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Journal of Clinical Oncology, Vol 23, No 30 (October 20), 2005: pp. 7751-7752 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.02.7698
In ReplySunnybrook & Women's College Health Centre, Toronto, Ontario, Canada
Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
Sunnybrook & Women's College Health Centre, Toronto, Ontario, Canada Dr Chamberlain et al are to be thanked for sharing their expertise on several issues related to the diagnosis and treatment of malignant extradural spinal cord compression (MESCC). Many of the issues identified in their expert review are important and should be considered in the management of MESCC. Expert reviews are different, but complementary to systematic reviews (SR). The latter requires an explicit scope of review, a formal and reported systematic review of the literature, including strict selection criteria for the articles to be included in the SR. Finally, a narrative but transparent analysis of the evidence addressing each question based on the validity and bias present in each piece of evidence is required. A clinical practice guideline,1 on which this SR was based,2 also includes practitioner feedback.3 Therefore, some of the issues raised by Dr Chamberlain et al were not addressed because they fell outside the scope of the guideline.4 In order to improve the outcomes for patients with MESCC, a research framework could be employed based on the natural history of the disease.5 Before the symptoms of cord compression occur, patients at risk could have screening MRI and prophylactic radiotherapy (SMART) if thecal sac indentation (TSI) is present. Chamberlain et al suggests that patients with new onset back pain are at highest risk and should be investigated. It is well recognized that back pain is nearly universal in patients with MESCC6 and has been suggested in the work-up of patients with MESCC for over 25 years.7 However, the utility of the symptom as a predictor of diagnosis of MESCC has not been scientifically validated to our knowledge. Moreover, two studies have specifically evaluated predictors for radiographically confirmed cord compression8 or its suspected precursor, TSI.9 One study utilized CTs8 while the other examined MRIs.9 In both studies, back pain was not predictive of spinal cord compression or TSI on multivariate analysis. An equally important strategy to prevent MESCC could be the use of systemic therapies like bisphosphonates or more effective chemotherapeutic agents. Once the symptoms occur, there are often delays before the patient starts treatment10,11 and neurologic decline occurs in the majority of patients during that time.10 Educating patients at risk for MESCC about the symptoms of MESCC and what to do about it is another potential area of research. In each of the above paradigms, focusing on patients at high risk8,9,12 for MESCC may maximize cost effectiveness and minimize patient anxiety. Finally, better outcomes will also emerge from better treatment and better patient selection for these treatments. Dr Chamberlain et al made many good suggestions in this regard and together with valid clinical practice guidelines should enhance the outcomes of patients with this devastating oncologic syndrome. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Browman GP, Levine MN, Mohide EA, et al: The practice guidelines development cycle: A conceptual tool for practice guidelines development and implementation. J Clin Oncol 13:502-512, 1995 2. Loblaw DA, Laperriere N, Perry J, et al: Malignant extradural spinal cord compression: Diagnosis and management evidence summary report #9-9. Cancer Care Ontario Practice Guideline Initiative, 2004. Last updated January 2004. http://www.cancercare.on.ca/index_neurooncologyGuidelines.htm 3. Browman GP, Newman TE, Mohide EA, et al: Progress of clinical oncology guidelines development using the Practice Guidelines Development Cycle: The role of practitioner feedback. J Clin Oncol 16:1226-1231, 1998[Abstract]
4. Loblaw DA, Perry J, Chambers A, et al: Systematic review of the diagnosis and management of malignant epidural spinal cord compression. The Cancer Care Ontario Practice Guideline Inititative's Neuro-Oncology Disease Site Group. J Clin Oncol 23:2028-2037, 2005
5. Loblaw DA, Laperriere NJ: Emergency treatment of malignant extradural spinal cord compression: An evidence-based guideline. J Clin Oncol 16:1613-1624, 1998 6. Gilbert RW, Kim JH, Posner JB: Epidural spinal cord compression from metastatic tumor: Diagnosis and treatment. Ann Neurol 3:40-51, 1978[CrossRef][Medline] 7. Rodichuk LD, Harper GR, Ruckdeschel JC, et al: Early diagnosis of spinal epidural metastases. Am J Med 70:1181-1188, 1981[Medline] 8. Talcott JA, Stomper PC, Drislane FW, et al: Assessing suspected spinal cord compression: A multidisciplinary outcomes analysis of 342 episodes. Support Care Cancer 7:31-38, 1999[CrossRef][Medline] 9. Bayley A, Milosevic M, Blend R, et al: A prospective study of factors predicting clinically occult spinal cord compression in patients with metastatic prostate cancer. Cancer 92:303-310, 2001[CrossRef][Medline]
10. Husband DJ: Malignant spinal cord compression: Prospective study of delays in referral and treatment. BMJ 317:18-21, 1998 11. Mitera G, Loblaw DA: Delays from symptom onset to treatment in malignant spinal cord compression: Quantification and effect on pre-treatment neurological status. Proc Amer Soc Clin Oncol 23:119, 2004 (abstr 8276) 12. Loblaw DA, Laperriere NJ, Mackillop WJ: Who should be screened for malignant spinal cord compression? Defining a high-risk population. Clin Invest Med 23:S23, 2000 Related Correspondence
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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