A Cancer Care Ontario Organizational Guideline for the Delivery of Stereotactic Radiosurgery for Brain Metastasis in Ontario, Canada

Abstract In Ontario, Canada there is increasing demand for Stereotactic Radiosurgery (SRS) for brain metastases. Recommendations for safe SRS delivery are needed to ensure that patients receive an equitable level of care across the province. This Guideline presents the minimal recommendations for the organization and delivery of SRS with respect to the multidisciplinary team, applicable technologies, imaging requirements, quality assurance (QA) program and patient follow-up. The recommendations are based on the consensus opinion of the Cancer Care Ontario SRS for Brain Metastasis Guideline Development Group, and clinical evidence when available. Primary consideration was given to the perceived benefits for patients and the small likelihood of harm arising from recommendation implementation. With the exception of the MRI follow-up strategy, all evidence was considered indirect, and was provided by the Working Group in conjunction with their collective expertise in the field of SRS. The application of SRS requires a multidisciplinary team consisting of a radiation oncologist, neurosurgeon, neuroradiologist, medical physicist, radiation therapist and/or medical dosimitrist. Volumetric imaging scanning parameters must be set to ensure sufficient spatial resolution, geometric fidelity and contrast signal for brain metastases to be adequately and reliably visualized, contoured and planned. The magnetic resonance imaging (MRI) to treatment time interval should be as short as possible, ideally no more than seven and certainly no more than 14 days as a maximum. QA programs must ensure that the treatment unit is in compliance with the manufacturer, as well as national and international guidelines. Follow-up of SRS patients should consist of routine clinical visits with an MRI every 2-3 months for the first year; every 3-4 months for the second and third year; and, thereafter, as determined by the MCC. The recommendations enclosed provide a framework for the minimum requirements for a cancer centre in Ontario, Canada to offer SRS for brain metastases.