New algorithm decodes spine oncology treatment

February 6, 2018 by Haley Otman, University of Michigan
Every kind of cancer can spread to the spine, yet two physician-scientists who treat these patients describe a paucity of guidance for effectively providing care and minimizing pain. To resolve the confusion and address the continually changing landscape of spine oncology, a recent Michigan Medicine-led publication details a guide to explain the management of spinal metastases. Credit: Michigan Medicine

Every kind of cancer can spread to the spine, yet two physician-scientists who treat these patients describe a paucity of guidance for effectively providing care and minimizing pain.

To resolve the confusion and address the continually changing landscape of , a recent Michigan Medicine-led publication details a guide to explain the management of spinal metastases.

Published in The Lancet Oncology, the work is the result of reviewing all of the existing studies and pulling in experts from across the world to provide insight. The goal, says senior author Nicholas Szerlip, M.D., a neurosurgeon at the University of Michigan, is to get all providers on the same page.

First author Daniel Spratt, M.D., who with Szerlip co-founded U-M's multidisciplinary spine oncology clinic, says with spine metastases are commonly managed in silos without integrated care. A patient with a spine metastasis might see a variety of subspecialty doctors. Recommendations could range from pain management to more aggressive treatment, and referring providers don't always know what will come out of a referral to spine oncology experts, or when a referral is necessary.

"Spine oncology is such a multidisciplinary pathology," says Szerlip, an associate professor. "We wanted to form a transparent understanding so everyone, from the oncologists and primary care providers to fellow neurosurgeons who aren't specifically trained on this, could lean on one algorithm in language we can all understand."

Spratt describes the algorithm, a report from the researchers' new International Spine Oncology Consortium, as a step-by-step method designed to help comprehensively manage these patients as they grow in number and their life spans lengthen after diagnosis. He says the goal is to help providers treat the patient and not just the tumor, taking into account the patient's performance status, life expectancy, burden of systemic disease and available treatment options.

"Most of the frameworks that have been available prior to this have focused on just surgery or just radiation," Spratt says. "This algorithm integrates all of the specialties together, including PM&R, radiology and medical oncology, to provide a much more personalized treatment approach for patients with metastatic to the spine."

A different approach

Cancer can spread widely through the body, yet this algorithm specifically focuses on metastases to the spine. Researchers say a metastasis in the spine throws a wrench in typical treatment plans because of the sensitivity of the spinal cord. Quality of life can worsen much faster.

"A spine metastasis causes a lot of pain," Szerlip says. "People can live with metastases in other areas of the body without much discomfort, but bone pain hurts a lot, and the ability to treat a tumor near the spinal cord is less. Surgeries on other bones are much easier than surgeries on the spine, and less morbid."

Popular treatment paths address both the neurologic benefit and the oncologic benefit. That might mean a surgical decompression of the tumor, followed by radiation to attempt to control the cancer. Spratt is particularly excited about offering spine stereotactic body radiotherapy (SBRT), a form of high-dose radiation that requires just one to three treatments. Conventional radiation results in only about a 50 percent reduction in pain three months after treatment, and the cancer is eliminated for only a short time. Spratt says spine SBRT is a game changer, showing greater than 90 percent pain reduction and more effectively controlling tumor growth beyond one year post-treatment.

"With this technique, you've basically spared the spinal cord so you can give a much higher dose just millimeters away," he says.

Patients are living longer

Most patients who present with metastatic spine cancer know they have cancer and have had it for some time, Szerlip says. The cancers that most often lead to spine metastasis tend to be renal cell, breast, prostate, sarcoma and lung, the researchers say.

But not all patients who could benefit from a spine oncology clinic will set foot inside one. Szerlip and Spratt say their algorithm will also raise awareness for doctors who care for people with metastatic spine cancer.

"If you look back 10 or 20 years, you'd see people with spine metastasis lived in the order of months," Spratt says. "Now, with new systemic therapies, targeted therapies and immunotherapies, it may be years."

That means there is more opportunity to treat the cancer, to manage the patient's comfort and to prevent painful and debilitating compression that can result after a period of living with a tumor pressing on your .

Szerlip says not long ago, physicians were much less likely to send a spinal metastasis patient to a neurosurgeon because of the high morbidity of surgeries. Now, he says, spine oncology clinics can offer additional options and surgical procedures with less morbidity than in the past. However, these huge surgeries are still highly morbid.

A long-term project

The algorithm that leads to these treatment decisions takes the user through a series of steps starting with an assessment of life expectancy. Then, the systemic burden of the disease is considered, followed by a calculation of how controlled the disease is, and then a consideration of systemic options. It's the result of combing through 243 studies and learning about what other spine oncology clinics' practices look like.

However, Szerlip says much more data are needed to continue to develop best practices and prove that current efforts are most effective.

"Identifying which patients should get these treatments is also difficult," he says. The researchers are working with oncologists to help determine who will live long enough to benefit from these procedures.

He says basic science research will be important to continue to develop treatments specifically for spine metastases, because they develop differently than other metastases.

Jessica Webster Sendra contributed to this report.

Explore further: ASCO: single radiation Tx enough for spinal pain in cancer mets

More information: Daniel E Spratt et al, An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report, The Lancet Oncology (2017). DOI: 10.1016/S1470-2045(17)30612-5

Related Stories

ASCO: single radiation Tx enough for spinal pain in cancer mets

June 5, 2017
(HealthDay)—Just one dose of radiation works as well as a full week of treatment for metastatic spinal canal compression, according to a study presented at the annual meeting of the American Society of Clinical Oncology, ...

First US trial of procedure to relieve pain from spinal tumors

January 5, 2015
When metastatic cancer spreads to the spine, it can cause spinal fractures, severe pain and impaired mobility.

A single radiation treatment sufficiently relieves spinal cord compression symptoms

June 5, 2017
"Spinal cord compression is a debilitating condition that many patients with advanced cancer experience. Until now, patients often had to spend multiple days traveling back and forth to undergo radiation treatments. This ...

Controlling spine metastases with tumor 'separation surgery' and high-dose stereotactic radiosurgery

January 22, 2013
Researchers from Memorial Sloan-Kettering Cancer Center (New York, NY) have found that tumor "separation surgery" followed by high-dose hypofractionated stereotactic radiosurgery (SRS) or high-dose single-fraction SRS is ...

Is the pain coming from your hip, spine or both?

February 6, 2017
Many patients live with low back pain that radiates to the buttock, groin, thigh, and even knees. The challenge for patients, and often their doctors, is determining the origin of the pain—the hip, the spine, or both. A ...

Surgery consultation common after MRI of the spine

January 2, 2013
(HealthDay)—Almost half of patients whose primary care physicians recommend a lumbosacral or cervical spine magnetic resonance imaging (MRI) scan go on to receive a surgical consultation, but few end up undergoing spinal ...

Recommended for you

Stem cell vaccine immunizes lab mice against multiple cancers

February 15, 2018
Stanford University researchers report that injecting mice with inactivated induced pluripotent stem cells (iPSCs) launched a strong immune response against breast, lung, and skin cancers. The vaccine also prevented relapses ...

Induced pluripotent stem cells could serve as cancer vaccine, researchers say

February 15, 2018
Induced pluripotent stem cells, or iPS cells, are a keystone of regenerative medicine. Outside the body, they can be coaxed to become many different types of cells and tissues that can help repair damage due to trauma or ...

Team paves the way to the use of immunotherapy to treat aggressive colon tumors

February 15, 2018
In a short space of time, immunotherapy against cancer cells has become a powerful approach to treat cancers such as melanoma and lung cancer. However, to date, most colon tumours appeared to be unresponsive to this kind ...

Can our genes help predict how women respond to ovarian cancer treatment?

February 15, 2018
Research has identified gene variants that play a significant role in how women with ovarian cancer process chemotherapy.

First comparison of common breast cancer tests finds varied accuracy of predictions

February 15, 2018
Commercially-available prognostic breast cancer tests show significant variation in their abilities to predict disease recurrence, according to a study led by Queen Mary University of London of nearly 800 postmenopausal women.

Catching up to brain cancer: Researchers develop accurate model of how aggressive cancer cells move and spread

February 15, 2018
A brief chat at a Faculty Senate meeting put two University of Delaware researchers onto an idea that could be of great value to cancer researchers.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.