Page 116 - Predicting survival in patients with spinal bone metastasesL
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                                CHAPTER VIII
Spinal bone metastases (SBM) are a multifactorial and multidisciplinary clinical entity. Patient-specific symptoms, life expectancy, spinal stability and patient preference all need to be evaluated, in order to provide a balanced treatment.
Chapter II described a systematic review of risk factors associated with estimating survival in patients with SBM. In the 22 included studies, the prognostic factors most frequently associated with survival were the primary tumor and the performance status. The prognostic factors most frequently not associated with survival were age, gender, number and location of the SBM and the presence of a pathologic fracture. Models aiming to provide a prognosis for patients with SBM should be based on an accurate primary tumor classification, combined with a performance score. The benefit of adding other prognostic factors was considered uncertain.
Chapter III evaluated risk factors for survival in a surgical cohort of 106 patients operated for SBM. Even though the study was performed prior to the systematic review of chapter II, the results are almost identical.
The large retrospective cohort study described in Chapter IV was the basis of this thesis and described the creation of our own predictive model for life expectancy in SBM. By using the presented flowchart and assessing the primary tumor type, functional status and the presence of visceral metastases, a patient is stratified to a risk category. This risk category corresponds with a median overall survival and provides a decent measure of certainty when assessing life expectancy.
Chapter V aimed to further fine-tune the most important variable in estimating survival, namely the primary tumor type. Along with lung and prostate cancer, breast cancer is the most common cause of SBM. Predictive models do not take breast cancer phenotypes based on estrogen (ER), progesterone (PR) and human epidermal growth factor 2 (HER2) receptors into account. The aim of this study was to ascertain whether receptors are associated with survival, when the disease has progressed up to the point of SBM. Patients with SBM from breast cancer with a triple negative phenotype have a shorter survival time than patients with a receptor positive phenotype, showing that models estimating survival should be adjusted accordingly.
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