Orthopedic oncologists are often called after the damage is already visible. A bone has fractured. A metastasis has weakened the skeleton. Radiation has impaired healing. A patient who survived cancer treatment is now facing another threat to mobility and independence.
Joel Mayerson, MD, associate chief medical officer and chief of orthopedic oncology at The James Cancer Hospital and Solove Research Institute at The Ohio State University in Columbus, wants to intervene earlier.
At The James, Dr. Mayerson is launching a pilot program designed to identify and manage bone loss before it becomes a fracture or another major complication.
“We’ve been the people who treat fractures, and we’ve been the people who deal with things after they’ve occurred,” Dr. Mayerson told Becker’s. “This is an attempt to try to get upstream of the problem.”
The program focuses on three groups: patients whose cancer has spread to bone, patients exposed to chemotherapy that can compromise bone health and patients receiving radiation to bone.
Each can arrive at the same endpoint through a different path. The larger issue is that modern cancer care increasingly extends survival without always treating skeletal health as part of that survival. Dr. Mayerson believes it should.
Cancer treatment can leave a skeletal legacy
Bone loss is often framed as a problem of aging. Cancer can accelerate the timeline.
Chemotherapy in younger patients may interfere with the development of peak bone density. Radiation can impair normal bone remodeling. Metastatic disease can create structural defects that weaken bone directly.
Those risks may remain long after the acute cancer treatment ends. Dr. Mayerson said that makes bone health a survivorship issue as much as an orthopedic one.
The pilot is designed to establish a more deliberate surveillance pathway. Patients undergo bone-density assessment with DEXA scanning and selected laboratory testing. An advanced practice provider is being trained to oversee screening, interpret results and help connect patients with treatment when abnormalities are identified.
The goal is straightforward: find deterioration before the patient breaks a bone.
“When they do develop a fracture, the fractures don’t heal as well,” Dr. Mayerson said. “The complications from the treatment are more severe.”
Preventing the fracture can therefore mean more than avoiding an orthopedic procedure. It can protect mobility, reduce pain and help keep the patient’s cancer treatment on course.
Bone health should start at diagnosis, not fracture
The right time to intervene is not identical for every cancer patient. Dr. Mayerson believes younger patients exposed to chemotherapy may benefit from establishing a baseline early, even when their age would not ordinarily trigger bone-density screening.
Patients receiving radiation to bone may need assessment around the time treatment begins so future changes can be measured against a meaningful baseline. Patients with metastatic disease involving bone may need bone health incorporated into the diagnostic workup itself.
The common principle is timing. “Meet patients where they’re at,” Dr. Mayerson said.
Cancer patients already return for oncology visits, imaging and survivorship care. Bone health should be integrated into those encounters rather than treated as another disconnected appointment patients have to navigate.
Nutrition belongs in the same conversation. Vitamin D, protein intake and other aspects of skeletal health can be incorporated into survivorship planning alongside surveillance for recurrence.
Dr. Mayerson’s argument is that the cancer journey should not end with the question of whether the disease is controlled. It should also ask what condition the patient has been left in afterward.
Orthopedics has historically entered too late
Part of the gap is structural. Orthopedic oncologists are a very small specialty. Dr. Mayerson estimates there are roughly 250 in the country, concentrated largely at major cancer centers.
Their traditional role has been intervention. Fix the pathologic fracture. Stabilize the bone weakened by metastatic disease. Resect the tumor.
Preventive bone health has generally lived elsewhere, often with oncology or primary care. But Dr. Mayerson argues that the current division of labor has left too many patients uncaptured.
Primary care physicians already carry broad preventive responsibilities. Oncology teams are focused on cancer treatment and surveillance. Orthopedic surgeons are typically reimbursed and organized around procedural care.
The result is a familiar healthcare problem: Everyone can see the importance of prevention, but no one fully owns it.
“We don’t really get reimbursed as a physician for doing this,” Dr. Mayerson said. “As surgeons, most of our income comes from operating, and this is comprehensive care that is preventative care.”
That makes the pilot as much a care-model experiment as a clinical one.
Can an orthopedic program build preventive bone care into its workflow in a way that is financially sustainable? Dr. Mayerson believes it can.
He said the model Ohio State has developed could become cost-neutral or financially beneficial if the referral volume is sufficient and advanced practice providers manage much of the screening and follow-up.
But broader adoption may require payment policy to catch up. If orthopedic specialists are expected to move upstream into prevention, he argues, reimbursement has to recognize that work.
Orthopedics may be better positioned upstream than it thinks
Dr. Mayerson sees an argument for greater orthopedic ownership. Orthopedic surgeons understand what happens when bone health fails. They see the hip fracture that takes away independence. They see the wrist fracture that signals greater skeletal fragility. They see the cancer patient whose weakened bone cannot tolerate the next stage of treatment.
That experience can make prevention more tangible to patients.
“We’re the only ones who really know what happens when a problem occurs,” Dr. Mayerson said.
The challenge is translating that expertise into a system that acts before the complication. One possibility is dedicated bone-health programs staffed by trained APPs within orthopedic practices. Another is stronger integration with cancer survivorship clinics and primary care.
The precise model may vary. The underlying shift is the same: Orthopedics moves from being the specialty that repairs the consequence to one that helps prevent it.
This is also a spine problem
Dr. Mayerson was particularly clear that the issue should not be confined to extremity orthopedics. Cancer frequently involves the spine.
Metastatic disease can weaken vertebrae. Radiation can affect spinal bone quality. Skeletal deterioration can contribute to instability, pain and fracture risk.
“This is not just an extremity issue,” he said. “This is a spine issue too.”
That matters because patients with cancer may encounter orthopedic surgeons, spine surgeons, radiation oncologists, medical oncologists and primary care physicians at different points in the same disease course.
If bone health is treated as someone else’s responsibility at every handoff, it can disappear. Dr. Mayerson sees education as part of the solution.
Many physicians receive limited exposure to orthopedic oncology during training simply because the specialty is so small. That can make it difficult to recognize when a metastatic bone lesion is approaching fracture risk or when specialist referral should occur.
A stronger bone-health model would therefore require more than DEXA scans. It would require better recognition across specialties of when skeletal risk is becoming clinically important.
Survivorship has to include the skeleton
Cancer survivorship has broadened over time. Health systems increasingly think about rehabilitation, nutrition, emotional health and returning patients to normal life after treatment.
Dr. Mayerson believes bone health belongs in that same framework. For some patients, the consequences of chemotherapy, radiation or metastatic disease may not become obvious until years after the original treatment.
By then, the opportunity for prevention may have passed. The Ohio State pilot is trying to move that moment forward.
If it works, its larger lesson may be less about one cancer center’s bone-health program than about where orthopedics sees its role.
For decades, orthopedic oncology has been called when cancer damages the skeleton. Dr. Mayerson wants the specialty involved before it does.
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