Patient experiences of decision-making in the treatment of spinal metastases: a qualitative study

Prospective validation of a clinical prediction score for survival in patients with spinal metastases: the New England Spinal Metastasis Score

“…At baseline, the NESMS can be used to provide patients and families with an intuitive and accessible predictive score to describe natural history, anticipated outcomes, and delineate treatment strategies [3]. This can aid in the construction of individualized treatment plans, allowing patients to better balance the risks of various treatment options against their goals and preferences [4,25]. In this regard, use of a survival table (Table 2) may be more accessible for patients and families than trying to present ORs, or factoring in other parameters not included in the NESMS but accounted for in our adjusted analyses.…”

A Natural History of Patients Treated Operatively and Nonoperatively for Spinal Metastases Over 2 Years Following Treatment

“…9,10 These realities complicate effective clinical decision making as management strategies must account for the patient's capacity to benefit from surgery or nonoperative care, while minimizing the potential for complications and accelerated functional deterioration. 5,11 Over the last 15 years, surgical treatment has been touted as a means to preserve functional independence, quality of life, and improve the prospect for survival. 4,5,[12][13][14][15] A balanced assessment of the literature supporting these notions, however, raises concern for both selection bias and confounding by indication.…”

Randomized controlled trials and high-intensity spine surgery

“…The treatment of these conditions is expensive and often requires experienced, multidisciplinary teams, with relatively low degrees of clinical equipoise and high levels of preference-based care. 9,10,11,12,13 While some RCTs have been completed in these arenas in the past, such as the oft-cited work of Patchell et al in 2005 14 , the fact of the matter remains that both surgical and nonoperative treatments have advanced considerably since that time, including improvements in minimally invasive procedures, interbody constructs, radiation techniques and the use of immunotherapy 13 . The landscape of the spine surgical field, as well as that of oncology, radiation oncology, pain management and physiatry cannot be considered comparable to that of 1992, when Patchell's study was initiated, or even 2002 when the investigation was concluded.…”

“…In fact, in recent qualitative work conducted among patients receiving treatment for spinal metastatic disease, strong preferences were expressed by these individuals for either operative or non-operative intervention. 12 Furthermore, the magnitude of the diagnosis and the prospect for irrevocable impact on functional status and survival led many patients to defer to their clinicians' judgment or the decision of a multidisciplinary team, regarding the treatment course that best suited their needs. 12 These realities would invariably raise ethical concerns regarding the conduct of RCTs among such vulnerable populations and difficulty recruiting a sample of sufficient size to allow for meaningful comparisons of outcomes.…”

“…12 Furthermore, the magnitude of the diagnosis and the prospect for irrevocable impact on functional status and survival led many patients to defer to their clinicians' judgment or the decision of a multidisciplinary team, regarding the treatment course that best suited their needs. 12 These realities would invariably raise ethical concerns regarding the conduct of RCTs among such vulnerable populations and difficulty recruiting a sample of sufficient size to allow for meaningful comparisons of outcomes. 15,17 This could also lead to large degrees of non-adherence to the randomized treatment among patients who did consent, which presents a particular challenge in interpreting the outcomes of an RCT.…”