Metastatic disease of bone is a major health problem across all cultures and socioeconomic levels. Care and treatment recommendations are best provided by multidisciplinary care teams. The role of the orthopaedic surgeon in these teams involves making decisions about when and when not to perform surgical treatment. However, the goals are quite different from those of most orthopaedic procedures. As Tang et al. noted, palliation, not cure, is the objective and thus quality of life becomes paramount in an assessment of the success or failure of surgical intervention. Despite increased clarity regarding surgical indications and documentation of neurologic improvement and pain relief, there is a paucity of literature on overall quality of life after surgical intervention for metastatic disease of bone involving the spine.
Tang et al. present an observational study of patients who had clear indications for surgical intervention for metastasis of bone involving the spine, including a neurologic deficit, pain, and a Tomita prognostic score of <8. Their focus was not on what type of surgery was performed, as that was tailored to the individual patient, but on the quality of life at baseline and after surgery as well as survival. With the limitations that are described in the article, they showed that both quality of life and overall survival were better after surgical intervention in these patients.
These findings are interesting and helpful. They support the clinical application of accepted surgical indications in this specific population. What is also of interest is that, while surgery was recommended to all patients, some chose to follow the recommendation and some did not. It is important to assess and recognize the issues that played a role in that decision—i.e., the social science behind surgical decisions. Some factors are personal, and some are societal. With some, there is real potential for mitigating or decreasing the burden on the patient and family, whereas, with others, that potential is very limited.
In originally reviewing this manuscript for acceptance by JBJS, I questioned the authors regarding individual quality-of-life scores at baseline, and they provided a thoughtful subanalysis. In this (unpublished) analysis, they noted no significant differences between the surgical and nonsurgical groups at baseline in terms of physical well-being, social/family well-being, or functional well-being but they observed that patients who decided to proceed with the recommended surgery had significantly better emotional well-being (as assessed with the Functional Assessment of Cancer Therapy-General [FACT-G] questionnaire) than those who did not. The authors noted that “. . . patients who had more confidence against the disease were more prone to actively receive surgery. On the contrary, patients who worried about the disease, complications of surgery and other things were more prone to refuse surgery. So, we thought the better emotional well-being was the fundamental reason for patients to receive surgery.”
One cannot underestimate the pressures faced by patients and families with metastatic disease of bone. There are financial stresses, which vary by health system and socioeconomic status. There are social stresses, which vary by culture but often involve a transition to a sense of not contributing to the family anymore and to becoming a burden to the family. These stresses seem have been similar among the patients in this population, who were similar to one another with respect to disease and culture. However, some patients had a higher level of emotional well-being at baseline and that led them to pursue the recommended surgery. It is one additional factor that we need to consider when we have discussions about the complex decision regarding surgery for patients with metastatic bone disease.
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