Latest / CareTalk: Healthcare. Unfiltered. / Raising Awareness of Sarcoma Cancer with James C. Wittig, MD

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Raising Awareness of Sarcoma Cancer with James C. Wittig, MD · CareTalk: Healthcare. Unfiltered.

• 0:00
  Sarcomas are cancers of the connective tissues, with more than 15, 000 new cases and 7, 000 deaths in the U.
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  S.
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  every year.
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  Sarcomas are often diagnosed when they're too late to treat effectively, leading to poor outcomes.
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  July was Sarcoma Awareness Month, featuring a major push to educate the public about recent discoveries, the value of early diagnosis, and the impact on patients and families.
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  My guest today is Dr.
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  James Wittig, an orthopedic oncologist and sarcoma surgeon who specializes in surgery of musculoskeletal tumors, saving limbs, and avoiding amputations.
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  Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
• 0:44
  I'm David Williams, president of Health Business Group.
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  And I have a favor to ask.
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  If you're enjoying the show, could you please leave us a rating or review of the Care Talk podcast on your favorite streaming service?
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  That helps us stand out from the crowd and lets others find us.
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  Dr.
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  Wittig, welcome to Care Talk.
• 1:00
  Thank you, David.
• 1:01
  I'm happy to be here.
• 1:02
  Thank you for inviting me.
• 1:03
  You know, orthopedics and oncology are not two specialties that I often hear about together.
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  What's the relationship between orthopedics and oncology?
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  Well, where orthopedics and oncology comes together is really treatment of sarcomas.
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  And sarcomas are cancerous types of tumors that develop directly from either the bones or the connective tissues, the soft tissues of the body, the muscles, the fatty planes between the muscles.
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  Those are the sources of sarcoma.
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  And generally speaking, those type of cancers are treated by orthopedic surgeons who specialize In orthopedic tumor removal or in Sarco or in specialized in orthopedic oncology.
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  You know, when I was reading about this sarcoma awareness month, it was mentioning that these tumors are often kind of deep within the body and are hard to find.
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  Are there particular challenges in diagnosis for sarcomas?
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  So one of the biggest challenges is that sarcomas are often, uh, misconstrued as being other types of problems.
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  In children and as adolescents often, uh, they're athletic or they're playing sports.
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  And many times the pain that starts from a sarcoma or the swelling is dismissed as a sports injury.
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  Um, so it can go overlooked for a period of time.
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  Generally speaking, they might see their family doctor, might see an orthopedist.
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  They're treated conservatively for a period of time.
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  Uh, but then it gets worse usually over the course of time when it's, and that's when it's diagnosed on either an x ray or an MRI.
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  Uh, adults on the other hand, same type of thing.
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  They might bump their leg on something and develop a swelling or many times I've heard them call it a knot in the muscle.
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  The interesting thing about soft tissue sarcomas is, um, despite them being cancerous, they're usually not painful.
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  So they could go a period of time before the patient even really realizes that they have a problem.
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  And then many times they can also be misconstrued as other types of injuries or problems going on.
• 3:16
  So that sounds like a challenge, and I think, you know, certainly your average person isn't expecting, they might not, probably not even know what a sarcoma is, never mind they may be expecting one, um, especially, I know they, you know, strike kids, uh, as well as adults.
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  What are you seeing in terms of trends?
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  in diagnosis and treatment.
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  I'm sure, you know, the challenges have been there for a while, but are there, are there new things happening to help with, with diagnosis as opposed to just looking back in retrospect and saying, gee, I wish I had realized earlier that wasn't just a bruise.
• 3:43
  Well, I think awareness is the biggest thing that spread awareness that sarcomas are a real entity because you're right.
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  Most people would never have a neighbor who had a sarcoma.
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  Most children will never know another child who's had a sarcoma.
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  And awareness is, is very important so that parents bring their children or adults seek attention immediately when they have a mass or a swelling that doesn't get better sort of within a week.
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  And from, you always start with x rays.
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  It's always very important to examine a patient, get x rays in the office.
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  And then when, and sometimes you can't see it so readily on an x ray, next step is really an MRI, especially if there's any swelling or you feel a mass.
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  And those are really the most reliable means of diagnosing a patient with a sarcoma.
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  What about in terms of treatment?
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  Is treatment more or less the same as it was five to 10 years ago, or there've been changes in that?
• 4:40
  Uh, there have not been many changes in treatment.
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  Treatment often involves a combination.
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  of surgery and chemotherapy and or radiation depending upon the particular type of tumor, patient's age, et cetera.
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  And, uh, we have not seen substantial changes in those regimens that are given to patients.
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  which killed the disease.
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  Uh, a lot more investigation, a lot more, um, study is necessary for that.
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  And because it's sort of considered an orphan cancer, there's not a lot of money out there to study these type of cancers to see how they work.
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  One of the items, surgically, that's come up in the last 10 years has been a special type of extendable or expandable prosthesis.
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  So, children who are sort of less than 12 years of age Really in their lower extremities, arms are not as crucial, but in their lower extremities, if you take out the cancer and you have to take out their growth plate with it, which is often the case, they're going to end up with a leg length discrepancy as they grow older.
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  So there's a new type of prosthesis that's been developed.
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  that allows you to lengthen the leg and, uh, in a non invasive manner.
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  So previously there were types that were available that you'd have to take the surgery, the child to surgery, you know, 10 times before you got the legs the same length.
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  This one actually allows you to bring the child into the office.
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  They sit under a magnet for 16 minutes.
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  The magnet spins around their leg and it spins a mechanism within the prosthesis that elongates it much like a, uh, corkscrew mechanism.
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  Every 16 minutes under the magnet lengthens the extremity about four millimeters.
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  So they'll come in for repeated bouts of that.
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  And that's one of the nice inventions that sort of come about in the last.
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  10 years.
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  I know people, you know, my age that had, uh, childhood cancer or other issue, uh, at that age had had is that sometimes heard dozens of surgeries, um, you know, sort of to correspond with their growth.
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  It sounds like this is a good, uh, a good innovation for them at least.
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  Now we talk a lot on CareTalk about, uh, healthcare policy changes.
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  One of the things we talk about is value based care.
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  You know, the idea that of, of, uh, rewarding physicians, not just in practice, it's not just for.
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  Uh, the volume of services, but the value that they provide, does the value based care have any impact on, on practice?
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  Is it, does it do something to, you know, either way improve or make it more difficult to, uh, diagnose and treat these patients?
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  Uh, well, I mean, there's, you know, value based care has not touched sarcomas at this point in time, and I don't know if it, if it's Um, you know, every sarcoma, if you take, for instance, total joint replacements, total joint replacements are a very consistent, similar operation.
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  One patient to the next arthritis is arthritis is some people with some deformities or more major deformities, but generally speaking, it's a very reliable operation where it's based, uh, where it's the same operation over and over every patient with the sarcoma.
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  It's they're different and big.
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  They're small patients are different sizes, et cetera.
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  So it's very hard to apply value based care.
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  to treatment of sarcomas, and every sarcoma sort of requires a different, unique, patient centric, innovative approach for that individual patient, so sort of tailored.
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  So that's, I think, I see value based care fitting very, you know, being a hard fit for sarcoma treatments.
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  Got it.
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  Yeah, and whereas for some of the sort of mainline orthopedic...
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  procedures.
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  It could be a, it could be a better approach.
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  Let me ask you, let me change topics a little bit and ask you about practice settings.
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  You know, this in the olden days is sort of this, you know, the single shingle physician that's their orthopedist.
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  You say, you know, who's the best orthopedist?
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  I want to go find them or, you know, orthopedic oncologist in this case, what do you find in terms of practice settings?
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  Cause there's a lot of very big practices.
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  There's smaller, medium practices, multi specialty practices.
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  Is there a difference?
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  If I'm a, if I'm a patient and considering one type of practice versus another, some better than others.
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  You know, how do you encourage someone to evaluate that?
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  Well, I think, I think you're going to, you know, it's not going to be a necessarily a group of doctors that's going to take care of your problem, right?
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  So, uh, there's many fantastic doctors that are in small groups.
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  Some, you know, it's very rare to see a solo doctor or solo practitioner these days.
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  Now, uh, there's some doctors that are in very large groups.
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  But each doctor has their own reputation and their own skill set, similar to going to see doctors at different hospitals, you know, um, you know, I happen to work for, you know, one of the best hospitals in the state and work here and take care of my patients here, which works out fantastic for my patients on from multiple aspects.
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  But it doesn't mean that.
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  You know, a doctor at a less rated hospital is, is not a fantastic doctor, you know, so it's really depends on the individual.
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  It's hard to classify by a particular group.
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  Now we talked right up front about orthopedics and oncology.
• 9:58
  It seems like some of the cases you're dealing with are fairly complicated and I have the sense that there are.
• 10:03
  Other specialties too.
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  What can you give a sense maybe of a, if you can describe maybe a complicated case and what other sort of specialties come in and how you manage the, you know, the teamwork, uh, what, what some of the rewards and challenges are there.
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  Yeah.
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  So let's say a child comes in with a Ewing sarcoma.
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  So in the femur.
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  And often the child will be referred to me by either another orthopedic surgeon or a pediatrician or an oncologist.
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  And I'll get the radiology studies done.
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  We will review them with a special musculoskeletal radiologist who's familiar with tumors, really, and reading tumors.
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  Then we'll do a biopsy.
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  The pathologist will look at the radiology studies and confer with the radiologist and myself.
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  and come up with the diagnosis based on the tissues that are given to the pathologist.
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  Then the treatment begins and the treatment for Ewing's sarcoma involves chemotherapy and usually surgery.
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  So usually the first step is chemotherapy before surgery, before doing a limb sparing surgery.
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  So the chemotherapy immediately treats any potential microscopic or metastatic disease that could have developed.
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  And also kills the tumor, either shrinks it or kills it, makes it easier to take it out so you can save more, more normal tissue in a limb and during surgery actually realize what is more normal versus abnormal.
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  So there's a lot of discussion then between the pediatric oncologist and myself.
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  The surgery is done, and then we involve groups of rehabilitation specialists, physical therapists, occupational therapists, nursing is involved, a lot of physician assistants and physician extenders, and then there's this, then there's sometimes consideration of radiation.
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  It's rare with pediatric sarcomas.
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  It's more common with adult soft tissue sarcomas.
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  But again, there's that, uh, dialect and discussion and collaboration between all of us to make sure the patient gets extraordinary care.
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  You know, what you're describing and bringing all those, you know, highly trained specialists together in such a team environment, of course, requires a lot of resources, very much worthwhile.
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  Uh, you know, to save somebody's limb, save somebody's life.
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  And we also talk a lot about sort of social determinants of health and disparities on this podcast.
• 12:24
  I noticed that you had been involved in establishing a clinic for indigent patients at Bellevue.
• 12:29
  Can you talk a little bit about that experience and what you see in terms of, you know, disparities of care among different, uh, different patient populations?
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  Yeah.
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  So after I finished my fellowship in Washington, D.
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  C.
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  I started my practice at N Y U and at the time the, the orthopedic hospital there was called Hospital for Joint Diseases and Bellevue Hospital, which is part of the N Y U system.
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  And Bellevue Hospital is, uh, is the major city hospital and there's a group of cities in what's called the Health and Hospital Corporation Group of hospitals within it.
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  And when I went to Bellevue, it was obvious that there was a need for somebody, uh, an orthopedic oncologist.
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  and nobody was taking care of those patients with musculoskeletal tumors and cancers.
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  So I established the first clinic at Bellevue hospital and instantaneously the first year I performed over a hundred surgeries just at Bellevue hospital.
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  Some of the most complex surgeries that I've ever performed were there because the, you know, it's, it wasn't only indigent patients from New York, they came from all over the world and flew into Manhattan and they got their care there because they didn't have the finances to afford it where, where they lived and the, you know, there was plenty of patients in New York who didn't have the finances, but we gave them, it was extremely rewarding and we gave them the same exact care that they would receive at the private Tish, it was called Tish Hospital, now it's called NYU Langone at the private hospital.
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  It was all the same doctors.
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  They got state of the art care exactly like you would.
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  But again, generally speaking, patients who, who, who, um, are either underinsured or not insured.
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  Uh, they tend to be neglected in terms of identifying the tumors, and you see much bigger and larger tumors, more aggressive, more advanced stages of the tumors also.
• 14:33
  So that's where I think this disparity comes in, is the identification of the tumor.
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  I want to step back a little more broadly from sarcomas at the moment.
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  I've saw some articles, I think even maybe one in the Wall Street Journal recently, about increasing incidence of cancer in younger patients, so otherwise healthy individuals without any, you know, particular...
• 14:50
  risk factors.
• 14:51
  I wonder whether you're seeing that phenomenon in your practice, or there's just always a lot of patients.
• 14:56
  The, you know, the incidence of sarcomas in, in young adults and children has remained, uh, constant.
• 15:04
  That hasn't changed.
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  Still, it's about one out of a million that develop a sarcoma of bone.
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  So, there hasn't been that shift as there may be with some other types of cancers in the younger population.
• 15:19
  Um, generally speaking, there's about 600 osteosarcomas that occur in the United States each year, and osteosarcoma is the most common bone sarcoma.
• 15:29
  So, um, Um, you know, it may have to do with, you know, the development of an osteosarcoma.
• 15:36
  It might have to do something with forces across the limbs as well as growth spurts.
• 15:42
  We see boys develop it a little bit, um, more frequently than, than girls.
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  We see the boys develop it at a younger age.
• 15:53
  Uh, we see that, um, if you compare us to, to animals or to dogs, which is a good example of osteosarcomas.
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  Dogs get it in their primary weight bearing.
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  limbs, which are their front limbs.
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  We get it in our hind limbs, which are our primary weight bearing bones.
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  So there's a lot of factors involved, not necessarily environmental, where you would think that there would be a shift in younger patients.
• 16:20
  You know, as I mentioned at the outset, uh, we just wrapped up sarcoma awareness month.
• 16:24
  Uh, from your perspective, was it successful from my perspective?
• 16:28
  Yes, I think it was very successful.
• 16:29
  I myself in the hospital made many social media posts which, uh, received a lot of recognition and it's all about really spreading the word and making the, you know, developing an awareness of sarcoma so that patients who have pain or swelling or masses.
• 16:50
  That they go and get it checked immediately, and that there is this disease out there that's an orphan disease that hopefully we could raise money for, develop, uh, you know, better research for it, and find the pill that turns them off right, and shuts them down and kills 'em.
• 17:07
  Well, Dr.
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  James Wittig, thank you for joining me today on Care Talk to talk about sarcomas.
• 17:12
  Well, if you like what you heard or even if you didn't, please make sure to subscribe to care, talk on your favorite screening service.