Shreyaskumar R. Patel, MD: We are now going to move into symptom management for these patients, and then transition into the systemic therapy discussion. Before we jump into the systemic therapy discussion, 1 of the important aspects of management of these patients tends to be pain management and overall symptom control in terms of mobility and quality of life. Since the patients are followed by an orthopedic surgery team at this stage, John, do you have any comments on your perspective on pain management? How do you do it? Whom do you engage? Are there differences that are age related that you may want to bring up before we move into systemic therapy?

John A. Abraham, MD: From my perspective, I approach it as whether it is a problem I can address surgically or not. If it’s not, then I would turn the patient over to the medical oncologist for management. We try to avoid leaving the disease there without any management because we know it’s a progressive and chronic condition that will cause pain and increasing disability over time.

I try to avoid managing with pain medicine alone. That being said, if there are reasons for delay of surgery or delay of treatment, anti-inflammatories can sometimes help because even the blood that’s produced in the joint can be very irritating. Some of that can propagate inflammation and anti-inflammatories can help, regular NSAIDs [nonsteroidal anti-inflammatory drugs]. That also has to be approached carefully because that can cause some increased bleeding at the time of surgery, so we want to make sure we are thinking about patients who are using NSAIDs when they’re about to undergo very large-scale surgery.

Postoperatively, if there is a patient with a small recurrence that is asymptomatic or minimally symptomatic, that might be a patient who we don’t necessarily want to expose to more surgery. They’re minimally symptomatic, but they do have a small recurrence that causes some minor symptoms. That might be a patient where some intermittent pain medicine or anti-inflammatories can manage for a long period of time, especially if that limited disease is not changing. I do have a number of patients in that type of situation. In general, it’s not something that we’re going to manage with pain medicine alone.

I think in terms of the age differences, the younger patients definitely do feel the disability more because the younger patients are active in general. Those are patients for whom I do tend to be aggressive surgically, so I do try very hard to get as much of the disease out. If there is a patient who I think is borderline regarding whether we can remove all the disease surgically, I would have that discussion with them and say I think the best shot is probably with surgery, so here is the risk and this is what I think we can do and not do.

For older patients, because of lower activity level in general—as I get older, I try to watch what I say about older patients—the disability may take a little longer to manifest. That’s probably why we end up seeing older patients. I have nothing to support this other than clinical experience, but I tend to see older patients who have more in the way of bone erosions and things like that. It may just be because it takes a little longer to experience the full effect of a disability from the symptoms. That disease being around longer may cause more erosions. Those are patients who may consider things like joint replacement. I try to avoid long-term symptom management with pain control. We go 1 way or the other: either we’re going to utilize surgical management or turn it over to the medical oncologist for medical therapies.

Transcript Edited for Clarity