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What is Orthopedic Oncology?

Orthopedic oncology specializes in the treatment of men and women with bone cancer, sarcoma or cancer that has spread to the bone from other areas of the body.

The treatment of metastatic bone cancer is evolving rapidly - advances in treatment have made it possible to treat metastatic disease more like a chronic condition and less like a terminal illness.

Dr. Schmidt discusses how to improve quality of life and pain management for both patients with metastatic cancer and cancer patients suffering from unrelated issues, such as arthritis, and osteoporosis for example.
What is Orthopedic Oncology?
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Dr. Schmidt graduated from Pennsylvania State University College of Medicine in 1980. He completed an internship, orthopedic residency and fellowship in orthopedic research at the Hospital of the University of Pennsylvania in 1985. Additionally, Dr. Schmidt completed an orthopedic oncology fellowship at Shands Hospital at the University of Florida in Gainesville. Dr. Schmidt specializes in sarcomas, which includes cancer of the bone and soft tissue. He also has significant experience in treating metastatic bone cancer. He is known for his expertise in the surgical management of limb salvage surgery.

Melanie Cole (Host): Orthopedic oncology specializes in the treatment of men and women with bone cancer sarcoma or cancer that has spread to the bone from other areas of the body. My guest is Dr. Richard Schmidt. He's the medical director of orthopedic oncology. Welcome to the show, Dr. Schmidt. Why is it important to even have a Department of Orthopedic Oncology?

Dr. Richard Schmidt (Guest): Well, Melanie, it's a great question. It's important because patients with bone or soft tissue cancers deserve a specialist. Today, we have many specialists, so people have been programmed and taught that if they have a sports injury, they need a sports orthopedic surgeon; if they have a back problem, a neurosurgeon. We really need to get there with patients with bone cancer as well. They need to have specialists in orthopedics who deal with that particular problem, because those patients are different than the patient with ordinary orthopedic needs.

Melanie: When cancer has spread to the bone, it doesn't typically start there, does it?

Dr. Schmidt: No. That's right. Most of the time, when you see someone with bone cancer, it's because it has spread from what we call the paired midline structures, which is thyroid, breast, lung, prostate, and kidney.

Melanie: When it has spread to the bone, people often feel hopeless at that point, Dr. Schmidt,
but that's not really the case, because even metastatic cancers that have spread to the bone, there are certainly plenty of treatment options. Explain a little bit about the treatment of bone cancer and some pain management as well.

Dr. Schmidt: Certainly. You bring up a very good point. It's a shame that often patients will get diagnosed with metastatic or stage 4 cancer and they'll look upon that as a quick terminal illness. It is not unusual for many healthcare providers still to convey that impression. But we know today that patient with stage 4 breast cancer can live for many, many years, and they really shouldn't look upon this as an acute illness but more of a chronic condition. Years ago, when patients got diabetes, right before insulin, insulin pumps, it was considered a very short lifespan. But nobody looks today at diabetes as a terminal illness. It's a chronic condition, and that's particularly applicable to patients with breast cancer. The treatment modalities have absolutely skyrocketed today in terms of hormonal manipulation, targeted therapies, and that's why many more women today are developing metastatic lesions. So it sounds like bad news, but it's actually because they're living longer because they're now out there getting treatment. They're living 10 to 15 years. They develop a bone met and those can be treated with a combination of many modalities—radiation therapy, medical oncology, and then orthopedic stabilization type of procedure. What we don't want to have happen is a patient to get disconnected from their care, develop a lesion in their bone, develop a hole in their bone, and then break that bone. We aim for what is called prophylactic fixation. We've all heard the saying "a stitch in time saves nine" with things like that, and it couldn't be truer for the patient with, for instance, metastatic breast cancer to bone.

Melanie: So the pioneering advances in the treatment of bone cancer—radiation, surgery, chemotherapy—these are all treatments that you can do. Are these treatments, Dr. Schmidt, ways to get rid of the cancer? Is this a cancer that can go into remission and you can, as you said, live many years with?

Dr. Schmidt: Yes. Because of a lot of the hormonal therapies that we have today and a lot of the bone-stabilizing drugs—we call them bisphosinates—we can actually put patients with metastatic bone cancer, particularly classic breast, for example, into a state of remission and stabilize them so that they can enjoy their life and their children and maintain a very active lifestyle.

Melanie: So you're treating it more like a chronic condition rather than a terminal illness?

Dr. Schmidt: Exactly.

Melanie: Now, what about pain management? Because bones can be very painful. As you said, you don't want to get to the point where someone does fracture or break a bone, and I know that bone pain is painful. What do you do for people while they're going through these treatments?

Dr. Schmidt: If we identify a patient with metastatic, let's say breast cancer to bone, and we identify it early, the doctor and the patient are vigilant, it shows up on a bone scan or an x-ray, typically, those patients can be treated with radiation therapy. Or, if they have sizeable lesions in their bone which put them at risk for fracture, we want to do what is called a prophylactic stabilization of their femur using an intramedullary rod. We do many of those surgeries at Midwestern Regional Medical Center, and those surgeries can be done in less than an hour to two small incisions under x-ray guidance, and this prevents the patient from breaking. It also relieves them of their pain.

Melanie: That's wonderful, because it takes the pressure off the bone having to support itself if it's got a lesion on it or something. You've talked about radiation and the rod that you can use and some prophylactic things. Now, what if they're suffering from some other issues at the same time, bone-related, arthritis? There are so many things that we get as we age. How do all of these tie together?

Dr. Schmidt: That's a great question. Often we'll see patients who have metastatic cancer to bone who develop conditions such as arthritis who are often turned away from getting a joint replacement because they're kind of looked as a patient with a stigmata, they're too complicated. And often, we will see patients here at Midwestern -- for example, I just saw a lady with myeloma. She's apparently in remission. She needs a total hip because of arthritis. But the doctors in her area would not do her total hip arthroplasty because they've looked upon her as too much of a risk, too much of a complicated patient. So here we have a patient who can enjoy the quality of their life even though their cancer has been successfully treated because they are looked upon as more of a complex patient, more of a risk situation. Often, we'll see patients with arthritis and do their joint replacements as well even though that arthritis is not cancer-related. But as a whole, they should still be considered as a cancer patient but still get the treatments that everyone else can get to maintain independence.

Melanie: And that's really what's so important is that quality of life. Now, talk about the importance of bone scans for a minute. What do those show us?

Dr. Schmidt: Bone scan is basically a very simple test. What it does is it lights up an area of abnormality in your bone. I'd liken it to the oil light in your car. For example, when you're oil light comes on, it just tells you that you have an oil problem. It doesn't say exactly what the problem is, but it obviously means that you should get your oil checked out, get your car checked out. The bone scan is like an early warning system with the presence of early metastatic disease. In this situation with our patients, it's so much better to be proactive. Know that there is a problem even before it becomes clinically apparent with pain so that you can follow up an x-ray or an MRI study. Often, patients who get a bone scan and will see an area of abnormality, and it turns out to be nothing. But you follow it. At least you know what's going on. You have an idea of what their bone scan looks like as a baseline study so that you can then compare to other studies down the road. I like bone scans very much. It's an early warning system. It maintains a proactive approach to cancer care. I lean heavily on patients getting regular bone scan studies.

Melanie: In the last minute that we have, Dr. Schmidt, your best advice and most important info you'd like the listeners to hear.

Dr. Schmidt: I would tell patients, be your own advocate, be vigilant in your own cancer care. Don't be a passive traveler in your cancer journey. If you have a problem, tell your doctor. If you develop bone pain, don't let yourself be put into a situation where, "Well, don't worry about it." Demand an x-ray, demand a bone scan, demand an MRI. Be proactive, be vigilant, be part of your cancer care, and just stay in touch with your physicians but be involved as the champion of your own diagnosis.

Melanie: Patient advocacy, self-advocacy is certainly wonderful advice. Thank you so much, Dr. Richard Schmidt, medical director of orthopedic oncology. The cancer experts at Cancer Treatment Centers of America have extensive experience in properly staging and diagnosing the diseases and developing a treatment plan that's tailored to your specific types of cancer. This is Managing Cancer with Cancer Treatments Centers of America. I'm Melanie Cole. Thanks for listening.