The Metastatic Early Prognostic (MEP) score

Abstract

Aims The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. Methods This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. Results There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. Conclusion This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72–81

Developing a novel set of quality performance indicators (QPIs) for metastatic bone disease (MBD)

“…The demographics of the patients included in this field test (47% female, average age 72 years, rate of pathological fracture 56% and commonest primaries lung, breast and prostate) were largely comparable to the general MBD population in the international literature (range female gender 52-55% (3,29,30), age 63-72 years (3,(29)(30)(31) and commonest primaries breast, prostate, kidney and lung (3,(29)(30)(31). The rate of pathological fracture was highly variable in the literature (range 30-74%) (2,3,31).…”

“…Why we need markers of care quality in metastatic bone disease (MBD) Patients with MBD are a complex cohort. They are under-researched in orthopaedics and have a high early mortality (80% at 12-months in pathological proximal femoral fractures) (1,2). In addition, the unpredictable nature of their cancer complicates their management (3).…”

Survival analysis after intramedullary stabilization for metastatic disease of the femur: prognostic value of common laboratory parameters

“…19 More recently, Downie et al incorporated serum album into the 'Metastatic Early Prognostic Score' for predicting survival in proximal femoral fracture secondary to metastases. 20 Serum albumin may be considered a key prognostic marker such is the consistency of evidence and should be incorporated as we strive for improved treatment algorithms. 8,9 The use of the platelet : lymphocyte ratio as a predictive measure in a variety of settings is gaining interest.…”

Diagnosis and referral of adults with suspected bony metastases

“…In frail patients with a short prognosis (1-6 months), prophylactic “damage control” surgery (eg, with an intramedullary nail or plate, fig 4a, 4b) can prevent fracture, relieve pain, and improve likelihood of discharge to the patient’s own home 42434748. Patients most likely to benefit from this approach include those with multiple metastases, an expected survival of 1-6 months,1249 or symptoms such as severe pain or difficulty mobilising 13. Observational studies of patient reported outcomes in surgery for bony metastases show sustained improvements in function and pain relief up to one year post surgery, and complication rates comparable with the older adult trauma patient population 405051…”

“…Factors favouring survival include low volume oligometastatic disease, certain types of primary cancer (eg, breast, renal, thyroid, myeloma, or lymphoma),55 patient fitness,56 and a long disease-free interval between primary and recurrence 38. Factors indicating a shorter prognosis (ie, less than six months) include high volume “polymetastatic” disease, multiple “organs” involved, pathological fracture, and significant biochemical abnormalities (eg, low albumin or high calcium) 4144955. The Ratasvuori score (table 2) can help to estimate prognosis 56.…”