Clinical study Trends in the initial management of vestibular schwannoma in the United States Janet Leon a , Daniel M. Trifiletti a,b,⇑ , Mark R. Waddle a , Laura Vallow a , Stephen Ko a , Byron May a , Katherine Tzou a , Henry Ruiz-Garcia a , Larry Lundy c , Kaisorn Chaichana b , Prasanna Vibhute d , Jennifer L. Peterson a,b a Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA b Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA c Department of Otolaryngology, Mayo Clinic, Jacksonville, FL, USA d Department of Radiology, Mayo Clinic, Jacksonville, FL, USA article info Article history: Received 12 April 2019 Accepted 5 July 2019 Available online xxxx Keywords: Acoustic neuroma Vestibular schwannoma NCDB abstract Introduction: Vestibular schwannomas are benign tumors of the 8th cranial nerve. Initial treatment options include active surveillance, surgery, and/or radiation therapy. We analyzed the United States National Cancer Database (NCDB) for patients with vestibular schwannomas and evaluated the initial management trends after diagnosis. Methods: We queried the NCDB for patients with vestibular schwannomas, excluding patients who did not have schwannomas of the vestibulocochlear nerve. Categorical and continuous variables were ana- lyzed, and multivariate Cox regression analyses were performed to investigate for predictors of initial local therapy at diagnosis. All statistical analyses were performed using commercially available software (SPSS, Version 22; SPSS Inc., Chicago, IL). Results: A total of 28,446 patients met the inclusion criteria. In this cohort, 7351 (25.8%) underwent observation, 12,362 (43.5%) underwent surgical resection, 7785 (27.4%) underwent SRS, 824 (2.9%) underwent EBRT, and 124 (0.4%) underwent RT NOS. On multivariate analysis, younger age, increased distance to treating facility, Charlson/Deyo score of 1, primary payer insurance, facility location and facil- ity type (academic or cancer center) (p < 0.001) were all factors that predicted patients undergoing initial definitive treatment. Conclusion: Age, distance to treating facility, Charlson/Deyo score, primary payer, facility location, and facility type are factors that influence initial treatment for patients with vestibular schwannoma. Clinical stratification systems are needed to identify which patients would benefit most from initial local therapy versus active surveillance. Ó 2019 Elsevier Ltd. All rights reserved. 1. Introduction Vestibular schwannomas (VS) are benign tumors of the eighth cranial nerve. They make up about 8% of brain tumors and are found in 1 in 100,000 persons per year. This number has steadily increased over the years likely due to the increased frequency of radiographic imaging for other causes [1]. Although benign, vestibular schwannomas can impact quality of life. These tumors can cause hearing loss, tinnitus, imbalance, facial paralysis, facial paresthesia, and large vestibular schwanno- mas can exert mass effect on the brainstem and cerebellar pedun- cle, causing other major issues. There are currently three main approaches for managing newly diagnosed VS. Current data supports active surveillance as a rea- sonable option for many newly diagnosed VS patients in order to delay or avoid unnecessary risks associated with treatment [2]. Surgical resection has been a long standing option for vestibular schwannoma patients. VS surgery, like any surgery, has risks, including the risk of damage to nearby critical structures such as the facial nerve. Patients with larger tumors are more likely to undergo surgery and often benefit from this approach by decreas- ing the mass effect on the surrounding brainstem and critical structures [3]. The third approach for vestibular schwannomas involves radiation, most commonly in the form of radiosurgery. https://doi.org/10.1016/j.jocn.2019.07.002 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved. ⇑ Corresponding author at: Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA. E-mail address: trifiletti.daniel@mayo.edu (D.M. Trifiletti). Journal of Clinical Neuroscience xxx (xxxx) xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article as: J. Leon, D. M. Trifiletti, M. R. Waddle et al., Trends in the initial management of vestibular schwannoma in the United States, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.002