Optimizing care for patients with spinal metastases

The main goal of treatment for patients with spinal metastases is to maintain or improve quality of life by relief of pain, preservation or restoration of spinal instability and neurological function. The decision between management with surgery, radiotherapy, medical treatments or a combination of modalities is multifactorial and requires a multidisciplinary approach. The research presented in this thesis aimed to optimize care for patients with symptomatic spinal metastases, through improvements in patient screening and treatment strategies. The introduction of the Spinal Instability Neoplastic Score (SINS) has assisted to standardize the assessment of neoplastic spinal instability and improved communication among physicians involved in the care of patients with spinal metastases. Yet, the predictive value of the SINS for treatment outcome requires further research. Accurately evaluating the effect of treatment for spinal metastases on health related quality life (HRQOL) requires the use of an instrument that is specific and sensitive to change in HRQOL in this patient population. Minor adjustments in the Spine Oncology Study Group Outcome Questionnaire (SOSGOQ) resulted in the SOSGOQ2.0 which demonstrated to be a reliable and valid instrument for the evaluation of HRQOL. Clinically meaningful improvement in HRQOL were observed in carefully selected patients with (potentially) unstable spinal metastases who were treated surgically with or without adjuvant radiotherapy. The benefits of surgery should however carefully be weighed against the risks of adverse events. The use of sterotactic body radiotherapy (SBRT) allows for selective sparing of the posterior surgical area thereby decreasing the radiotherapy dose to the soft tissues without compromising the dose to the spinal tumor. In a first-in-man study we demonstrated the safety of SBRT with sparing of the surgical area followed by surgical stabilization within 24 hours for the treatment of unstable spinal metastases. Wheter this new combined treatment strategy also results in superior outcomes compared to current standard of care, surgery followed by radiotherapy after a minimum of two weeks, remains to be determined.