The SOaR2 program: Returning patients to their families and enhancing survival in spinal metastases
An evolving and growing initiative, SOaR2 has the objective of advancing the early discovery and treatment of spinal metastases.
A multidisciplinary team has introduced a program with the objective of advancing the early discovery and treatment of spinal metastases (SMs).
The decades-old, constantly evolving, and growing initiative, named SOaR2, is composed of four key components: Surgical spinal oncology, medical oncology, radiation oncology, and neuroradiology.
The impact of delay in spinal metastases (SM) discovery and treatment
The spine is the most common site for metastases from primary cancers, particularly those originating in the breast, prostate, and lung.
Left untreated, SMs are a source of pain, vertebral fractures, and radiculopathy.
Perhaps the greatest clinical concern for malignant invasion of the spine is metastatic spinal cord compression (MSCC), a debilitating oncological emergency with the potential to provoke irreversible neurological deficits, loss of function, and morbidity.
Unchecked MSCC has a far more profound impact on quality of life and survival than the original cancer diagnosis. MSCC can be effectively treated if spinal metastases are identified early, but this is possible only with timely recognition and treatment.
Recent studies of referral patterns suggest that delays in MSCC diagnosis and treatment occur in gaps in clinical communication, which occur in the time between:
- Onset of symptoms and medical consultation (often at an ER)
- Medical consultation and diagnosis
- Diagnosis and referral to a spine surgeon
- Referral to the spine surgeon/radiation oncologist and surgical treatment or radiation therapy
The same studies suggest that the average time between the onset of complaints and initiation of comprehensive treatment ranges from 11 to 14 weeks.
The SOaR2 program seeks to initiate treatment with immediacy and compress the entire treatment course to 6-8 weeks.
SOAR2 : Time to spine
The stated goal of the SOaR2 program is to provide the right interventions at the right time for the right patients to hasten their return to their communities and lives. This is achieved by streamlining the spinal oncology referral process from the outset through multidisciplinary group collaboration to reduce time to consultation and treatment, enhance patient navigation, and prioritize scheduling.
A chief benefit of the SOaR2 program is that all care takes place within a single uniform system.
The success of the SOaR2 program is evidenced in its recorded capacity to return patients to the community in 6-8 weeks from onset of symptoms (this may include imaging, biopsy, multi-disciplinary tumor board, evaluation, surgery, and post-operative radiation).
SOaR2 protocols and pathways
The leading advantage of early intervention in spinal metastases is avoidance of the destructive progression of MSCC.
Moreover, early diagnosis and consensus on care can prompt neurological improvement, a return to ambulation, and, for many patients, restoration to working life (BMC Palliative Care, March 2018).
To expedite the diagnosis and treatment of spinal metastases, the SOaR2 program eliminates delays from the outset to abbreviate gaps and delays in the patient journey:
At hospital admission, a SOaR2 team of specialists works together to form a timely consensus on direction of care. If hospital admission can be avoided, it will be avoided.
Effective communication between radiologists and treatment teams is critical to ensure timely treatment.
To address this, the team developed a novel dictation template incorporating spine oncology imaging standardized language and findings. With a common language and automated notification system, spine oncology referrals are prioritized and accelerate where appropriate.
Prompt diagnosis and confirmation is ensured by the SOaR2 program’s combination of same-day outpatient Rapid MRI and dedicated MRI slots expressly for patients requiring evaluation for urgent spinal symptoms.
Rapid MRI involves a series of accelerated imaging techniques that streamline the MRI scanning process to significantly reduce scan times without sacrificing image quality. Patients have access to same-day outpatient appointments.
All patients are assigned a radiology risk score to accelerate decision-making. In addition to accelerating care, rapid MRI reduces clinician emergency burden (the cumulative effects of high-demand, complex emergent care) and ER/hospital resource needs.
A weekly multidisciplinary conference involving specialists in addition to the SOaR2 clinical core team is drawn from a variety of disciplines, including palliative care, thoracic, orthopaedic, and plastic surgery, urology, interventional pain, vascular care, and spinal interventionists. The object of each meeting is to garner recommendations and develop an expert consensus care plan for individual patients.
The multi-disciplinary spine oncology tumor board now evaluates 12-20 patients each week.
Surgery is a fundamental part of the SOaR2 program and seeks to provide timely interventions predicated on innovation to enhance disposition to home for at-risk patients, improve the care path, improve recovery after surgery, and reduce readmissions.
Surgical innovations include a Surgical Rapid Access Clinic (SRAC), the use of carbon fiber instrumentation, separation surgery (a surgical technique used to create a space between MSCCs and the spinal cord), and advanced wound care.
The surgery program also involves risk assessment and prediction tools to abate readmissions, and a post-surgical enhanced recovery path to simplify post-surgical patient care. All innovations are designed to improve and ease the course of therapy.
The SOaR2 team is led by radiation oncologists who specialize in spinal oncology and are experts in the delivery of spine stereotactic body radiotherapy (SBRT). An efficacious treatment for SMs, SBRT targets lesions with ablative doses that spare critical organs at risk, particularly neural tissues.
All participating radiation oncologists undergo a rigorous credentialing process, and the department has advanced treatment infrastructure and a dedicated planning team that is solely focused on spine SBRT. This means that every member is committed to understanding the evolving techniques of surgical and radiotherapeutic management for spinal metastases and is proficient in the development of complex radiation plans, even in the setting of prior radiation.
A weekly multidisciplinary spine oncology clinic is held in conjunction with Neurosurgery to facilitate patient-centered, comprehensive care. On the same day, a dedicated CT/MR simulation slot is available for patients proceeding with spine SBRT to expedite treatment.
Neuroradiology innovations include a recently developed structured spine MRI dictation macro integrating MRI-relevant elements of the Spine Imaging Neoplastic Score and an expanded Epidural Spinal Cord Compression scale into a novel in-house Spine Oncology Imaging Score (SOIS).
When combined with an automated notification system to a specialized SOaR2 spine oncology team, the macro significantly reduced time to consultation and treatment in patients with spinal metastases.
Development of the in-house novel radiology risk score (SOIS) resulted in >3,400 Automated Electronic Notifications of our program’s Spinal Oncology Macro report for spine MRIs since 2021 (American Journal of Neuroradiology, May 2025). These notifications have led to improved time to visits (median 3 days in patients who underwent spine MRI with the SOIS report), accelerated time-to-treatment from diagnostic imaging (median 14 days).
A smooth return to home is ensured via the Penn Medicine at Home Program, which extends hospital-level care to the community setting.
This includes skilled nursing, rehabilitation therapies (physical, occupational, speech), and medical social services, among much else, to improve patient outcomes and promote greater patient independence.
Success of the SOaR2 program
The SOaR2 program has seen significant growth with multi-disciplinary consultations increasing from 87 to 122 (140%) over the last year. Patients treated with spine SBRT increased from 112 to 178 (159%), and total treatment sessions from 272 to 512 (188%).
Case report
Mrs. R, a 46-year-old woman with a history of breast cancer, was referred to Penn Orthopaedic Oncology for evaluation of a femur lesion.
Mrs. R was also referred to SOaR2 program radiation oncologist Anish Butala, MD, a specialist in spinal oncology, who discovered a previously undetected high-risk lesion at T9 on her CT simulation scan, requiring urgent evaluation .
Three days later, a rapid MRI confirmed Mrs. R’s T9 disease. This was followed the next day by a spinal biopsy, which was reviewed the same day at the multidisciplinary spine tumor board meeting.
Mrs. R was then referred to neurosurgeon Neil Malhotra, MD, who performed a T9 laminectomy and bilateral transpedicular corpectomy with a T7-11 fusion to ablate the tumor and address consequent instability in the spine.
Mrs. R then had post-operative stereotactic radiotherapy for a total of three treatments over six days. In the subsequent weeks, she had no significant side effects from her SBRT aside from mild temporary fatigue and nausea, and had no incisional issues. Penn Medicine Home Health provided access to at-home occupational and physical therapy and nursing.
Mrs. R’s total time from imaging to completion of treatment for her T9 lesion comprised 52 days (7 weeks, 3 days), which included a 12-day pause to accommodate her concomitant femur surgery.
About the SOaR2 Program
At Penn Medicine, the SOaR2 Program has brought together experts in surgical spinal oncology, medical oncology, and radiation oncology for over a decade with the goal of improving spinal tumor outcomes and reducing spinal cord metastases.
Our goal is to provide the right interventions at the right time for the right patients so they can return to their communities and lives faster. We do this by streamlining the spinal oncology process from the beginning, involving a collaborative multidisciplinary group and priority scheduling.
Program Leadership Team
The SOaR2 program is led by six leaders encompassing the key specialties that patients most need when cancer spreads to the spine.- Anish Butala, MD – Radiation Oncology
- Alvand Hassankhani, MD – Radiology
- Hayley Knollman, MD – Medical Oncology
- Neil Malhotra, MD – Neurosurgery
- Gabrielle Peters, MD– Radiation Oncology
- James Schuster, MD, PhD – Neurosurgery
Clinical consult and patient referral
Referrals into the SOaR2 Program can be made directly through program leads Anish Butala, MD, and Neil R. Malhotra, MD.
- For hospital transfers and urgent clinical consults, call 877-937-7366, press 1. For non-urgent clinical consults and patient referrals, press 2 or visit PennMedicine.org/Refer.
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