(294) DECISION MAKING IN ORTHOPAEDIC ONCOLOGY
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Transcript of (294) DECISION MAKING IN ORTHOPAEDIC ONCOLOGY
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
DECISION MAKING IN
ORTHOPAEDIC ONCOLOGY
DECISION MAKING IN
ORTHOPAEDIC ONCOLOGY
Robert J GRIMER
Adesegun ABUDU
Consultant Orthopaedic Oncologists
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
THE CHALLENGETHE CHALLENGE
• Orthopaedic Oncology has come of age !
• Cure possible for more than half the patients
• Limb salvage possible in 80-85%
but
• What is best for the individual patient
and
• How do we decide the best procedure?
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
DECISIONS, DECISIONS……DECISIONS, DECISIONS……
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
HOW DECISIONS USED TO BE MADE !HOW DECISIONS USED TO BE MADE !
• Local expertise and enthusiasm
• What was availableeg. Amputation
Rotationplasty
Endoprosthesis
Autograft
Allograft
Arthrodesis
Distraction osteogenesis
etc……...
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
WHAT HAS CHANGED ?WHAT HAS CHANGED ?
• We now have much more information:
• Long term results
• Complications
• Functional assessments
• Quality of life assessments
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
BUT -
HOW DO WE COMPARE THEM ?
WHAT IS BEST ??
HOW DOES A PATIENT DECIDE ?
BUT -
HOW DO WE COMPARE THEM ?
WHAT IS BEST ??
HOW DOES A PATIENT DECIDE ?
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
IF YOU HAD A TUMOUR ,WHAT WOULD YOU WANT TO KNOW ?
IF YOU HAD A TUMOUR ,WHAT WOULD YOU WANT TO KNOW ?
1.Survival - what is the safest procedure?
2.Early complications - how serious, how long ?
3.Function & Quality of life - how good will it be, what can / can’t I do?
4.Late complications - will it fail, what is the risk of failure, how bad will it be, how easy to put right ?
5.What will I look like? Will I be “deformed”.
6. How expensive / available is it ?
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
HOW DO WE ANSWER THESE QUESTIONS SIMPLY ?
HOW DO WE ANSWER THESE QUESTIONS SIMPLY ?
• Bombard the patient with facts and figures
• Be paternalistic - “doctor knows best”
• Be biased - “I’ve done *** and I know it’s best”
• Try and simplify (!) the process
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
AN ALTERNATIVE SOLUTIONAN ALTERNATIVE SOLUTION
• Try and structure the information
• Quantify it and express it numerically
• Similar to QALYs
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
WHAT ARE QALYs ?WHAT ARE QALYs ?
• Quality Added Life Years• Developed by health economists to try and compare
various interventions in terms of value for money
• Hip replacement scores highly:– Relatively low cost
– Significant improvement in QoL
• eg. if we assume that a THR costs 10,000 $/Euros and that the average survival is 15 years with an alteration of QoL from 0.75 to 0.95, then the QALY value is:
– 10,000 / 15 X (0.95 - 0.75) = 3,300 $/Euros per QALY
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
The Rosser Index MatrixThe Rosser Index Matrix
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
WHY NOT DO THE SAME FORORTHOPAEDIC ONCOLOGY
WHY NOT DO THE SAME FORORTHOPAEDIC ONCOLOGY
• QoL notoriously difficult to assess and compare
• MSTS or TESS functional scores much more widely used
• Why not produce a FUNctional Life Year score or FUNLY ?
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
WHAT INFORMATION DO WE NEED ?WHAT INFORMATION DO WE NEED ?
• Average functional score of a procedure
• Time to achieve that score
• Does function alter with time ?
• Risk of failure of that procedure
• Functional score after correction of failure
• Any survivorship disadvantage ?
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
THE TOTAL FUNCTIONAL SCORE IS THE AREA UNDER THE CURVETHE TOTAL FUNCTIONAL SCORE IS THE AREA UNDER THE CURVE
504030201000.0
0.2
0.4
0.6
0.8
1.0
Successful EPR, no failure
Units of time
Fu
nct
ion
al
Sco
re
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
EPR - FAILED AT TWO YEARS - AMPUTATION
EPR - FAILED AT TWO YEARS - AMPUTATION
504030201000.0
0.2
0.4
0.6
0.8
1.0
Units of time
Fu
ncti
on
a S
core
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
SUCCESSFUL EPR - PATIENT DIES AT TWO YEARS
SUCCESSFUL EPR - PATIENT DIES AT TWO YEARS
4030201000.0
0.2
0.4
0.6
0.8
1.0
Units of Time
Fu
ncti
on
al S
core
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
EPR - FAILED AT TWO YEARS - REVISED
EPR - FAILED AT TWO YEARS - REVISED
504030201000.0
0.2
0.4
0.6
0.8
1.0
Units of Time
Fu
ncti
on
al S
core
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
HOW TO ADD IT ALL TOGETHERHOW TO ADD IT ALL TOGETHER
504030201000.0
0.2
0.4
0.6
0.8
1.0
EPR failure
Failed EPR - followed by amputation
Units of time
Funct
iona S
core
504030201000.0
0.2
0.4
0.6
0.8
1.0
Successful EPR, no failure
Units of time
Fun
ctio
na
l S
core
4030201000.0
0.2
0.4
0.6
0.8
1.0
Units of Time
Fu
nct
ion
al
Sco
re
Successful EPR- but die after two years
Successful EPR,functions at 80%,
Successful EPR,but patient dies(mean of 2yrs)
Successful initially,but failure leads to amputation
0.5% risk /yr
40% will die50403020100
0.0
0.2
0.4
0.6
0.8
1.0
Revision Surgery
Units of Time
Fu
ncti
on
al S
core
3% risk / yr
Revision andrecovery
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
10 YEAR SCORES10 YEAR SCORES
504030201000.0
0.2
0.4
0.6
0.8
1.0
Failed EPR - followed by amputation
Units of time
Fu
ncti
on
a S
co
re
504030201000.0
0.2
0.4
0.6
0.8
1.0
Successful EPR, no failure
Units of time
Fun
ctio
na
l S
core
4030201000.0
0.2
0.4
0.6
0.8
1.0
Units of Time
Fu
nct
ion
al
Sco
re
Successful EPR- but die after two years
Score = 7.75
Score = 1.5
Score = 6.15
0.5% risk /yr
504030201000.0
0.2
0.4
0.6
0.8
1.0
Revision Surgery
Units of Time
Fu
ncti
on
al S
core
3% risk / yr
Score = 7.65
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
CUMULATIVE SCORECUMULATIVE SCORE
Sum of all functional scores over a defined time period
eg. over 10 years:
60% have a successful EPR score 7.75
40% successful but die score 1.5
3% revision rate score 7.65
0.5% amputation rate score 1.5
TOTAL 5.38 FUNLYs
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
COMPARISONSCOMPARISONS
• Amputation - lower function throughout
• Rotationplasty - longer recovery time but good function
• Allograft - high early complications, long time to recover, lower rate of long term complications
• Arthrodesis - low risk, low function
• Distraction osteogenesis - slow, early complications• Endoprosthesis - quick recovery, low early
problems, inevitable revision with time.
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
TEN YEAR SCORESTEN YEAR SCORES
• Endoprosthesis 5.38 FUNLYs
• Rotationplasty 5.25 FUNLYs
• Distraction osteogenesis 5.2 FUNLYs
• Allograft 5.2 FUNLYs
• Amputation 3.98 FUNLYs
• Arthrodesis 3.5 FUNLYs
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
WE DO THIS EVERY DAY !WE DO THIS EVERY DAY !
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
DECISION MAKING….DECISION MAKING….
•Cost, •Residual value, •Problems, •Street cred, •Will it fit in my garage•etc.
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
AMPUTATION OR LIMB SALVAGE ?AMPUTATION OR LIMB SALVAGE ?
• Large Gd 3 chondrosarcoma pelvis
• Hindquarter amputation – Poor function
– Best chance clear margins
• Limb salvage– Better function
– Higher risk of local recurrence
– ? Higher risk of mets
– Higher risk of complications
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
ASSUME THE FOLLOWING. . .ASSUME THE FOLLOWING. . .
• Chances of getting LR– Clear margins 10%
– Close margins 40%
• Chances of cure– 80% if no LR
– 30% if get LR0
.2
.4
.6
.8
1
Cu
m.
Su
rviv
al
0 50 100 150 200 250 300 350Time in months
No LR
LR
Survival by LR
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
The FUNLY methodThe FUNLY method
Amputation Limb Salvage
Clear margins 80% 30%
Risk of LR
(margin risk x risk LR)
(0.8 x 0.1) + (0.2 x 0.4)
= .08 + .08 = 0.16
(0.3 x 0.1) + (0.7 x 0.4)
= .03 + 0.28 = 0.31
Chances of survival
(no LR risk + LR risk)
(0.84 x 0.8) + (0.16 x0.3)
0.67 + 0.05 = 0.72
(0.69 x 0.8) + (0.31 x 0.3)
0.55 + .09 = 0.64
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
FUNLY SCORESFUNLY SCORES
• Assume functional scores:– Hindquarter = 35%
– Limb salvage = 70%
» But 30% have major complications with loss of function to 50%
• Assume median survival of 5 years for those who die
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
THE CALCULATION…THE CALCULATION…
• For Limb salvage– 64% survive, of whom 70% have function 70%, 30% with 50%
– 36% succumb with function as above
– FUNLY = (0.64 x .7 x .7 x 10) + (0.64 x .3 x .5 x 10) + (0.36 x .7 x .7
x 5) + (0.36 x .3 x .5 x 5) = 3.136 + 0.96 + 0.088 + 0.27 = 4.454• For Hindquarter
– 72% survive with function 35% = 0.72 x 0.35 x 10 = 2.52
– 28% succumb with function 35% = 0.28 x 0.35 x 5 = 0.49
– FUNLY = 3.01
Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K.
CONCLUSIONCONCLUSION
• FUNLY scores offer a mathematical model of comparing outcomes
• FUNLY scores may have a place in assessing what is best for an individual (especially if they can identify relative importance of different factors)
• A computerised model is being developed so that results can be produced based on more refined data