Bone Metastases Pain Treatment with Targeted Ablation & Pain Pumps

[Dr. Jacob Fleming]
Have you dabbled with anything like the SINS score, or tell us about just generally what is your process for assessing these tumors on the imaging?

[Dr. Glade Roper]
Is it replacing the marrow signal on T1? That's the big thing that I'm looking for. Is there a fracture line? That's the other thing I'm looking for. Is it pooching into the spinal canal? Sometimes it's okay for it to be pooching out a little bit into the spinal canal. I can still burn it and get a good result. If it is going up the pedicles, that tends to be something that requires a little bit more finesse to take care of. As in, you've got to burn the pedicle on your way out in order to treat that. Those are the big ones that I'm looking for is, does it look like they are actually getting a fracture? A fracture is always going to hurt, and that's something that I know that I'm going to get a good result treating. If it's a painful bony met, that's the question because there's a lot of people who've got mets all over the place that aren't painful.

[Dr. Jacob Fleming]
Exactly. That was my next question is when you have a patient who has multifocal metastases and there's not a pathologic fracture, what's your process for narrowing down?

[Dr. Glade Roper]
Physical exam.

[Dr. Jacob Fleming]
What?

[Dr. Glade Roper]
I know. Who does that anymore? Gross.

[Dr. Jacob Fleming]
As a radiologist, I can't even spell physical exam.

[Dr. Glade Roper]
No. Physical exam is the key to it. You push on their back and find the spot that hurts is the quick and easy way to do it. I've gotten pretty good at that, and my PAs have gotten pretty good at that. We've worked with the PAs very closely on this. Painful bony metastases, especially if they've got an associated pathologic fracture.

[Dr. Jacob Fleming]
Tell us about when you see them in consultation for the first time, like you said, if the words out of your mouth are RFA, the next words are going to be pain pump. That can be a little-- It can come across in different ways to different patients when you start talking about a pain pump.

[Dr. Glade Roper]
Sure

[Dr. Jacob Fleming]
How have you talked about that process of, we're going to start with this, and then we'll have other things in our back pocket to use?

[Dr. Glade Roper]
What I do is I say something along the lines of, "You've got this bone metastasis. We're going to go in, we're going to burn it, and then we're going to cement it." I give them my spiel about termites and fumigation. Then I say something along the lines of, "Now, one of the most important things that we know is if you've got bone mets, you're likely to have more, and it's likely to be difficult with your pain." I'll ask them, "How is your pain control right now?" If they're saying, "Oh, my pain is great," then I'll say, "Then something that we may want to look at later on is a pain pump because then you don't have to go to the pharmacy to get your medications. You never are at risk of overdose. You never are at risk of getting loopy or constipated from the drugs that you're taking."

I explain that at the get-go, so when the time comes it's, they're at a point where they're willing to do it, then they've already had that spiel. There's a lot of Kübler-Ross going on with a lot of these patients of being in denial and not quite being at a place where they are ready to pull the trigger on anything because they are saying, "Oh, I've got to live for the next several years." You're thinking, "That's going to be tricky."

[Dr. Jacob Fleming]
I will have to jump in there and say that one of the amazing things about modern oncology is it's made it so some of these patients are living for years.

[Dr. Glade Roper]
Absolutely.

[Dr. Jacob Fleming]
For me, it's about maximizing the quality of life. The point is well taken that you're meeting these patients at the very vulnerable point in their lives, oftentimes an inflection point in their disease state. It is a lot to take in, and so I like to have strategy of introducing the idea early on so that you go through Step 1, or whatever step you're going to call it, bone tumor ablation, and then revisit that topic later if it is necessary.

[Dr. Glade Roper]
Yes, because we bring them back for follow-up in a couple of weeks, and they're usually doing a lot better as far as their pain is concerned from that met. A lot of them, frankly, are really excited about this possibility. This is especially the case if the patient is there with their adult children who are caring for them because the adult children really like the idea of having somebody else managing the pain medication so that mom isn't going to overdose.

[Dr. Jacob Fleming]
There are so many benefits to the pump, and you have to be able to walk through what does this mean for them. I've generally found that that's the case, too, because it's a family process that they go through. The patient is facing it, but also, as you said, oftentimes the adult children who are caregivers. Getting buy-in from all of them is so important. They're looking for help.

[Dr. Glade Roper]
Absolutely. These are patients who, as you say, they're in a very vulnerable time in their lives. You want to make sure that you're not coming across as mercenary, I guess, is one of the things to say here. You have to say it because it's a procedure that you're doing that you're getting paid to do. There could be a perception that you're just doing this to try and make some money off of this patient. I think there's enough data out there about the effectiveness of pumps and enough other patients who have gotten really good results from these pumps that that is not the case.

You're not doing this for yourself, is the bottom line. You're doing this because you can make their life better by putting a pump in them. For whatever time they've got left, whether it's a year or six years or whatever time they've got left, if they can spend that time not being loopy, not being constipated, that is time well spent. Whatever effort and difficulty you've had to go through to get them to that point is absolutely worth it. Just to get personal here, my grandmother died of colon cancer when I was just three or four. I remember my dad talking to me about times when he would hear her sobbing to my grandpa, "Why can't I just die?" because the pain was so bad. People living in pain are not living. They have a horrendous time of it. Whatever we can do to control that pain, I think, is absolutely worth it.

[Dr. Jacob Fleming]
That was fantastic. Thank you for sharing that, Glade. What a powerful example. Something that happens very frequently for a lot of these patients living with cancer that is painful for whatever reason, it's chronic opioids, as you said, oral opioids, living with loopiness, not really being engaged with the time left they have. You really spelled out so many of the benefits there. I think that anyone who's listening who doesn't yet see the benefit of the pumps should go back and re-listen and come back. You've really well outlined how this is a complementary approach to the bone tumor ablation.