• Spine Surgery

Background: Improvements in cancer treatment have led to an increased number of patients with metastatic spinal cord compression (MSCC). The goal of the treatment is often to improve the quality of life rather than to increase the length of life and for this reason the expected survival time is an important element in the evaluation of patients with MSCC. Prognostic scoring systems, with the primary oncologic diagnosis as a key variable, are routinely used to evaluate the expected survival among patients with MSCC. In order to improve the treatment and the evaluation of patients with MSCC, we need additional knowledge regarding the survival among cancer patients, the precision of the prognostic scoring systems, and on the health related quality of life (HRQOL).

Objective: The overall aim of this PhD thesis was to evaluate the planning and treatment of patients with MSCC. Specifically the aims were to assess the changes in one-year survival for patients with MSCC according to the primary cancer diagnosis (Paper I), to validate and compare the Tokuhashi Revised score and the Tomita score among patients with MSCC (Paper II) and to assess the feasibility of routine measurements of health-related quality of life (HRQOL) in patients with MSCC (Paper III).

Material and methods: The analyses were based on a retrospective and a prospective cohort. The retrospective one-center cohort consisted of 2321 patients diagnosed with MSCC at Rigshospitalet between January 1, 2005 and December 31, 2010. The prospective one-center cohort consisted of 544 patients diagnosed with MSCC at Rigshospitalet between January 1, 2011 and December 31, 2011. Both cohorts had a follow-up of one year. Patients were treated with surgery and radiotherapy (SR) or radiotherapy alone (RA). Primary tumor type, treatment, and one-year survival were registered for all patients. In the prospective cohort we additionally registered the Tokuhashi Revised score, the Tomita score, and the EQ-5D score. The EQ-5D scores were collected at 6, 12, 26 and 52 weeks follow-up.

Results: The overall one-year survival did not change significantly from 2005 to 2010, but there was a significant increase in one-year survival for the subgroups of patients with lung cancer, Hazard Ratio (HR) = 0.93 (p = 0.008, 95% CI: 0.83; 0.98) and renal cancer, HR = 0.77 (p = 0.004, 95% CI: 0.56; 0.92) (Paper I). The overall precisions for the prognostic scoring systems were 58.7% for the Tokuhashi Revised score and 52.9% for the Tomita score. The observed survival in each of the scoring groups categorized by the scoring systems was statistically significant different (Paper II). The overall response rate of the EQ-5D questionnaires was 84% and the overall completion rate was 72%. At baseline, the mean EQ-5D scores were significantly lower for SR patients compared to RA patients, 0.28 vs. 0.42 (P < 0.001). At the one-year follow-up, the mean EQ-5D scores had improved to 0.71 (95% CI: 0.64; 0.77) for SR patients and to 0.63 (95% CI: 0.56; 0.70) for RA patients (Paper III).

Conclusions: Based on the findings presented in this thesis we conclude that patients with MSCC from pulmonary and renal cancer experienced improved survival in the study period. These results could preferably be incorporated in the pre-operative scoring systems. The Tokuhashi Revised score and the Tomita score are useful in categorizing patients into prognostic groups. However, due to the relatively low precision and the improved survival for patients with lung- and renal- cancer, we suggest that a modification of both scoring systems is necessary. Lastly, we conclude, that it is feasible to do routine measurements of HRQOL in an unselected cohort of patients with MSCC. We also conclude that the HRQOL varies significantly over time.