The indications for cancer combined with bone metastasis- When is surgery required?

(Preface) One thing that impressed me very much was that when I was the first-year visiting staff (VS), the physician sent me a consultation form. The patient who was consulted was Mr. A, a 70-year-old male patient with lung cancer. Mr. A was unable to walk because of pain in his left hip; so, he wanted to ask an orthopedic oncologist for advice. When I saw the X-ray images, I determined it as a bone metastasis at the left hip bone with a Mirels score of 12 points (close to pathological fractures); Hence, after discussion with the patient, we gave intralesional curettage and steel plate fixing surgery. The day after the surgery, Mr. A was able to get out of bed with crutches, and he was very happy! However, if that was the story, I wouldn't be impressed. One day afterward, I occasionally hear a physician's opinion on the surgery, which is about: 'The new orthopedic surgeon is ridiculous. How dare could he bring the patient with advanced cancer to a surgery!’

by PQ Wu

The physician's opinion has two big problems:

First, cancer combined bone metastasis in current medical standards is not the ‘advanced cancer.' We have many bone metastasis patients who can move every day and often tell me, "Dr. Wu, I walk one million steps every day!" and we've been tracking them for more than five years!

Second, even if some patients’ cancer is really 'advanced cancer' when needed, giving proactive treatment to improve patients' quality of life is enhanced!

Let's take a look at the indications and surgical treatment methods for cancer combined with bone metastasis:

Surgical indications of bone metastasis, when is surgery required?

Pain

The pain that cannot be controlled by medication and radiation therapy

Fracture

Close to or already incur pathological fractures

Nerve oppression

Bone metastatic tumors compress the spinal nerves

A solitary metastasized tumor

Actively remove cancer to cure it

The prognosis is good

Actively remove cancer to cure it

Since patients with cancer themselves do have poor physical strength and immunity, especially when combined with distal metastasis, the risk of surgery will surely increase a lot! Therefore, in the current environment with many medical disputes, surgeons tend to choose to do less. In most cases, bone metastasis can be treated in a conservative way, including pain-relieving medication, local radiation therapy, etc., and patients can get good pain control. In some cases, however, surgical treatment is necessary:

First, the pain of bone metastasis cannot be controlled by medication and radiation therapy. Let's start by quoting a statement from the Taiwan Pain Society: 'In 1996, American Pain Society clarified the reason of why pain is the fifth vital sign. If the pain is assessed in the same way as other vital signs, the pain will continue to be evaluated and have access to more appropriate treatment.'

So, we can understand the importance of 'pain control' for the general patient and even for patients with cancer combined with bone metastasis! If the patient's pain is out of control by both medication and radiation therapy, surgery is the most immediate method! Most patients, after surgery, will immediately relieve from that 'deep,' 'sour,' 'hidden' pain and exchange for a better quality of life.

Second, the patient is on the verge of or already incur pathological fractures. Pathological fractures have a very large influence on cancer patients! Therefore, for patients on the verge of pathological fractures, we do not recommend using only medication or radiation therapy to control it unless the patient's medical condition is unsuitable for surgery. Yet, how do the clinicians and patients determine whether the bone metastasis site is already 'on the verge of pathological fracture'? The simple way is to use the Mirels score sheet to determine. The readers can go through the link below for more detail.

Additional reading: What is Pathological Fracture?

Third, bone-metastatic tumors compress the spinal nerves. The spine is the location where cancer cells are most likely to incur bone metastasis, and most of the cancer cells that metastasize to the spine can cause damage to the bone structure and lead to pathological fractures. At this point, we can choose to use radiation therapy, back frame support, or spinal fixation surgery. However, in a small number of cases, the tumor passes through the bone and then compresses the spinal nerves. It can collapse the patient's limbs in severe cases, and the tumor size is even uncontrollable. Surgery is then required to remove the tumor (decompression surgery).

Fourth, the primary cancer is expected to have a relatively good prognosis or a solitary metastasis. For primary cancer with a better prognosis, such as at early-stage, cancer that responds well to specific targets, young patients, or only a single location of bone metastasis without any other organ metastasis, clinically, we will proactively remove the metastasized tumor since we assess a good prognosis of the patient.

Conclusion

From the explanation above, we should understand that cancer combined with bone metastasis is not unnecessary to have surgical treatment. In line with the above situations, we still have to give progressive surgery to improve patient’s quality of life and control the disease development. But what most important and needed to reemphasize is that since cancer patients are in poorer health than the general public, the overall risk of surgery and anesthesia is greatly increased! Before surgery, physician teams will complete the comprehensive assessment. Patients and family members must also communicate, discuss, and understand the surgeon's dilemma between conducting the operation to reduce the patient’s pain and a regretful outcome that no one wants to see!). With the premise of a mutual understanding, the physicians can keep their faith to help patients!