DECISION MAKING IN ORTHOPAEDIC ONCOLOGY Robert J GRIMER

DECISION MAKING IN ORTHOPAEDIC ONCOLOGY Robert J GRIMER Adesegun ABUDU Consultant Orthopaedic Oncologists Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

THE 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…… Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

HOW DECISIONS USED TO BE MADE ! • Local expertise and enthusiasm • What was available eg. Amputation Rotationplasty Endoprosthesis Autograft Allograft Arthrodesis Distraction osteogenesis etc……. . . Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

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 ? Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

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 ? • 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 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 ? • 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 Qo. L • eg. if we assume that a THR costs 10, 000 $/Euros and that the average survival is 15 years with an alteration of Qo. L 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 Matrix Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

WHY NOT DO THE SAME FOR ORTHOPAEDIC ONCOLOGY • Qo. L 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 ? • • • 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 CURVE Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

EPR - FAILED AT TWO YEARS - AMPUTATION 1. 0 Functiona Score 0. 8 0. 6 0. 4 0. 2 0. 0 0 10 20 30 40 50 Units of time Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

SUCCESSFUL EPR PATIENT DIES AT TWO YEARS 1. 0 Functional Score 0. 8 0. 6 0. 4 0. 2 0. 0 0 10 20 30 40 Units of Time Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

EPR - FAILED AT TWO YEARS - REVISED 1. 0 Functional Score 0. 8 0. 6 0. 4 0. 2 0. 0 0 10 20 30 40 50 Units of Time Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

HOW TO ADD IT ALL TOGETHER Successful EPR, functions at 80%, 0. 5% risk /yr Successful EPR, but patient dies (mean of 2 yrs) 3% risk / yr Successful initially, but failure leads to amputation Revision and recovery 40% will die Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

10 YEAR SCORES 1. 0 Failed EPR - followed by amputation 0. 8 Score = 7. 75 Score = 6. 15 Functiona Score 0. 6 0. 4 0. 5% risk /yr 0. 2 0. 0 0 10 20 30 40 50 Units of time Score = 7. 65 Score = 1. 5 3% risk / yr Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

CUMULATIVE SCORE Sum of all functional scores over a defined time period eg. over 10 years: 60% have a successful EPR 40% successful but die 3% revision rate 0. 5% amputation rate TOTAL score 7. 75 score 1. 5 score 7. 65 score 1. 5 5. 38 FUNLYs Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

COMPARISONS • 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 SCORES • • • Endoprosthesis Rotationplasty Distraction osteogenesis Allograft Amputation Arthrodesis 5. 38 FUNLYs 5. 25 FUNLYs 5. 2 FUNLYs 3. 98 FUNLYs 3. 5 FUNLYs Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

WE DO THIS EVERY DAY ! Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

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 ? • 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. . . • Chances of getting LR – Clear margins 10% – Close margins 40% • Chances of cure – 80% if no LR – 30% if get LR Survival by LR Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.

The FUNLY method Clear margins Amputation Limb Salvage 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 x 0. 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 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… • 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 10) + (0. 64 x. 3 x. 5 x 10) + (0. 36 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.

CONCLUSION • 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 Royal Orthopaedic Hospital Oncology Service, Birmingham, U. K.