royal orthopaedic hospital oncology service, birmingham, u.k. decision making in orthopaedic...

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


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?


DECISIONS, DECISIONS……DECISIONS, DECISIONS……


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……...


WHAT HAS CHANGED ?WHAT HAS CHANGED ?

• We now have much more information:

• Long term results

• Complications

• Functional assessments

• Quality of life assessments


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 ?


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 ?


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


AN ALTERNATIVE SOLUTIONAN ALTERNATIVE SOLUTION

• Try and structure the information

• Quantify it and express it numerically

• Similar to QALYs


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


The Rosser Index MatrixThe Rosser Index Matrix


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 ?


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 ?


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


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


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


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


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


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


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


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


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


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.


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


WE DO THIS EVERY DAY !WE DO THIS EVERY DAY !


DECISION MAKING….DECISION MAKING….

•Cost, •Residual value, •Problems, •Street cred, •Will it fit in my garage•etc.


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


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


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


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


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


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

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