Metastatic Spine Care

Metastatic Spine Care

A newly published algorithm helps coordinate the multidisciplinary care needed to help patients with spinal metastases live longer with less pain and better quality of life, researchers reported in the December issue of The Lancet Oncology. The algorithm was developed by the international Spine Oncology Consortium, and provides a personalized approach to treatment of spine metastases by individualizing care based on performance status, life expectance, burden of systemic disease, and available treatment options. The algorithm incorporates multidisciplinary care from spine surgeons, radiation oncologists, neurosurgeons, and physical medicine and rehabilitation physicians. “The goal is to make oncologists and other practitioners who are not familiar with the treatment of spine metastases comfortable with the treatment algorithm,” said senior author Nicholas Szerlip, MD, Associate Professor of Neurosurgery at Michigan Medicine, University of Michigan, and co-founder of Michigan Medicine’s Spine Oncology Clinic, in Ann Arbor, MI. “These physicians are the gatekeepers for many patients with spinal metastases, and it is important for them to understand everyone’s role in the treatment of spinal metastases to help patients get to the right physician in time to do something meaningful.”

The panel of experts developed two algorithms: one for the initial assessment of patients with spinal metastases, and one for spine metastasis management that incorporates a degree of mechanical stability, neurological risk, oncological parameters, and preferred treatment.

“We hope that this algorithm can now be put into test in randomized clinical trials,” Dr. Szerlip said. “The more rigorous data we get about who would benefit from different treatments, the less risk the patient assumes with more benefit.”

Multidisciplinary Approach Is Essential to Care for Spinal Metastases Care for patients with spinal metastases requires careful consideration of the risks versus benefits of treatment, “and the multidisciplinary approach is essential when calculating this equation,” he said. “It is so important in this patient population to have input from everyone on the care team, including the patient,” Dr. Szerlip told SpineUniverse.

“By putting together multidisciplinary care teams, all physicians can have a better understanding of the role and treatments used by other parts of the team,” Dr. Szerlip said. “Most practitioners are super subspecialized in this day and age, making the multidisciplinary team approach more important. I can’t keep up with the range of chemotherapeutic options for different cancer types like an oncologist can; it would take away from being good at my role as a neurosurgeon. The same goes for all practitioners.”

Stereotactic Body Radiotherapy Has Changed the Treatment Landscape Historically, spinal metastases have been treated with invasive surgical approaches (eg, en-bloc resection) and/or low-dose palliative conventional external-beam radiotherapy, the researchers explained. However, these treatments do not offer long-term control or have suboptimal outcomes.

Dr. Szerlip explained that development of spine stereotactic body radiotherapy (SBRT) as well as stereotactic radiosurgery have changed the treatment paradigm by providing treatments with lower risk of complications and greater oncologic benefit.

“SBRT has allowed our treatment algorithm to drastically change over the last 15 years,” Dr. Szerlip explained. “It treats the tumor with much lower risk to the patient than historical surgery and with good local control of the tumor. This has allowed us to change our surgical paradigm and perform more minimally invasive surgeries.”

Clinical Judgement Still Takes Precedence Commenting on the study, James S. Harrop, MD, FACS, noted that the algorithm’s clear steps and decision trees provided make it an excellent educational tool and help direct care using a multispecialty approach to a complex problem. In addition, he emphasized that many patients do not fit into the specific “boxes” and, therefore, “use of good clinical judgment as well as care and respect for patients’ wishes are mandatory.”

“For example, some patients may refuse an invasive procedure due to their beliefs and desires,” said Dr. Harrop, who is Professor of Neurological and Orthopedic Surgery, and Director of the Division of Spine and Peripheral Nerve Surgery, at Thomas Jefferson University in Philadelphia, PA. “As physicians, our goal is to educate and guide patients to help them make the best choices.”

In addition, Dr. Harrop said that while the steps in this algorithm are practiced by many physicians, the algorithm provides nonsurgeons with a better appreciation for surgical decisions.

Dr. Harrop is a consultant for Depuy Spine and has received honorarium from Globus and Stryker.

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