Palliative Orthopaedic Interventions in Metastatic Cancer

Introduction

Cancer with osseous metastases presents unique challenges to musculoskeletal oncologists. With the increasing survivorship of cancer patients, the evolution of subspecialties, and a growing awareness of end-of-life issues in Asia, considerations of quality of life have become central to clinical decision-making. Patients with osseous metastases who do not have visceral involvement often experience better outcomes, necessitating careful prognostication, survivorship assessment, and cost-conscious management strategies.

Common Orthopaedic Interventions

• Spinal decompressions and stabilization for metastatic spinal disease

• Hip replacement surgery for metastatic hip disease

• Long bone stabilization

Although these interventions can be costly, accumulating evidence demonstrates that palliative surgery may be more cost-effective than conservative management. Surgical palliation has been shown to significantly improve quality of life and is supported by recent publications and regional initiatives advocating for its broader adoption.

Global Quality of Death Index

A 2010 study conducted by the Lien Foundation and the Economist Intelligence Unit ranked Singapore as follows:

• 18th overall

• 11th in quality of end-of-life care (40% weightage)

• 16th in availability of care (25% weightage)

• 20th in cost of care (15% weightage)

• 30th in healthcare environment (20% weightage)

These rankings underscore the urgent need for reform in perspectives, cultural attitudes, and healthcare resource allocation to enhance end-of-life care.

Prognostication and Survival Predictors

Nathan et al (2005) identified several independent predictors of survival in patients with bone metastases, including:

• Diagnosis

• ECOG performance status

• Number of bone metastases

• Presence of visceral metastases

• Hemoglobin level

While these parameters predict survival with an accuracy of 5–15%, the assessment by senior surgeons improves predictive accuracy to approximately 33%, highlighting the importance of clinical experience.

Hip Arthroplasty Outcomes

Studies indicate that the median survival following arthroplasty is approximately 8.6 months. Factors influencing outcomes include fracture site, time elapsed from primary diagnosis, and tumor type. Notably, breast cancer patients often exhibit shorter survival times. Despite this, hip reconstruction has been shown to significantly improve functional outcomes:

• ECOG score improved from 2.6 pre-operatively to 1.1 post-operatively

• Functional results: 25% excellent, 57% good, 12% fair, and 6% poor

Preliminary data from Singapore corroborates these findings, demonstrating cost savings and a return to activity following surgery.

Cost Analysis

Data from the UK estimates the cost of proximal femoral replacement at approximately £18,000 per inpatient stay, although quality-of-life comparisons remain limited. Preliminary results from Singapore reveal:

• 87% of patients ambulant post-operatively

• 70% regained the ability to walk

• Significant cost savings compared to conservative management

Preliminary Results

Nathan SS et al (2013)  studied cost savings in surgical interventions in hip metastatic disease. in Singapore in thiA review of 38 patients (mean age 63, 58% female, median survival 201 days) revealed:

• 39% presented with pathological fractures

• 52.6% were non-ambulant at presentation

• Significant cost difference: SGD 615,263 (non-surgical) versus SGD 28,134 (surgical)

• Even non-ambulant post-operative patients showed a trend toward cost reduction (SGD 60,290 versus SGD 28,600)

Conclusions

Reconstructive hip surgery in metastatic hip disease improves quality of life and reduces healthcare costs. Similar benefits are anticipated in long bone metastases. Outcomes for spinal metastases depend on timing and neurological status. Future studies will refine prognostication and cost-benefit analyses to optimize end-of-life orthopaedic interventions.