Collaborations With Orthopedic Surgeons, Interventional Radiologists Key to Novel Approaches in Metastatic Bone Cancer

R. Lor Randall, MD

Medical oncologists who have patients with metastatic bone cancer should consult with orthopedic surgeons and interventional radiologists to provide patients with improved or minimally invasive therapeutic options, according to R. Lor Randall, MD.

“There is growing work in collaboration with interventional radiologists to try and do this with advanced imaging techniques to [treat these patients] percutaneously,” Randall explained. “While some of them still require overnight stay, many of these patients can get some of these stabilization procedures done on an outpatient basis. This is just starting to emerge.”

In an interview with OncLive^®, Randall who is the David Linn Endowed Chair for Orthopaedic Surgery and professor and chair of the Department of Orthopaedic Surgery, University of California Davis Health, discussed the importance of these collaborations and how they are beginning to pick up steam in the United States for patients with metastatic bone cancer.

OncLive^®: Please discuss this collaboration happening in practice in metastatic bone cancer.

Randall: Metastatic bone cancer takes up approximately 20% of the cancer care economy for patients with advanced cancer. For every dollar spent on patients with cancer, 20% of it goes to skeletal-related events, and that's a big portion of the pie. That includes the bisphosphonates, the Rank-ligand inhibitors, surgical interventions, hormonal treatments—there is a variety of different things that go into that. There are some patient-reported outcome data from our institution and others, showing that the number one concern about patients with advanced cancer is their locomotive apparatus. [They ask things such as] “Can I pick up my daughter? Can I take a walk with my spouse?”

There is now a growing movement where orthopedic surgeons are starting to work with interventional radiologists to look at minimally invasive techniques to stabilize the musculoskeletal system percutaneously. The medical oncologist may be aware of things like kyphoplasty for osteoporotic fractures, or insufficiency fractures where bone cement is introduced. However, we're doing this more and more now with patients with bone destruction due to metastatic carcinoma. [These patients have] been done generally with more open, aggressive techniques—making a big incision, scraping out the tumor, putting in an artificial joint, or potentially putting in a bunch of rebar screws and cement to rebuild a part portion of the bone.

Now, there is growing work in collaboration with interventional radiologists to try and do this with advanced imaging techniques to do them percutaneously. While some of them still require overnight stay, many of these patients can get some of these stabilization procedures done on an outpatient basis. This is just starting to emerge.

The story for our medical oncology partners is to approach orthopedic surgeons and your interventional radiologists to ask if they are collaborating in any way around this and if not, to raise awareness about it. There are 2 different pipelines; you have the surgical pipeline and you have the interventional radiology pipeline. If I'm a medical oncologist, and I pick up the phone to my interventional radiologists, they're going to get "X" treatment. If I call my surgeon, they're going to get "Y" treatment. There are now centers with programs that are emerging where the surgeons and the interventional radiologists are working together. The medical oncologists can help drive this by asking their surgeons and their interventional radiologists: "Are you guys working together on this? I read this article [about this collaboration] on OncLive^®."

There is this discussion around these processes where you're getting the best of both worlds. You get the structural integrity perspective from the orthopedic surgeon and you get the minimally invasive imaging perspective of the interventional radiologist. Because it's involving the orthopedic surgeon, it's more structurally sound. Because it's involving the interventional radiologist, it's minimally invasive.

What advice do you have for a medical oncologist in these situations? Are there certain types of criteria or factors to keep in mind to determine whether a patient might be a candidate for one of these more minimally invasive techniques?

Because of the complex anatomy of the pelvis, it lends itself to interventional radiology techniques. The extremities are more straightforward. It's much more of a simplistic model by which you don't need interventional radiology. However, in areas in the pelvis, a medical oncologist is seeing someone with osteolytic lesions around the talus, [which is] concerning for fracture, or lesion in the sacrum, which in the pelvis is a risk for fracture.

That should prompt them to think about potentially a dual modality approach to this, especially if they obviously only have time to make the 1 referral. I don't know if that's going to be an actual communication or it's just going to be an order deployment. However, when they socialize with their orthopedic oncologist or their interventional radiologist, they should say, "I'm hearing about this being done in concert between these 2 [health care providers] working together to do this one procedure. Do you know anything?"

That will then prompt them to reach out to other colleagues around the country. We're going to start getting some data around this, and there are going to be some techniques that will be coming out. This is very much on the front end of this movement.

Are you seeing this movement pick up at centers across the country?

We are not doing it quite as much here at UC Davis now, but we are planning to. There are some places in Colorado, and there are places on the East coast [such as] Yale, where they are really starting to do these techniques. What you're seeing at conferences, such as by the Musculoskeletal Tumor Society, the Connective Tissue Oncology Society, and the International Society of Limb Salvage, is that these abstracts are of just a few cases where we did this in concert with an interventional radiologist.

You mentioned this is also a way to improve quality-of-life issues for these patients. Could you elaborate on that?

We want the emotional component to obviously be enhanced. We want to address the emotional concerns of the families. But as orthopedic surgeons, the metrics we're using are physical function and pain interference through the patient-reported outcome measures. We are assuming that if we can get their physical function up and improve their pain interference so they have less pain, that their emotional state, as a secondary [measure] will be improved. We at UC Davis are working with thought leaders around the country in nursing and palliative care. We have submitted a federal grant, and we're also looking at a state grant and internal grant to be able to pursue quality-of-life measures for patients with metastatic bone disease.