As Orthopedic Oncology Evolves, Caring for the Clinician Must Be a Priority

R. Lor Randall, MD, FACS

As the field of orthopedic oncology continues to evolve, with the Musculoskeletal Tumor Society conducting prospective randomized control trials independently and orthopedic oncologists assuming primary stewardship of patients with metastatic bone disease, healing and practicing self-care techniques is key for clinicians, according to R. Lor Randall, MD, FACS.

“We look forward to working with our medical and nonsurgical colleagues and acknowledging the communal grief that we experience is something that we should embrace together. It may be something to be brought up at our tumor boards to [ask] how we can build healthy grieving into what we do as a team,” Randall said in an interview with OncLive®.

In the interview, Randall, the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at UC Davis Comprehensive Cancer Center in Sacramento, California, discussed takeaways on processing grief from the 2024 American Academy of Orthopedic Surgeons Annual Meeting, which took place from February 12 to 16, and changes within the orthopedic oncology treatment landscape.

OncLive: How have research methods shifted in the orthopedic oncology field?

Randall: The state of affairs with orthopedic oncology as it relates to the multidisciplinary care of patients with either primary or secondary cancer is evolving like all of oncology [is]. Orthopedic [oncologists] manage primary neoplasms that arise from the musculoskeletal tissue such as bone sarcomas, soft tissue sarcomas, and a variety of pseudotumorous conditions. We also deal with primary solid tumors and some liquid tumors that secondarily involve the bone or the musculoskeletal system. We take care of children to adults, we cover all of these aspects, and we integrate [care] through NCI-designated cancer centers and multidisciplinary tumor boards with our counterparts in surgical oncology, medical oncology, and radiation therapy.

It’s important to realize that we are evolving [and] because of the rarity of the primary sarcomas of the musculoskeletal system, there have not been a lot of level 1 data. There have not been prospective randomized clinical trials [although] that is changing.

Under the leadership of Michelle A. Ghert, MD, who is an orthopedic oncologist, we did the global [phase 3] PARITY trial [NCT01479283] which was looking at 1 vs 5 days of intravenous [IV] antibiotics for megaprosthetics for bone sarcomas because these have such a high risk for infection. We asked the fundamental question of 1 vs 5 days[and] we came together as a global community to develop prospective randomized data which were published in JAMA. We were able to show that there is no real significant difference in IV antibiotics 1 vs 5 days, but there was an uptick in Clostridioides difficile cases when you gave longer antibiotics—most of us have now changed our practice based upon this impactful study.

Ghert and colleagues [have also] put out a survey to our Musculoskeletal Tumor Society and the global community about how this study has or has not changed their practices, and that will be coming out soon. We are now fully operational in terms of doing prospective randomized control trials on our own as well as when we complement cooperative groups [such as] Southwestern Oncology Group or Children’s Oncology Group with their sarcoma trials. The Musculoskeletal Tumor Society is [also] doing their own clinical trials.

How has orthopedic oncology care evolved?

We are evolving now in how we manage complex musculoskeletal tumors in terms of not just resections, but stabilization using percutaneous techniques, ablation technologies, and 3D-printed custom jigs and devices to reconstruct defects after more precise resections with less morbidity. We are on the leading edge for 3D printed types of technology as well as minimally invasive surgical oncologic techniques, and there will be more to come on that.

We are [also] assuming primary stewardship around metastatic bone disease. We realize that medical oncologists appropriately are looking at overall survival, disease-free survival, and progression-free survival of patients with advanced stage IV solid tumors. Unfortunately, many of these patients are afflicted with metastatic involvement of the musculoskeletal system and there’s been no primary steward of those patients for this sub-issue.

When you ask patients what is most important to them, they will often say that their musculoskeletal involvement is the primary driver for their quality of life and that they feel that they are abandoned by the health care system because no one is assuming that the primary stewardship. The Musculoskeletal Tumor Society is embracing that right now and we have leadership [with] Felasfa Wodajo, MD, who is putting together guidelines for managing these patients with his panel.

What were some of the highlights of the 2024 American Academy of Orthopedic Surgeons Meeting?

The meeting in San Francisco was a special day within the Musculoskeletal Tumor Society embedded in the American Academy of Orthopedic Surgeons. These were the world leaders in orthopedic oncology coming together to talk about all these salient points. The highlight was a wonderful talk by University of California San Francisco professor, Michael Rabow, MD, about caring for caregivers, which is important.

We face so many headwinds—emotionally, physically, and otherwise—as we try to care for patients with cancer. We are constantly sympathetic and empathetic with families [of patients] who are dying, and we are wounded in the process. We have to deal with more challenges with the electronic medical record and management of all of the things outside of the actual caring for the patients, and we know everyone is burning out.

Dr Rabow gave a wonderful talk to the orthopedic oncology community about [how] we need to be able to heal from the losses of our patients. Sometimes that means doing a deeper emotional dive into the experience of the patient so that we can grieve. [He] highlighted opportunities such as potentially going to the funerals of patients who succumb to their cancer [and] reaching out with a card or gesture to show that you’re sharing in the grief. That grief leads to healing. Often, we move on from one lost battle to another—we often win the battle, I don’t want to sell that short—but it takes a toll on us, makes us potentially embittered, and leads some of us to behaviors that are destructive to our careers or loved ones.

Highlighting the fact that grieving for oncologists, as well as doctors in general, is an important part of being a better doctor is the one message I want to drive home; it’s agnostic to subspecialty or specialty [and] beyond caring for patients with cancer, we do need to find ways for us to be able to better grieve the losses that we experience in our professional life.

We also need to [partake in] the usual self-care and wellness making sure that we are finding that balance where we can reflect on the joys of life when we’re day in and day out facing the [realities] of cancer. That was a highlight and that’s not the kind of talk we are used to getting as surgeons, but it was refreshing. Being in that room, you could feel how the audience was moved by this presentation—it was remarkable.

Who needs to be the stewards of clinician wellbeing, the clinicians themselves or the hospital administration?

The hospital needs to recognize it, beyond just self-care and wellness, and [provide support on] how to manage your medical record and deal with the day-to-day challenges of modern-day health care. The health system with our psychology and psychiatry counterparts can help us too. We talked about having some workshops for providers to help them come to grips with how they may want to grieve—grieving comes naturally to some, and they don’t need a lot of structure around it to find their mechanisms for grief.

For the administration to say we will recognize that a certain period of time in your work year can be allocated to some of these grieving opportunities, and it’s not time away from work, would be a good process. For others [who] need more structure, that gets a little bit more difficult, [but] we could get psychologists and social workers to potentially provide mechanisms and arenas by which providers can face their grief. Demonstrating your vulnerability is a sign of strength and it’s important.

Regarding the various cancer awareness days, what can be done to ensure that they carry a true impact beyond their name?

We need to develop some metrics and we have to be careful because raising awareness is important, and some of the deliverables that we ask of ourselves are beyond our control. Having a policy either at the local, state, or federal level towards one of these issues would be ideal but that’s sometimes beyond the scope of any advocacy group.

If we charge ourselves with philanthropy, look to raise funds that can help drive research, and then when we look at driving the research, hold ourselves accountable for the return on investment [that would be key]. Did that money go to investigators, did they go on to get federal funding, and did they go on to [be a part of] impactful science? What goals or metrics were achieved through these mechanisms?

When we have these organizations, we need to internally hold ourselves accountable but then welcome outside individuals to [ask] how we [can] move the needle in a way that demonstrates some durable traction on the issue. We’ve had awareness initiatives for at least a decade in most specialties—breast cancer and sarcoma [for example]—and if we look back over these 10 years what progress has been made? We also [do not] want to be too punitive or discouraging if progress hasn’t been made because awareness itself is important. We know since [former President] Richard Nixon put together the ‘War on Cancer’ in the 1970s [that] cancer is an elusive ‘Emperor of All Maladies’.