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Metastatic bone disease and the development of local specialist networks in the UK
Ashley Scrimshire, Tom Beckingsale, Kenneth S Rankin and Kanishka Ghosh
The incidence of cancer has increased by approximately 12% since the 1990s, with approximately 385,000 new cases each year in the UK [1]. Some of the most common types of cancer include breast, lung, prostate and renal. Along with thyroid cancer, these are also the types which commonly metastasise to long bones. Traditionally, once a patient develops symptomatic bone metastases their life expectancy was short, often measured in weeks to months, and functional demands were low. Thus, where surgery was indicated, implants such as intra-medullary nails would usually provide stability for long enough to outlive the patient and their systemic disease. However, treatment options for a wide range of cancers have dramatically improved over recent years. As a result, cancer survival has doubled in the past 40 years and there will be an estimated four million people living with cancer in the UK by 2035.
The presence of metastatic bone disease (MBD) at the time of a cancer diagnosis can be as high as 30% [2]. In addition, for those without MBD on presentation the cumulative annual incidence is estimated as 4.8% within one year, and 8.4% by ten years [3], with a mean time from cancer diagnosis to developing bone metastases of 400 days. However, this varies substantially depending on the tumour type and stage, with prostate cancer being the highest risk (up to 70% at 10 years), followed by lung, renal and breast cancer.
Due to the higher number of cancer survivors and high rates of bony metastases, the overall prevalence of MBD is increasing. In addition, these patients are becoming increasingly complex, with higher functional demands and expectations. Studies have repeatedly shown that quality not just quantity of life is important to oncology patients. Combined, this means that traditional treatments, such as intra-medullary nailing, may no longer be durable enough to outlast a significant proportion of these patients. Instead, more complex reconstructions, such as cement augmented fixation or endoprosthetic replacement, is often indicated to provide a reconstruction that will outlast the patient (Figure 1). In addition, it is important these cases are identified early as complication rates, length of stay and costs are significantly higher when MBD presents late, with a pathological fracture, compared to earlier prophylactic management [4].
Guidelines for management
As with any condition presenting to trauma and orthopaedic services the correct assessment, management and follow up of patients with MBD, with impending or complete pathological fracture, is essential. The British Orthopaedic Oncology Society (BOOS) and BOA standards for trauma and orthopaedics (BOAST) on the management of metastatic bone disease, set out the standard of care patients should receive5. Key elements of this guidance include the provision of a MBD lead in each unit, improved multi-disciplinary working, the development of pathways for prompt advice and referral, preoperative investigations and imaging, referral to a recognised tertiary MBD centre for solitary metastases (not always a primary bone sarcoma unit), follow-up and involvement of patients and their family/carers in decision making. Where indicated, surgical interventions should allow immediate weight-bearing and aim to outlast the lifetime of the patient. As outlined above, this means that traditional fixation techniques may require additional supplementation (i.e. with cement), and/or that alternative, more robust approaches to reconstruction may be required. In addition, these patients often have multiple co-morbidities and are frail. Recently published guidance commissioned by the Joint Collegiate Council for Oncology provides a useful benchmark for frailty assessment and holistic care for these patients [6].
However, co-ordinating care and setting up pathways for these complex patients is challenging. A wide range of multi-disciplinary teams are often involved in their work up, management and postoperative rehabilitation. This may include oncology, radiology (including interventional radiology where pre-operative embolisation is required), surgical teams and specialist physiotherapists. A recent study that collected data from 84 UK orthopaedic units has shown that UK practice is highly variable and often falls short of the BOAST standards [7].
MBD networks
The rapid expansion of MBD and the associated complexity is quickly outstripping the capacity of the UK’s primary bone sarcoma units, to whom many of these cases are referred. This has led to the development of regional MBD networks, with a drive towards regional management, in designated MBD units who have the appropriate MDT capabilities and expertise. The MBD network model follows a hub and spoke type design, with the development of regional MBD units who receive referrals from local Trusts, who are in turn supported by the primary bone sarcoma units for advice, support, or to take over care if appropriate (Figure 2).
There are however several barriers which have slowed the development of regional MBD centres in some areas. These include awareness of the issue, developing patient pathways, staff training and experience, funding, system resilience and new MDT working. The British Orthopaedic Oncology Society (BOOS) are actively engaging with surgeons and professional bodies to increase awareness of the burden of MBD and support regions setting up their networks. The past two BOOS conferences have included dedicated sessions, or more recently a whole day, for MBD. It is hoped this article will also go some way to increasing awareness. As for staff training and experience there are increasing numbers of ways this can be achieved, examples include visitations to primary bone sarcoma units, such as part of the Royal Orthopaedic Hospital’s educational offering, or newly developed post-CCT MBD fellowships.
Developing new patient pathways is often difficult and relies on dedication from a few key motivated individuals. However, collaborative working and sharing of ideas with other centres, including those that have successfully developed MBD pathways, networking at events such as the BOOS MBD conference, and working with industry partners can support the development and sustainability of local pathways.
Funding is often a concern when setting up MBD services. They require time for MDT preparation and discussion, theatre time and often expensive implants. One of the first steps to developing a new service and business cases is to understand the scale of the problem locally by collecting data on the incidence of MBD and the surgeries they receive. However, this is often difficult given the complexity of current, non-standardised pathways and variable modes of presentation. Furthermore, centres that have developed a MBD service typically find that once their service is set up the volume of referrals increases rapidly. Once services are developed it is important that time is appropriately job planned and resilience built into the system, so that if the one or two committed individuals can no longer run the service it doesn’t collapse. It is advised units work closely with their management, clinical coding and billing teams to ensure appropriate coding and remuneration of multidisciplinary clinics, complex cases, and implant recharging, where appropriate, to limit costs to a department. The ongoing BOOM-C audit is studying the costs associated with MBD management and how these are currently managed.
MBD is also increasingly being recognised by bodies such as the National Joint registry. In collaboration with BOOS new MBD and endoprosthetic data collection forms are under development, to allow monitoring of these implants and outcomes. Alongside this, a new complexity classification system for MBD is also being developed.
Research
In addition to setting out standards and raising awareness based on current literature, there are efforts under way to better understand and improve MBD patient care. This includes high quality research, such as the PORTRAIT randomised controlled trial. This trial will study the effectiveness of post-operative radiotherapy in surgically treated bone metastases8 and is due to start recruiting in 2025.
Summary
In summary, metastatic bone disease is a problem that is increasing in volume and complexity. As a community, we need to address this proactively, not reactively, or patients will suffer. As is the case across the spectrum of orthopaedic care we must strive to ensure these patients receive the most appropriate care and that, if surgery is recommended, we get it right first time. This should be delivered by appropriately experienced, multi-disciplinary teams, working to BOAST standards to ensure the best outcomes. The development of dedicated patient pathways and regional MBD networks, is challenging, but will lead to improved care and outcomes. Efforts from colleagues and societies to develop such pathways and networks should be supported by all of us. Our combined efforts here have the potential to make a significant positive impact on the quality of life and experience of our patients and their families, despite the complexity and life limiting nature of their disease.
References
1. Cancer Research UK. Cancer Statistics for the UK. Available at: www.cancerresearchuk.org/healthprofessional/cancer-statistics-for-the-uk.
2. Jiang W, Rixiati Y, Zhao B, et al. Incidence, prevalence, and outcomes of systemic malignancy with bone metastases. J Orthop Surg (Hong Kong). 2020;28(2):2309499020915989.
3. Hernandez RK, Wade SW, Reich A, Pirolli M, Liede A, Lyman GH. Incidence of bone metastases in patients with solid tumors: analysis of oncology electronic medical records in the United States. BMC Cancer. 2018;18(1):44.
4. Mosher ZA, Patel H, Ewing MA, et al. Early Clinical and Economic Outcomes of Prophylactic and Acute Pathologic Fracture Treatment. J Oncol Pract. 2019;15(2):e132-e140.
5. British Orthopaedic Association. Available at: www.boa.ac.uk/resource/boast-managementof-metastatic-bone-disease.html.
6. Royal College of Physicians. Implementing frailty assessment and management in oncology services. Available at: www.rcr.ac.uk/media/bwpmjnmz/ implementing-frailty-assessment-andmanagement-in-oncology-services.pdf.
7. Archer JE, Chauhan GS, Dewan V, et al. The British Orthopaedic Oncology Management (BOOM) audit. Bone Joint J. 2023;105B(10):1115-22.
8. The National Institute for Health and Care Research (NIHR). The PORTRAIT trial Post-operative radiotherapy in surgically treated bone metastases. Available at: www.dev.fundingawards.nihr.ac.uk/award/ NIHR159676.
