC Dmax was12 and13 Gy for 109 (75%) treatments, ≥13 and14 Gy for 28 (19%) treatments, and ≥14 Gy for 9 (6%) treatments. The 1-year local control rate was 94%. With a median follow-up time of 42 months, there were zero (0) RM events observed. Assuming a prior 4.3% risk of RM, the true rate of RM for SC Dmax of ≤14 Gy was computed as1% with 98% probability.In one of the largest series of patients treated with single fraction, de novo SSRS, there were no cases of RM observed with a median follow-up of 42 months. These data support safe relaxation of MRI-defined SC dose up to D0.01cc ≤ 12 Gy, which corresponds to1% risk of RM.

Purpose MRI-assisted radiosurgery (MARS) is a modern technique for prostate brachytherapy that provides superior soft tissue contrast. The purpose of this analysis was to evaluate treatment planning factors associated with urinary toxicity, particularly damage to the membranous urethra (MUL) and external urethral sphincter (EUS), after MARS. Material and Methods We retrospectively reviewed 227 patients treated with MARS. Comparisons were made between several factors including preimplantation length of the MUL and EUS dosimetric characteristics after implantation with longitudinal changes in American Urological Association (AUA) urinary symptom score. Results Rates of grade 3 urinary incontinence and obstructive urinary symptoms were 4% and 2%. A piecewise mixed univariate model revealed that MUL and V200, V150, V125, and D5 to the EUS were all associated with increased rates of urinary toxicity over time. On univariate logistic regression, MUL >14.2 mm (odds ratio [OR] 2.03 per cm3, 95% confidence interval [CI] 1.10–3.77, p = 0.025), V125 to the EUS (OR 3.21 cm3, 95% CI 1.18–8.71, p = 0.022), and use of the I-125 isotope (OR 3.45, 95% CI 1.55–7.70, p = 0.001) were associated with subacute urinary toxicity (i.e., that occurring at 4–8 months). Optimal dose-constraint limits to the EUS were determined to be V200 Conclusions MARS brachytherapy provides detailed anatomic information for treatment planning, implantation, and quality assurance. Overall rates of urinary toxicity are low; however, several dosimetric variables associated with the EUS were found to correlate with urinary toxicity.

Highlights • Consolidative radiotherapy (RT) has been shown to improve overall survival in oligometastatic non-small cell lung cancer (NSCLC). • We quantified the costs of RT in oligometastatic NSCLC, by applying time-driven activity-based costing (TDABC). • This analysis uses TDABC to estimate the relative internal costs of various RT strategies associated with treating oligometastatic NSCLC. • This methodology will become increasingly relevant in context of the anticipated mandate of alternative/bundled payment models., Background: Consolidative radiotherapy (RT) has been shown to improve overall survival in oligometastatic non-small cell lung cancer (NSCLC), as demonstrated by a growing number of prospective trials. Objective: We quantified the costs of delivery of consolidative RT for common clinical pathways associated with treating oligometastatic NSCLC, by applying time-driven activity-based costing (TDABC) methodology. Methods: Full cycle costs were evaluated for 4 consolidative treatment regimens: (Regimen #1) 10-fraction 3D conformal radiation therapy (3D-CRT) as palliation of a distant site; (#2) 15-fraction intensity-modulated RT (IMRT) to the primary thoracic disease; (#3) 15-fraction IMRT to the primary plus 4-fraction stereotactic ablative radiotherapy (SABR) to a single oligometastatic site; and (#4) 15-fraction IMRT to the primary plus two courses of 4-fraction SABR for two oligometastatic sites. Results: For each of the four treatment regimens, personnel represented a greater proportion of total cost when compared with equipment, totaling 61.0%, 65.9%, 66.2%, and 66.4% of the total cost of each care cycle, respectively. In total, a 10-fraction regimen of 3D-CRT to a distant site represented just 37.2% of the total cost of the most expensive course. Compared to total costs for 15-fraction IMRT alone, each additional sequential course of 4-fraction SABR imparted a cost increase of 43%. Conclusion: This analysis uses TDABC to estimate the relative internal costs of various RT strategies associated with treating oligometastatic NSCLC. This methodology will become increasingly relevant to each organization in context of the anticipated mandate of alternative/bundled payment models for radiation oncology by the Centers for Medicare and Medicaid Services.

Dose escalation via stereotactic radiation therapy techniques has been necessary for hepatobiliary malignancies in the primary and oligometastatic setting, but such dose escalation is challenging for spine metastases due to spinal cord proximity. Here, we investigate the role of spine stereotactic radiosurgery (SSRS) in the management of such metastases. We retrospectively reviewed patients treated with SSRS to spinal metastases from hepatobiliary malignancies between 2004 and 2017 at our Institution. We used the Kaplan–Meier method to calculate overall survival (OS) and local control (LC) and Cox regression analysis to identify factors associated with disease-related outcomes. We identified 28 patients treated to 43 spinal metastases with SSRS for either HCC or cholangiocarcinoma. The 1-year LC and OS were 85% and 23%, respectively. The median time to death was 6.2 months, while median time to local failure was not reached. Tumor volume > 60 cc (SHR 6.65, p = 0.03) and Bilsky ≥ 1c (SHR 4.73, p = 0.05) predicted for poorer LC, while BED10 > 81 Gy trended towards better local control (SHR 4.35, p = 0.08). Child–Pugh Class (HR 3.02, p = 0.003), higher PRISM Group (HR 3.49, p = 0.001), and systemic disease progression (HR 3.65, p = 0.001) were associated with worse mortality based on univariate modeling in patients treated with SSRS; on multivariate analysis, PRISM Group (HR 2.28, p = 0.03) and systemic disease progression (HR 2.67, p = 0.03) remained significant. Four patients (10%) developed compression deformity and one patient (2%) developed radiation neuritis. SSRS provides durable local control in patients with metastatic hepatobiliary malignancies, with higher BED necessary to ensure excellent LC. PRISM scoring is a promising prognostic tool to aid SSRS patient selection.

Therapeutic improvements for Hodgkin's Lymphoma (HL) has resulted in excellent survival outcomes. Thus, patients are increasing susceptible to developing secondary malignancy (SM) a feared iatrogenic complication.We evaluated the SM risk in a cohort of patients with HL treated over a 50-year period. In total, 1653 patients were treated for HL from 1956 to 2009 at a tertiary-cancer-center. A cumulative incidence function was used to quantify SM risk and the Fine and Gray competing risk model was used to identify disease and treatment related correlates.Two-hundred-ninety patients (19%) developed SMs. Paradoxically, SM risk was higher in the modern era with 20-year cumulative incidence rates of 11.1%, 11.9%, 17% and 21.8%, for patients treated1970, 1971-1986, 1986-1995 and 1996-2009, respectively. We hypothesized that the disproportionately high rate of early deaths in the early era may skew the assessment of SM risks, a much-delayed event. When the analysis was restricted to patients with early-stage favorable HL treated1980, we found a reversal of the trend, especially on the risk of solid tumor, with a hazard ratio of 0.57 (p = 0.0651) in patients treated after 1996.Our findings highlight the limitations of comparing the risk of a late event between groups with disparate rates of early deaths, despite the use of a competing risk model. When partially corrected for, patients treated in the more recent time period experienced a lower solid tumor risk.

Given the relative radioresistance of sarcomas and their often large size, conventional palliative radiation therapy (RT) often offers limited tumor control and symptom relief. We report on our use of hypofractionated RT (HFRT) as a strategy to promote durable local disease control and optimize palliation.We retrospectively reviewed 73 consecutive patients with sarcoma who received10 fractions of HFRT from 2017 to 2020. Clinical scenarios included: (1) palliative or symptomatic intent (34%), (2) an unresectable primary (27%), (3) oligometastatic disease (16%), and (4) oligoprogressive disease (23%).The HFRT target was a primary tumor in 64% of patients with a median dose of 45 Gy in 15 fractions (59% ≥45 Gy). The 1-year disease-specific survival was 59%, which was more favorable for patients receiving HFRT for oligometastatic (1-year 100%) or oligoprogressive (1-year 73%) disease (HFRT is an effective treatment strategy for patients with unresectable or metastatic sarcoma to provide durable LC, symptom relief, and systemic therapy breaks with limited toxic effects.

Subspecialty exposure during medical school can be limited. Moreover, the COVID19 pandemic prevented most onsite elective medical student (MS) rotations during 2020. Therefore, we sought to create and assess the efficacy of an informal virtual elective (IVE) for MSs to explore radiation oncology (RO) at our institution. We created IVE activities including invitations to resident didactics, a faculty lecture series, and interactive virtual events with residents and faculty. MSs were offered RO resident and faculty mentors and the opportunity to deliver a lecture. Pre- and post-IVE evaluation surveys were sent to 27 4th year MSs. Surveys utilized importance ordering (1=most important; reported as median (interquartile range), free response, and Likert-type questions (5 = extremely, 1=not at all). Our IVE, held from July to October 2020, had a median of 11 students (range 7-18) attend each activity. Pre- and post-IVE surveys were completed by 22/27 (81%) and 20/27 (74%) MSs, respectively. In pre-IVE, MSs reported participating in the IVE for faculty/resident interaction (1.5 [1, 2]), networking (3 [2, 3]), and learning (4 [3-5]). In post-IVE, MSs reported benefit from faculty mentors (5 [4, 5]), delivering a presentation (5 [3-5]), and faculty lectures (4.5 [4, 5]). In post-IVE, MSs preferred a full onsite away elective (16, 80%) over an official virtual elective (1, 5%) or IVE (3, 15%). Overall, MSs reported that the IVE provided an adequate introduction to RO at our institution (4 [4, 5]). Alternative virtual elective experiences allow MSs to informally evaluate medical subspecialties and could be offered even if formal elective opportunities are available.

PURPOSE: Cervical cancer (CC) disproportionately affects minorities who have higher incidence and mortality rates. Standard of care for locally advanced CC involves a multimodality approach including brachytherapy (BT), which independently improves oncologic outcomes. Here, we examine the impact of insurance status and race on BT utilization with the SEER database. MATERIALS AND METHODS: In total, 7,266 patients with stage I-IV CC diagnosed from 2007 to 2015 were included. BT utilization, overall survival (OS), and disease-specific survival (DSS) were compared. RESULTS: Overall, 3,832 (52.7%) received combined external beam radiation therapy (EBRT) + BT, whereas 3,434 (47.3%) received EBRT alone. On multivariate logistic regression analysis, increasing age (OR, 0.98; 95% CI, 0.98 to 0.99; P < .001); Medicaid (OR, 0.80; 95% CI, 0.72 to 0.88; P < .001), uninsured (OR, 0.67; 95% CI, 0.56 to 0.80; P < .001), and unknown versus private insurance (OR, 0.61; 95% CI, 0.43 to 0.86; P < .001); Black (OR, 0.68; 95% CI, 0.60 to 0.77; P < .001) and unknown versus White race (OR, 0.30; 95% CI, 0.13 to 0.77; P = .047); and American Joint Committee on Cancer stage II (OR, 1.07; 95% CI, 0.93 to 1.24; P = .36), stage III (OR, 0.82; 95% CI, 0.71 to 0.94; P = .006), stage IV (OR, 0.30; 95% CI, 0.23 to 0.40; P < .001), and unknown stage versus stage I (OR, 0.36; 95% CI, 0.28 to 0.45; P < .001) were associated with decreased BT utilization. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% ( P < .0001) and the 5-year DSS was 55.6% versus 60.5% ( P < .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT + BT, with the 5-year OS of 57.3% versus58.5% ( P = .24) and the 5-year DSS of 66.3% versus 66.6% ( P = .53) for Black and White patients, respectively. CONCLUSION: This work demonstrates notable inequities in BT utilization for CC that particularly affects patients of lower insurance status and Black race, which translates into inferior oncologic outcomes. Importantly, the use of BT was able to overcome racial survival differences, thus highlighting its essential value.

Purpose The purpose of this study was to quantify the cost of resources required to deliver adjuvant radiation therapy (RT) for high- to intermediate-risk endometrial cancer using time-driven activity-based costing (TDABC). Methods and Materials Comparisons were made for three and five fractions of vaginal cuff brachytherapy (VCB), 28 fractions of intensity-modulated radiation therapy (IMRT), and combined modality RT (25-fraction IMRT followed by 2-fraction VCB). Process maps were developed representing each phase of care. Salary and equipment costs were obtained to derive capacity cost rates, which were multiplied by process times and summed to calculate total costs. Costs were compared with 2018 Medicare physician fee schedule reimbursement. Results Full cycle costs for 5-fraction VCB, IMRT, and combined modality RT were 42%, 61%, and 93% higher, respectively, than for 3-fraction VCB. Differences were attributable to course duration and number of fractions/visits. Accumulation of cost throughout the cycle was steeper for VCB, rising rapidly within a shorter time frame. Personnel cost was the greatest driver for all modalities, constituting 76% and 71% of costs for IMRT and VCB, respectively, with VCB requiring 74% more physicist time. Total reimbursement for 5-fraction VCB was 40% higher than for 3-fractions. Professional reimbursement for IMRT was 31% higher than for 5-fraction VCB, vs. IMRT requiring 43% more physician TDABC than 5-fraction VCB. Conclusions TDABC is a feasible methodology to quantify the cost of resources required for delivery of adjuvant IMRT and brachytherapy and produces directionally accurate costing data as compared with reimbursement calculations. Such data can inform institution-specific financial analyses, resource allocation, and operational workflows.

BACKGROUND Predicting survival of patients with spinal metastases would help stratify treatments from aggressive to palliation. OBJECTIVE To evaluate whether sarcopenia predicts survival in patients with lung, breast, prostate, or multiple myeloma spinal metastases. METHODS Psoas muscle measurements in patients with spinal metastasis were taken from computed tomography scans at 2 time points: at first episode of stereotactic body radiation therapy (SBRT) and from the most recent scan available. Overall survival and hazard ratios were calculated with multivariate cox proportional hazards regression analyses. RESULTS In 417 patients with spinal metastases, 40% had lung cancer, 27% breast, 21% prostate, and 11% myeloma. Overall survival was not associated with age, sex, ethnicity, levels treated, or SBRT volume. Multivariate analysis showed patients in the lowest psoas tertile had shorter survival (222 d, 95% CI = 185-323 d) as compared to the largest tertile (579 d, 95% CI = 405-815 d), (HR1.54, P = .005). Median psoas size as a cutoff value was also strongly predictive for survival (HR1.48, P = .002). Survival was independent of tumor histology. The psoas/vertebral body ratio was also successful in predicting overall survival independent of tumor histology and gender (HR1.52, P

Purpose/objective(s) Chordomas are rare tumors of notochordal origin affecting the skull base, spine, and sacrum. Given their high propensity for local recurrence and chemo/radioresistant biology, current treatment paradigms involve maximally safe en-bloc resection with or without adjuvant radiation therapy (RT). SSRS describes a modern approach to dose escalated RT, most commonly used for spine metastases. We analyzed our large single-institution database to test the hypothesis that SSRS provides comparable oncologic and safety outcomes relative to historical controls. Materials/methods We identified 21 patients with mobile spine or sacral chordoma (25 lesions) treated with SSRS at our institution from 2006 to 2020. We reviewed records to obtain patient, disease, and treatment characteristics, as well as outcome data including survival, local control, and toxicity attributable to SSRS. We performed a Kaplan-Meier analysis to estimate overall survival and local control rates, and a Cox proportional hazard model was used for univariate and multivariate analysis. We also performed a logistic regression to examine risk factors for insufficiency fractures. Significance was defined at a P Results Patients were treated with IMRT in 1,3, or 5 fractions with a simultaneous integrated boost. The median BED2 was 312 Gy (24 Gy/1 fraction to the GTV, 16 Gy to CTV) (Range 120-312 Gy). 44% of lesions were treated in the salvage setting, and 36% were treatments for metastases. All patients had gross disease at the time of SSRS. With median follow-up of 30 months, overall survival (OS) was 95.0%, 89.1%, 48.2% and local control (LC) was 91.5%, 86.9%, and 55.3% at 1, 2, and 5 years respectively. Covariates significantly associated with OS included: performance status, prescribed BED, mobile spine location, non-metastatic site treated, disease limited to 1 site, and GTV Dmin BED2 > 119.28), and the multivariate analysis did not converge. Covariates significantly associated with LC on univariate analysis included: conventional histology, and prescribed BED, while chondroid histology was associated with decreased LC. Only prescribed BED was significant on multivariate analysis. Seven patients were treated with definitive SSRS to their primary site, and there was 1 death (not attributable to RT) and 1 local failure in this group. No radiation myelopathy events were identified. Six patients (29%) required stabilization for sacral or spinal insufficiency after SSRS (median 13 months). No features were identified that significantly predicted for fracture. Conclusion To the best of our knowledge, this series represents over a quarter of all reported spine and sacrum chordoma cases treated with stereotactic radiation in the literature. Our data are comparable to published population-based and single-institution case series, particularly given the prevalence of salvage and metastatic cases in this cohort, and they support the use of SSRS throughout the disease course of spine and sacral chordoma. Author disclosure S. Maroongroge: None. D. Boyce-Fappiano: None. K. Diao: None. B. Amini: None. A.P. Conley: None. J. Li: Research Grant; BMS, Medtronic. Honoraria; Monteris. Travel Expenses; Elekta. D.N. Yeboa: Research Grant; Brockman Foundation, MD Anderson Shirley Stein Award, MD Anderson Cancer Center. member for reviewing abstracts; ASTRO.M. McAleer: Honoraria; PREX S. p. A., AOSpine, Osler Institute. Speaker's Bureau; Osler Institute. Travel Expenses; Osler Institute. C. Tatsui: None. L.D. Rhines: None. A.J. Ghia: None.

Purpose/Objective(s) The COVID19 pandemic prevented most onsite elective rotations for medical students (MSs) in 2020; therefore, alternate methods of subspeciality exploration were necessary. We assessed the efficacy of an informal virtual elective (IVE) for students interested in radiation oncology (RO). Materials/Methods We created a series of IVE activities (non-credit granting) related to RO. MSs interested in the formal RO away elective at MD Anderson Cancer Center (MDACC) were invited to participate. A pre- and post-IVE survey was performed in the Summer and Fall of 2020, respectively. Likert-type scores (1 = not at all, 5 = extremely) were reported as median [interquartile range]. The Wilcoxon rank sum test was used to compare pre/post values. Results The pre- and post-IVE surveys were completed by 22/27 (81%) and 20/27 (74%) students, respectively. Prior to the IVE, students reported their top reasons for participation: promote self in preparation for interview season (5, 23%), receive an introduction to the field of RO (4, 18%), interact with faculty/residents at MDACC (3, 14%), networking (3, 14%), initiate research collaborations (3, 14%), self-exposure in RO (2, 9%), explore research opportunities (1, 5%), explore learning opportunities (1, 5%). Students reported that resident mentors would be extremely beneficial (5 [4-5]) on the pre-IVE survey vs. quite beneficial (4 [4-5]) on the post-IVE survey (P = 0.42). Faculty mentors were rated slightly more beneficial after the IVE (5 [4-5]) compared to prior (4.5 [4-5]) (P = 0.79). Students rated preparing and delivering a virtual presentation as quite beneficial (4 [3-4]) prior to the IVE and extremely beneficial (3 [3-5]) after the IVE (P = 0.16). The MS lecture series was rated as quite beneficial both prior to (4 [4-5]) and after (4.5 [4-5]) the IVE (P = 0.86). The remote resident didactics were rated as quite beneficial on both the pre- and post-IVE survey (4 [4-5] vs 4 [3-4], respectively, P = 0.054). On the pre-IVE survey, MSs preferred a full onsite away elective (16, 73%) vs. an official virtual elective (3, 14%), or an IVE (3, 14%). On the post-IVE survey, fewer MSs preferred an official virtual elective (1, 5%), and most still preferred a full onsite away elective (16, 80%). On the post-IVE survey, students reported participating in an onsite elective at their home institution (14, 70%), a full virtual away elective (7, 35%), a full onsite away elective (4, 20%), and none (2, 10%). Overall, students scored the ability of the IVE to provide an adequate introduction to RO higher after the experience (4 [4-5] vs 3 [3-4.25], P = 0.10 Conclusion MSs report that IVE experiences can provide an adequate introduction to RO, although they prefer a formal onsite away elective. These informal virtual activities could be used to introduce MSs to smaller, less accessible subspecialties such as RO, even when onsite rotations are again allowed.

Purpose/Objective(s) Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but a substantial proportion of patients do not undergo surgery. Evidence is limited regarding overall survival (OS) outcomes and factors associated with lack of surgery. We sought to measure OS among patients with breast cancer who do not undergo surgery, and assess factors for association with lack of surgery and OS. Materials/Methods Retrospective cohort study of patients in the US National Cancer Data Base from 2004–2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Descriptive statistics were used to summarize patient characteristics. Chi-square tests and Wilcoxon rank-sum were used to test for differences between variables between groups. OS was analyzed utilizing the Kaplan-Meier method for non-surgical patients diagnosed in 2010–2015 to account for receptor status (Median follow-up time 34 months). The Cox proportional hazards model was used to assess association of risk factors with OS. Results Of the 1,192,294 patients, 50,626 (4.3%) did not undergo surgery. Socioeconomic factors that were more prevalent in the non-surgical cohort were Black race, age > 50 years, lower income, uninsured or public insurance, and lower education; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for all patients who did not have surgery was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 months) and RT (85 vs 56 months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with high-risk (triple-negative, HER2+) disease, whereas receipt of RT led to improved OS for patients with ER+ and favorable (ER+, early-stage, age > 60) disease. Conclusion More than 4% of women with non-metastatic breast cancer do not undergo surgery for their cancer, particularly those with more aggressive disease, of minority race/ethnicity and lower socioeconomic status. Despite its known benefits, RT was significantly underused. This study provides one of the first benchmarks of survival outcomes for patients who do not undergo surgery for breast cancer, and highlights a potential role for increased use of RT. Additionally this report highlights significant disparities effecting women of minority race/ethnicity and lower socioeconomic status.

Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but many patients do not undergo surgery. Evidence is limited regarding this population. We sought to assess factors associated with lack of surgery and overall survival (OS) in patients not receiving breast cancer surgery. Retrospective cohort study of patients in the US National Cancer Database treated in 2004–2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Chi-square and Wilcoxon rank-sum tests were used to assess differences between groups. OS was analyzed using the Kaplan–Meier method with a Cox proportional hazards model performed to assess associated factors. In total 50,626 (4.3%) did not undergo surgery. Black race, age >50 years, lower income, uninsured or public insurance, and lower education were more prevalent in the non-surgical cohort; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for the non-surgical patients was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 (no-chemo) months) and RT (85 vs 56 (no-RT) months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype, treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with triple negative (HR 0.66, 95% CI 0.59–0.75, P + (HR 0.74, 95% CI 0.65–0.84, P + (HR 0.72, 95% CI 0.64–0.82, P 60) (HR 0.61, 95% CI 0.45–0.83, P = 0.002) subgroups. Approximately 4% of women with breast cancer do not undergo surgery, particularly those with more aggressive disease and lower socioeconomic status. Despite its benefits, RT was underutilized. This study provides a benchmark of survival outcomes for patients who do not undergo surgery and highlights a potential role for use of RT.

Context Minority patients receive more aggressive and potentially suboptimal care at the end of life (EOL). We investigated preferences about pharmacologic interventions at the EOL and their potential variation by sociodemographic factors among recently diagnosed cancer patients. Methods A population-based cross-sectional survey of cancer patients identified through the Texas Cancer registry was conducted using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about potential pharmacologic interventions at the EOL were the focus of this investigation. Inverse probability weighted multivariate analysis examined associations of sociodemographic characteristics, health literacy, and trust in medical professionals with pharmacologic preferences. Results Of the 1480 included responses, 13.3% stated they would take a medication that may prolong life at the cost of feeling worse. Adjusted analyses showed Black or Hispanic race/ethnicity, living with another person, and having a higher trust score were more likely to express this preference. In contrast, 41–65 years (vs. 21–40 years), living in a rural area, and adequate or unknown health literacy were less likely to express this preference. Overall 16% of respondents were opposed to potentially life shortening palliative drugs. In adjusted analysis Black or Hispanic respondents were more likely to be opposed to potentially life shortening drugs although age 65–79 and ≥college education were associated with a decreased likelihood of opposition to this item. Conclusion Black and Hispanic cancer patients were more likely to express preferences toward more aggressive EOL pharmacologic care. These findings were independent of other sociodemographic characteristics, health literacy and trust in the medical profession.

Postoperative radiation therapy (PORT) for non-small-cell lung cancer remains controversial with studies showing no overall survival (OS) benefit in the setting of excessive cardiopulmonary toxicity. Proton beam therapy (PBT) can potentially reduce toxicity with improved organ-at-risk sparing. We evaluated outcomes of PORT patients treated with PBT and intensity-modulated radiation therapy (IMRT).This is a retrospective review of 136 PORT patients (61 PBT, 75 IMRT) treated from 2003 to 2016. A Kaplan-Meier analysis was performed to assess oncologic outcomes. A Cox regression was conducted to identify associated factors. Total toxicity burden (TTB) was defined as grade ≥ 2 pneumonitis, cardiac, or esophageal toxicity.Median OS was 76 and 46 months for PBT and IMRT with corresponding 1- and 5-year OS of 85.3%, 50.9% and 89.3%, 37.2% (P = .38), respectively. V30 Gy heart (odds ratio [OR], 144.9; 95% confidence interval [CI], 2.91-7214; P = .013) and V5 Gy lung (OR, 15.8; 95% CI, 1.22-202.7; P = .03) were predictive of OS. Organ-at-risk sparing was improved with PBT versus IMRT; mean heart 2.0 versus 7.4 Gy (P.01), V30 Gy heart 2.6% versus 10.7% (P.01), mean lung 7.9 versus 10.4 Gy (P = .042), V5 Gy lung 23.4% versus 42.1% (P.01), and V10 Gy lung 20.4% versus 29.6% (P.01). TTB was reduced with PBT (OR, 0.35; 95% CI, 0.15-0.83; P = .017). Rates of cardiac toxicity were 14.7% IMRT and 4.9% PBT (P = .09). Rates of ≥ grade 2 pneumonitis were 17.0% IMRT and 4.9% PBT (P = .104).PBT improved cardiac and lung sparing and reduced toxicity compared with IMRT. Considering the impact of cardiopulmonary toxicity on PORT outcomes, PBT warrants prospective evaluation.

Although intensity-modulated radiation therapy (IMPT) is dosimetrically superior to passive scattering proton therapy (PSPT) for locally advanced non-small cell lung cancer (LA-NSCLC), direct comparisons of clinical outcomes are lacking. Here, we compare toxicity profiles and clinical outcomes after IMPT vs. PSPT for LA-NSCLC.This is a non-randomized, comparative study of two independent cohorts with LA-NSCLC (stage II-IIIB, stage IV with solitary brain metastasis) treated with concurrent chemotherapy and proton beam therapy. Toxicity (CTCAE v4.0) and outcomes were prospectively collected as part of a clinical trial (NCT00915005) or prospective registry (NCT00991094).Of 139 patients, 86 (62%) received PSPT and 53 (38%) IMPT; median follow-up times were 23.9 and 29.0 months, respectively. IMPT delivered lower mean radiation doses to the lungs (PSPT 16.0Gy vs. IMPT 13.0Gy, P0.001), heart (10.7Gy vs. 6.6Gy, P = 0.004) and esophagus (27.4Gy vs. 21.8Gy, P = 0.005). Consequently, the IMPT cohort had lower rates of grade ≥3 pulmonary (17% vs. 2%, P=0.005) and cardiac (11% vs. 0%, P = 0.01) toxicities. Six (7%) PSPT patients and 0 (0%) IMPT patients experienced grade 4 or 5 toxicity. Lower rates of pulmonary (28% vs. 3%, P = 0.006) and cardiac (14% vs. 0%, P = 0.05) toxicities were observed in the IMPT cohort even after propensity score matching for baseline imbalances. There was also a trend toward longer median overall survival in the IMPT group (23.9 months vs. 36.2 months, P = 0.09). No difference was found in 3-year rates of local (25% vs. 20%, P = 0.44), local-regional (29% vs. 36%, P = 0.56) and distant (52% vs. 51%, P = 0.71) recurrences.IMPT is associated with lower radiation doses to the lung, heart and esophagus, and lower rates of grade ≥3 cardiopulmonary toxicity; additional clinical studies will be needed to assess potential differences in survival between the two techniques.

Background Context The current standard of care for prediction of survival of cancer staging is based on TNM staging. However, for patients with spinal metastasis, who all have identical stage IV disease, identifying accurate prognostic markers of survival would allow better treatment stratification between more aggressive treatment strategies or palliation. Analytical morphometrics enables physicians to quantify patient frailty by measuring lean muscle mass. Morphometrics also predicts survival in patients with lung cancer metastases to the spine. Purpose Our study evaluates whether morphometrics is predictive of survival in patients with breast cancer spinal metastasis. Design This is an observational retrospective cohort study. Patient Sample This study includes female patients with breast cancer spinal metastases and patients who have undergone stereotactic body radiation therapy. Outcome Measures Overall survival was the primary outcome measure. Methods Morphometric measurements of the psoas muscle were taken using computed tomography scans of the lumbar spine. We then stratified patients into tertiles based on the psoas muscle area. Results We identified 118 patients, with a median survival of 104 days (95% confidence interval [CI]=73–157 days). Overall survival was not associated with age, chemotherapy, or number of levels radiated. Patients in the lowest tertile of psoas size had significantly shorter survival compared with the highest tertile (68 days versus 148 days, hazard ratio 1.76 [95% CI=1.08–2.89], p=.024). The shorter survival was also true for the lowest tertile versus the middle tertile (68 days versus 167 days, hazard ratio 1.95 [95% CI=1.19–3.19], p=.007). Kaplan-Meier survival curves were used to visually illustrate the differences in survival between different tertiles. Conclusions Morphometric analysis of the psoas muscle size in patients with breast cancer metastases to the spine was effective in identifying patients at risk of shorter survival. Further research is needed to validate these results, as well as to see if these methodologies can be applied to other cancer histologies.

BACKGROUND The role of adjuvant radiation after gross total resection (GTR) for grade II meningioma is evolving, prompting further evaluation in NRG-BN003, a phase 3 national trial. Furthermore, the relationship between facility volume and outcomes in patients with grade II meningioma after GTR has not been examined at a national level. We aim to assess overall survival (OS) of patients with grade II meningioma after GTR by surgical case volume and OS by receipt of adjuvant radiation. METHODS We used the National Cancer Database to identity 2823 patients diagnosed with grade II meningioma who underwent GTR. Propensity score matching was applied to balance covariates in patients with grade II meningioma after GTR stratified by adjuvant radiation status. Multivariable logistic regression was used to assess factors associated with radiation receipt. Kaplan-Meier and log-rank tests were used to assess OS by facility volume. RESULTS As facility volume increased, OS increased, with a 5-year OS of 72.8% for facilities with GTR grade II meningioma volumes of ≤8 cases per decade and 87.5% for >8 cases per decade (P < 0.0001). There was no difference in 5-year OS between GTR alone and GTR with adjuvant radiation (84.8% vs. 86.4%; P = 0.151). Covariates significantly associated with radiation receipt included facility location, facility volume, distance, and tumor size. CONCLUSIONS Treatment at higher surgical case volume facilities is associated with improved OS for GTR grade II meningioma. These facilities also have more patients receiving adjuvant radiation. However, we observed no difference in OS between adjuvant radiation and surgery alone.

Benign tumors of the spine pose unique challenges as they are typically located in proximity to the spinal cord and are relatively radio-resistant. Surgery is usually the first line of treatment, but recurrence can be common. Stereotactic radiosurgery (SRS) is an effective treatment for malignant spine lesions. However, patients with benign tumors generally have longer life expectancies and may develop long-term treatment side-effects. Our institutional experience in treating benign tumors with SRS is presented to display its utility for symptom and local control. A retrospective cohort analysis was performed at a single institution between 2001 and 2013. A total of 26 patients (61 vertebral levels) with benign spine tumors were treated. Electronic medical records were queried for clinical, neurological, and radiological examinations. Post-treatment pain, neurological, and radiographic control were the primary endpoints of this study. Five patients (19.2%) were deceased with a median survival time of 16.9 months. Follow-up to evaluate pain response was available for 23 (88%), neurological for 20 (77%), and radiographic for 23 patients (88%). Median follow-up time was 15.5 months. Total pain response was 82.6%. Neurological improvement and radiographic control were noted in 75 and 87% of patients. One case of radionecrosis of the sacrum and one case of axillary numbness were observed. The results of SRS for benign tumors of the spine appear to be promising, and as a result SRS may have a role in treating benign spinal tumors for patients who are not surgical candidates.

Purpose/objective(s) Given the relative radioresistance of sarcomas and their often large size, conventional palliative radiation therapy (RT) provides limited tumor control and poor symptom relief. In select patients that warranted dose-escalated treatment, we have used hypofractionated (HF) RT as a strategy to affect durable control of targeted lesions. We evaluated this treatment approach in a sarcoma cohort. Materials/methods We retrospectively reviewed 73 consecutive patients with sarcoma who received > 10 fractions of HFRT from 2017-2020. Clinical scenarios included: 1) palliative intent (34%), 2) an unresectable primary (27%), 3) or oligometastatic (16%) or 4) oligoprogressive (23%) disease. Results The median follow-up was 9 months (m) (interquartile range [IQR] 5-13). The HFRT target was a primary tumor in 64% of patients. Most tumors were of soft tissue origin (73%) and the median target size was 7cm (IQR 4-12). Prior to HFRT, most tumors were radiographically progressing (77%). The median HFRT dose to the GTV was 45 Gy (IQR 42-45) over a median of 15 once daily fractions with 59% of patients receiving ≥45 Gy. For 27% of cases, heterogeneity of dose was planned to increase the central tumor to a median of 52.5 Gy (IQR 48-52.5). The 1-year DSS was 59%, which was more favorable for patients receiving HFRT for oligometastatic (1-y 100%) or oligoprogressive (1-y 73%) disease (P = 0.001). The 1-y targeted lesional control (TLC) was 73% with 26% developing progression at a median time of 7.5 m (IQR, 5.5-13). A metastatic target (1-y 95% vs 60% primary, P = 0.02; HR 0.27, P = 0.04) and soft tissue origin (1-y 78% vs 61% bone, P = 0.01; HR 0.33, P = 0.02) were associated with better TLC on univariate and multivariable analyses. The rate of distant failure was high with a 6-month DMFS of only 43%. HFRT use for unresectable (P Conclusion HFRT is an effective treatment strategy for patients with unresectable or metastatic sarcoma to provide durable TLC, symptom relief, and meaningful systemic therapy breaks with limited toxicity. Patients with unresectable or oligo-metastatic/progressive disease benefited from longer systemic therapy breaks and lower rates of distant relapse. If overall disease control is the primary goal for HFRT, patient selection remains crucial as distant relapse is high.

The aim of this retrospective analysis is to evaluate the role of stereotactic radiosurgery (SRS) in treating multiple myeloma (MM) of the spine. Medical records of MM patients who underwent single fraction spine SRS between 6/2001 and 12/2014 at our institution were retrospectively reviewed in this institutional review board-approved analysis. Post-treatment radiographic, neurologic, and pain response were the primary endpoints. Endpoints were evaluated with periodic clinical exams and imaging studies (magnetic resonance imaging and computed tomography). Median SRS dose was 16 Gy (10–18) in a single fraction. Seventy-eight patients (121 treatment sites) were treated. Clinical follow-up was available for 71 patients. Radiographic follow-up was available for 94 treatment sites. Median follow-up was 27.8 months (24 days–12.1 years). Radiographic control was observed in 89.4% of the treated sites. Pain relief occurred in 88.3% of the patients that presented with pain; pain progression occurred in 3.3%. Neurological improvement was observed in 63.6% of the patients that presented with a deficit. In sites where MM approached or compressed the epidural canal or the thecal sac, after SRS, evidence of radiographic regression was observed in 87.1%. Toxicities observed included one patient who experienced a tracheoesophageal fistula 2 years after SRS. After SRS, there were 39 VCFs that were potentially SRS-induced. SRS appears to be effective in the treatment of MM of the spine. To the best of our knowledge, this is the largest such experience reported.

Purpose To determine the potential benefits and adverse effects associated with reirradiating the spinal cord when at least 1 course of radiation therapy (RT) is stereotactic radiosurgery (SRS). Methods and materials This institutional review board–approved retrospective review included 162 patients (237 reirradiated spine lesions). All patients received SRS at our institution between 2001 and 2013. Electronic medical records were reviewed for clinical exams and radiologic tests (computed tomography/magnetic resonance imaging). Primary endpoints were pain, neurological, radiographic responses, and the development of adverse effects. Results A total of 120 patients (74.1%) were deceased with a median survival of 13 months. Time between courses of RT was a median of 10.2 months. Median SRS dose was 16 Gy in 1 fraction, whereas the median conventional external beam radiation therapy (cEBRT) dose was 30 Gy in 10 fractions. The median tumor equivalent dose in 2-Gy fractions (EQD2) for SRS doses was 34.7 Gy, whereas the median tumor EQD2 for cEBRT was 32.5 Gy, providing a median total tumor EQD2 of 69.3 Gy (22-145.6 Gy). The median critical nervous tissue EQD2 for SRS and cEBRT was 56 Gy and 37.5 Gy, respectively, resulting in a median total critical nervous tissue EQD2 of 93.5 Gy. Overall pain, neurological, and radiographic response rates were 81%, 82%, and 71%, respectively. Adverse effects occurred in 11 (6.8%) patients. Seventy-seven vertebral compression fractures were observed, 22 (9.3%) of which may be attributed to RT. Conclusions Our results demonstrate that reirradiation achieves favorable response rates with minimal toxicity if recommended dose constraints to the spinal cord with SRS are carefully observed. To the best of our knowledge, this is the largest reported single-institution experience analyzing the efficacy and toxicity of reirradiation of the spine when at least 1 course of RT is stereotactic radiosurgery.

Purpose To determine our institutional vertebral compression fracture (VCF) rate after spine stereotactic radiosurgery (SRS) and determine contributory factors. Methods and Materials Retrospective analysis from 2001 to 2013 at a single institution was performed. With institutional review board approval, electronic medical records of 1905 vertebral bodies from 791 patients who were treated with SRS for the management of primary or metastatic spinal lesions were reviewed. A total of 448 patients (1070 vertebral bodies) with adequate follow-up imaging studies available were analyzed. Doses ranging from 10 Gy in 1 fraction to 60 Gy in 5 fractions were delivered. Computed tomography and magnetic resonance imaging were used to evaluate the primary endpoints of this study: development of a new VCF, progression of an existing VCF, and requirement of stabilization surgery after SRS. Results A total of 127 VCFs (11.9%; 95% confidence interval [CI] 9.5%-14.2%) in 97 patients were potentially SRS induced: 46 (36%) were de novo, 44 (35%) VCFs progressed, and 37 (29%) required stabilization surgery after SRS. Our rate for radiologic VCF development/progression (excluding patients who underwent surgery) was 8.4%. Upon further exclusion of patients with hematologic malignancies the VCF rate was 7.6%. In the univariate analyses, females (hazard ratio [HR] 1.54, 95% CI 1.01-2.33, P =.04), prior VCF (HR 1.99, 95% CI 1.30-3.06, P =.001), primary hematologic malignancies (HR 2.68, 95% CI 1.68-4.28, P P =.02), and lytic lesions had a significantly increased risk for VCF after SRS. On multivariate analyses, prior VCF and lesion type remained contributory. Conclusions Single-fraction SRS doses of 16 to 18 Gy to the spine seem to be associated with a low rate of VCFs. To the best of our knowledge, this is the largest reported experience analyzing SRS-induced VCFs, with one of the lowest event rates reported.

PURPOSE: Several treatment options for spinal metastases exist, including multiple radiation therapy (RT) techniques: three-dimensional (3D) conventional RT (3D-RT), intensity-modulated RT (IMRT), and spine stereotactic radiosurgery (SSRS). Although data exist regarding reimbursement differences across regimens, differences in provider care delivery costs have yet to be evaluated. We quantified institutional costs associated with RT for spinal metastases, using a time-driven activity-based costing model. METHODS: Comparisons were made between (1) 10-fraction 3D-RT to 30 Gy, (2) 10-fraction IMRT to 30 Gy, (3) 3-fraction SSRS (SSRS-3) to 27 Gy, and (4) single-fraction SSRS (SSRS-1) to 18 Gy. Process maps were developed from consultation through follow-up 30 days post-treatment. Process times were determined through panel interviews, and personnel costs were extracted from institutional salary data. The capacity cost rate was determined for each resource, then multiplied by activity time to calculate costs, which were summed to determine total cost. RESULTS: Full-cycle costs of SSRS-1 were 17% lower and 17% higher compared with IMRT and 3D-RT, respectively. Full-cycle costs for SSRS-3 were only 1% greater than 10-fraction IMRT. Technical costs for IMRT were 50% and 77% more than SSRS-3 and SSRS-1. In contrast, personnel costs were 3% and 28% higher for SSRS-1 than IMRT and 3D-RT, respectively ( P < .001). CONCLUSIONS: Resource utilization varies significantly among treatment options. By quantifying provider care delivery costs, this analysis supports the institutional resource efficiency of SSRS-1. Incorporating clinical outcomes with such resource and cost data will provide additional insight into the highest value modalities and may inform alternative payment models, operational workflows, and institutional resource allocation.

OBJECTIVEPatients with metastatic thyroid cancer have prolonged survival compared to those with other primary tumors. The spine is the most common site of osseous involvement in cases of metastatic thyroid cancer. As a result, obtaining durable local control (LC) in the spine is crucial. This study aimed to evaluate the efficacy of spine stereotactic radiosurgery (SSRS) in patients with metastatic thyroid cancer.METHODSInformation on patients with metastatic thyroid cancer treated with SSRS for spinal metastases was retrospectively evaluated. SSRS was delivered with a simultaneous integrated boost technique using single- or multiple-fraction treatments. LC, defined as stable or reduced disease volume, was evaluated by examining posttreatment MRI, CT, and PET studies.RESULTSA total of 133 lesions were treated in 67 patients. The median follow-up duration was 31 months. Dose regimens for SSRS included 18 Gy in 1 fraction, 27 Gy in 3 fractions, and 30 Gy in 5 fractions. The histology distribution was 36% follicular, 33% papillary, 15% medullary, 13% Hurthle cell, and 3% anaplastic. The 1-, 2-, and 5-year LC rates were 96%, 89%, and 82%, respectively. The median overall survival (OS) was 43 months, with 1-, 2-, and 5-year survival rates of 86%, 74%, and 44%, respectively. There was no correlation between the absolute biological equivalent dose (BED) and OS or LC. Patients with effective LC had a trend toward improved OS when compared to patients who had local failure: 68 versus 28 months (p = 0.07). In terms of toxicity, 5 vertebral compression fractures (2.8%) occurred, and only 1 case (0.6%) of greater than or equal to grade 3 toxicity (esophageal stenosis) was reported.CONCLUSIONSSSRS is a safe and effective treatment option with excellent LC and minimal toxicity for patients with metastatic thyroid cancer. No association with increased radiation dose or BED was found, suggesting that such patients can be effectively treated with reduced dose regimens.

This survey study compares use of prophylactic cranial irradiation in patients with extensive-stage small cell lung cancer before and after the publication of a phase 3 trial that demonstrated no overall survival benefit for this therapy.

The purpose of this study was to evaluate the role of stereotactic radiosurgery in the treatment of primary tumors of the spine and spinal cord.An Institutional Review Board approved retrospective analysis of 30 patients with primary spine tumors treated at a single institution was performed. Post-treatment pain, neurological, and radiographic responses were the endpoints.Nine patients were treated for benign tumors, and 21 patients were treated for malignant tumors. The median dose delivered was 16 Gy in one fraction. Median follow up was 13.13 months (range, 1 month-84 months). Pain relief was 88% initially. Pain recurred in five patients with a median time to recurrence of 5 months (range, 3.6 months - 80 months). Neurological improvement was achieved in 65% of patients. Three patients experienced a recurrence in their neurological deficit (at 3.6 months, 1.6 years, and 3.7 years after SRS). Radiographic control was achieved in 77% of sites treated with SRS. Thirteen of the treated sites recurred with a median time of 9.9 months. Two long-term toxicities were observed (asymptomatic radio-necrosis of the erector spinae muscle and foot drop).Our results suggest that SRS is a safe and effective treatment option for primary tumors of the spine and spinal cord.

Background Surgery for spinal metastases can improve survival but has high morbidity that can potentially diminish benefits. New objective methods of predicting overall survival would be beneficial for surgical decision making. Morphometrics quantifies patient frailty and has been successfully used to predict overall survival in patients with lung cancer spinal metastases. This study evaluated whether morphometrics can predict survival in patients with prostate cancer spinal metastases. Methods Using a retrospective registry of patients with spinal metastases who underwent stereotactic body radiation therapy, we identified patients with primary prostate cancer. Morphometric measurements of the psoas muscle were taken from most recent lumbar spine computed tomography. Patients were stratified into lowest, middle, and highest tertiles based on psoas muscle area. Primary outcome measure was overall survival from the date of computed tomography scan. Results We identified 92 patients. Median survival for all patients was 124 days (95% confidence interval, 98–197 days). Patients in the smallest third for average psoas size had significantly shorter survival compared with patients in the largest third: 117 days versus 302 days (hazard ratio 2.42; 95% confidence interval, 1.32–4.43; P = 0.004). Patients in the middle third for average psoas size also had shorter survival compared with patients in the largest third: 113 days versus 302 days (hazard ratio 2.31; 95% confidence interval, 1.25–4.25; P = 0.007). Conclusions In patients with prostate cancer spinal metastases, morphometric analysis of psoas muscle size can identify patients at risk for shorter survival. This technique can aid in surgical decision making by weighing expected survival and fitness versus potential morbidity of intervention.