Ongoing Research in Orthopedic Oncology Is Revolutionizing MBD Management

R. Lor Randall, MD, FACS, who serves as the David Linn Endowed Chair for Orthopedic Surgery, chair of the Department of Orthopedic Surgery, and a professor at the University of California (UC) Davis Comprehensive Cancer Center in Sacramento, California, sat down for an interview with OncLive® to highlight ongoing efforts to improve the management of metastatic bone disease (MBD) caused by primary cancers through surgical intervention.

In the interview, Randall shared the relevance of these efforts, as previously discussed in an op-ed that he penned over a decade ago; expanded on ongoing research within this rare subset of patients; and emphasized the role of orthopedic oncologists in improving quality of life (QOL) outcomes for patients with MBD.

Randall shared more on this topic and spotlighted a review of supportive care interventions in MBD in another article.

OncLive: What is the importance of addressing MBD from the perspective of an orthopedic oncologist?

Randall: Regarding metastatic bone disease, in this case, I'm talking about metastases from carcinomas and other solid tumors in the musculoskeletal system. [It] primarily [manifests as] secondary involvement of the locomotive apparatus from metastatic carcinoma, but sometimes it also involves myeloma. This is something that I'm passionate about. Even though, as an orthopedic oncologist, I spend a large part of my time talking about primary malignancies of the musculoskeletal system, the bulk of our work is in patients with secondary involvement of the musculoskeletal system from carcinomas.

I wrote an op-ed on this [topic] approximately 10 years ago in the Annals of Surgical Oncology. The op-ed was entitled 'A Promise to Our Patients with Metastatic Bone Disease'. Ever since writing that op-ed, I've had a fervent commitment to trying to help this group of patients. I also have edited a book on metastatic bone disease. It's been wonderful to put out the second edition, because it's enabled me to speak to thought leaders around the country and the world on this topic, as we bring together our thoughts to address an orphan population within the cancer community with advanced disease.

There are approximately 400,000 patients per year in the United States who cannot obtain specialized palliative care for their metastatic bone disease. They don't have the interventions and are particularly vulnerable to fragmented care. Orthopedic oncologists think of ourselves as the primary stewards for the metastatic bone disease aspects of care. This is not to say that the medical oncologists aren't fully engaged, but their lens tends to be on survival curves, and ours tends to be on quality of life as relates to musculoskeletal issues. As orthopedic oncologists, we often feel we're sometimes on the periphery of the care team, and the coordination, decision-making, and management of [a patient’s] musculoskeletal burden of disease can be difficult.

Regarding the op-ed that you penned on this subject, how have your opinions and recommendations remained relevant over the past 10 years?

I wrote [this op-ed] because, as I was rolling a patient back to surgery for an intervention on their femur, [they] asked me why we would put a patient with advanced cancer through a surgical intervention when their disease was terminal and they had other issues at hand. It was a very appropriate, provocative question, and it made us realize that we had to prove that what we were doing, what we thought we knew, was the right thing to do. We needed to prove [that] through patient-reported outcome data, and so we published that initial article in the Journal of Surgical Oncology.

Now, we have a national study called REcovery of patient-reported outcomes after intervention for extRremity MBD [REPAIR]. It is an ongoing multicenter trial for patients undergoing surgical stabilization for MBD in the femur, and it involves several centers around the country. We just presented this at the 2024 Musculoskeletal Tumor Society Annual Meeting, to hopefully accrue additional sites to be looking at these patient-reported outcomes.

Our preliminary data are very favorable, [and indicate] that a patient’s physical function and pain interference returns very quickly to baseline and improves once the intervention is undertaken for these patients.

What future investigations are needed to further validate this management approach?

We have just submitted an R21 to look at nurse navigation for these patients. Medical oncologists are diligent about taking care of the whole patient and looking at the survivorship and disease-free progression as relates to the cancer, but the musculoskeletal system doesn't get the attention it deserves sometimes. Therefore, we are hoping to demonstrate that having nurse navigation intervention can enable improved outcomes through patient-reported outcome measures by these nurse navigators being the primary stewards for these patients.

[When] I moved to UC Davis from [my previous institution, Huntsman Cancer Institute at] the University of Utah, I noticed that there was an increasing number of patients presenting through the emergency room with realized fractures. We do think that patients with realized fractures—secondary to metastatic bone disease—as opposed to impending fractures, does reflect a socioeconomic distress signal that these patients are in lower socioeconomic brackets. We hope to be able to establish that as a paradigm for managing metastatic bone disease.

It is fair to say that MBD is a pandemic within a growing population of patients afflicted with cancer. There's a lot going on there, but MBD is first and foremost on patients and families’ minds. We think surgical intervention can improve function and reduce pain. Finally, inequities in af care in access to care are present United States and we need to address them. Navigation for at-risk populations for MBD may be part of the solution.