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

2. 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?

3. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. DECISIONS, DECISIONS……

4. 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……...

5. 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

6. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. BUT - HOW DO WE COMPARE THEM ? WHAT IS BEST ?? HOW DOES A PATIENT DECIDE ?

7. 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 ?

8. 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

9. 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

10. 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 QoL eg. if we assume that a THR costs 10,000 $/Euros and that the average survival is 15 years with an alteration of QoL from 0.75 to 0.95, then the QALY value is: –10,000 / 15 X (0.95 - 0.75) = 3,300 $/Euros per QALY

11. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. The Rosser Index Matrix

12. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. WHY NOT DO THE SAME FOR ORTHOPAEDIC ONCOLOGY QoL 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 ?

13. 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 ?

14. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. THE TOTAL FUNCTIONAL SCORE IS THE AREA UNDER THE CURVE

15. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. EPR - FAILED AT TWO YEARS - AMPUTATION 50403020100 0.0 0.2 0.4 0.6 0.8 1.0 Units of time Functiona Score

16. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. SUCCESSFUL EPR - PATIENT DIES AT TWO YEARS 403020100 0.0 0.2 0.4 0.6 0.8 1.0 Units of Time Functional Score

17. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. EPR - FAILED AT TWO YEARS - REVISED 50403020100 0.0 0.2 0.4 0.6 0.8 1.0 Units of Time Functional Score

18. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. HOW TO ADD IT ALL TOGETHER Successful EPR, functions at 80%, Successful EPR, but patient dies (mean of 2yrs) Successful initially, but failure leads to amputation 0.5% risk /yr 40% will die 3% risk / yr Revision and recovery

19. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. 10 YEAR SCORES 50403020100 0.0 0.2 0.4 0.6 0.8 1.0 Failed EPR - followed by amputation Units of time Functiona Score Score = 7.75 Score = 1.5 Score = 6.15 0.5% risk /yr 3% risk / yr Score = 7.65

20. 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 score 7.75 40% successful but diescore 1.5 3% revision ratescore7.65 0.5% amputation ratescore 1.5 TOTAL5.38 FUNLYs

21. 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.

22. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. TEN YEAR SCORES Endoprosthesis5.38 FUNLYs Rotationplasty5.25 FUNLYs Distraction osteogenesis5.2 FUNLYs Allograft 5.2 FUNLYs Amputation3.98 FUNLYs Arthrodesis3.5 FUNLYs

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

24. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. DECISION MAKING…. Cost, Residual value, Problems, Street cred, Will it fit in my garage etc.

25. 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

26. 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

27. Royal Orthopaedic Hospital Oncology Service, Birmingham, U.K. The FUNLY method AmputationLimb Salvage Clear margins80%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 x0.3) 0.67 + 0.05 = 0.72 (0.69 x 0.8) + (0.31 x 0.3) 0.55 +.09 = 0.64

28. 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

29. 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.7 x 10) + (0.64 x.3 x.5 x 10) + (0.36 x.7 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

30. 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