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Featured Clinical Reviews

Perspectives on Care at the Close of Life
Clinician's Corner
February 27, 2008

Spinal Cord Compression in Patients With Advanced Metastatic Cancer: “All I Care About Is Walking and Living My Life”

Author Affiliations

Author Affiliations: Department of Medical Oncology, Division of Psychosocial Oncology, and Palliative Care, Harvard Medical School, Dana-Farber Cancer Institute, and Brigham and Women's Hospital (Dr Abrahm) and Department of Orthopedic Surgery, Harvard Combined Orthopedics Program (Dr Banffy) and Department of Orthopedic Surgery (Dr Harris), Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

JAMA. 2008;299(8):937-946. doi:10.1001/jama.299.8.937

As 1 of the 12 700 US cancer patients who, each year, develops metastatic spinal cord compression, Ms H wishes to walk and live her life. Sadly, this wish may be difficult to fulfill. Before diagnosis, 83% to 95% of patients experience back pain, which often is referred, obscuring the site(s) of the compression(s). Prediction of ambulation depends on a patient's ambulatory status before therapy and time between developing motor defects and starting therapy. Ambulatory patients with no visceral metastases and more than 15 days between developing motor symptoms and receiving therapy have the best rate of survival. To preserve ambulation and optimize survival, magnetic resonance imaging should be performed for cancer patients with new back pain despite normal neurological findings. At diagnosis, counseling, pain management, and corticosteroids are begun. Most patients are offered radiation therapy. Surgery followed by radiation is considered for selected patients with a single high-grade epidural lesion caused by a radioresistant tumor who also have an estimated survival of more than 3 months. Team discussions with the patient and support network help determine therapy options and include patient goals; assessment of risks, benefits, and burdens of each treatment; and discussion of the odds of preserving prognosis of ambulation and of the effect of therapy on the patient's overall prognosis. Rehabilitation improves impaired function and its associated depression. Clinicians can help patients cope with transitions in self-image, independence, family and community roles, and living arrangements and can help patients with limited prognoses identify their end-of-life goals and preferences about resuscitation and entering hospice.

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