In 2004, Dr. Mark Bilsky changed the world of spinal oncology forever with the introduction of the NOMS decision framework. This provided a basis for the rational integration of new technologies and evidence-based medicine into the treatment of metastatic and primary spine tumors. Long since had standard scoring systems such as the Tomita and Tokuhashi models become antiquated. We needed metrics that accounted for spinal cord compression and this was it! But Dr. Bilsky didn’t just create a new scoring system, he would ultimately develop spinal oncology clinics around this model that drastically improve patient outcomes.
What is NOMS?
The NOMS assessment uses four sentinel decision points to determine the best course of treatment and each point represents a letter in the acronym. N stands for neurologic and is used to determine if the tumor has low-grade epidural spinal cord compression (ESCC) with no myelopathy or high-grade ESCC with or without myelopathy. This feeds into O which stands for Oncologic and determines if the tumor is either radiosensitive or radioresistant/previously radiated. Based on the neurologic answer, you can determine if the tumor needs radiation, what type of radiation treatment, or if surgery is a more viable option.
M is another metric to determine if surgery is necessary because it stands for Mechanical and is used to determine if the patient’s spine is in a stable or unstable condition. If the patient is suffering from spinal instability they may need several procedures to correct the issue, depending on the severity of their condition. Finally, S stands for Systemic and is foundational in the treatment planning process because it indicates whether or not the patient can tolerate surgery. Using NOMS allows medical professionals to comprehensively individualize the treatment plan for every patient with universal standards.
Practice makes perfect
Applying NOMS as the framework for his cancer centers has been a game-changer for Dr. Bilsky and his patients. “We couldn’t do this in a vacuum” he states, as he recalled the disappointed looks on patients’ faces when they were sent to him, only to need a separate radiation appointment from a different specialist three weeks later. He knew he needed all of the specialists tied to the NOMS categories in the same space at the same time. Because while radiation oncologists are excellent at determining things like radiosensitivity, they don’t know how to treat mechanical instability.
After three years of trying, Dr. Bilsky was finally able to convince his benefactors to make that dream a reality. Today, he runs a successful and efficient practice based on the NOMS model. Once an initial course of action is determined, patients are placed in a multidisciplinary clinic with one of the multiple attendings available on any given day. From there, patients are traded around between specialists to decide the best management options. Dr. Bilsky now runs four multidisciplinary clinics per week with a minimum of four services per clinic. What an incredible impact he’s making for spinal cancer patients and their physicians!