Towards Better Patient Journeys in Metastatic Spinal Disease
Authors:   , van Tol Floris Rudolf 
Published: October 2023

Advances in cancer treatment have improved life expectancy for patients but have also seen an increase in metastatic spinal disease cases. While initial stages might be managed with non-invasive treatments, untreated spinal metastases can cause severe pain, mechanical issues, or neurological deficits, necessitating surgery. It's essential to maintain patients' quality of life, especially given their extended survival period. Timely diagnosis of spinal metastases is challenging due to symptom similarities to general back or neck pain, often resulting in delays. Untreated, spinal metastases can cause complications like pathologic fractures and neurological deficits, currently affecting 25%-50% of patients. A study on over 300 patients at a tertiary care center divided them based on treatment urgency: timely or delayed. Delayed treatment was linked to more invasive surgeries, leading to longer operation times, more blood loss, and complications. Furthermore, hospital stays were prolonged, with fewer patients returning home. In terms of long-term results, timely treatment showed better functional status and survival rates. The importance of quick intervention is highlighted by the grossly irreversible decline in functional status and reduced overall survival rates associated with delayed treatment. Optimizing referral pathways can expedite treatment, potentially reducing overall healthcare costs. In fact, timely treatment was found to be more cost-effective, costing around €14,000 less than delayed treatment within three months post-treatment. Even after considering neurological status, delayed treatment consistently showed inferior outcomes, emphasizing the urgency of early diagnosis and intervention in metastatic spinal disease. The journey of patients with metastatic spinal disease is complex, with multiple types of delay from symptom onset to treatment. These delays include the time taken by patients to seek medical help after noticing symptoms (patient delay), diagnosis duration (diagnostic delay), referral time (referral delay), and treatment initiation (treatment delay). In this thesis, the median total delay was observed to be 99 days. The separate delay components varied based on whether the metastasis was synchronous (cancer history unknown) or metachronous (known cancer history), but the total delay did not. Another crucial aspect is the time before irreversible neurological symptoms appear. Research showed that patients with metastatic spinal disease develop neurological deficits within a median time of 64 days. The study also underscored the importance of monitoring "red flags" indicative of metastatic spinal disease, such as nocturnal back pain and poor general health, to ensure timely intervention. Only about a third of these red flags were documented, emphasizing the need for systematic screening in patients with back pain symptoms. Despite recognition of the need for prompt treatment, methods to achieve this are scarce. Successful management demands a multidisciplinary approach, uniting oncology, radiology, radiotherapy, and surgery experts. A coordinated care model emphasizing communication, facilitated by tools like regional health records or standardized referral processes, is suggested. Monitoring and continuous quality improvement are essential. However, the successful implementation depends largely on healthcare providers adhering to these guidelines and being educated appropriately. In summary, a multifaceted approach, rather than a single solution, is required to ensure timely treatment for metastatic spinal disease patients.