(Focus - India)
July holds special significance as it is recognized as Sarcoma and Bone Cancer awareness month, underscoring the importance of raising awareness and directing attention towards these health concerns. Osteosarcoma, a malignant tumor originating from abnormal bone cell growth, presents complex challenges due to its elusive cause. Exciting breakthroughs involving biodegradable nanoparticles, oncolytic viruses, and genome-informed targeted therapy are currently under exploration, paving the way for a promising era in managing this disease.
In a recent interview, we had the privilege of speaking with Dr. Abhishek Kumar, an esteemed Orthopedic Surgeon from India. In our discussion, Dr. Kumar shed light on the potential advancements in the treatment of osteosarcoma and elucidated the distinctive challenges encountered within the Indian healthcare system. His expertise provides a comprehensive understanding of early detection, treatment advancements, and the hurdles in delivering quality care.
Dr. Abhishek Kumar is a Consultant Orthopedic Surgeon currently serving at Trome Hospital, Muzaffarpur, Bihar, India.
The main symptoms of osteosarcoma are bone pain and swelling. These two are very important and the initial symptoms. Some patients can come with a late presentation with unexplained fracture of the bone due to the pathologic factor, or if swelling is too huge, then there will be a limited range of movement, but the initial thing is the bone pain and lump.
Osteosarcoma is one of the most common malignant tumors of bone in teenagers and young adults.[1] What are the causes of osteosarcoma in teenagers? Is there any genetic factor associated with it?
Dr. Abhishek - The main osteosarcoma etiology is still unknown. We don't know the etiology and why osteosarcoma occurs in some particular segments of people. However, there are risk factors that increase the chances of getting osteosarcoma. That does not mean that a person with a risk factor will definitely develop osteosarcoma in the future. There is a chance they may not develop, they may develop, or some people without risk factors can also develop osteosarcoma. So, these risk factors are:
Age: As you already told the teenager, it also occurs in older adults (above 60 years). Osteosarcoma has an association with pubertal growth.
Gender: It occurs slightly more in the male sex.
Previous history: If there is any history of radiation therapy or some particular disease like fibrous dysplasia, the person has some inherited syndrome or cancer syndromes like retinoblastoma or lymphoma syndrome.
Race: There is some association with race also, like it is less in the white people and more in the African American, Hispanic, and Latin Americans.
Are there any symptoms to look for in the early detection of osteosarcoma in teenagers and young adults?
Dr. Abhishek - The main symptoms are bone pain and swelling. These two are very important and the initial symptoms. Some patients can come with a late presentation with unexplained fracture of the bone due to the pathologic factor, or if swelling is too huge, then there will be a limited range of movement, but the initial thing is the bone pain and lump.
So, doctor, how can early detection and screening techniques help to improve the prognosis for patients with osteosarcoma?
Dr. Abhishek - Currently, there is no screening test for osteosarcoma, which is the problem. So, any bone pain and swelling must be taken seriously, and they must visit the doctor despite treating themselves.
Cancer is more proliferation of the cells. The cell division will be more when a person has pubertal growth sprawl. So, at that time, they may lose the programmed cell death structure or apoptosis.
Some studies show the association between taller stature and increased risk of developing osteosarcoma, but some suggest the contrary. What are your thoughts on this? Do you see any such cases in your clinical practice? [2],[3],[4]
Dr. Abhishek - Usually, children with osteosarcoma are taller than the normal population. Six studies favored that, and around 62% of patients found their height above the median.
Doctor, is there any correlation between taller stature and the likelihood of developing osteosarcoma?
Dr. Abhishek - Cancer is more proliferation of the cells. The cell division will be more when a person has pubertal growth sprawl. So, at that time, they may lose the programmed cell death structure or apoptosis. That may be a reason, but nobody knows the cause of the osteosarcoma. It's still unknown.
To date, novel immunotherapies remain limited for osteosarcoma due to finite T-cell infiltration and secondary immune toxicity. [5] What does the future of osteosarcoma treatment look like?
Dr. Abhishek - There are biodegradable nanoparticles, oncolytic viruses, and genome-informed targeted therapy to resolve the problem of finite T-cell infiltration and secondary immune toxicity. These three can reduce toxicity, and that is called targeted therapy. They go to the target area where they have to act. All the above three are currently under research.
Are there any ongoing clinical trials that might change the treatment landscape of osteosarcoma in the future?
Dr. Abhishek - The main thing is the genome-informed targeted therapy clinical trial that is going on in the US. In osteosarcoma, there are two clinical trials going on Pembrolizumab and Avelumab, which are already used in other cancers, but at present, it's not FDA-approved for osteosarcoma.
Currently, so many NGOs and others are willing to assist the patients with funds. The unmet need is mainly the education of the healthcare workers and strengthening the primary care practices and infrastructure. I see a patient suffering from osteosarcoma getting delayed 1-2 years to get the right treatment as they are going to multiple doctors and didn't get the treatment indicated for that patient.
What are the challenges in the treatment and management of osteosarcoma in India?
Dr. Abhishek - India is a very resource-limited country, as everybody knows. Our struggle is still not over with tuberculosis, and osteosarcoma is a long road we must travel. For that, we need education in primary healthcare. We must strengthen our structure at the district hospital because many medical colleges in India are still not equipped to manage osteosarcoma.
A study published in Lancet on financial toxicity in cancer care in India shows that high out-of-pocket expenditure, coupled with a lack of financial assistance from the government, results in catastrophic health expenditure and distress financing. [6] So, how is the Indian government working to improve access to cancer care?
Dr. Abhishek - With the help of Tata Memorial Center, they are developing some new centers for cancer treatment in the existing medical colleges. But there are not enough healthcare workers for them. India has healthcare personnel trained for oncology, not for osteosarcoma particularly. That is the main issue. They have to channel their revenue and the existing resources better.
Regarding funding, I think money is not an issue. Currently, so many NGOs and others are willing to assist the patients with funds. The unmet need is mainly the education of the healthcare workers and strengthening the primary care practices and infrastructure. I see a patient suffering from osteosarcoma getting delayed 1-2 years to get the right treatment as they are going to multiple doctors and didn't get the treatment indicated for that patient.
To conclude our session, based on your experiences with patients and families affected by osteosarcoma, what message would you like to share with our readers who may be going through a similar experience?
Dr. Abhishek - The patient and the family must be educated about the treatment options, pain management, and support services. So, if they get all this information, they will be better positioned to decide further. Osteosarcoma is not something that is not treatable. It is a treatable cancer. Many people think that cancer means it's not treatable and is the end of their life. It's not like that because 70 to 80% of osteosarcoma can be treated with existing chemotherapy. It's treatable with neoadjuvant chemotherapy, and limb salvage surgery is also there.
Thank you so much for your time.
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