Estimating Survival in Patients with Skeletal Metastases Using PATHFx: An Adaptive, Validated, Clinical Decision Support Tool

  • Jonathan A. ForsbergEmail author
  • Rikard Wedin


We are in the middle of a healthcare revolution. Big data including demographics, molecular markers, and physiologic indicators are being codified by advanced techniques in information technology. The result is an explosion in the number of prognostic models that have been applied to a variety of clinical problems. Given that mobile or otherwise interconnected applications are ubiquitous in modern society, physicians may be tempted to confuse fingertip availability and relative ease of use with a tool that has been properly vetted for clinical use. It would seem that tech-savvy doctors are abandoning their healthy skepticism that has been ingrained by years of journal clubs, academic medicine, and/or clinical practice. However, this should not be the case. When using an “app,” physicians should demand the same level of scrutiny and apply the same healthy skepticism as they do for the literature they read, the implants they select, and the medications they prescribe [1].


  1. 1.
    Forsberg JA. Suggested guidelines. In: Wedin R, Bauer H, Weidenhielm L, editors. Turning data into decisions. Stockholm: Karolinska University Press; 2015. p. 1–74.Google Scholar
  2. 2.
    Glare P, Virik K, Jones M, et al. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ. 2003;327(7408):195–8. Scholar
  3. 3.
    Hartsell WF, Desilvio M, Bruner DW, et al. Can physicians accurately predict survival time in patients with metastatic cancer? Analysis of RTOG 97-14. J Palliat Med. 2008;11(5):723–8. Scholar
  4. 4.
    Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med. 2001;134(12):1096–105.CrossRefPubMedGoogle Scholar
  5. 5.
    Weeks JC, Cook EF, O'Day SJ, et al. Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA. 1998;279(21):1709–14.CrossRefPubMedGoogle Scholar
  6. 6.
    Clohisy DR, Le CT, Cheng EY, Dykes DC, Thompson RC. Evaluation of the feasibility of and results of measuring health-status changes in patients undergoing surgical treatment for skeletal metastases. J Orthop Res. 2000;18(1):1–9. Scholar
  7. 7.
    Harrington KD, Sim FH, Enis JE, Johnston JO, Dick HM, Gristina AG. Methyl methacrylate as an adjunct in internal fixation of pathological fractures. J Bone Joint Surg Am. 1976;58(8):1047–55.CrossRefPubMedGoogle Scholar
  8. 8.
    Forsberg JA, Wedin R, Bauer H. Which implant is best after failed treatment for pathologic femur fractures? Clin Orthop Relat Res. 2013;471(3):735–40. Scholar
  9. 9.
    Sugiura H, Yamada K, Sugiura T, Hida T, Mitsudomi T. Predictors of survival in patients with bone metastasis of lung cancer. Clin Orthop Relat Res. 2008;466(3):729–36.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Schneiderbauer MM, Knoch von M, Schleck CD, Harmsen WS, Sim FH, Scully SP. Patient survival after hip arthroplasty for metastatic disease of the hip. J Bone Joint Surg Am. 2004;86(8):1684–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Lin PP, Mirza AN, Lewis VO, et al. Patient survival after surgery for osseous metastases from renal cell carcinoma. J Bone Joint Surg Am. 2007;89(8):1794–801. Scholar
  12. 12.
    Narazaki D, Alverga Neto C, Baptista A, Camargo M. Prognostic factors in pathologic fractures secondary to metastatic tumors. Clinics. 2006;61:313–20.PubMedGoogle Scholar
  13. 13.
    Nathan S, Healey J, Mellano D, et al. Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care. J Clin Oncol. 2005;23(25):6072–82.CrossRefPubMedGoogle Scholar
  14. 14.
    Hansen BH, Keller J, et al. The Scandinavian Sarcoma Group Skeletal Metastasis Register. Survival after surgery for bone metastases in the pelvis and extremities. Acta Orthop Scand Suppl. 2004;75(311):11–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Stevenson JD, McNair M, Cribb GL, Cool WP. Prognostic factors for patients with skeletal metastases from carcinoma of the breast. Bone Joint J. 2016;98-B(2):266–70. Scholar
  16. 16.
    Sørensen MS, Gerds TA, Hindsø K. Prediction of survival after surgery due to skeletal metastases in the extremities. Bone Joint J. 2016;98-B(2):271–7. Scholar
  17. 17.
    Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5(6):649.CrossRefPubMedGoogle Scholar
  18. 18.
    Bauer H, Wedin R. Survival after surgery for spinal and extremity metastases: prognostication in 241 patients. Acta Orthop. 1995;66(2):143–6.CrossRefGoogle Scholar
  19. 19.
    Tokuhashi Y, Matsuzaki H, Toriyama S, Kawano H, Ohsaka S. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine. 1990;15(11):1110–3.CrossRefPubMedGoogle Scholar
  20. 20.
    Karnofsky DA. The clinical evaluation of chemotherapeutic agents in cancer. New York: Columbia University Press; 1949.Google Scholar
  21. 21.
    Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine. 2005;30(19):2186–91.CrossRefPubMedGoogle Scholar
  22. 22.
    Yamashita T, Siemionow KB, Mroz TE, Podichetty V, Lieberman IH. A prospective analysis of prognostic factors in patients with spinal metastases: use of the revised Tokuhashi score. Spine. 2011;36(11):910–7. Scholar
  23. 23.
    Paulino Pereira NR, Janssen SJ, van Dijk E, et al. Development of a prognostic survival algorithm for patients with metastatic spine disease. J Bone Joint Surg Am. 2016;98(21):1767–76. Scholar
  24. 24.
    Katagiri H, Takahashi M, Inagaki J, Sugiura H, Ito S, Iwata H. Determining the site of the primary cancer in patients with skeletal metastasis of unknown origin. Cancer. 2000;86(3):533–7.CrossRefGoogle Scholar
  25. 25.
    Forsberg JA, Wedin R, Bauer HCF, et al. External validation of the Bayesian Estimated Tools for Survival (BETS) models in patients with surgically treated skeletal metastases. BMC Cancer. 2012;12(1):493. Scholar
  26. 26.
    Mavrogenis AF, Angelini A, Vottis C, et al. Modern palliative treatments for metastatic bone disease. Clin J Pain. 2016;32(4):337–50. Scholar
  27. 27.
    Steensma M, Healey JH. Trends in the surgical treatment of pathologic proximal femur fractures among Musculoskeletal Tumor Society members. Clin Orthop Relat Res. 2013;471(6):2000–6. Scholar
  28. 28.
    Wedin R, Bauer HC, Wersäll P. Failures after operation for skeletal metastatic lesions of long bones. Clin Orthop Relat Res. 1999;358:128–39.CrossRefGoogle Scholar
  29. 29.
    Steensma M, Boland PJ, Morris CD, Athanasian E, Healey JH. Endoprosthetic treatment is more durable for pathologic proximal femur fractures. Clin Orthop Relat Res. 2012;470(3):920–6. Scholar
  30. 30.
    Forsberg JA, Eberhardt J, Boland PJ, Wedin R, Healey JH. Estimating survival in patients with operable skeletal metastases: an application of a Bayesian belief network. PLoS One. 2011;6(5):e19956. Scholar
  31. 31.
    Piccioli A, Spinelli MS, Forsberg JA, et al. How do we estimate survival? External validation of a tool for survival estimation in patients with metastatic bone disease-decision analysis and comparison of three international patient populations. BMC Cancer. 2015;15(1):424. Scholar
  32. 32.
    Forsberg JA, Wedin R, Boland PJ, Healey JH. Can we estimate short- and intermediate-term survival in patients undergoing surgery for metastatic bone disease? Clin Orthop Relat Res. 2017;475:1252–61. Scholar
  33. 33.
    Forsberg JA, Sjoberg D, Chen Q-R, Vickers A, Healey JH. Treating metastatic disease: which survival model is best suited for the clinic? Clin Orthop Relat Res. 2013;471(3):843–50. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Orthopaedic Oncology, Orthopaedics, Walter Reed Department of SurgeryUniformed Services University of the Health SciencesBethesdaUSA
  2. 2.Department of Molecular Medicine and SurgeryKarolinska InstituteStockholmSweden
  3. 3.Orthopaedic Oncology, Department of Orthopaedic SurgeryJohns Hopkins UniversityBaltimoreUSA
  4. 4.Department of Molecular Medicine and SurgeryKarolinska InstituteStockholmSweden
  5. 5.Department of OrthopaedicsKarolinska University HospitalStockholmSweden

Personalised recommendations