Metastatic spine disease Agreement in the assessment of metastatic spine disease using scoring systems Estanislao Arana a,b,c,⇑ , Francisco M. Kovacs c,d , Ana Royuela c,e,f , Beatriz Asenjo c,g , Ursula Pérez-Ramírez c,h , Javier Zamora c,e,f,i , and the Spanish Back Pain Research Network Task Force for the improvement of inter-disciplinary management of spinal metastasis a Department of Radiology, Valencian Oncology Institute Foundation, Valencia; b Research Institute in Health Services Foundation, Valencia; c Spanish Back Pain Research Network, Kovacs Foundation; d Scientific Department, Kovacs Foundation, Palma de Mallorca; e CIBER Epidemiology and Public Health (CIBERESP); f Clinical Biostatistics Unit, Hospital Ramón y Cajal, IRYCIS, Madrid; g Department of Radiology, Hospital Regional Universitario Carlos Haya, Málaga; h Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain; i Barts and the London School of Medicine & Dentistry. Queen Mary University of London, London, UK article info Article history: Received 15 January 2015 Received in revised form 13 March 2015 Accepted 15 March 2015 Available online 10 April 2015 Keywords: Spine metastases Intraobserver variability Interobserver variability Magnetic resonance imaging Classification Agreement abstract Purpose: To assess variability in the use of Tomita and modified Bauer scores in spine metastases. Materials and methods: Clinical data and imaging from 90 patients with biopsy-proven spinal metastases, were provided to 83 specialists from 44 hospitals. Spinal levels involved and the Tomita and modified Bauer scores for each case were determined twice by each clinician, with a minimum of 6-week interval. Clinicians were blinded to every evaluation. Kappa statistic was used to assess intra and inter-observer agreement. Subgroup analyses were performed according to clinicians’ specialty (medical oncology, neurosurgery, radiology, orthopedic surgery and radiation oncology), years of experience (67, 8–13, P14), and type of hospital (four levels). Results: For metastases identification, intra-observer agreement was ‘‘substantial’’ (0.60 < k < 0.80) at sacrum, and ‘‘almost perfect’’ (k > 0.80) at the other levels. Inter-observer agreement was ‘‘almost perfect’’ at lumbar spine, and ‘‘substantial’’ at the other levels. Intra-observer agreement for the Tomita and Bauer scores was almost perfect. Inter-observer agreement was almost perfect for the Tomita score and substantial for the Bauer one. Results were similar across specialties, years of experience and type of hospital. Conclusion: Agreement in the assessment of metastatic spine disease is high. These scoring systems can improve communication among clinicians involved in oncology care. Ó 2015 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 115 (2015) 135–140 The organ most commonly affected by metastatic cancer is the skeleton, which is also where it causes the highest morbidity [1]. While new chemotherapeutic agents hinder the progression of spinal metastases and surgery is helpful for selected patients [2], radiotherapy continues to be the cornerstone in the treatment [3,4]. The Tomita and the modified Bauer scoring systems (Appendix 1) have been advocated as two of the most accurate methods for establishing the prognosis of metastatic spine disease and helping to select the most appropriate treatment for each case [5,6]. They are based on clinical data and imaging findings. However, few studies have analyzed the reliability of these scoring systems across different medical specialties [7], and none have assessed their intra and inter-observer agreement [8]. It has been reported that up to 98% of oncologists do not use a standardized method to assess the risk of pathological fracture [9]. Gathering data on the reliability of the Tomita and modified Bauer scores in clinical practice might be useful to promote their use when appropriate. Assessing the agreement among the different specialists involved in the assessment of spine metastatic disease (medical oncologists, radiologists, radiation oncologists, orthope- dic surgeons and neurosurgeons), may contribute to improving consensus in the decision making process when determining the most suitable treatment for each patient. Therefore, the purpose of this study was to assess the intra- and inter-observer agreement in the identification of the spine levels affected by metastatic cancer and in the calculation of the Tomita and modified Bauer scores, among a large sample of http://dx.doi.org/10.1016/j.radonc.2015.03.016 0167-8140/Ó 2015 Elsevier Ireland Ltd. All rights reserved. ⇑ Corresponding author at: Fundación Instituto Valenciano de Oncología, C/Beltrán Báguena, 19, 46009 Valencia, Spain. E-mail address: aranae@uv.es (E. Arana). Radiotherapy and Oncology 115 (2015) 135–140 Contents lists available at ScienceDirect Radiotherapy and Oncology journal homepage: www.thegreenjournal.com