An Evidence-based Scoring System for Patients with Metastatic Spine Cancer

Female doctor writing medical records in the officeFor patients with spinal metastases, it remains challenging for providers to choose between operative and nonoperative treatments, especially when life expectancy and quality of life are difficult to predict. At Brigham and Women’s Hospital, Andrew J. Schoenfeld, MD, MSc, and investigators in the Department of Orthopaedic Surgery, are using the New England Spinal Metastasis Score (NESMS) to navigate this complex decision-making process.

Statistically, about 50 percent of patients who develop spinal metastases will not survive within a year of their diagnosis. In interviews with patients, Dr. Schoenfeld and his colleagues found that the diagnosis is so emotionally profound that most patients don’t want to share in treatment decisions with their physician. Overwhelmed by the prognosis and various treatment choices available, most patients want to defer the decision to their physician.

“In these life and death decisions, where patients are on a fixed timeline, the New England Spinal Metastasis Score is a powerful tool that can meaningfully inform patient care at the time of presentation. The NESMS allows providers to present the patient with their score and then make strategic decisions regarding their treatment, together,” says Dr. Schoenfeld, an orthopaedic surgeon and researcher at Brigham Health.

Developed at Brigham Health in collaboration with other leading academic medical centers across New England, including Massachusetts General Hospital, the New England Spinal Metastasis Score measures a patient’s tumor characteristics and tumor burden, ambulatory function, and serum albumin levels at presentation. The spinal metastasis score ranges from zero to three.

A patient with the highest score of three, for example, may have a longer life expectancy and benefit from surgical intervention, because they: 1) have favorable tumor characteristics (e.g., an unaggressive cancerous process), 2) are an independent ambulator, and 3) have high serum albumin (indicating strong health and a high capacity to heal from a surgery).

“At the Brigham, we are using the NESMS to help patients understand their risk of mortality in the near-term, the likelihood of complications, and what their functional independence might be as we consider surgery versus non-operative treatments,” says Dr. Schoenfeld.

Currently, at the time of diagnosis, most providers offer treatment trajectories that aren’t tailored to a patient’s specific condition or health. The NESMS is a powerful tool, according to Dr. Schoenfeld, because it allows providers to offer a personalized treatment plan unlike the current generalized approach to navigating treatment trajectories.

Across orthopaedics and spine surgery, the NESMS is one of several evidence-based scoring systems. Dr. Schoenfeld thinks the NESMS is the easiest to use at the bedside. It can be performed in an exam room and only takes a few minutes to complete.

With current funding from the NIH and the Orthopaedic Research and Educational Foundation (OREF), Dr. Schoenfeld and his colleagues are conducting prospective studies to further evaluate the capacity of the NESMS to guide operative versus non-operative decision-making for patients with metastatic spine cancer.

In a 2016 study published in the journal The Spine Journal, Dr. Schoenfeld and colleagues demonstrated the clinical accuracy of the NESMS for predicting short-term major morbidity and mortality after metastatic spinal surgery.

“We also want to understand if the NESMS can predict complications, functional outcomes (e.g., maintenance of independence), preservation of ambulatory function with or without surgery, and how these factors intersect,” says Dr. Schoenfeld.

In a study published in a 2019 issue of Cancer, the Brigham and Women’s research team demonstrated that patients treated operatively were less likely to lose ambulatory function six months after presentation compared to patients managed nonoperatively.

A prospective study is currently enrolling patients treated operatively and nonoperatively to measure physical function, independence and patients’ ability to remain ambulatory, based on treatments that are selected at the time of presentation for spinal metastatic disease.

This fall, the investigators will conduct focus groups with clinicians, including surgeons, radiation oncologists, and non-operative providers to understand what drives their treatment decision-making at presentation. These provider insights may help update the NESMS to provide the best evidence-based scoring system for patients with metastatic spine cancer.

“Ultimately, a score can’t directly improve a patient’s life, but it can help them pick the right treatment, and that may translate into improved survival, enhanced functional independence, and a better quality of life,” says Dr. Schoenfeld.