Driving safety in patients with primary brain tumours and brain metastases in Canada: a scoping review

Introduction

Background

Driving demands a complex coordination between cognitive, sensory, motor, and visual functions. Patients diagnosed with primary brain tumours or brain metastases often experience neurological impairments, including cognitive decline, seizures, and motor deficits, that can compromise their ability to drive safely. Beyond clinical symptoms, these diagnoses are often aggressive and incurable, with implications for both safety and quality of life. Distinct from other neurologic conditions such as stroke, neurologic function in this population is often dynamic, introducing distinct challenges in the assessment of driving fitness and risk over time. Driving restrictions can profoundly impact patient independence, particularly within palliative care settings where ensuring quality of life is a priority (1). Determining fitness to drive in these patients poses a complex clinical challenge, requiring physicians to balance medical risk, patient well-being, and road safety.

Canada observed a total of 89,982 reported motor vehicle crashes, including drivers, motorcyclists, and bicyclists, that resulted in an injury in 2023 (2). A further 1,768 collisions were classified as fatal (2). In providing care for patients with brain tumours, physicians play a vital role in determining their ability to drive and ensuring their safety on the road based on careful assessments.

Rationale and knowledge gap

While there are clear driving restrictions for conditions such as seizures, there are no standardized national guidelines in Canada specific to patients with brain tumours. Provincial guidelines mirror this gap, largely deferring to the decision of the treating physician, and in certain cases, a review by the driving safety panel. As a result, recommendations vary across provinces and even among clinicians within the same institution. There is a scarcity of literature on driving outcomes in this population, further complicating evidence-based decision-making.

Objective

The purpose of this paper was to examine current literature on determinants of driving safety and guidance for driving regulations among patients with primary or metastatic brain tumours. Particular attention was given to how these guidelines address the dual priorities of maintaining road safety and protecting patient autonomy, especially within palliative care contexts. We further reviewed provincial and international guidelines to provide context for developing Canadian policies and propose potential clinical approaches to assessing driving fitness in this vulnerable patient group. We present this article in accordance with the PRISMA-ScR reporting checklist (3) (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-136/rc).

Methods

Eligibility criteria

Scientific articles published in international peer-reviewed journals, referring to (I) driving performance, licensing outcomes, or fitness-to-drive assessments in patients with brain tumour; (II) guidelines or policies about driving for patients with brain tumour; (III) clinical outcomes linked to driving restrictions (e.g., quality of life, functional independence), were considered, limited to English language and independently of publication date. Excluded sources included books and book chapters, opinion-based articles, conference abstracts, and news articles.

Information sources and search strategy

We used Medical Subject Headings (MeSH) and free texts related to “brain cancer”, “brain neoplasms”, “driving”, and “automobile safety”, to perform an initial literature search on PubMed. In collaboration with a librarian at the University of British Columbia, we optimized the search strategy and ran our search on Medline and American Psychological Association (APA) Psychinfo. The full search strategy and the keywords used in APA Psychinfo are reported in Table S1. We also included the first 25 articles on Google Scholar sorted by relevance, based on our search terms. In addition to the published literature, we reviewed existing Canadian provincial driving guidelines for tumour-specific recommendations and, if present, the extent of detail provided. Studies that contained the search terms used but were not specifically related to driving safety for those with brain tumours were excluded. Study selection and screening were conducted by two authors, K.N. and J.O., who independently reviewed the titles and abstracts of all records identified in the search and entered them into a Microsoft Excel document. This document was used to compile database hits for each article, remove duplicate records, and assess preliminary eligibility. Full-text versions of potentially relevant articles were then reviewed independently to determine compliance with the inclusion and exclusion criteria. The search was performed from database inception to April 1, 2025. Consistent with the methodology of a scoping review, the methodological quality of the included studies was not assessed (4).

Data extraction

Data extracted from included studies comprised study characteristics (author, year, study period and location, objective, study design), methodological details (survey or data collection methods, sample size, response rate, variables assessed, statistical analyses), and reported outcomes relevant to driving safety in patients with brain tumours. Data was extracted and reviewed by two authors (K.N. and J.O.).

Results

The literature search identified 175 articles of which 5 were duplicates and removed. The abstracts and titles of the remaining 170 articles were screened after which 154 articles were found to be irrelevant to the study topic. Full-text reviews were conducted for the remaining 16 articles. Two articles were excluded for not including patients with brain tumours and one article was only available as a conference abstract. The screening process is presented in the PRISMA flow diagram (Figure 1) (5). In total, 13 articles were included and assessed in this study (Table 1).

Figure 1 Selection process PRISMA flow diagram (5). APA, American Psychological Association.

Risk of driving post-tumour diagnosis

A systematic review by Tran et al. (in 2024) found only three observational studies that directly examined motor vehicle collisions (MVCs) among patients with brain tumour (17). The findings were mixed with one retrospective study showing no significant increase in crash rates, and while the simulation-based studies reported increased speed exceedances and performance differences in the domains of memory and visual attention, there was no overall significant difference in MVC rates (17).

While empirical data on MVCs in patients with brain tumour is limited, several studies emphasize that cognitive and visual impairments, even in the absence of overt neurological symptoms, can impair driving safety. In a cohort of patients with primary brain tumours, Estevis et al. (in 2019) reported that 98% had a Karnofsky Performance Status (KPS) score ≥80, a threshold indicating physician-assessed ability to carry out normal activity with some effort; however, roughly one-third failed the Cognitive Behavioural Driver Inventory (CBDI) despite meeting this functional threshold (9). The CBDI is an off-road assessment battery that helps classify patients as potentially safe, borderline, or unsafe to drive (9). In their study, patients performed variably in speeded visual search and set-shifting, speeded response inhibition, and visual scanning speed, reinforcing that memory and visual attention were particularly important cognitive domains for safe driving (9). Similarly, a self-report study by Mansur et al. (in 2018) found that patients diagnosed with a brain tumour generally did not report deficits in driving capacity, with less than 20% self-restricting driving after their diagnosis, despite almost 40% sustaining at least one MVC (11). Their simulation-based assessments revealed greater speed exceedances and increased speed variability compared with controls (11).

Furthermore, physicians often face challenges in assessing fitness to drive, with many relying on apparent clinical symptoms rather than standardized assessment tools. Chan et al. (in 2013) found that 56% of surveyed physicians reported a lack of assessment tools as a barrier to reporting medically unfit drivers, and the vast majority instead relied on overt clinical symptoms such as seizures and hemiparesis rather than comprehensive, standardized evaluations (6). Similarly, Thomas et al. (in 2011) reported that only 25% of U.S. physicians used formal, standardized tools to assess fitness to drive while most relying on seizure history as the primary clinical determinant (18). A Delphi consensus study by Lapidus et al. (in 2025) involving radiation oncologists, neurosurgeons, and neurologists revealed a strong agreement that a combination of a thorough neurological history, clinical exam, baseline visual field testing, and magnetic resonance imaging (MRI) or computed tomography (CT) scan for radiological stability should form the basis of determining driving fitness (10). Their panel emphasized the importance of continual reassessment using consistent criteria, reporting that over 50% of physicians had previously imposed driving recommendations that overrode clearance from another provider (10).

Across international guidelines, seizure history remains a major determinant of driving eligibility. The Canadian epilepsy guideline generally advises seizure-free periods of 6 months; however, tumour-related seizures are often unpredictable and affected by disease progression and treatments (19). While seizure recurrence in patients with brain tumours require tailored monitoring, the Canadian Medication Association (CMA) Driver’s Guide lacks specific recommendations on tumour-related seizures which may lead to clinical uncertainty (20).

Driving and brain metastases

Compared to primary brain tumours, current literature on the impact of brain metastases on driving is even less robust, reflecting greater heterogeneity in symptoms and disease course. The prognosis of the disease is influenced not only by the lesion size and location, but also by the extracranial burden of disease, central nervous system (CNS)-penetrating systemic treatments, and differences in radiotherapy options including stereotactic radiosurgery and whole-brain radiation therapy.

One identified study in this population was conducted by Valencia-Sanchez et al. (in 2019), who assessed 41 patients with brain metastases to compare the concordance between a typical outpatient neurological examination and a standardized occupational therapy driving assessment (OTDA) (13). The OTDA comprised 10 performance measures spanning visual, cognitive, and motor domains related to driving, with predefined cutoffs used to determine driving fitness. In their study, the concordance between the two assessments was poor, with neurology exam showing low sensitivity (16.1%) but with high specificity (90%) compared to OTDA (13). Most performance differences occurred in the context of patients who were deemed safe by neurologists but failed OTDA, highlighting the limits of in-office neurological exams to fully capture subtle cognitive and visuomotor deficits that impact driving (13). Older age appeared to be a factor affecting OTDA performance and failures most commonly occurred in subtests assessing visual-motor coordination, global cognition, and executive function (13).

Driving restriction in palliative context

Loss of driving privileges emerged as a large source of distress among patients with brain tumours, particularly those in advanced or palliative stages of care. In a qualitative study by Molassiotis et al. (in 2010), patients consistently described the inability to drive as one of the most painful consequences of their illness, often using terms such as “it hurts” and “a kick” to express the emotional impact of losing independence (16). The inability to drive intensified the sense of dependency on others, reinforced feelings of being a burden, and compounded the isolation already caused by fatigue, cognitive decline, and physical limitations (16). Even modest improvements, such as regaining a license or returning to limited driving, were described as regaining “freedom” and “independence”, highlighting how driving may be tied to quality of life in the palliative context (16).

Current practices in Canada

Canada currently lacks standardized, tumour-specific guidelines for assessing driving fitness in patients with brain tumours. The Canadian Medical Association’s Driver’s Guide (20) outlines general recommendations that largely depend on the discretion of the consulting physician following a neurological exam. While it offers guidelines for seizures, it does not seem to offer detailed criteria tailored specifically to brain tumour populations, such as driving cessation periods after each treatment modality, and lacks risk stratification based on tumour type. Our review of provincial driving guidelines also did not identify any that provide detailed, brain tumour-specific recommendations. Instead, most reference Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards for Drivers, which are variably incorporated into individual provincial guidelines across Canada (19). For instance, British Columbia integrates CCMTA guidelines broadly for neurological conditions but offers no explicit thresholds that reflect the complexities of brain tumours, including cognitive impairment, tumour-related seizures, or the side effects of tumour-specific treatments such as radiotherapy and surgery (21).

Jurisdictional differences between provinces further these gaps. Provinces such as Ontario and Manitoba have mandatory physician reporting requirements, and while British Columbia enforces mandatory reporting, it only requires physicians to submit a report when medically unfit patients continue to drive after being warned of the danger (20). Alberta, Nova Scotia, and Quebec allow discretionary reporting which depends on the consulting physician’s assessment of their patient (20). However, previous studies report that physician understanding and compliance vary. A survey of radiation oncologists in Canada revealed that 87% of the respondents felt unclear about provincial reporting criteria for driving, and those from provinces with discretional reporting laws were less likely to submit a report (14). This uncertainty may influence clinical communication practices. In one Canada-based study, documentation of discussions regarding driving safety following tumour-related seizures was absent in 34% of included patients (7).

International driving guidelines

Countries with nationally available guidelines published in English, including Canada, the United Kingdom, and Australia, were examined for comparison (Table 2).

The UK’s Driver and Vehicle Licensing Agency (DVLA) offers detailed guidance for patients with brain tumour, highlighting clear timelines and recommendations that vary by tumour type, grade, and treatment modality. For low-grade gliomas, patients can resume driving one year following treatment, while those with high-grade gliomas are generally cleared for driving 2 years after the primary treatment (22). These recommendations are further subdivided into the type of treatment, with patients undergoing radiotherapy or immunotherapy requiring shorter cessation intervals if determined clinically stable (22). Patients with benign tumours are restricted from driving depending on treatment modality where they are cleared of driving 6 months after craniotomy and one month after stereotactic radiosurgery (22). For brain metastases, the standard restriction is 2 years; however, in select cases treated with immunotherapy or targeted therapy, relicensing may be considered after one year if there is no recurrence and radiological stability is confirmed (22).

In contrast, Australia adopts a more individualized approach. The Austroads guidelines recommend physicians to assess driving fitness based on cognitive, visual, and motor impairments as well as seizure history (23). While this model offers clinical flexibility, it places increased responsibility on individual physicians. One symptom for which they offer specific recommendations is seizure history, where driving may be resumed 6 months after the first seizure or after 12 months if involved in an MVC (23). The remaining criteria depends largely on physician assessment of cognitive, visuospatial, and motor function. A scenario-based study by Chin et al. (in 2004) showed an overall poor consistency in driving advice among surveyed Australian physicians where 73.1% of the respondents were unaware of the current driving guidelines (8). Among respondents who were aware of the guidelines, 67.7% felt the need for a more tailored, tumour-specific criteria (8).

Discussion

To the author’s knowledge, this scoping review represents the first synthesis of evidence on driving safety in patients with brain tumours that situates existing data within Canadian clinical practice. Across 13 eligible studies, driving-related risk was most commonly identified through deficits in attention, executive function, and visuomotor coordination using simulation-based testing or standardized driving assessments (9,11,17). These deficits may not be adequately captured by routine neurological examination or performance status measures alone (9,13). Despite the evidence, Canadian driving guidelines largely emphasize seizure history and physician discretion, without clearly defined, brain-tumour specific assessment pathways (19,20). Current Canadian approaches leave physicians without standardized criteria supported by available evidence, contributing to uncertainty and variability in driving recommendations.

The subjectivity involved with making clinical judgements complicates this challenge. In a survey of Ontario physicians, fewer than 10% reported feeling comfortable about judging fitness to drive, with many citing uncertainties around legal responsibilities and guideline interpretation (15). Consistent with these findings, our review of literature reveals that driving recommendations are often guided by overt neurological symptoms, such as seizures or motor deficits, rather than by standardized, driving-specific assessment tools—a pattern also reflected in previous physician surveys (6,18). Together, these findings suggest that both the absence of clearly defined assessment pathways and limited physician awareness of available frameworks create reliance on discretionary judgment. In practice, this may shift decision-making toward individual experience and risk tolerance, contributing to variability in driving recommendations between physicians.

International guidelines offer driving recommendations based on distinct classifications. Austroads adopts a function-first approach in which licensing is based on documented performance in vision, cognition and attention, and motor domains, often using conditional licenses with time-bound reassessment (23). This approach accommodates clinical heterogeneity and can allow earlier return to driving when validated assessments are favourable and seizure risk is controlled. Its limitations resemble current Canadian practice, including the lack of tumour-specific timelines that pushes decisions to individual physicians. The UK DVLA sets tumour- and treatment-specific timelines for non-commercial drivers and applies seizure rules in addition to tumour guidance, with decisions contingent on radiological stability and the absence of disqualifying neurological deficits (22). This model supports structured, diagnosis-specific timelines that enable shared interpretations across physicians.

When considered in the Canadian context, challenges in assessing driving fitness are shaped not only by clinical complexity, but also by the structure of provincial driving regulations. Canadian surveys of physicians involved in neuro-oncology care have shown that provincial reporting requirements are frequently unclear, with many respondents unable to determine whether reporting is mandatory in their province (7,14,15). Notably, the presence of mandatory reporting laws most strongly predicted physician inclination to report, indicating that policy architecture itself may impact reporting behaviours (14). Our review of provincial driving policies reinforces these observations. While most jurisdictions reference the CCMTA Medical Standards for Drivers, implementation varies and none provide detailed, brain tumour-specific guidance beyond seizure-related restrictions and visual requirements (19). Reporting obligations can thus become an important driver of how fitness-to-drive decisions are communicated and enacted, even as physicians continue to weigh clinical factors. This regulatory emphasis may contribute to variations in how similar clinical scenarios are managed across provinces.

Driving restrictions also take on unique ethical and emotional significance in the palliative setting. For many patients with advanced brain tumours, driving can represent independence in accessing medical care and maintaining social, professional, and familial responsibilities. Patients have described the inability to drive as one of the most distressing losses associated with their illness, often equating this to a loss of their autonomy (16). Driving cessation therefore have consequences that extend beyond physical mobility, increasing reliance on others and may even reinforce feelings of social burden and isolation (16,24). In Canada, many patients with advanced disease who live in rural or remote communities must travel long distances to access cancer and palliative services. A previous Canadian study of rural cancer populations highlighted persistent challenges related to travel distance, cost, and access to practical supports (25). Canada has established community programs such as the Canadian Cancer Society’s Wheels of Hope and national travel-assistance initiatives like Hope Air to facilitate access to care, though they are primarily designed for episodic needs rather than addressing the broader mobility challenges (26,27). Ongoing efforts to shift cancer follow-up to local communities through general practitioners and nurse practitioners represent a broader paradigm shift within the Canadian health system toward supporting patients access care closer to home (28,29). Within this context, inclusion of patients with advanced cancer in driving-safety guideline development is essential to ensure that recommendations reflect patient-centered priorities and access to supports.

Given the inconsistency in current Canadian guidelines, adopting a comprehensive, structured framework inspired by international best practices is imperative. Prior studies have proposed multidisciplinary, symptom-based approaches tailored to patients with brain tumours, emphasizing structured assessment across visual, cognitive, and functional domains (10,12). Recommended components include formalized visual field testing, targeted neuropsychological evaluation of key cognitive domains, and standardized driving assessments using on-road testing or advanced simulators (12). In the Canadian context, brain tumour-specific criteria could be developed through a national, interdisciplinary Delphi process and supported by prospective evaluation to ensure clinical relevance and real-world practicability prior to adoption as national standards. Such evaluation would benefit from collaboration with licensing authorities to support quality assurance through outcome measures such as collision or reporting data. While having a robust structure promotes consistency, it is also worthwhile to note that a more flexible guidance may sometimes help preserve the patient-physician relationships by supporting shared decision-making. In the past, RoadSafetyBC has taken initiative to remove licensing decisions away from physicians to minimize potential conflict in the therapeutic relationship. Thus, implementing regular follow-ups incorporating both medical and practical reassessments, as outlined by Mondia et al. (in 2025) and demonstrated internationally, would ensure ongoing safety monitoring and ultimately leading to more transparent decision-making (12,22). In a disease characterized by dynamic progression, fitness to drive should be regarded as inherently time-limited, requiring regular clinical and radiological reassessment rather than indefinite clearance.

Future work in Canada could build on these principles by establishing a national driving safety working group under Canadian Neuro-Oncology Society. This would involve multidisciplinary and multi-provincial representation, including physicians, licensing authorities, rehabilitation specialists, and people living with brain tumours. Targeted surveys of physicians and patients could identify key risk factors, barriers, and feasible strategies for implementing standardized, tumour-specific driving policies across relevant specialties. Complementary population-level data are also needed to define true crash risk among Canadians with brain tumours or metastases, incorporating clinical and geographic factors that reflect the diversity of Canadian practice settings, including rural and remote regions. Collaboration among neuro-oncology societies, provincial medical regulators, and CCMTA will be critical to develop a unified, evidence-informed framework that balances road safety with patient-centered care. Such coordinated efforts would increase the clarity of driving recommendations across provinces, ensuring that decisions are consistent, patient-centered, and reflective of both safety priorities and the realities of living with brain cancer in Canada.

This review has several limitations, including the scarcity of longitudinal and large-scale studies specifically investigating driving outcomes in brain tumor patients, limiting evidence-based recommendations. Variability in international practices and limited empirical data on practical driving evaluations further constrain comprehensive conclusions. One of the key limitations of this work relates to its study design. However, just like a systematic review, scoping reviews offer a structured approach to map existing evidence, summarize and disseminate findings from bibliographic research, and identify gaps within the literature (30). Its use has become particularly common for broad or heterogenous topics, especially when the scope of existing research is unclear (31).

Conclusions

Driving recommendations for patients with primary brain tumours and brain metastases in Canada remain inconsistent, shaped largely by seizure-based criteria, physician discretion, and heterogenous provincial policy structures. For many patients, especially those in advanced or palliative contexts, driving represents more than mobility; it stands for independence and participation in daily life, making restrictions a meaningful loss. Existing policies stress road safety but offer limited tumour-specific guidance, leaving physicians to navigate these decisions without a standardized framework. Adopting structured, multidisciplinary assessment methods from international models may help bridge this gap in Canada. Developing national consensus guidelines that blend medical evidence with patient-centered values would promote decisions that are consistent, balancing public safety with quality of life for patients with brain cancer.

Acknowledgments

We would like to acknowledge Aubrey Geyer, a librarian from University of British Columbia, for the help in developing our search strategy.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-136/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-136/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-136/coif). S.L. reports serving as a consultant for Bayer, Alexion, Novocure, and Servier, and receiving speaker fees and honoraria from Alexion and Servier. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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