Quality of life in patients with malignant spinal cord compression: a review of evidence-based literature.

Review

Quality of life in patients with malignant spinal cord compression: a review of evidence-based literature Mary Harris

© 2016 MA Healthcare Ltd

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alignant spinal cord compression (MSCC) is a devastating complication of metastatic cancer, which affects approximately 4000 patients in England and Wales each year (National Institute for Health and Care Excellence (NICE), 2008). It occurs in 3–5% of patients with cancer, and affects 10% of patients who have spinal metastases (Watson et al, 2005). Bone metastases in the spinal column can progress to MSCC when tumours in the pedicles of the vertebrae directly invade the spinal canal. This leads to vertebral destruction, blocking of the cerebrospinal fluid and pressure on the spinal cord (Dowling, 2001). Initial symptoms of back pain and neurological symptoms often go unrecognised. Delay in diagnosis is common, and symptoms are often attributed to general debility. Diagnosis is usually confirmed by magnetic resonance imaging (MRI), which should include the whole spine, enabling detection of multiple areas of compression. The functional status at the time of presentation often predicts functional ability after treatment (Husband, 1998). MSCC is a palliative care emergency and prompt treatment (high-dose steroids, radiotherapy or surgical intervention) is vital to maintain function (Falk and Fallon, 1997). Diagnosis and treatment within 24 hours is vital, since delay can be associated with irreversible loss of motor and bladder function and quality of life (QoL); such patients often require a permanent indwelling catheter and spend the remainder of their life bed-bound (Husband, 1998). Hence, prognosis is poor, and patients with MSCC are often frail, with a reported median survival following diagnosis of only 59 days (Conway et al, 2007). This group of patients require high levels of care, often need 24-hour nursing, and suffer loss of independence. A diagnosis of MSCC may therefore be costly for patients (in terms of QoL and poor survival) and costly to the NHS (in terms of resource usage) (NICE, 2008). MSCC can also represent a threat to a patient’s psychological wellbeing. In addition to the sudden and permanent effect on independence,

International Journal of Palliative Nursing 2016, Vol 22, No 1

Abstract

Malignant spinal cord compression (MSCC) is a devastating complication of metastatic cancer. The majority of existing studies focus on treatment guidelines for MSCC, with little emphasis on the impact that MSCC has on quality of life (QoL) for this patient group. This literature review aims to critically appraise available literature focusing on QoL for patients with MSCC. Relevant literature was identified from key electronic databases. A dearth of credible studies representative of the patient population with MSCC was found. Thematic analysis was used as a guide to identify key themes that impact on QoL. Interestingly, patients with MSCC generally report good QoL and low levels of distress in over 50% of cases. However, a significant percentage of patients are distressed. The review concludes that increased awareness and further research into the impact of MSCC is required. Key words: Spinal cord compression l Specialist palliative care l Quality of life l Psychological l Emotional l Outcome measure This article has been subject to double-blind peer review.

the condition represents progression of their disease (Warren, 2011). Key guidelines recommend that clinicians offer patients with MSCC and their families specialist psychological and spiritual support appropriate to their needs when MSCC is diagnosed (NICE, 2008). Moreover, this support should continue during treatment and on discharge from hospital (NICE, 2008). A preliminary review of the wealth of literature relating to MSCC reveals the focus of most reviews and clinical guidelines is the early recognition and treatment of MSCC. There is little focus on the impact on QoL for this group of patients. Clinical experience also suggests that patients diagnosed with MSCC are usually referred to specialist palliative care services for advice on symptom management and rehabilitation, rather than to offer psychological support for patients and their families. The purpose of this review is to identify and critically appraise available literature that details the impact on QoL for patients diagnosed with MSCC. Through increased understanding of the patient experience of MSCC, recommendations

Mary Harris, Clinical Nurse Specialist Palliative Care, Southampton General Hospital, UK Correspondence to: [email protected]

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ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 129.096.252.188 on February 18, 2016. For personal use only. No other uses without permission. . All rights re

Review

Population: Adults with malignant spinal cord compression due to advanced malignancy. Appropriate search terms were used to identify this particular patient group. Intervention: Psychological/emotional support. Search terms to capture this area of care were defined. Comparison: This area of study is unlikely to have a comparative group. Outcome: Quality of life. It could be hypothesised that patients who receive emotional and psychological support will have an improved quality of life, and these search terms were also incorporated within the literature search.

Table 1. Key words used for literature search Key word/s

Notes

Medical subject heading (MeSH) ‘spinal cord compression’

1. The whole phrase ‘spinal cord compression’ was used, as it is a defined clinical condition, and is a MeSH

Psycholog*

2. Truncation was used to find any variations in word ending

Emotion*

See 2

Support*

See 2

Feeling*

See 2

MeSH ‘quality of life’

See 1

Distress

See 2

for clinical practice can be made. Additionally, palliative care professionals will have increased awareness of the psychological and emotional needs of this patient group and consider how these needs can be best addressed, to ensure that appropriate support is provided.

Review question The PICO tool was used to aid the development of the focused primary research question (Beecroft et al, 2010) (Box 1). Against this background, the research questions this review sought to answer was: ●●What is the impact on QoL for patients with MSCC? ●●What are the key factors that contribute to good QoL for patients with MSCC, and what are the limiting factors?

Methodology

Identification of studies

Cochrane Reviews are systematic reviews of research in health care and policy that are published in the Cochrane Database of Systematic Reviews (http://tinyurl.com/hxw4rc9). To avoid duplication the database was searched to ensure that a review of this topic had not been carried out previously. The database contained two papers that review intervention and treatment regimens relating to MSCC, but no reviews relating to assessment of QoL issues for patients with MSCC. To find relevant articles, the following electronic databases were searched

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in August 2015: CINAHL Plus with Full Text, MEDLINE and PsycINFO. Key terms and other search words (Table 1) were entered and then the database mapped to the most appropriate search terms. The Boolean operator ‘OR’ was used to combine similar searches within the facets, then ‘AND’ used to combine the different subject searches. To ensure that the search was as comprehensive as possible the databases were searched separately. Use of ‘spinal cord compression’ as a standalone search term generated thousands of papers. To seek appropriate studies, which explored QoL issues and the psychological and emotional needs of patients, the search terms (Table 1) were combined using OR to provide a pool of papers. The two searches were combined using spinal cord compression AND the group of papers detailing QoL and the psychological and emotional needs of patients. Additional limiters were then applied to reduce the amount of literature and ensure that appropriate papers were identified. Citation tracking was also used to add further papers.

Study selection When deciding on the inclusion and exclusion criteria for this review, it was important to consider both the practical and ethical difficulties that might arise while studying patients with advanced malignancy. Patients with MSCC are often very unwell with short prognoses; therefore numbers of patients eligible to enter studies can be small with high dropout rates. There is a fine balance between including vulnerable patients and enabling those who wish to participate in research to do so (Kassa and Forbes, 2015). Systematic reviews and randomised controlled trials (RCTs) have become the ‘gold standard’ for finding answers to clinical questions. If carried out in a rigorous and systematic manner, they can provide the best level of clinical evidence (Sackett et al, 1996). While systematic reviews and RCTs were sought, the possibility that not enough strong evidence of this nature would be found was also considered. Inclusion criteria were both qualitative and quantitative studies, it was therefore anticipated that observational cohort studies would need to be included within the review. Although single descriptive or case studies can provide useful narratives and clinical guidance for this group of patients, they were excluded because they are usually the opinion of a single author. Figure 1 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, 2009) shows a flow chart of


Box 1. Application of the PICO tool



Identification

Review

Additional records identified through other sources (n=2)

Records identified through database searching (n=355)

Screening

Records screened (n=316)

Records excluded after abstract review (n=306)

Eligibility

Records after duplicates removed (n=316)

Full-text articles assessed for eligibility (n=10)

Full-text articles excluded, with reasons (n=4)

❛There is little focus on the impact on quality of life for this group of patients.❜

Included

2 articles—case studies

Studies included in evidence based review (n=6)

1 article—guidelines for practice 1 article—literature review

Figure 1: PRISMA 2009 flow diagram the process used to select appropriate studies for inclusion within the review. The titles and abstracts identified from this process were then assessed for eligibility. The inclusion criteria set for the review is detailed in Box 2. The results of the literature search were reviewed to ensure that only studies meeting the inclusion criteria were selected. The Critical Appraisal Skills Programme (CASP) (2013) was used as a guide to identify the methodology, population and limitations of each paper (Table 2).


Results The search identified 355 electronic citations (245 in MEDLINE, 69 in CINAHL, and 41 in PsycINFO). From the initial number of 355 citations, citation tracking added two additional studies, only six studies were suitable for inclusion in the review. Many of the excluded articles focused on clinical management of MSCC, failed to meet the inclusion criteria as they were not relevant to the topic or were individual case studies. Six papers met the inclusion criteria, including four quantitative studies and two qualitative studies. It is acknowledged that the volume of papers is small and that no RCT’s exist. The six papers broadly fall into three groups. The first


group includes two papers that report findings from the Scottish Cord Compression Study. Patients were first interviewed immediately after diagnosis (n=261), (Levack et al, 2004) and then again 1 month later (n=128) (Conway et al, 2007). The patients within this cohort were the largest representative sample of patients with MSCC, and were recruited over a period of 15 months at three oncology centres. The second group of studies were patients fit enough to undergo surgical intervention for MSCC (n=110) (Sundaresan et al, 1995) and (n=62) (Mannion et al, 2007). The third category of studies were qualitative studies (n=9) (Eva et al, 2009) and (n=10) (Warnock and Tod, 2013).

Box 2. Inclusion criteria 1. The research design should be: systematic reviews or meta-analysis, well-designed randomised trials, well-designed trials without randomisation or well-designed nonexperimental studies 2. Single descriptive or case studies will be excluded 3. The focus of the studies will be on adults with a diagnosis of malignant spinal cord compression 4. Aspects relating to quality of life and psychological and emotional and needs of this group of patients need to be an important focus of the studies 5. Both quantitative studies, using psychological scores, and qualitative studies will be included 6. The studies have to be a full article in English

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Review

❛Additionally, for hospital inpatients, the importance of getting home was another major concern.❜

Data synthesis The data were synthesised using thematic analysis as a guide (Table 3). This flexible approach involves identifying, analysing and reporting themes or patterns within data (Braun and Clarke, 2006). There was a significant amount of clinical heterogeneity that made interpretation of the data difficult; however the study findings were individually interpreted and common themes emerged.

Discussion A number of important factors appear to contribute to QoL (Table 3). Four key themes that have been identified from the literature are: ●●Family life and marriage ●●Mobility (independence vs dependence) ●●Impact of physical symptoms ●●Coping. These themes will now be discussed.

Quality of life: key themes Family life and marriage were the most important cues nominated by patients when QoL was assessed (Levack et al, 2004). The changes a

diagnosis of MSCC might bring to family, social life and leisure activities were also considerations for participants when anticipating a future with MSCC (Warnock and Tod, 2013). Concerns about dependence on others, due to altered mobility, and limitations on family activities were also considered (Eva et al, 2009; Warnock and Tod, 2013). Additionally, for hospital inpatients, the importance of getting home was another major concern. Patients’ QoL was affected by physical symptoms such as fatigue and unpredictable bowels (Eva et al, 2009). Another key symptom was pain; Conway et al (2007) reported that 1 month after diagnosis nearly 50% of patients experienced continuing pain. The studies clearly present a variety of physical disabilities and symptoms that impact on QoL. In the context of an uncertain future, it is also important to understand coping mechanisms and strategies that are identified within the literature. Eva et al (2009) demonstrated that patients acknowledged that their situations had changed and that their future plans would need to consider altered circumstances. However, they resisted the

Table 2. Review of papers using Critical Appraisal Skills Programme (CASP, 2013) Methods

1. Sundaresan et al (1995)

Retrospective study to Focus of study clear, however determine results including main focus appears to quality of life (QoL) of validate type of surgery used. patients with malignant spinal cord compression (MSCC) following surgery.

Main focus is evaluating effect of surgery. Limited result details within paper. Data now 20 years old.

2. Levack et al (2004)

Prospective observational study of patients immediately after diagnosis of MSCC.

Large representative sample, demonstrates robust methodology, (see also Conway et al (2007)).

Those with the poorest physical performance status were least likely to be able to consent to be interviewed

Authors were members of the Scottish Cord Compression Group. First of two papers published by this group.

3. Conway et al (2007)

Further study of the above patient group interviewed 1 month after diagnosis.

No apparent bias to compromise the generalisability of the findings. Reliable outcome measures used. High internal validity and reliability.

The relatively low number of patients who were alive or able to complete the follow up assessment reflects the frailty of this population.

Authors were members of the Scottish Cord Compression Group. Second of two papers published by this group.

4. Mannion et al (2007)

Prospective cohort study. Assessment and longterm follow-up of patients with MSCC treated with surgery.

Specific outcome measures used to measure function and QoL. Appropriate methodology.

Patients recruited from one clinician only, selection bias may compromise findings. Also includes those with imminent MSCC as well as proven diagnosis.

5. Eva et al (2009)

Process tracing longitudinal case studies to ascertain the constructions placed upon disability by patients with MSCC.

Semi-structured interviews. Context-MechanismOutcome configuration used as a conceptual basis. Appropriate methodology.

In depth nature of the interviews limited number of cases that were studied.

6. Warnock and Tod (2013)

Framework analysis techniques were used to capture patients concerns and priorities.

Semi-structured interviews. A small study with a clearly defined focus.

It is acknowledged that the sample size is small.

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Validity and reliability

Limitations

Notes

At the time of publication the only qualitative paper that details the experiences of those with MSCC. Unique and unexplored area.


Article



Review


Table 3.Thematic analysis Study

Setting and Sample

How was quality of life (QoL) measured?

Key themes/areas identified that impact QoL

1. Sundaresan et al (1995)

110 patients treated in a surgical unit in the US.

FACT-G scale used, it is described as a QoL questionnaire.

Main focus of paper is to validate type of surgery used. Rather than to detail factors influencing QoL.

2. Levack et al (2004)

319 consecutive patients recruited across four Scottish oncology centres. 261 interviewed shortly after diagnosis.

Schedule for the Evaluation of QoL (SIEQoL Dw) used to assess QoL.

Family life. Marriage. Leisure activity. Health. Social life/ friends. Mobility/physical activity. Home living/environment.

Patients had just been diagnosed with MSCC and at the time of interview, most were undergoing active treatment.

3. Conway et al (2007)

319 consecutive patients recruited across four Scottish oncology centres. 128 (40%) patients interviewed 1 month after diagnosis.

(SIEQoL Dw) used to assess QoL.

Ongoing pain. Mobility/ physical dependence.

Authors conclude that 1 month after diagnosis of MSCC many patients rated their QoL as good and few screened positive for moderate or severe anxiety or depression.

4. Mannion et al (2007)

62 patients treated in one NHS surgical unit.

SF36 QoL questionnaire used.

Physical function, role limitation and pain.

Statistical significance does not appear to be demonstrated within the paper.

5. Eva et al (2009)

9 patients, 6 carers and 29 health professionals in a radiotherapy unit in a UK regional cancer centre.

Questions about levels of care/goals. ‘What has changed?’

Unpredictable bowels. Fatigue. Questions/thinking about the future. Adaptation. Concerns about independence.

Patients acknowledge their situation has changed, but resist the ideas of seeing themselves as disabled.

6. Warnock and Tod (2013)

10 patients from a radiotherapy unit in a UK regional cancer centre.

idea of seeing themselves as disabled, wanting to retain an image of themselves as resourceful and able to cope. Eva et al (2009) suggested that there are tensions between acknowledging and not acknowledging the problem, and found evidence of unrealistic goals. This contrasts with Warnock and Tod (2013), who identified more realistic and focused goals. They suggested that uncertainty may not be a wholly negative concept, as some patients use the uncertainty about outcomes as a potential source of hope. It is suggested that patients with MSCC do not necessarily consider their QoL as poor as health professionals would imagine it to be (Levack et al, 2004). This may link with findings that suggested patients both acknowledge and fail to acknowledge the practical consequences of their situation (Eva et al, 2009). Less than 50% of patients were anxious or depressed shortly after diagnosis with MSCC (Levack et al, 2004), nevertheless, a significant proportion of patients were either moderately or severely anxious, and 24% of patients were depressed either moderately or severely and this should not be overlooked. It is also important to consider that, having only recently been diagnosed with MSCC, the full implications of their medical condition may not have been evident (Levack et al, 2004).


Notes

Mobility and independence. Getting home. Thinking about the future.

It is also acknowledged that the relatively low number of patients who completed the follow-up assessments reflects the frailty of this population; but despite major physical disability only few demonstrate moderate or severe anxiety (Conway et al, 2007). However, 1 month after a diagnosis of MSCC, 16% of patients were distressed either moderately or severely, and it was not possible to assess the levels of distress experienced by those who were too frail to complete the assessments. This is an area that requires further consideration and investigation to ensure that health professionals are meeting the needs of this vulnerable patient group. In fact, few studies have explored interventions and care for patients with cancer who experience major depression. One RCT examined the effect of a model of care for lung cancer patients with major depression, which was compared to the usual care given to this patient group (Sharpe et al, 2014). The study found that those who participated in the interventional group experienced significantly less depression, anxiety, pain and fatigue, and better functioning health and QoL (Sharpe et al, 2014). It is useful to consider such models and whether they would be transferable to support those diagnosed with MSCC.

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Review

Prognosis for patients with MSCC Although not a key theme, it is important to consider the variation in prognosis of the patients included within the various studies, as this may also impact on QoL. The study by Sundaresan et al (1995) examined 110 patients following surgery, and demonstrated an overall median survival duration of 16 months, with 46% alive at 2 years. In contrast, a median survival of only 59 days was found in the Scottish Cord Compression Study (Conway et al, 2007). In this group of 319 patients only 8% were treated with definitive surgery and 5% with surgery followed by radiotherapy. This suggests that the population of those who present with MSCC who are too unwell for surgical intervention usually have a very limited prognosis. Two studies examined patients who had undergone surgical intervention for MSCC, or impending MSCC, (Sundaresan et al, 1995; Mannion et al, 2007). These studies focused on patients well enough to undergo surgery, suggesting that they were likely to have improved performance status, and longer anticipated prognoses, compared to patients who were too unwell for surgical intervention. It could be hypothesised that patients with a longer anticipated survival and improved performance status could have better QoL and emotional wellbeing than those with poorer physical ability and prognosis. However, due to the heterogeneity of the QoL outcome measures used, this would be difficult to assess.

Quality of life measurement The quantitative studies used a variety of outcome measures to assess QoL for those with MSCC. Sundaresan et al (1995) used the FACT-G scale to measure QoL. Mannion et al (2007) used SF36, which is a widely used QoL questionnaire scoring from 0 to 100, with 100 representing perfect health (Ware, 2000). Statistically and clinically significant improvements in QoL following surgery for MSCC were demonstrated by Mannion et al (2007). However, only 18 patients completed full pre and postoperative data sets, and the median survival of these patients was higher than the overall population (18 vs 13 months), suggesting that patients with a more favourable prognosis were more likely to complete the questionnaires (Mannion et al, 2007). The Scottish Cord Compression study (Levack et al, 2004; Conway et al, 2007) used the Schedule for the evaluation of QoL (SIEQoL DW). The SEIQoL DW is a reliable semistructured questionnaire in which patients

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nominate five cues, which contribute most to their QoL. It provides a global QoL score ranging from 0 (no quality whatsoever) to 100 (perfect QoL) (Mitera et al, 2010). A total of 319 patients were recruited to the Scottish Cord Compression study, 82% (n=261) consented to be interviewed to collect QoL data shortly after diagnosis (Levack et al, 2004). The survival, function, QoL and emotional wellbeing of the same patients 1 month after diagnosis were presented by Conway et al (2007). Some 69% (n=180) of the 261 patients who were interviewed shortly after MSCC was diagnosed (median 3 days) completed a SEILQoL-DW (Levack et al, 2004). The global SEIQoL-DW scores (n=180) were normal with a median score of 66, and 25% of patients had a high QoL score of greater than 83. It is observed that patients with the poorest performance status were least likely or able to consent to be interviewed. Though it is interesting to note that statistically a high percentage of patients with MSCC who were able to complete questionnaires report good QoL (Levack et al, 2004; Conway et al, 2007).

Limitations This review was also carried out by a single reviewer, who is a palliative care clinical nurse specialist (CNS). If two or more reviewers had undertaken this process, there would be the potential for a more rigorous and thorough review of the literature and additional themes may have been identified. The search terms used in the literature search were possibly too broad, the term, ‘spinal cord compression’ was used, rather than MSCC. However, the search was very comprehensive and all the articles that met the inclusion criteria, focus on MSCC. The review focused solely on the needs of patients, and the support needs of relatives, carers and other health professionals were not considered in the review. This was mainly due to time restrictions, but also to ensure that the review was as focused as possible. There is a lack of robust studies available to inform this review. This could have questioned the viability of this project, however it was felt that the needs of this vulnerable patient group are important, and should not be overlooked.

Conclusions Patients who are fit enough to undergo surgery for MSCC report positive benefits and good QoL, however these only represent a minority of patients with a diagnosis of MSCC. Interestingly, patients who are too unwell to undergo surgery generally report low levels of distress and good


❛In fact, few studies have explored interventions and care for patients with cancer who experience major depression.❜



Review

QoL in over 50% of cases. Some patients with MSCC acknowledge that their situations have changed, and that their future plans need to include consideration of altered circumstances, but they resist the idea of seeing themselves as disabled (Eva et al, 2009). There is only very limited data available to inform us of the impact that a diagnosis of MSCC has, and the majority of studies are not necessarily representative of the population of patients with MSCC. It has been suggested that patients with MSCC rate their QoL higher than health professionals imagine (Levack et al, 2004). However, this group of patients were interviewed immediately after a diagnosis of MSCC, and as previously considered the full implications of their medical condition may not have been evident at this point. Many patients with MSCC are too frail to be interviewed, or die within a few weeks, and these patients are not represented in research findings (Levack et al, 2004; Conway et al, 2007). It is important to consider that significant proportions of patients are distressed by their situation and report a poor QoL. This review concludes that there is a dearth of credible clinical studies to inform health professionals how to meet the holistic needs of those diagnosed with MSCC. Before health professionals can meet these needs and offer appropriate support, further research into this area is needed. The author hopes that the awareness and importance of this topic to clinical practice is recognised and that further steps will be taken by clinicians and health professionals to improve the delivery of care for this patient group.


Recommendations All clinicians and health professionals need to be aware of the impact and potential distress that a diagnosis of MSCC can bring to individual patients and their families. The psychological needs of patients with MSCC must be considered as part of holistic care delivery within treatment protocols and pathways for MSCC. Clinicians should offer patients with MSCC and their families and carers specialist psychological and/ or spiritual support appropriate to their needs when MSCC is diagnosed, at other key points during treatment and on discharge from hospital (NICE, 2008). Consequently, referrals to specialist palliative care services or other support services for psychological support should be routinely considered as part of patients’ treatment regimens for MSCC. Consideration could also be given to develop a QoL outcome measure specific for patients with MSCC. Further research into the impact of MSCC is required to


inform clinical practice. Health professionals can only begin to consider how best to support patients with MSCC and their families once their needs are fully understood. Declaration of interests The author has no interests to declare Beecroft C, Booth A, Rees A (2010) Finding the evidence IN: Gerrish K and Lacey A, eds The Research Process in Nursing. 6th ed. Wiley-Blackwell Publishing, Oxford Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101 Critical Appraisal Skills Programme (2013) Making sense of evidence. www.casp-uk.net/ (22 December 2015) Conway, R, Graham, J, Kidd, J et al (2007) What happens to people after malignant cord compression? Survival, function, quality of Life, emotional wellbeing and place of care 1 month after diagnosis. Clin Oncol 19(1): 56–62 Dowling, J (2001) Acute events in terminal care IN: Corner, J and Bailey eds Cancer nursing: care in context. Blackwell Science, London Eva G, Paley J, Miller M et al (2009) Patients’ constructions of disability in metastatic spinal cord compression. Palliat Med 23(2): 132–40 Falk S, Fallon M (1997) ABC of palliative care. Emergencies. BMJ 315(7121): 1525–8 Husband, D (1998) Malignant spinal cord compression: a prospective study of delays in referral and treatment. BMJ 317(7150): 18–21 Kassa S, Forbes K (2015) Research in palliative care In: Cherny N, Fallon M, Kassa S et al Oxford Textbook of Palliative Medicine. 5th edn. Oxford University Press, Oxford Levack, P, Graham, J and Kidd, J (2004) Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability. Palliat Med 18(7): 594–601 Mannion R, Wilby M, Godward S et al (2007) The surgical management of metastatic spinal disease: prospective assessment and long-term follow-up. Br J Neurosurg 21(6): 593–8 Mitera G, Zeiadin N, Sahgal A et al (2010) Quality of life measures used in radiation therapy trials for patients with metastatic spinal cord compression (MMSCC): a literature review. J Pain Manage 3(1): 31–8 Moher D, Liberati A, Tetzlaff J et al (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. In J Surg 8(5): 336–41 National Institute for Health and Care Excellence (2008) Metastatic spinal cord compression in adults: diagnosis and management. http://tinyurl.com/jdf4rj4 (accessed 21 December 2015) Sackett DL, Rosenburg WM, Gray JA et al (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312(7023): 71–2 Sharpe M, Holm Hansen C, Martin P et al (2014) Integrated collaborative care for comorbid major depression in patients with cancer (SMART Oncology-2): a multicentre randomised controlled effectiveness trial. The Lancet 384(9948): 1099–108 Sundaresan N, Sachdev V, Holland J et al (1995) Surgical treatment of spinal cord compression from epidural metastasis. J Clin Oncol 13(9): 2330–5 Ware JE Jr (2000) SF-36 health survey update. Spine 25(24):3130–9 Warnock C and Tod A (2013) A descriptive exploration of the experiences of patients with significant functional impairment following a recent diagnosis of metastatic spinal cord compression. J Adv Nurs 70(3): 564–74 Warren, D (2011) Spinal lesions causing cord compression: a practice-related evaluation of care. Br J Neuro Nurs 7(3): 536–40 Watson M, Lucas C, Hoy A et al (2005) Oxford Handbook of Palliative Care. Oxford University Press, Oxford

❛This is an area that requires further consideration and investigation to ensure that we are meeting the needs of this vulnerable patient group.❜

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