Palliative medicine


In the light of international differences in cultural perspectives on end-of-life issues, increased survivorship of cancer patients, evolution of musculoskeletal oncology as a subspecialty and increasing awareness of end-of-life issues among Asians, cancer with osseous metastases presents a unique challenge to the musculoskeletal oncologist. Quality of life issues are gaining importance in the management and decision making of these patients, as opposed to conventional decision making based on survivorship alone (Figure 1).  The sheer number of patients who present with osseous metastases without visceral metastases has risen over the last few years and these patients tend to do better than those with osseous and visceral metastases. Management challenges in these patients involve prognostication, assessing survivorship, improving quality of life while balancing this with ever-increasing health-care costs.

The most common orthopedic interventions in these settings involve spinal decompressions and stabilization for metastatic disease of the spine, hip replacement surgery for metastatic hip disease and long bone stabilization. These are often costly affairs but our analysis presented below shows that it is actually cheaper to offer palliative surgery in the appropriately selected patient. While an overarching principle of ethics and humane consideration drives surgery in this area, this article attempts to extend the role of surgery and its consideration even further. It is our belief that surgical palliation is actually more cost-effective than conservative management and this has been substantiated by our own recent publications. Similarly the author is involved in a number of regional initiatives and organizations that are raising awareness of the plight of terminally afflicted patients and the great differences to life quality that can be achieved with these interventions. This has become readily apparent in the light of recent publications that suggest the poor attention palliative care has received despite the relative affluence of the country (Figure 2).

Figure 1. The Lien Foundation Poll , ST April 4, 2009 conducted on 800 respondents very clearly showed the desires of people in terminal states. Of interest the top desires of mobility, indulging and not being a burden to family can very readily be afforded by procedures as shown in the xrays. Such procedures allow the patient to remain mobile. The patient shown in bottom right was even able to return to line dancing and work after being told she would never walk again.

A study by the Lien Foundation and conducted internationally by the Economist Intelligence Unit (EIU) In July 2010 defined a global Quality of Death Index.  40 countries were surveyed, The United Kingdom ranked 1st and Singapore ranked 18th overall. Singapore ranked 11th with respect to quality of end-of-life care, a factor with 40 per cent weightage.  It ranked 16th on availability of care (25 per cent weightage). With reference to cost of care (15 per cent weightage) the Singapore was at 20th position. Basic end of-life healthcare environment (20 per cent weightage) put Singapore at the 30th position (Figure 2a).

As alluded to below, previously survivorship was the main consideration for surgery. However as tools for assessing quality of life now become more accessible we are in a better position to evaluate and make statements about the most appropriate therapy for correct siting of care. So for example while a patient with a pathological hip fracture may be allowed to walk again after hip replacement surgery, the patient with paralysis after a spine pathological fracture might remain paralyzed and therefore have his terminal agony extended by the surgery. It is too difficult and too sensitive to answer these sorts of questions presently because this data does not exist. The author who has been publishing on the subject for close to a decade has lectured extensively and globally. It is our belief that many of these patients with the right interventions can continue to be active members of society (Figure 2b) but there must be a better siting of most appropriate care.

Figure 2(a). Press Release July 14, 2010- Singapore ranks 18th for death quality. More importantly it showed that the prosperity of a country did not equate to better end-of-life care. This may spell a very skewed allocation of resources in a country preferring instead to look after potentially salvageable rather than terminal patients. The results of this study would be able to shed some light on these options and the right siting of care both for patients and doctors as well as administrators. 

The message is clear - perspectives on palliative care as a nation, cultural attitudes towards death and end-of-life issues, and most importantly allocation of resources and healthcare budgeting needs a reform. End-of-life care can no longer be ‘sidelined’ and attitudes which encourage indifference of health care professionals towards this issue need to be seriously examined. Cost analyses of various palliative interventions and hospice care have to be carried out objectively.

Figure 2(b). The journey of a patient facing end-of-life issues and death – the importance of palliative care and quality of life (ST October 9, 2010). Such patients through programs in palliative centres are thought the value of cosmetics to allow them to continue meaningful lives in the community. Similarly the ability to continue walking would allow for this interaction.

Providing tangible improvements and changes in perspective of palliative care practice in Singapore ande Southeast Asia 

Decisions regarding potential surgery for metastatic disease require reliable data about patient survival and quality of life. Various indices for prognostication have been proposed but their accuracy in predicting actual survival is questionable. Nathan et al, 2005, has shown that the only independent predictors of survival in the patient with bone metastases are diagnosis, Eastern Cooperative Oncology Group (ECOG) performance status, number of bone metastases, presence of visceral metastases, and hemoglobin level. These parameters distinguish, with an accuracy of 5% to 15%, the ability of patients to survive less than 6 months when these parameters are unfavorable and more than 12 months when they are favorable. An assessment by a senior surgeon independent of these factors is far more accurate at 33%.

There have been numerous studies analyzing the predictive factors for survival post surgery for hip and proximal femoral metastases. A large study of two hundred and ninety-nine patients who had undergone a total of 306 hemiarthroplasty or total hip arthroplasty between the period of 1969 to 1996 for an impending or present pathologic hip fracture showed a median duration of survival post arthroplasty of 8.6 months, with fracture site, time from primary diagnosis and diagnosis of primary tumor being significantly associated with length of survival post arthroplasty. In general patients with diagnosis of breast cancer and shorter duration from primary diagnosis to surgery have shorter length of survival and this can aid the surgeon in weighing the risk and benefit in offering a hip arthroplasty to the patient. Another study of 62 consecutive patients who underwent 63 hip arthroplasties with acetabular reconstruction again demonstrated that primary tumor as well as presence of visceral metastases predicted survival in these patients, length of survival post operatively in breast cancer was longer at 21 months compared to 9 months in other cancers. 

Hip reconstruction has been shown to improve functional outcome in patients with hip metastases, in the above mentioned study the ECOG score of the 62 patients who underwent hip arthroplasty with acetabular reconstruction improved from an average of 2.6 preoperatively to 1.1 postoperatively. In another study of total hip replacement for proximal femur metastases functional results were excellent in 25% of patients, good in 57%, fair in 12%, and poor in 6%. To date the PI has performed more than two hundred hip, spine and long bone reconstructive procedures for metastasis both in Singapore and in New York and the results globally are comparable. It is inexcusable to somehow entertain the idea that Asian patients in Singapore would be more fatalistic and less likely to benefit from such procedures. Our own preliminary data of 40 local Singaporeans undergoing hip replacements for metastasis shows both a significant cost savings and return to activity following hip replacement surgery. 

There have been studies that attempt to quantify the cost of surgical treatment of osseous metastases. A study of 62 patients who had underwent 63 proximal femoral replacements for metastatic bone disease over a seven year period in the United Kingdom showed the estimated cost of one inpatient stay for the surgical treatment of proximal femoral metastases with a proximal femoral replacement is approximately £18,000. However this study did not document the whether there was an improvement of quality of life and post operative ambulatory status in these patients and did not compare the cost of surgical treatment with non surgical treatment and stay in a palliative step down care facility.

Our preliminary results with hip reconstruction surgery in patients with metastatic hip lesions have been encouraging with 87% of our patient’s being ambulant post operatively and significant cost savings. All patients who were ambulant pre-operatively continued to walk afterwards and 70% of those who were non-ambulant pre-operatively regained the ability to walk post-operatively. We aim to evaluate the role of end-of-life orthopaedic interventions among subgroups of patients with metastases to the spine as well as long bones as a form of surgical palliation to keep these patients ambulant and provide them with a better quality of life during the terminal stages of their disease. At the same time a cost-benefit analysis comparing the cost of surgical management and conservative management in a hospice care setting will help us assess the economic benefits of end-of-life orthopaedic interventions in these groups of patients. With improved prognostication and knowledge as to which patients will benefit from end-of-life orthopaedic interventions, and the comparative costs between conservative and surgical management, we hope to improve the quality of life of our patients with metastatic cancer in a cost-effective manner.

The major criticism of all cost-benefit analysis is that the lessons may not be applicable across nations especially in the region. Typically, the author faces great resistance in the region lecturing on the merits of palliative orthopedic intervention in end-of-life care. The commonest reason for this is the cost of the procedure. We circumvent this by making use of economic indices like the Big Mac Index (Figure 3). This gives a value of the currency in a normalized fashion that would then be able to be used for the purposes of international conversion. For example, using figures in July 2008, the price of a Big Mac was $3.57 in the United States (Varies by store). The price of a Big Mac was £2.29 in the United Kingdom (Britain) (Varies by region). The implied purchasing power parity was $1.56 to £1, that is $3.57/£2.29 = 1.56. This compares with an actual exchange rate of $2.00 to £1 at the time. The pound was thus overvalued against the dollar by 28% (ie. [(2.00-1.56)/1.56]*100= +28%). Therefore by knowing what the cost of the procedure is in 2 different countries we may be able to conclude that the procedure is indeed cost-effective relative to a “standard global dollar” which we have designated “Big Mac Dollar” in the chart below.

Our preliminary data shows that reconstructive hip surgery is both cost-effective as well as increases quality of life (outcome measure being ambulatory status) in patients with metastic cancer with destructive hip lesions. Future sudies will evaluate the cost-effectiveness and role of orthopaedic surgical interventions in patients with metastases to long bones as well as the spine. 

Figure 3. The author has published widely and presented in a number of countries globally. It has become clear that orthopaedic intervention in a palliative setting is viewed as a “waste of resources”. One of the mistaken beliefs for this is that it is not cost-effective to operate on such patients. This is understandable as there has been no good studies on which to make comparisons. Singapore under this proposal can lead the way regionally and globally. By using indices like the Big Mac Index (The Economist 2010), the author has been able to show that palliative care across nations is cost-effective. In the above table for example, the Malaysian dollar is grossly undervalued hence a procedure may seem very expensive in Singapore but when normalised to the Big Mac Index, this gap is much smaller than anticipated.

Preliminary Results

We have been actively involved in cost benefit research in palliative orthopaedic care over last decade with multiple local and international publications and conferences. In a recent publication of 101 patients with bony metastases managed by the author's unit it was discovered that physicians prediction of survival was poor. Preliminary data from 38 of these patients with osseous metastases around the hip suggest that pre-operative ambulatory status and absence of pathological fracture pre-operatively predict post-operative ambulatory status. Among these patients, hip reconstruction in patients with destructive hip tumors was cost-effective compared to no surgery. Patients with poorer ambulatory status at presentation also benefited from 2.1 fold reduction in costs expenditure. Details of this preliminary review are presented in Figures 4 to 6.

Briefly, 38 patients (mean age 63 years SD 10.9, 58% females, median survival 201 days (34 to 1602), median duration of hospital stay 16 days (5 to 67) were studied. Fifteen patients (39%) presented with pathological fractures. Eighteen (47.4%), 4 (10.5%), 12 (31.6%), 4 (10.5%) had Harrington Type I, II, II, IV fractures respectively. Twenty (52.6%) patients were non-ambulating (ECOG 3, 4) at presentation. Postulated excess in costs among non-surgical group compared to surgical group was significant (SGD615263 vs SGD28134, p=0.03). Even in non-ambulating patients, there was a non-significant trend towards lower costs after hip reconstruction (SGD60290 vs SGD28600, p=0.08) compared to no surgery.

It is fairly apparent from this review that reconstructive hip surgery in patients with metastases around the hip has its merits both in terms of improving quality of life as well as significant cost-savings overall.  We postulate that similar cost savings will result in patients who have osseous metastases to long bones. This data needs to be collected. However, in the case of spinal metastases, those who present acutely and have reversible neurological deficits are likely to benefit from the cost-savings point of view, whereas patients who have established neurological deficits and present late are still going to be non-ambulant after surgery and will incur the costs of hospice care etc. This critical piece of information is presently missing and does not permit health care providers to make good recommendations for cost effective treatment.

Figure 4. Cost difference between non-surgical and surgical patient. The cost of managing a terminal patient was significantly lower when hip replacement surgery was performed on the patient compared to when no surgery was offered (p=0.03).


Figure 5. Pre-morbid ambulatory status as predictor for post-operative mobility. Our analysis showed that the ability to walk was best conferred on the patient who was still ambulant pre-operatively. This was statistically significant (p<0.05). One should therefore not wait till the patient is non-ambulant as the benefits would be reduced.


Figure 6. Pre-morbid fracture status as predictor for post-operative mobility. Our analysis showed that the ability to walk was best conferred on the patient operated on prophylactically and not after the patient had had a pathological fracture. This was statistically significant (p<0.05).