Carving Out Cancer: Orthopedic Oncology

Session 216

Today’s physician in the spotlight is Dr. Lukas Nystrom an Orthopaedic Oncologist. Let’s talk about what led him to Oncology after doing Orthopaedics. He talks about his journey to orthopedics, and ultimately, his training and interest in the oncology side of orthopedics.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:01] Interest in Orthopedic Oncology

What drew Lukas into orthopedic oncology was the first time he put his hands on a screwdriver and applied a screw to the bone of a human being while he was a medical student. He entered orthopedic surgery residency thinking he was going to do something like Sports Medicine or Trauma. He didn’t know that orthopedic oncology was a thing until he was in residency.

What he likes about the specialty is the anatomic variety in many different senses of the word. You’re operating all over the entire body, whereas many other specialties tend to focus on a particular joint or a particular skill set.

In orthopedic oncology, it’s head to toe, and you’re using skills that you’ve gained from all of the other subspecialty exposures. You have to develop trauma skills, reconstructive skills with joint replacements, and skills that don’t really even exist, but they just make sense in how you have to attack the problem.

There’s also a variety of pathology – benign, malignant, and metastatic disease. All of which appealed to Lukas including the variety in the patient type that they see from pediatric to old adults.

[04:14] Traits that Lead to Someone Being a Good Ortho Oncologist

Lukas explains how the specialty has really high highs and really low lows. For some people, it’s straightforward. But for the malignant cases, these are life-changing events for, not only the patient but their entire family. That being said, it can wear on a person over time. And so, you have to be somebody who can take that on without owning it forever.

'You have to be able to compartmentalize your life a little bit.'Click To Tweet

Lukas stresses the importance of being able to compartmentalize your life as much as possible. Self-care is very important so make sure you have a daily exercise routine.

Try to have that physical separation from the hospital, but also mental separation when possible.

[07:30] Ortho Oncology: The Hidden Gem in the Ortho World

Historically, the number of orthopedic oncologists has been dictated by the number of sarcomas, which are rare malignant tumors. As a specialty, Lukas says they wanted to be known as the sarcoma surgeons.

They have currently groomed this specialty with about 200 active people across the United States.

Realizing they have additional benefits to the world of orthopedics, they’re owning more of this metastatic disease, some of that stuff is a little bit more complex than they’ve given it credit for. And it’s becoming more complex.

As medical treatments improve, more and more patients are living longer with their cancers. Thereby, there’s an increased incidence of metastatic bone disease. Patients are fortunately living longer, but also acquiring these unique problems.

[09:27] Types of Pathologies

Sarcoma is a bone cancer but it’s also a type of cancer that happens in all the connective tissues muscles, tendons, nerves, fats.

Lukas is primarily seeing patients with tumors of the upper and lower extremities including the shoulder girdle, scapula, and pelvis. He doesn’t do spine but some people are dual-trained in spine and orthopedic surgery. He’s also seeing bone and soft tissue sarcoma in addition to the metastatic disease as well as certain benign conditions that may mimic or be confused with these malignant tumors.

In terms of the ratio of new diagnoses to those who come in for definitive treatment, Lukas explains he’s seeing both. But by and large, they’re coming with some kind of lump that hasn’t been diagnosed. It’s a mass in the arm or leg, bone, or soft tissue. It may or may not have been completely imaged, but the person who saw them initially is concerned and has sent them along. Generally, once certain keywords start getting used in the scheduling and triage thing, they find their way to them pretty quickly.

For the most part, they’re doing the diagnostic evaluation, which includes completion of the imaging if they haven’t had it done, and then a biopsy.

[11:53] Message to Primary Care Physicians

Lukas says that as ortho oncology specialists, they’d be happy to take on the burden of the evaluation. Primary care doctors don’t have to try to figure out which is the right test to do or to try to send a patient for a biopsy.

Lukas wants to let aspiring primary care physicians know that if there’s any concern, they could always let them know.

A lot of times, Lukas sees primary care physicians having trouble ordering imaging. And that may or may not be because of some documentation issues. But it’s important to know the keywords to say.

Additionally, the weight of the title of oncologist tends to “grease the wheels” for this type of thing. Lukas likes to be very responsible about the imaging and the evaluations they order. He’s cost-conscious as well, for the sake of the healthcare system, but they can get it done easier in general.

The operating room can sometimes be his long days, but the others are pretty predictable. Lukas is operating for about two and a half days in a typical week.

[14:43] Longitudinal Care

'The medical oncologist, oftentimes, will become the primary care physician.'Click To Tweet

For patients that never needed chemotherapy, for instance, medical oncologists will be the ones doing their surveillance and imaging. They’re checking to make sure they didn’t have metastases to the lung, and they didn’t have a local recurrence of their tumor in the arm or leg.

When things go the way that they want them to, Lukas will know a patient with sarcoma for five years, and then become more distant after that.

[15:48] Taking Calls

Lukas says he takes general orthopedic calls as most physicians in his position do. He is part of a big health system so he takes a full weekend of calls every two months, and then a weekday, every one to two weeks. And he doesn’t find this overwhelming.

He also gets to work with residents which make the burden even more tolerable. They’re very much on the frontlines and are triaging a lot of things he doesn’t necessarily need to hear about in the middle of the night.

In terms of ortho oncology calls only, Lukas says this doesn’t happen. The type of emergency he could envision in the orthopedic oncology setting would be primarily a post-operative emergency. There’s some infection or some kind of bleeding event.

But for a new patient to come in with some kind of tumor that would need something in the middle of the night would be very unusual. And if they have a spine tumor, Lukas works in conjunction with one of their spine surgeons.

[17:48] The Training Path

After medical school, orthopedic surgery residency is five years, and then the oncology fellowship is one year of additional training.

The goal of an oncology fellowship is to learn the principles of how to approach problems, learn the basics of pathology, and how to approach things. They learn how to function in a multidisciplinary team.

You can’t see or do everything, unfortunately, in a year, and he doesn’t think three years would be either.

'There's no way you can see everything in a year of orthopedic oncology. And if you can, you can't see it in three years.'Click To Tweet

[19:49] Overcoming Negative Bias Against DOs

Lukas knows a few osteopathic orthopedic oncologists out there. And it’s becoming even more common with the recent combination of the two training pathways under the ACGME, and having the same requirements for their education. The standardization of education is allowing that to become even more of a reality.

That being said, Lukas doesn’t think there are any great barriers to an osteopathic student becoming an orthopedic oncologist. You just have to make sure you get that exposure.

[20:49] Message to His Younger Self

Lukas says he wouldn’t do anything differently than what he had done. But he would just tell himself to make sure he learned some skills for how to separate work and home life. It’s something you do learn along the way but he would make a more concerted effort to do that from the very beginning.

Lukas adds that some of the stuff he sees is just incredibly sad, and it’s hard to not put himself in their parents’ shoes. Seeing parents in tears as they accompany kids to the operating room is just tough that sometimes he just had to leave so he won’t have to witness that particular moment. And he has learned to separate that.

[22:26] The Most and Least Liked Things

'At the end of the day, I get to be by a patient’s side in one of the scariest moments of their entire life.'Click To Tweet

Lukas loves being able to take care of patients during one of the scariest times of their life and he doesn’t take that responsibility lightly. He’s happy to be able to provide comfort to them at a scary time and what he could potentially do for them, hopefully.

Lukas adds that they can’t fix every problem, even the ones they think they did really well on. Sometimes it comes back, sometimes it spreads, but he knows how to approach it. Giving that confidence to them can be a huge benefit at a really scary time. He also feels has the ability to just comfort them emotionally, which is something he likes in his job.

On the flips side, what he likes the least is that, at times, he could be spreading himself thinly. It’s hard to feel you’re providing great care to the ones that you need to if you’re trying to do it for everybody. Lukas admits this is a skill he has to work on over the next ten years of his life.

[25:22] Major Changes Coming to the Field

As we’re getting a lot more targeted therapies, Lukas is seeing a decrease in the amount of ortho oncology surgeries because the therapeutics are going to get better. At least, that is what they are all looking for.

Unfortunately, sarcoma lags behind the other cancer subtypes for a couple of reasons. Number one, it’s extremely rare. All of the major funding goes to where the prevalence is higher. That makes sense, in a lot of ways. But if it’s a smaller subset of patients, it’s harder to study it, it’s harder to fund it. And so, that becomes a limiting factor.

Moreover, when they look at the genetic mutations of sarcoma as compared to breast cancer, the mutations are so sporadic. They’re all over the map. There are a few subtypes that have translocations and that can have some potential ability to target. That being said, the vast majority of sarcomas are just really random. in their mutations. So it’s hard to see a silver bullet happening anytime real soon.

[27:00] Final Words of Wisdom

If he had to do it all over again, Lukas would still have chosen to become an orthopedic oncologist. As he was going through the residency match process, he had a lot of different things in his mind, all the way from internal medicine to orthopedic surgery.

The field of medicine is incredible and there are so many incredible things that you can do after you’re done with your MD degree. But knowing what he knows now, he would absolutely do it all over again.

Finally, he wishes to tell premeds who might be interested in Orthopedic Oncology to explore anything that interests them within medicine. It’s very easy to be enamored by all of the really cool and fancy things that you get to do. But there are also things like hand-holding and giving bad news that they need to prepare themselves for.

'Look at both sides of any specialty that you're looking at because every specialty has ups and downs. It's important to evaluate both of those critically.'Click To Tweet

[29:38] Insights Into Step 1 Being Pass-Fail

The ortho world is unique in terms of being one of the more competitive specialties, historically, going back to Step 1 scores. With the change starting in 2022 with Step 1 being pass-fail, this can change the future of medical education. Medical students are now able to apply to a residency based on their passion and not just because they can.

Lukas admits he has never considered it that way since a lot of people think about that change in a negative light. People are concerned about how they’re going to differentiate between these applicants as they have nothing objective.

Because Step 2 is still scored, most of the weight of what residency programs are putting on Step 1 will just shift to Step 2. Lukas thinks this will probably be the case for a while.