Orthopedic Oncologists Essential to Optimal QoL for Patients With Metastatic Bone Disease

R. Lor Randall, MD, FACS

Orthopedic oncologists are the stewards of the musculoskeletal system, according to R. Lor Randall, MD, FACS. Therefore, he said, more medical oncologists should refer their patients with metastatic bone disease to orthopedic oncologists in an effort to improve their quality of life (QoL).

Cachexia, impending fractures, and muscle wasting are all issues that patients with metastatic bone disease regularly face, Randall explained. Therefore, upon diagnosis of symptoms, medical oncologists should quickly refer their patients to orthopedic oncologists to properly manage their care.

“If there's an affirmative response to [patients] having new pains, rather than [a medical oncologist] trying to even take that on, they should get the musculoskeletal oncologist involved sooner rather than later,” said Randall.

In an interview with OncLive, Randall, The David Linn Endowed Chair for Orthopaedic Surgery and professor and chair of Department of Orthopaedic Surgery, University of California Davis Health, discussed the referral challenges for orthopedic oncologists and the importance of improving QoL for patients with metastatic bone disease.

OncLive: Why is it important to raise further awareness about metastatic bone disease?

Randall: Metastasis to bone is when you have [a cancer such as] breast cancer, lung cancer, prostate cancer, kidney cancer—and a few other cancers, such as thyroid cancer—with a propensity to go to the bone. [The disease] can eat away at the bone, and it can really impact the patient's QoL. When you hear about those cancers, everyone's first concern is, "Oh my goodness, this is a life-threatening condition." It is, and I am not trying to steal from that because obviously [patients need to] enjoy their QoL. However, what gets sort of lost in the wash of this is, not only do we want to save patients' lives, but we want to give them lives worth living.

Therefore, when patients develop one of these cancers that then spreads to the bone, they're faced with a whole onslaught of issues that affect their QoL. When you talk with these patients, and you say, "What are you most afraid of on a daily basis?" They will tell you things like, "I'm afraid to leave my house because I might break a bone. I'm afraid to pick up my grandson because I'm afraid my arm bones are going to snap. My muscles are so weak that I can't even take a walk with my spouse."

These patients are facing these sorts of things on a daily basis, and yet everyone searches for the "storylines." You hear about a decrease in cancer mortality from lung cancer—that is all over the press. That's great, but I can tell you that a lot of these patients are still suffering, even if they're alive. It's not just the goal of being alive; it's about being happy while you're alive. When [a patient's] tumor regresses, [the patient is] happy, but the patient may still be [struggling] from some of these other conditions.

Orthopedic oncologists are the steward of the musculoskeletal system and these patients. The orthopedic oncologist needs to be at the table when we're managing patients with metastatic bone disease; sometimes [patients] don't get referred to us. Patients don't get referred to an orthopedic oncologist because the medical oncologists [are sometimes] just is not thinking about those types of things.

Why do you think there is a disconnect between the medical and orthopedic oncologists when it comes to referrals?

Interestingly, almost 20% of the cancer dollars spent in the United States are spent on skeletal-related events (SREs); all of that cancer money that's being spent on a daily basis—on therapies, and remedies—almost 20% of it is exclusively on the musculoskeletal system in the form of bisphosphonates, RANKL inhibitors, surgeries, and radiation therapy. [It encompasses] all of these things, and that's a pretty big slice of the pie.

What are some steps that the field can take to resolve the lack of referrals? Is more education needed?

This, right now, is the very first step—through OncLive, getting attention and making sure that this interview gets in front of medical oncologist is a part of it. But, yes, when we think about educational forums in ASCO, we make sure that there is a section about musculoskeletal health in patients with metastatic carcinoma, that people are thinking about it, and that there are educational forums through ASCO and other cancer arenas to engage the medical oncologists. The orthopedic oncologists are already aware of this. However, the referrals are often not made [at all], or they're not [made to us] until the bone is broken.

You spoke anecdotally about what patients with metastatic bone disease experience on a daily basis. Could you expand on the QoL issues that arise?

The things that threaten their QoL are basically impending fractures, meaning that, because the metastasis is spread to the bone, the bone has become so much at risk for breaking. There's also cachexia, so patients develop decreased bone density. They also [experience] muscle wasting; that is a real threat to them because they just don't have the energy to move about.

You listed some of the agents currently being used to help manage some of these SREs. Are there other agents in the pipeline that are currently being explored that could further improve QoL?

Right now, those RANK-L inhibitors and bisphosphonates are the 2 major classes of drugs that we have available for SREs. However, other things that can play into it is also making sure, from a nutrition standpoint and from a physical therapy standpoint, that these patients are getting the non-pharmaceutical therapies to really optimize their QoL. There should be a call to arms to see if there are other agents that can help with these QoL issues.

What other challenges are orthopedic oncologists facing in treating these types of patients?

[A challenge is needing more] attention to it from the point of overall oncologic care. The challenges are making sure that, on the checklist of how a patient is doing, the musculoskeletal system is evaluated. For every visit to a medical oncologist with a patient who has metastatic carcinoma to the bone, [the medical oncologist] should be specifically asking, "How is your level of energy as relates to physical function? How well are you able to take a walk? Do you feel like you're becoming weaker? Do you have any new physical ailments and new pains in your musculoskeletal system that we need to be made aware of?” Usually the interview doesn't take all that into account.

We need to push that front for the general oncologist in these patients, in terms of challenges of referral. It's also that, if [the medical oncologists] ask those questions, then they're more likely to make that referral to an orthopedic oncologist. The Musculoskeletal Tumor Society, of which I am the past president, has really embraced the idea that we would be happy to be sort of the "subcontractors" or the "stewards" of the musculoskeletal health system for the medical oncologist.

Is this an example of harping on the importance of multidisciplinary care?

Multidisciplinary care is particularly important in sarcoma, and it's important that when we talk about orthopedic oncology and orthopedic cancers that we distinguish primary versus secondary cancers. The primary cancers of the musculoskeletal system are relatively rare compared with these patients who have metastatic bone disease. Because of that, it takes a long time to get a lot of experience [with the primary cancers of the musculoskeletal system]. They involve so many different types of treatment that multidisciplinary tumor boards are really critical for those primary tumors of the musculoskeletal system.

For patients with metastatic carcinoma in the bone, there are so many patients with this that to present all of them at a multidisciplinary tumor board would be overwhelming. A multidisciplinary tumor board around this is a little bit more of a volume [issue]; it is just not as feasible. However, it's fair to say that the medical oncologist must keep in their mind the need to engage with an orthopedic oncologist at the first signs of musculoskeletal involvement.

Are there any other aspects of metastatic bone disease that are particularly important to touch upon?

There is a great opportunity to get some traction around this because it is where more and more patients are living longer with their cancer. We have just seen that the cancer mortality [rate] has dropped off, but there's more patients therefore living with their cancer, and this becomes more and more of an issue.

Ultimately when patients have metastatic carcinoma, whether it's to the bone or other sites, the chance of an absolute cure is probably very, very small—but we can push it into a chronic state. This means that patients can live with their metastatic carcinoma, like with diabetes, or with Crohn's disease, or with some of these other things. They can hopefully live with their metastatic carcinoma, and all the more reason that we need to pay special attention to their musculoskeletal health so they can live the life they want to live.