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Advanced Metastatic Cancer: Janet L. Abrahm, MD, discusses spinal cord compression in patients with advanced metastatic cancer.
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Advanced Metastatic Cancer: Janet L. Abrahm, MD, discusses spinal cord compression in patients with advanced metastatic cancer.
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>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspective section. Today I have the pleasure of talking with Janet Abrahm about spinal cord compression in patients with advanced metastatic cancer, a topic discussed in Care at the Close of Life in a chapter co-authored by today's guest. Welcome to the podcast, Dr. Abrahm, and please introduce yourself to our listeners. >> Pleased to be with all of you. I'm Janet Abrahm. I'm the division chief of the adult palliative care division at Dana-Farber Cancer Institute in the department of psychosocial oncology and palliative care here at Dana-Farber and Brigham and Women's Hospital in Boston, Massachusetts.
>> Dr. Abrahm, what is spinal cord compression and what is its relationship to metastatic cancer? >> Spinal cord compression in patients who have metastatic cancer comes from the tumor itself compressing the spinal cord. The tumor can come from the vertebra where it's metastasized or, rarely, in lymphoma patients, for example, it can grow in through the foramina from the lymph nodes in which it had metastasized. So, it's usually the case that the spinal cord is compressed because the tumor has grown out of the bone or has grown in through the foramina and is then compressing with spinal cord so that the nerves don't work anymore.
>> What is the prevalence of spinal cord compression among patients with various kinds of cancer? >> Well, among around the 12,700 cancer patients in the US each year who develop spinal cord compression, the most common causes are breast, prostate and lung cancer. They each account for 15 to 20 percent of cases. Non-Hodgkin's lymphoma, myeloma and renal cell carcinoma each account for 5 to 10 percent of cases, and the remainder are mainly from colorectal cancer, cancer of unknown primary and sarcoma.
>> Which are the most common symptoms and signs of spinal cord compression? >> The cardinal sign and symptom, really, of spinal cord compression is back pain. A patient who has known cancer who develops back pain has to be considered a possibility of having spinal cord compression with no other physical signs or symptoms, so that if a patient has back pain but has normal neurologic function, has no paresthesias, can walk, has normal bowel and bladder function, they can still have an important spinal cord compression, important enough that it could be treated and any of the neurologic sequela could be completely prevented.
Eighty-three to 95 percent of patients have back pain prior to the diagnosis. It can be local, it can be referred, or it can be radicular. The referred ones can be tricky. You can have a spinal cord compression in your C7 vertebra but not feel it in your neck; you feel it between your scapula. Similarly, you can have a spinal cord compression at T12 but not feel it there, only feel it in your hip. So, patients who have known cancer and have pain in the hip or have pain between their shoulder blades have to be considered for spinal cord compression in those other sites.
>> I'd like to ask you about how spinal cord compression is diagnosed when screening for this problem is recommended and what screening tests are used? >> For spinal cord compression, there is no substitute for magnetic resonance imaging. It is the gold standard. There have been no algorithms or other kinds of studies that have shown that in a patient with back pain who has cancer, you always have to get the MRI to rule out a spinal cord compression. A CT will not do that.
The MRIs are 93 percent sensitive, 97 percent specific, and overall accuracy is 95 percent. In contrast, the plain X-ray has inadequate sensitivity and a false negative rate of 10 to 17 percent. It's not unusual to find unsuspected lesions. In 45 percent of patients, the MRI findings altered the radiation therapy field. There's one category of patients who you might think about getting a screening MRI, and that's a prostate cancer patient with more than 20 bone metastasis and who has had hormone therapy for several years.
They have a 44 percent incidence of spinal epidural disease. So, if function is really important and the patient might not let you know about back pain in time, you might even think about doing an MRI as a screen. >> Are there any other screening tests that might be used? >> There are no other screening tests. The most important screening test is a really heightened sensitivity to that symptom of back pain. >> What treatments are available for spinal cord compression?
>> There are a number of different treatments for spinal cord compression. In patients who have the kinds of cancers that tend to be refractory to radiation therapy like prostate cancer, melanoma, colon cancer, those kinds of tumors, surgery for limited spinal cord compression has been shown to maintain function even better than radiation therapy alone. So, in selected patients who are still ambulatory and who have a limited amount of a spinal cord compression, surgery followed by radiation therapy is more effective than radiation therapy alone.
Most patients will receive radiation therapy alone, and that radiation can be external beam radiation or more targeted radiation therapy. Now, for symptomatic therapy, glucocorticoid therapy is the gold standard. The dose of dexamethasone, however, is not settled. The early studies indicated very large doses were needed in people who had an actual cord compression to prevent functional deterioration. Doses like 100 milligram intervenous bolus followed by 24 milligrams every six hours.
Obviously, the side effects from these doses were enormous, and most people tend to use a 10 milligram bolus IV followed by 4 to 6 milligrams IV q six hours for patients. The dexamethasone decreases pain immediately, but it also preserves function by decreasing the vasogenic edema and preserving the spinal cord artery, which is the key to maintaining function. The artery has to remain open for the nerves to work. >> What factors should clinicians and patients take into consideration when weighing treatment options?
>> There are a number of factors that clinicians and patients take into account when weighing treatment options. I think that the symptomatic treatments are pretty standard. The dose of dexamethazone may be altered depending on the extent of the spinal cord compression. If there's just epidural disease and the patient has had a lot of difficulty with high doses of dexamethazone, then the clinician might choose a lower dose for that patient. But in anyone with a true spinal cord compression, high doses of dexamethazone are going to be needed.
The other pain medications should be individually tailored to the needs of the patient. The prognosis of the patient is really important to take into account when you think about whether you should suggest a surgery option or just a radiation therapy option. If a patient is expected to live a long time and paralysis would be an important problem, then it would be very important to take into account the fact that surgery may provide the best palliation in terms of continued ability to walk.
That's another thing that's very individual, though. There are some patients for whom the ability to walk is not that key and the additional healing from surgery would be a real problem so that they would take the chance of just getting the radiation therapy. Now, how many fractions of radiation therapy are needed are also determined by prognosis. For people who have a short prognosis, maybe a matter of months, radiation is very helpful to relieve the pain, but it can be given in only one or maybe two to four fractions rather than a long course of radiation therapy.
The shorter courses are good because they relieve pain. The only downside of them is that the disease doesn't get as well controlled so that if a patient was going to live six months or longer, then that patient would get a longer course of radiation therapy. >> What role does palliative care play in helping patients with spinal cord compression? >> Palliative care clinicians can help patients and families begin to explore and cope with changes in the self-image, independence, roles in the family and community and living arrangements that having a spinal cord compression may raise.
Here's some questions that may help you as you work with your patients who have a spinal cord compression. Help me understand what a typical day at home or work or school was like before all this started. What are the things that you need to get done? What do you really enjoy doing? Have you ever needed help to take care of yourself before? Do you know anyone who had to use a cane or wheelchair? How did you feel about that? How do you think it might make you feel?
If you weren't able to walk on your own, what would it take for you to be able to stay at home? Who's there to help during the day and overnight? Whom do you regularly consult about important issues? Is there one person who really understands what's important to you? Should we talk to them? Those are the kind of questions that can help you understand how to best help your patient who may have an impaired function and what resources you need to get in there for the patient and the family to help them cope with whatever changes in their physical functioning and, therefore, their personhood, their sense of self, their sense of their role in the world that this change might bring about.
Because even if you treat the cord compression, you need to treat the whole person, and palliative care can help you focus on restoring that whole person, healing that whole person, whether that person can walk again or not. >> That makes a lot of sense. Is there anything else you would like to tell our listeners about spinal cord compression in patients with advanced metastatic cancer? >> I think the thing I'd really like them to keep in mind is that having a very heightened sensitivity that a possibility of spinal cord compression and very aggressively treating patients even who have advanced disease can make an enormous difference to the quality of life that remains in these patients.
Being able to walk, having your own bowel and bladder function, those things can make all the difference in the last months of life for any patient, even with advanced disease. So, I would say be attuned to that symptom of back pain and be really aggressive about treating the patient. >> Thank you, Dr. Abrahm, for this helpful discussion of spinal cord compression in patients with advanced metastatic cancer. Additional information about this topic is available in Chapter 10 of Care at Close of Life.
This has been Joan Stephenson of JAMA talking with Dr. Janet Abrahm about spinal cord compression in patients with advanced metastatic cancer, for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspective section. Today I have the pleasure of talking with Janet Abrahm about spinal cord compression in patients with advanced metastatic cancer, a topic discussed in Care at the Close of Life in a chapter co-authored by today's guest. Welcome to the podcast, Dr. Abrahm, and please introduce yourself to our listeners. >> Pleased to be with all of you. I'm Janet Abrahm. I'm the division chief of the adult palliative care division at Dana-Farber Cancer Institute in the department of psychosocial oncology and palliative care here at Dana-Farber and Brigham and Women's Hospital in Boston, Massachusetts.
>> Dr. Abrahm, what is spinal cord compression and what is its relationship to metastatic cancer? >> Spinal cord compression in patients who have metastatic cancer comes from the tumor itself compressing the spinal cord. The tumor can come from the vertebra where it's metastasized or, rarely, in lymphoma patients, for example, it can grow in through the foramina from the lymph nodes in which it had metastasized. So, it's usually the case that the spinal cord is compressed because the tumor has grown out of the bone or has grown in through the foramina and is then compressing with spinal cord so that the nerves don't work anymore.
>> What is the prevalence of spinal cord compression among patients with various kinds of cancer? >> Well, among around the 12,700 cancer patients in the US each year who develop spinal cord compression, the most common causes are breast, prostate and lung cancer. They each account for 15 to 20 percent of cases. Non-Hodgkin's lymphoma, myeloma and renal cell carcinoma each account for 5 to 10 percent of cases, and the remainder are mainly from colorectal cancer, cancer of unknown primary and sarcoma.
>> Which are the most common symptoms and signs of spinal cord compression? >> The cardinal sign and symptom, really, of spinal cord compression is back pain. A patient who has known cancer who develops back pain has to be considered a possibility of having spinal cord compression with no other physical signs or symptoms, so that if a patient has back pain but has normal neurologic function, has no paresthesias, can walk, has normal bowel and bladder function, they can still have an important spinal cord compression, important enough that it could be treated and any of the neurologic sequela could be completely prevented.
Eighty-three to 95 percent of patients have back pain prior to the diagnosis. It can be local, it can be referred, or it can be radicular. The referred ones can be tricky. You can have a spinal cord compression in your C7 vertebra but not feel it in your neck; you feel it between your scapula. Similarly, you can have a spinal cord compression at T12 but not feel it there, only feel it in your hip. So, patients who have known cancer and have pain in the hip or have pain between their shoulder blades have to be considered for spinal cord compression in those other sites.
>> I'd like to ask you about how spinal cord compression is diagnosed when screening for this problem is recommended and what screening tests are used? >> For spinal cord compression, there is no substitute for magnetic resonance imaging. It is the gold standard. There have been no algorithms or other kinds of studies that have shown that in a patient with back pain who has cancer, you always have to get the MRI to rule out a spinal cord compression. A CT will not do that.
The MRIs are 93 percent sensitive, 97 percent specific, and overall accuracy is 95 percent. In contrast, the plain X-ray has inadequate sensitivity and a false negative rate of 10 to 17 percent. It's not unusual to find unsuspected lesions. In 45 percent of patients, the MRI findings altered the radiation therapy field. There's one category of patients who you might think about getting a screening MRI, and that's a prostate cancer patient with more than 20 bone metastasis and who has had hormone therapy for several years.
They have a 44 percent incidence of spinal epidural disease. So, if function is really important and the patient might not let you know about back pain in time, you might even think about doing an MRI as a screen. >> Are there any other screening tests that might be used? >> There are no other screening tests. The most important screening test is a really heightened sensitivity to that symptom of back pain. >> What treatments are available for spinal cord compression?
>> There are a number of different treatments for spinal cord compression. In patients who have the kinds of cancers that tend to be refractory to radiation therapy like prostate cancer, melanoma, colon cancer, those kinds of tumors, surgery for limited spinal cord compression has been shown to maintain function even better than radiation therapy alone. So, in selected patients who are still ambulatory and who have a limited amount of a spinal cord compression, surgery followed by radiation therapy is more effective than radiation therapy alone.
Most patients will receive radiation therapy alone, and that radiation can be external beam radiation or more targeted radiation therapy. Now, for symptomatic therapy, glucocorticoid therapy is the gold standard. The dose of dexamethasone, however, is not settled. The early studies indicated very large doses were needed in people who had an actual cord compression to prevent functional deterioration. Doses like 100 milligram intervenous bolus followed by 24 milligrams every six hours.
Obviously, the side effects from these doses were enormous, and most people tend to use a 10 milligram bolus IV followed by 4 to 6 milligrams IV q six hours for patients. The dexamethasone decreases pain immediately, but it also preserves function by decreasing the vasogenic edema and preserving the spinal cord artery, which is the key to maintaining function. The artery has to remain open for the nerves to work. >> What factors should clinicians and patients take into consideration when weighing treatment options?
>> There are a number of factors that clinicians and patients take into account when weighing treatment options. I think that the symptomatic treatments are pretty standard. The dose of dexamethazone may be altered depending on the extent of the spinal cord compression. If there's just epidural disease and the patient has had a lot of difficulty with high doses of dexamethazone, then the clinician might choose a lower dose for that patient. But in anyone with a true spinal cord compression, high doses of dexamethazone are going to be needed.
The other pain medications should be individually tailored to the needs of the patient. The prognosis of the patient is really important to take into account when you think about whether you should suggest a surgery option or just a radiation therapy option. If a patient is expected to live a long time and paralysis would be an important problem, then it would be very important to take into account the fact that surgery may provide the best palliation in terms of continued ability to walk.
That's another thing that's very individual, though. There are some patients for whom the ability to walk is not that key and the additional healing from surgery would be a real problem so that they would take the chance of just getting the radiation therapy. Now, how many fractions of radiation therapy are needed are also determined by prognosis. For people who have a short prognosis, maybe a matter of months, radiation is very helpful to relieve the pain, but it can be given in only one or maybe two to four fractions rather than a long course of radiation therapy.
The shorter courses are good because they relieve pain. The only downside of them is that the disease doesn't get as well controlled so that if a patient was going to live six months or longer, then that patient would get a longer course of radiation therapy. >> What role does palliative care play in helping patients with spinal cord compression? >> Palliative care clinicians can help patients and families begin to explore and cope with changes in the self-image, independence, roles in the family and community and living arrangements that having a spinal cord compression may raise.
Here's some questions that may help you as you work with your patients who have a spinal cord compression. Help me understand what a typical day at home or work or school was like before all this started. What are the things that you need to get done? What do you really enjoy doing? Have you ever needed help to take care of yourself before? Do you know anyone who had to use a cane or wheelchair? How did you feel about that? How do you think it might make you feel?
If you weren't able to walk on your own, what would it take for you to be able to stay at home? Who's there to help during the day and overnight? Whom do you regularly consult about important issues? Is there one person who really understands what's important to you? Should we talk to them? Those are the kind of questions that can help you understand how to best help your patient who may have an impaired function and what resources you need to get in there for the patient and the family to help them cope with whatever changes in their physical functioning and, therefore, their personhood, their sense of self, their sense of their role in the world that this change might bring about.
Because even if you treat the cord compression, you need to treat the whole person, and palliative care can help you focus on restoring that whole person, healing that whole person, whether that person can walk again or not. >> That makes a lot of sense. Is there anything else you would like to tell our listeners about spinal cord compression in patients with advanced metastatic cancer? >> I think the thing I'd really like them to keep in mind is that having a very heightened sensitivity that a possibility of spinal cord compression and very aggressively treating patients even who have advanced disease can make an enormous difference to the quality of life that remains in these patients.
Being able to walk, having your own bowel and bladder function, those things can make all the difference in the last months of life for any patient, even with advanced disease. So, I would say be attuned to that symptom of back pain and be really aggressive about treating the patient. >> Thank you, Dr. Abrahm, for this helpful discussion of spinal cord compression in patients with advanced metastatic cancer. Additional information about this topic is available in Chapter 10 of Care at Close of Life.
This has been Joan Stephenson of JAMA talking with Dr. Janet Abrahm about spinal cord compression in patients with advanced metastatic cancer, for JAMAevidence.
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