Do you routinely offer spine SBRT for vertebral metastases regardless of overall patient disease burden or response?

I presume this will be controversial, but I tend to offer SBRT if feasible for palliation of pain from bone metastases. We have two positive studies (MDACC for non-spine, Canadian for spine) and one negative study. In addition, these are just 1-2 treatments. Billing becomes an issue, as I’ve continually battled Evicore on this, and the reviewer typically says there is not enough data or that it is experimental. This is an odd position to take, as there are treatments with far less robust data or no data at all that are easily approved. If the indication is pain control, the balance of the data leans towards a benefit for SBRT, so I do offer it routinely. I also do prior auth, and our company approves it. Interestingly, countries that are no...

For me, the volume of disease and progression affects the decision of whether or not to use SBRT.

For example, if someone is effectively pre-terminal from systemic disease, I'm not going to make them come back for an MRI, and bill them for an SBRT sim, image fusion, etc. Rather, the same day as their consult, we could do a simple CT sim and treat them with 800 in 1 that day (or bring them back at their convenience) and be done. If their performance remains stable and their pain progresses at a later date, we could SBRT them then. In some situations, the extra burdens (including financial) an SBRT plan places on the patient outweigh the benefits it provides them.

OTOH, for most people whose spine disease is appropriate for SBRT who appear st...