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Melanie Cole: Welcome to Right Beside You, a Reid Health Podcast. I'm Melanie Cole. And I invite you to listen as we explore the field of musculoskeletal oncology. Joining me is Dr. James Nuttall. He's an orthopedic surgeon with Reid Health. Dr. Nutall, it's such a pleasure to have you join us today. today. So tell us a little bit about what is an orthopedic oncologist. What do you do?

Dr. James Nutall: So, first of all, thank you very much for having me. Orthopedic oncology is a really interesting specialty within orthopedics. It's one of the younger subspecialties that have developed in the last 30, almost 40 years now. What this started out as is there's a group of really devastating cancers that occur both in young people and in older people that start off in your extremities. The problem with these tumors is that they're very different from the ones that come out of solid organs, like your liver or your lungs. And they tend to be very aggressive. So for most of the early part of the last century, they were always treated with amputation. And because these types of tumors crop up in very young patients, that was a really devastating thing to have to go through. Advances in chemotherapy, mostly during the 1970s and '80s gave us a little bit more breathing room. All of a sudden these cancers became a little bit more treatable. And as such, attention turned to the idea of is there anything that surgeons can do to deal with the fact that we still need to remove these big tumors surgically, but in a way that would save primarily kids from these big amputations. And that spawned a whole field of what we called limb salvage surgery, and that's probably a better technical name for the subspecialty than orthopedic oncology.

What limb salvage involves is preserving the function and structure of any part of your body that might be affected by massive bone loss in such a way that you can retain all of the normal things that we do with our arms and our legs. Though it came out of tumor surgery, it's actually expanded to a whole range of indications where the suite of skills that we've developed to treat these cancers are applicable in other situations where patients lose a lot of bone and have extensive damage to muscles and soft tissues, whether it's a cancer or otherwise.

What that means practically is that I'm involved in a lot of very custom and very extensive surgeries designed to keep people on their feet and with all of their limbs intact to get through really difficult situations, whether that's an arthroplasty or a joint replacement that's gone really bad, or the classical indications of a tumor or even a really bad infection. All of those things would come to bear and you can bring the skills that you developed for one to the others. So I really enjoy what I do. You get a lot of rewarding activity, designing custom surgeries to get people back on their feet and able oftentimes when other orthopedic surgeons have thrown in the towel.

Melanie Cole: Isn't that fascinating, this new burgeoning field that you're in? So what additional training does an orthopedic specialist have to have? As you said, this is pretty broad now and it's kind of expanding out into other areas. So tell us about any additional training that you need.

Dr. James Nutall: Correct. So, one thing to point out is that these types of complex surgeries are very difficult to accomplish with any one specialty. Often, I liaise with plastic surgeons, vascular surgeons, as well as the non-surgical specialties in order to provide these really cutting edge treatments. However, from the orthopedic standpoint, one, the first stage for anyone going through this is obviously medical school. And once you're done with medical school, you start the standard orthopedic training process, which is five years.

Orthopedic residencies, you have the ability to develop interests early on and to start categorizing yourself as interested in one field over another. You know, some people want to go into joint replacement, some people go into sports surgeries. So you focus your training early. And in my case, I had a fabulous mentor where I trained at McMaster University in Canada, who was very involved with development of both the evidence-based medicine side and the day-to-day limb salvage procedures that I was talking about. So I started identifying with her and she provided a lot of the early training as well as elective training during residency.

Fellowship after residency is either one or two years. I did an intensive one-year fellowship focusing on surgical applications of limb salvage, and that was at Rutgers University in Newark, New Jersey. After that, you are out in the field and practicing these types of surgeries.

Melanie Cole: So interesting. So tell us, you mentioned a little bit about some of the history and some of the types that you're seeing. But what conditions, if listeners are wondering what cancers you're talking about, are these systemic cancers? And you mentioned solid organs and solid tumors, but do systemic cancers -- Tell us about what you're talking about as far as the types of cancers that you're looking at.

Dr. James Nutall: So cancer is a very big word encompassing a lot of diseases. As practicing oncologists, we divide it into three distinct categories based on what type of tissue the cancer is originally developed from. Most of the cancers, in fact, 90% of the cancers out there, come out of what we call solid organs or in the group called carcinomas. And those are things like liver cancers, lung cancers, basically anything that came off of either the inside or the outside of the tube that we were all born as or we all started development as before we were born. The second big category are blood cancers. So these are cells that normally circulate around your body as part of either your blood or your white blood cell immune system. And those are the lymphomas and leukemias, which are also relatively common. The third group, which comes out of all of the stuff that doesn't move around, but started out not as part of the lining of that original tube, but it was actually the stuff in the middle, something called mesoderm are the group called sarcomas. Sarcomas develop from tissues like muscle and bone that developed in the middle of your body, not associated with one of these hollow tubes. Sarcomas are rare. For every 99 of the other tumors that are out there, there's 1% of sarcomas. But they are very dangerous when they do happen and they're very tough to identify from those benign lumps and bumps that almost everyone has and carries around with them. Within that group though, there is equal diversity to saying the carcinomas, so there's equivalence of the lung and the liver, there's more dangerous tumors, then there's less dangerous tumors. And they all need very sub-specialist care to identify what they are and to treat them appropriately.

Melanie Cole: What description, Dr. Nutall. I mean, that really you're a good teacher and that explains to the listeners and kind of put it all into perspective. So as we all worry about things and, women, we're taught to feel our breasts and all of these things, when is a lumper bump on a muscle or bone, when is something like that, that we may find ourselves something to worry about?

Dr. James Nutall: So in general, we live in a day and age where if you find something new and different on your body that you are worried about, it is always worthwhile to get it checked out. So I would never caution anyone away from getting anything checked. But in general, if you are looking at a part of your body and you notice something that wasn't there before, there are some features that would tend to push us in an area of more concern than others.

The first one is the lump, bump or mass growing. So if you keep an eye on any of these things that crop up, rapid growth is always a dangerous thing. Now, there's still a lot of things other than cancer it could be and, to be honest, those are probably more common. But things that you notice that are new and growing, changing color; in particular, things that are painless are definitely worth getting checked out by a physician at very least.

Melanie Cole: Well, thank you for that. So are there certain risk factors? Are there people that are more subjected to any of these types, sarcomas or musculoskeletal cancers, or even just benign lumps and bumps?

Dr. James Nutall: So, yes, there are a lot of people who are more prone to these types of problems. But generally, those types of people are identified in childhood. The big underlying cause of most cancers is some type of genetic mutation. We are really good at replicating ourselves to make sure that our DNA stays true to the previous copy with every successive generation of cells that we have. But this process is going on billions of times in your body every day. There are some people who are just better at error checking their DNA than others based on their own genetic makeup. And unfortunately, some people develop mutations faster. As I said, most of those patients are identified very early because unfortunately these cancers tend to present in childhood.

Outside of that very select group of people, which thankfully is very rare, the people who are at an increased risk are people who have a family history of any type of cancer by which, I mean, people who've developed cancers in their family below the age of 50. That tends to be a good differentiator between cancers that we're all at risk to and cancers that may represent something an issue in your own genetics.

Other than that, there's always the things that we can do to keep ourselves safe from these things. Avoiding things that cause mutations and that we know cause mutations is always a difficult one to balance. However, the big, bad actors out there, including cigarette smoke, any type of inhaled smoke, alcohol consumption to a certain extent and exposure to known carcinogens, if there are pesticides or things in the workplace are always things that we can avoid to keep ourselves safe.

Melanie Cole: What great advice. And before we wrap up, I'd like you to tell us about your multidisciplinary approach. You mentioned it a little bit before, but tell us the advantages to regional cancer center-based care and how important this is for patients that may have some of the things you've been describing today.

Dr. James Nutall: Absolutely. One of the things that is an advantage in the modern world is that all the medicine is very, very well connected. What that means to patients is that as a lot of smaller hospitals in areas are closing, things are substituting out in communities to get people the care they need close to where they live. Treatment of any type of cancer, whether it's a carcinoma or a sarcoma or anything else that I talked about, is very, very tough and requires a lot of time, effort and commitment on behalf of the patient and the whole team to make sure that you have the best chance of surviving with a good quality of life and treating these terrible, terrible diseases. What people don't often realize is that investment of time of driving back and forth to receive treatments, whether that's chemotherapy, radiotherapy, or followup with your surgeon, take a ton of time, effort and energy and coordination and a huge support group. And the farther away you get from your local medical center, the tougher it is on you. Often, you're going into unfamiliar areas and it's very stressful.

The modern model of cancer care is one where we all work together with centers of excellence. And so experts like myself in treating certain types of tumors are moving more and more out into the community and liaising with regional subspecialty centers in order to provide treatment plans that we then execute at the local level. So when I am, for example, starting treating a new sarcoma, often my patients will see me first and we'll identify the problem, confirm the disease, usually with a biopsy.

Once the disease has been confirmed, there's usually a consultation with one of the local oncology sarcoma experts and often those are at the major academic centers. However, after that point, we can work very closely with our general oncologists here at Reid Health, for example, and order to make sure that we execute a treatment plan under the direct supervision of our qualified oncologists here that we can modify and identify problems in consultation with larger subspecialty experts. What this does for patients is make sure that they can actually fulfill very complicated treatment regimens in a more reliable way and make sure that they're not exhausting themselves with the travel part and all of the stress that goes along with that commuting often two or three hours to more centralized locations.

One of the miracles of modern technology is that even though experts are scattered around somewhat haphazardly around the country, we can all liaise and work together almost like we're in the same building.

Melanie Cole: Isn't that amazing? Thank you so much, doctor, for joining us today and sharing your expertise in the fascinating topic of limb salvage and musculoskeletal oncology. It's so interesting. Thank you again for joining us. And for more information, you can call (765) 962-4444 to schedule your appointment today or you can visit reidhealth.org to get connected with one of our providers.

That concludes this episode of Right Beside You, a Reid Health podcast. Please remember to subscribe, rate and review this podcast and all the other Reid Health podcasts. Share these shows with your family and friends on your social channels. Because that way, we're all learning from the experts at Reid Health together. I'm Melanie Cole.