Musculoskeletal Interventions Can Improve Pain and Quality of Life

Patients are often left with skeletal complications and debilitating pain as a result of cancer or treatment for cancer. These fractures and other complications diminish quality of life and overall survival, but practitioners of interventional oncology have the potential to offer treatments that can steer patients towards a better outcome. In this Q&A, Sean Tutton, MD, FSIR, reviews recent research in musculoskeletal interventions, discusses his own practice, and provides advice for colleagues who may want to offer more of these procedures. Dr. Tutton is Division Chief of Vascular and Interventional Radiology at the Medical College of Wisconsin in Milwaukee, and he was a faculty member at the 2018 Symposium on Clinical Interventional Oncology (CIO) on February 3-4, 2018 in Hollywood, Florida.

What are some takeaways from recent studies in musculoskeletal interventions?

We’re still in an early phase of our development of musculoskeletal interventions in cancer, so there have been few prospective, randomized landmark trials. In the spine metastasis realm, the CAFÉ trial was published in 2011, but we haven’t had the next big prospective, randomized trial that confirming significant benefit and improvement in patients’ pain and quality of life in the setting of spine metastases. The CAFÉ trial was a cancer-focused trial looking at vertebral augmentation in spine metastases and fractures in the spine. It was a foundational study that demonstrated that we can relieve pain and improve patients’ quality of life in the setting of cancer-related spine fractures.(1)

After that trial, there was an emphasis on treating patients with cancer-related spine fractures. The evolution of that has been coupling vertebral augmentation with ablation. We’re now starting to use either ablation and augmentation or just augmentation throughout the skeleton. I’m particularly excited about a study on osteoplasty that was published in JVIR by Matt Callstrom and his group.(2) The following year our group published in JVIR the next iteration, which combines ablation, cement and reinforcing screws.(3)  

It is exciting to see that more and more large academic cancer centers are focusing and publishing on musculoskeletal interventions in cancer. The Mayo group is focusing on ablation and osteoplasty in the pelvis, and our group at the Medical College of Wisconsin is focusing on combining ablation with stabilizing a fracture in the pelvis or stabilizing an impending fracture in the pelvis either with cement alone or cement plus hardware.

The interventional oncology group at Gustave Roussy Cancer Center in Paris are also performing the same work and have publishedtheir series.(4) I’m very excited that we have a number of important cancer centers around the world that are starting to take the lead in focusing on minimally invasive therapies for the skeletal complications of cancer. In the next 5-10 years we’ll be on the steep part of the curve of the uptake of these types of therapies, and we’ll see the research and the publications follow. Even 5 years ago, there was very little research in this area, and now we have increasing activity and increasing focus on these patients.

Have any changes in cancer care driven this shift in focus?

We’re turning many cancers into chronic diseases, and that’s a huge paradigm shift. Five years ago, a pancreatic cancer diagnosis was an immediate death sentence, but now we’re seeing some of those patients surviving.

However, the lifesaving therapies they’re receiving take a significant toll on the skeleton. Loss of bone is accelerated, with patients essentially having a secondary osteoporosis from the steroids, aggressive therapies, and radiation involved in treatment. Thus, patients are living longer but have more skeletal complications of their cancer therapy.

That’s where we come into play as interventional oncologists. We can focus on those patients, provide minimally invasive therapies that relieve pain, and improve quality of life.

How can interventionalists prepare for this paradigm shift?

Much of this work is being done in the large cancer centers, but patients are being effectively treated with these cancer therapies in all practice settings, from small community hospitals to intermediate-sized hospitals that are not necessarily academic. This is not a problem or opportunity that’s unique to interventionalists who are working in large cancer centers.

It’s important for more interventionalists to gain training in spine interventions and in musculoskeletal ablation procedures. We’re training our fellows, and our fellows from previous years are doing these procedures and starting to offer these therapies in their own practices. I’ve heard from my fellows that they have been having successes and that there is much more demand for these services once they are offered. I believe we have an awareness problem and need to educate our oncologist and palliative care colleagues that we can perform these therapies and improve patients’ lives.

Are there any patient stories that illustrate the importance of this work?

One patient in particular was a wake-up call for me regarding the importance of the work we’re doing in pelvic metastasis and fractures. A woman who was a 5-year survivor of breast cancer presented to our musculoskeletal tumor board with a metastasis to the acetabulum around her hip joint. She had undergone radiation and her pain improved transiently, but then she had a significant fracture to the acetabulum.

Orthopedic surgery needed to do a total hip replacement on her with the hope that she would recover, rehabilitate, and survive. However, she ultimately died in the hospital after a surgery that was too invasive for her at that point in her journey.

I realized that a different approach may lead to better outcomes for such patients. The patient might be able to leave the hospital the next day and be eligible for chemotherapy and radiation if we could intervene earlier, ablate the tumor, cement it, and perhaps put screws in as reinforcement. Quality of life and need for narcotics would also be impacted. That’s the sort of significant difference these procedures can make—we can take a patient who would otherwise be destined for a huge surgery that they can’t tolerate and avoid that path of treatment.

Are there any challenges to offering these procedures?

The challenge that people ask me about most often is about how to overcome barriers to having patients referred for these procedures. In my own experience, I’ve found that orthopedic colleagues are very willing to collaborate and to refer patients who are at risk for poor outcomes with invasive surgery. No one wants a patient to have a poor outcome or to go to hospice days after having a large surgery. The key to jumpstarting this collaboration is attending tumor boards, raising awareness of the availability of these therapies, and quickly offering to work together. We’ve also ensured that we equally share in the care of the patients, from admitting them to seeing them in clinic and discharging them.

Another challenge is that these procedures are time intensive and require advanced imaging. A good interventional suite with cone beam CT is needed. Most centers now have good angiography suites with at least cone beam CT, so I think that that’s a good starting point, and that’s where I started. You have to have the resources to dedicate the time to do these multi-hour procedures, including scanner time, interventional suite time, and manpower.

Although more of these resources are available at larger centers, there are community practices that are performing these procedures as well.  Still, we’re early on in establishing good work flows and adapting the tools so that we can be as efficient as possible. For someone who likes to innovate, this process of improving tools and procedures is quite exciting.

What is one simple change that someone in a community center could make to their practice to better treat these patients?

Not all cases are complicated and require advanced equipment. Some cases involve performing a single ablation and then injecting some cement, and that can be done in a CT scanner. The single most important step to take is to start to attending tumor boards. Be present at the tumor boards, show up, and raise your hand and say, “That’s something that could be ablated. That’s something that we could actually stabilize with osteoplasty  in the spine as well as in other parts of the skeleton.” By taking that approach, you’re solving a problem for your colleagues because these patients have ongoing pain and need increasingly higher doses of narcotics. My past fellows have reported back to me that this type of problem-solving has been helpful in establishing their practices. The other strategy would be to get to know the palliative care physicians in your institution. Many palliative physicians don’t yet understand all we can offer as interventional radiologists.

Have you made any changes to your practice in the past year?

I’ve started offering more adjuvant pain injection procedures. For example, some patients need a celiac plexus block because they have severe epigastric pain, and I can offer a simple, low-risk procedure in which we target the celiac plexus or the hypogastric plexus and do a block followed by a nerve ablation. These procedures are very straightforward, and interventional radiologists are best suited to perform them because of our expertise in image guidance. Sometimes we’re not offering the big, flashy procedure. Sometimes a helpful procedure is a simple nerve block and ablation in a patient who has pancreatic cancer, or a patient with a pelvic malignancy who undergoes a targeted nerve block and ablation to relieve pain. These are often 15-minute procedures that can have a huge impact on the patient by relieving their pain and lowering their doses of narcotics.

Is there anything else that you would like to comment on?

I’m essentially at 20 years of practice, and it has been an amazing career, with a tremendous amount of satisfaction. Focusing on musculoskeletal interventions has been really exciting. I encourage anyone who is looking for something new at the midpoint of their career to consider this rapidly growing area that is in need of a significant research focus. This is a great space to enter and may be the next big thing.

References

1. Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011;12(3):225-235.

2. Kurup AN, Morris JM, Schmit GD, et al. Balloon-assisted osteoplasty of periacetabular tumors following percutaneous cryoablation. J Vasc Interv Radiol. 2015;26(4):588-594.

Hartung M, Tutton S, Hohenwalter EJ, Neilson JC. Safety and efficacy of minimally invasive acetabular stabilization for periacetabular metastatic disease with thermal ablation and augmented screw fixation.

4. DeChamps F, Farouill G, Hakime A, Teriitehau C, Barah A, de Baere T. Percutaneous stabilization of impending pathologic fracture of the proximal femur. Cardiovasc Interv Radiol. 2012;35(6):1428-1432.