Taking a team approach to sarcoma care at Ohio State | OSUCCC - James https://www.youtube.com/watch?v=eqE2Gc9gIU0&t=26s Joel Mayerson, MD: It became more personal this past January. My mother was diagnosed with a what's called a retroperitoneal soft tissue sarcoma in her pelvis that, unfortunately, she was diagnosed very late and it was not able to be operated on and she passed from her sarcoma in January. Steve Wurtenberg: This is the James cancer-free World podcast I'm your host Steve Wurtenberg and my guest is Joel Mayerson. Joel is the director of the James Sarcoma Program and one of the world's leading sarcoma surgeons. Joel has been on the podcast before in episode 48. He talked about some of the amazing surgical advances for patients with bone sarcomas and we met one of his patients, Jared Sylvester, who told us all about his inspiring cancer journey. And in episode 94, Joel filled us in on the impact of Steps for Sarcoma, an annual fundraising event that has raised well over a million dollars for sarcoma-related research here at The James. Today Joel will give us an update on the growing sarcoma program here at the James which under his leadership has continued to grow and is one of the top programs in the world. Welcome back to the podcast Joel. Mayerson: Thanks Steve. Wurtenberg: I thought as a good intro, and it's always good to sort of get the basics of of sarcomas. There's two types. Give us a quick overview. Mayerson: Yes Steve, there are two types of sarcoma; uh one is bone sarcoma and the second is soft tissue sarcoma. Bone sarcoma usually happens in younger people, most commonly in teenagers. It will present with a mass in your usually arm leg or pelvis and it's usually painful, and so usually if someone will have pain when they're walking, we then, they need diagnosis, so they get Imaging and a biopsy. Get diagnosed and then we treat them. Soft tissue sarcomas usually happen in older people, usually adults beyond the age of 50. They again happen in arms legs and the pelvis, but they're not painful most of the time. But they're painless growing soft tissue masses, so it sort of depends on where they're located, how easy they are to pick up. So you can imagine deep in your pelvis it's hard to pick one up, whereas if it's in your ankle it's pretty easy because there's not much tissue on top of the bump. Wurtenberg: So the ones that are not painful probably present later because the person just doesn't feel it until it's really pretty large and invasive. Mayerson: They do, And they're sort of, a unfortunately, a lack of Education even in the medical community. There's so many common benign soft tissue masses and trying to pick up the difference between the hundred benign soft tissue masses and the one malignant one is challenging, and so most people think "oh it's a benign bump it'll go away." Or that it's not going to be any big deal, and they watch it for a while, and sometimes they get pretty good size before they present. Wurtenberg: So what should primary care physicians and people who have some sort of growth; what should they know and do to find out if it is a sarcoma? Mayerson: So usually if you have something that's growing quickly, if it's deep inside your muscles; so if you feel something that's full, and if it's more firm than an orange, so if you squeeze your arm or your leg it's really squishy. Most of the time. If it feels hard, like an orange, then that's a little bit worrisome and you need to go get that looked at. Wurtenberg: So be a patient advocate and talk to your primary care physician and sort of say ‘Hey I need some screening and pictures taken to see what this is. Mayerson: Absolutely. Wurtenberg: Okay, so those are the basics. And would one doctor, such as you, be a specialist in both types of sarcomas or is the field advanced to the point that they're specialists in bone and soft tissue? Mayerson: So orthopedic oncologists take care of both bone and soft tissue sarcomas in the arms, legs and pelvis. There are also soft tissue sarcomas that occur in other places of the body, in your stomach, ah inside of your pelvis in the soft tissues, and we have general surgical oncologists as part of our team who take care of those. There are also less common places, like in the head and neck region, that head and neck oncologists will take care of. And they can occur anywhere in the body every now and then; one even occurs in the heart because it's a muscle. Wurtenberg: Yeah, so it's a specialized, not so much on the type of sarcoma, but the location. Mayerson: Correct Wurtenberg: And so you, I know, you do arms and legs. Is that is that. Mayerson: Correct, arms, legs and pelvis. Wurtenberg: okay so the big bones. Mayerson: Correct. Wurtenberg: And again in talking to you, um bone sarcomas can be very invasive and require tremendous surgery, removing parts or an entire bone. Mayerson: Really, You're absolutely right, sarcoma is really a team sport in caring for all of these patients. We use uh often trimodality care, so we use medical oncologists to give chemotherapy to a lot of these sarcomas. We also have radiation oncologists for many of our soft tissue sarcomas that need radiation therapy. Most of the time it's before surgery, but sometimes afterward, and then surgeons will take care of the problem based on anatomic location within their specialty. Wurtenberg: Wow, so okay, so those are the basics. Now give us a sense of the team here. You've been here a long time, more than 10 years. Mayerson: Almost 22 years. Wurtenberg: Wow 22 years, so give us a sense of of how the team here has grown, particularly in the last few years, and how you're how who and you're adding and and why, Mayerson: sure, when when I first started here in 2001, uh it was really me, myself and I. We were the three team members Wurtenberg: You were the only sarcoma surgeon. Mayerson: Correct. Wurtenberg: Wow Mayerson: We had a general surgical oncologist to help with some of the pelvic operations in the soft tissues, but it was really me, and we've expanded the program. Today we have three Orthopedic oncologists. We have two general surgical oncologists who take care of the inner side pelvis around the abdominal and pelvic organs. We have three plastic surgeons that, when we take the tumor out, we need the defect filled in to cover the wound. We have three medical oncologists that give chemotherapy on chemotherapy trials. We have um three Radiologists who work with us very closely. We have two radiation oncologists and two Pathologists that work with us on our team. One of the medical oncologists we've hired in the past year to help us improve the number of clinical trials that we have, and our third Orthopedic oncologist is coming this fall, as well. Wurtenberg: So 20 years ago would not have been unusual for a hospital, even a fairly big hospital, to only have one sarcoma surgeon I take. Mayerson: It was pretty common. There are only a few hospitals in the country that had more and today there still are only a few. There are about 175 to 180 Orthopedic oncology surgeons in the United States. Wurtenberg: Wow, so that the the; what I was thinking was that's the whole point of a large hospital connected to a comprehensive Comprehensive Cancer Center here at the James where you have that team of experts approach that you don't have at smaller hospitals Mayerson: Absolutely. They, it helps with the patients from the time, they referred to us because they get to see us in a coordinated fashion. The medical oncology team is right next to us in clinic. The radiation oncology team is just downstairs. And so we can coordinate their care as soon as we have their diagnosis. All of the surgical teams operate in one cancer facility and so if something crops up that was unexpected, we can have someone just pop over from another operating room and help us and so it absolutely markedly improves their Cancer Care yeah that team approach for each for a team for each different type of cancer seems to be where the James is going absolutely and I think that's one of the great things about the James and it really differentiates us from the other um cancer treatment sites here in central Ohio and beyond – because they just don't have the breadth and depth that we have to provide that team care all in one location on a regular basis. Wurtenberg: So over the years, you've recruited a lot of people, and I know everyone's different and there's different specialties, but is there anything in particular you look for when you're interviewing someone; thinking about bringing them on; that makes you think this person will fit in and do a great job? Mayerson: And so the really the things I look for is someone's personality. One of the great things about our Sarcoma Program are there no egos and so that way, we don't have anybody who's worried about themselves. It's really a team approach, and not an "I" approach. And then the second thing is: one of my favorite movies is the Karate Kid, and if you remember Mr Miyagi when he was talking to Daniel-son, he said "Karate is here" (Mayerson points to heart). And so I want sarcoma care to be here. Wurtenberg: Oh, I thought you're going to make potential people wax on and wax off, but okay but cancer character from the heart. Mayerson: From the heart, exactly. And it really has to be your passion in life, and I think that being passionate about an uncommon disease allows you to push through when there are challenges that don't happen in some of the other more common forms of cancer. And "heart" also equals empathy and caring for your patients. Mayerson: Absolutely. Wurtenberg: Wow. So we're going to take a quick break and when we come back we'll we'll go into some of the medical issues some of the new procedures, new clinical trials, new treatments for sarcomas ADVERTISEMENT: You didn't choose cancer, but you can choose where to treat it, and when you choose the James at Ohio State, you're picking a team of experts who understand there is no routine cancer. You're opting for care from a highly specialized team dedicated to treating one type of cancer – yours – a team that studies a unique makeup of your disease to develop a personalized treatment plan. You're choosing our region's only Comprehensive Cancer Center designated by the National Cancer Institute, where more than 1 700 scientists are working on new treatments and new hope for every form of cancer. At the James, you're making the choice to have the most advanced treatments, many of which were developed right here, and you're choosing access to the James world-class clinical trials, dedicated support services and an unmatched survivorship program to support your life after cancer treatment. You didn't choose cancer but the choice of where to treat it is clear. Wurtenberg: We're back with Joe Mayerson, the director of the Sarcoma Program here at The James, and he gave a great overview. And now it's dig down, and see what some of the new Innovations, the new treatment options, the new programs you're working on. Mayerson: So one of the programs that I'm really excited about is our Orthopedics plastic surgery collaboration program, what we call orthoplastics, and it allows us to do many things to help our sarcoma patients. When soft tissue sarcomas are resected, there's usually a large defect, because as we talked about, they often present late. And we have to give them pre-operative radiation therapy to try to sterilize the margins around where we're going to take the tumor out, that defect means that something's going to have to go to fill that hole so they don't have a large defect in their extremity. Wurtenberg: So meaning the radiation before destroys cells and creates empty pockets. Mayerson: It creates a, it doesn't create an empty pocket around the tumor, it creates, it sterilizes the rind or the rim around the tumor. When we take it out, it creates a large defect or a large pocket that needs filled in. Oftentimes, sarcomas grow along major nerves and major blood vessels, and we have to peel them off those blood vessels. And what the radiation therapy does is it increases the wound complication rate associated with surgery, to up to 30 to 35 percent, and so if you have a really small amount of skin only covering a major blood vessel and that opens up one third of the time, you can't really have someone's major artery floating in the breeze. And so the plastic surgeons will take muscle from somewhere else, and they will bring it into this field to cover the defect, and that's called a free tissue transfer. Sometimes when we have to take a functional muscle, they can even do what's called an innervated free tissue transfer where they can slow the nerves to make that muscle functional – so they can return the function to that patient. Wurtenberg: So even though the muscles missing, the function remains. Mayerson: So what they do is they bring a muscle from somewhere else, so they take it and then connect and they reconnect the nerves. So they take a muscle that was functioning somewhere else in your body, and bring it to a new place and let it have a new function based in a new anatomic location. Wurtenberg: So you have to take a muscle from somewhere else that is not, is maybe has duplicates or is not as important, so it's less useful. Mayerson: So they often will take these from another part of a leg where we usually, we have duplicate muscles, or they'll take them from your stomach, or they'll take them from your back. Wurtenberg: Oh I didn't realize I had muscles in my stomach anymore. Mayerson: That's what the six-pack's for. Yeah okay okay; Wurtenberg: Yeah, yeah, okay. So it helps if you're younger. Okay, so that's fascinating because we've talked about this before with Roman Skoracki that plastic surgery has a bit of a , is not really understood and it's so vital in cancer surgery. Mayerson: It is it is absolutely vital. We could not do the limb saving surgeries that we do for cancer without our plastic surgery colleagues. The other part of the Orthopedics Plastics collaboration is for amputee care, and unfortunately about 10 to 15 percent of the time, we're unable to do limb salvage operations for patients, and so we were one of the pioneers in the world in utilizing a technique called targeted muscle re-innervation to help with phantom pain and to help with pain after surgery. And what that is, is the cut ends of the nerve after an amputation, they are sewn into a motor branch that controls a muscle, and so the nerves have something to fire into rather than just firing into open space. We find that it creates less scar tissue and that it markedly decreases their risk long term of having phantom pain. Wurtenberg: Yeah, I've heard about this, and I actually met someone through Pelotonia, who I believe, you and Roman Skoracki did that surgery on him. Mayerson: Yeah so we've, we've started this about eight years ago, and it's now become commonplace in the entire country. And some of the trials we did here in the early studies were what brought that to standard of care here in the country. Wurtenberg: Wow, that that's why you're one of the best, man. Mayerson: We're also incorporating that with another newer surgical technique called osteointegration. Osteointegration is a metal stem that's placed into the residual bone in an amputee's residual limb. It actually is contoured by the plastic surgeon and all the soft tissues to make sure that it's right. And then there's an opening in the skin, where the metal will stick out, and they can snap their femur on, or their tibia on, and their artificial limb. And so instead of having a socket where they have to put it on their amputated limb, they can basically just take a keyed opening device that tightens and loosens and put their leg on – snap-on snap off. Wurtenberg: So it's connected better and more efficient. Mayerson: Absolutely, so it really, the patients will say it feels like my normal leg because it's walking there. We feel their proprioception is better. We're trying to take that to the next level for research. That been done in the military from one of our plastic surgeons Dr Souza where you can take, and if you have a amputation in that's high in someone's arm and their arm has to be removed, you can sew the nerves that work your arm into one of your pectorals in your chest muscles. You can then put an electrode on the skin, and you can train your body to fire the muscle where that nerve is tied into. And then when you put a prosthesis on someone, they can actually move their wrist or their fingers exactly the way that it would have moved in real life based upon the electrode. And those muscles firing. Wurtenberg: Is this already happening? Mayerson: It's happening in military research now. The problem is the expense. And so the prosthetics that do that are about a million dollars per patient. And so what we're trying to do is to try to develop a program and combine with the military to see if we can use less expensive materials, and to create a unique way that we can bring this to the general public. Wurtenberg: Wow, that's amazing. I feel like I've saw something like this on 60 Minutes or something. Mayerson: There there was a 60 Minutes. It was part of the military program that what they're doing, and a lot of those patients were Dr Souza's patients when he was at Walter Reed in the military. Wurtenberg: And you're working with him? Mayerson: Correct, he's here. He's the head of our sarcoma plastic surgery position, uh here at the James now. Wurtenberg: I might have to get him on the podcast. Okay, uh what's another area? Mayerson: So the next area is um our International profile that we've really developed. We currently have a an Egyptian International visiting fellow, and we're planning to have a visiting fellow starting this August from Ecuador. And the Ecuador fellow is in a really unique area, where I'm really excited because we're actually collaborating with the government of Ecuador through their National Cancer Institute to try to help them develop a sarcoma program in their country. I have a patient that is from Ecuador, and her father realized that care in their country was not as developed as it could be, and he wanted to help their country get care. And so he's helped us get contacts in Ecuador. With our Destination Medicine Program's help, we've now collaborated with their National Cancer Institute. We have tumor boards for their patients, where we help them make sure that they're getting state-of-the-art care, and with this physician coming to visit us for a year, hopefully we're going to be able to change the trajectory of care in South America. Wurtenberg: So this father whose daughter had a sarcoma; he found you? Mayerson: He found me. One of the anesthesiologists here at Ohio State, who obviously knew me from operating with me, had a a condominium in Florida, at the same condominium site where he did with the guy. Wurtenberg: The guy from Ecuador. Mayerson: And he knew he was a doctor and then asked him and sort of got him in contact with me. Wurtenberg: So that was a lucky coincidence for the guy in Ecuador that his neighbor in Florida was the anesthesiologist for one of the top sarcoma surgeons. Mayerson: Absolutely. Wurtenberg: And his daughter, it was you who treated her. Mayerson: I treated his daughter, and she's doing very well. Wurtenberg: Wow, and so he decided that he's going to upgrade Ecuador's sarcoma program. Mayerson: Correct. Wurtenberg: And, is he like a man of means, who can fund this, or.. Mayerson: He is an international businessman that certainly has means, and he's also working with the resources um down there. Um they're creating actually the South American version of Steps for Sarcoma. Wurtenberg: Oh, wow. Mayerson: They have already gotten the national soccer team in Ecuador to help fund uh their fundraising efforts to do that. Wurtenberg: Wow the Ecuadorian national soccer, or football team as they call it here, is equivalent to the Ohio State football team here. In terms of.. Mayerson: My guess, so; my guess so. Wurtenberg: So that getting them involved is huge. Will you go to their Ecuadorian Steps for Sarcoma? Mayerson: So I was planning on going down there this fall. They're having a little um challenges with the drug cartels down there now. Wurtenberg: Oh boy, yeah. Mayerson: I'm going to wait until the, it's a little safer. Wurtenberg: Be careful. Mayerson: But I I certainly am planning to go down there as part of helping them, yes. Wurtenberg: So another area I'm curious if it'll help. Because radiation has evolved, they're hopefully soon going to open the new proton radiation Center? Mayerson: Asolutely. And so there are a few rare bone sarcomas, such as a chordoma, which usually happens in your tailbone from an orthopedic standpoint; it can also happen in your skull base as well or chondrosarcoma that can happen in the same place. They're very very difficult to operate on tumors because of the complex anatomy. So all of the nerves for your bowel, your bladder and parts of your legs are all involved with this bone. And so if we have to take it out ,we've really dissociating your spine from your pelvis and taking all those functions out. And so it's a really, really morbid operation. And so one of the things where proton therapy can help is: it actually has been shown that proton therapy can treat these really rare tumors and sometimes prevent people from needing this morbid surgery. And so this is going to be a great advancement in sarcoma care for people of Central Ohio and Beyond. Wurtenberg: Wow, so it's obvious you're someone who always is pushing the envelope to do more for your patients. Where does your passion come, from this concern to do more and more for your patients to improve their quality of life and/or save their lives? Mayerson: Sarcoma is a rare disease, and so getting people to advocate for it is sometimes a challenge. And so that's really led me to try to advocate for my patients, to bring new care to them. And it's just been a fantastic experience over my career to see patients doing well, and survival rates improving and function improving. It became more personal this past January. My mother was diagnosed with a what's called a retroperitoneal soft tissue sarcoma in her pelvis that, unfortunately, she was diagnosed very late, and it was not able to be operated on, and she passed from her sarcoma in January. And so if it wasn't personal enough of being the passion for my career and being an advocate for my patients, now family. I lost my mother to sarcoma as well. Wurtenberg: Were you and your family able to spend a lot of time with her and? Mayerson: We were able to spend quite a bit of time with her; pretty much in the last two weeks from, unfortunately from the time she was diagnosed to the time she passed, it was about five weeks, and so she didn't last very long, because it was an advanced stage; but we we got a chance to spend some time with her. Absolutely. Wurtenberg: Yeah. I'm glad you and your family did because that's really important. Mayerson: Thank you. Wurtenberg: And let's close up. Let's again, I'm just a little very sad common um but as long as you remember her she's still around. Mayerson: Absolutely, absolutely. Wurtenberg: Um Steps for Sarcoma is coming up. And let me get the website out: stepsforsarcoma.com. When is it? What's, what will it be like? Mayerson: So this is going to be our 14th annual Steps for Sarcoma. Uh, it's going to be at Chemical Abstracts on September 17th, and uh hopefully, it's going to be bigger and better than ever. Last year was our first post-covid event, and we had uh probably as many people as we had pre-covid, which was absolutely amazing. We had about 1500 people. We raised about three hundred and fifty thousand dollars, bringing our total to 1.6 million over the 14 years. And it's just grown and grown. We're able to give more and more research grants to our young doctors to hopefully get new advances, and to bring better sarcoma care to people here in central Ohio and the rest of the world. Wurtenberg: So of the 1500 people, how many were current or former patients do you think? Mayerson: Our survivor picture usually has somewhere around 70 to 80 patients in it and then those people bring their family and their friends, and it just makes it a great community event. And our survivor picture, thankfully, gets bigger each year. Wurtenberg: Yeah. Mayerson: When we have more and more people. Wurtenberg: What's it like when you look at that picture or stand in there while they're taking the picture? Mayerson: That's one of my favorite parts of Steps of Sarcoma. I get to see both the patients that my team is taking care of and as well as myself. And, and you know that's the best satisfaction you can get, knowing that those people may not be here without your care and the fact that they're here with because of some of the advancements that we've done here at The James. Wurtenberg: Well, thank you. Thank you for sharing all this great information and for the great way you take care of your patients and keep going. Mayerson: Thank you Steve. It's always a pleasure to be here. Closing: This podcast is brought to you by The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute. For more information check out our website: cancer.osu.edu.