Where Are We Now?
White et al.  reported that in 2010, 74% of orthopaedic oncologists were working in an academic practice and that 70% of their time was dedicated to orthopaedic oncology. On average, the respondents performed 20 malignant bone and 40 malignant soft tissue tumor resections per year. Since this time, the number of programs and trainees has doubled . Between 2004 and 2013, only one-third of recently trained tumor fellows performed tumor-related surgery, accounting for greater than 50% of their practices . These observational trends are important for individuals considering orthopaedic oncology as a subspecialty, raising the question as to whether there are sufficient opportunities to contribute and grow professionally in this highly subspecialized and increasingly crowded area of orthopaedics. Aside from market saturation and dilution of experience, one might ask how doubling the number of fellowships and trainees has affected fellowship education.
Malik et al.  assessed the operative experience of trainees graduating from Accreditation Council for Graduate Medical Education (ACGME)–accredited orthopaedic musculoskeletal oncology fellowships between 2010 and 2017. They found that the total number of procedures performed by fellows did not change during the study period and that there was significant program variation in meeting Musculoskeletal Tumor Society–recommended numbers of procedures in certain areas of proficiency, for example, pediatric, spine, and limb salvage procedures. These are straightforward observations but they raise some very important issues regarding the future of orthopaedic oncology training and practice. It appears that the numbers of procedures are relatively stable; however, the types of procedures performed are variable and in some categories, deficient in select programs.
Where Do We Need to Go?
Malik et al.  raise some interesting questions. Are musculoskeletal oncology fellows adequately trained? Are the number and types of procedures a reasonable benchmark to measure success? Are the number and distribution of orthopaedic oncologists in the United States appropriate? What patient volume is needed to maintain, improve, and advance practice skills after training in this challenging and broad subspecialty?
Numbers of procedures and general categories of disease are useful yardsticks in measuring competence but may miss the mark. For example, soft tissue sarcomas represent a diverse group of diseases, and more than 50% of patients with these sarcomas have an inadequate diagnostic evaluation and inappropriate treatment before seeing an orthopaedic oncologist . These procedures alter future therapy and adversely affect outcomes, yet this subcategory of disease is not a part of the overall assessment of fellowship training; it falls under the auspices of malignant soft tissue tumors. It is important to know and assess what a practicing orthopaedic oncologist will eventually see and treat and to assess whether fellowship training programs prepare individuals for these clinical situations.
Eventually, larger numbers of trained orthopaedic oncology fellows will be competing for patients with the same programs that trained them. Multidisciplinary care is the hallmark of sarcoma treatment, and across the United States and abroad, this level of expertise and support are not tenable in smaller academic and community programs. In the end, patient care will suffer.
Some orthopaedic oncology practices and fellowships are many decades old, whereas others are relatively new. An understanding of the long-term consequences of certain therapies and reconstructions is best achieved in established practices that offer the benefit of time and experience, thus compelling a fellow to think through past failures and beyond to the next procedure or medical intervention.
Even the busiest, most-established fellowships will not make their trainees well versed in every aspect of orthopaedic oncology. This is especially true for spine tumor surgery. Only a handful of surgeons in major centers are competent in treating patients with primary spine tumors. Although general tumor principles apply, spine surgery requires different skill sets that may be difficult to master during 1 year of orthopaedic oncology fellowship training. The same is true for pelvic tumors, which are best treated by a multispecialty surgical team using intraoperative imaging, navigation, custom implant designs, an understanding of the role and use of biologics, complex postoperative medical care, and above all, institutional support. This care is best provided by major orthopaedic tumor centers that have the resources and personnel to manage these difficult tumors. Finally, similar to every other area of subspecialty expertise, excellence comes from institutional and personal experience that not all fellowships provide.
Why has the number of musculoskeletal oncology fellowships increased? The number of applications to the specialty of adult reconstruction, of which orthopaedic oncology is a small part, seems to have grown compared with other areas of fellowship training . Still, there is not a surplus of orthopaedic oncology fellowship candidates to fill the available slots, which may be fortunate because opportunities to practice orthopaedic oncology in a meaningful way have not increased [1, 5].
The reason why there are more programs and fellows has to do with institutions or individuals believing there is volume and expertise to support post-residency training, a desire to teach and pass along knowledge and skills, the recognition and prestige that accompanies fellowship training programs, and finally, the satisfaction that comes with the accomplishments and contributions of graduating fellows. The burgeoning number of fellows is unfair to the graduating fellows who cannot advance their personal aspirations in the field for lack of opportunity. There is a regional and national need for comprehensive outcome-driven and center-based service that will improve patient care.
How Do We Get There?
As a specialty, we need to agree on the basic competencies for fellowship training and enforce adherence through ACGME review, but numbers and types of procedures aside, the important elements of orthopaedic oncology care are nurtured and perfected over time. This involves intense and focused attention on diseases and, most importantly, the patients with these diseases. Practice is where training stops and real education begins, and in this specialty, it takes a village to properly diagnose and treat musculoskeletal tumors. With very few exceptions, this only happens in select centers in the United States and worldwide, not in community hospitals or small academic centers.
There are too many graduating orthopaedic oncology fellows and too few opportunities for them. Limiting fellowship training to established high-volume centers that have resources, multidisciplinary teams, basic and translational research programs, and robust clinical trial portfolios is a good start. This is the setting to which graduating fellows should aspire and a place where they can thrive professionally.
In the end, improving outcomes in patients with musculoskeletal tumors is the goal. This can be accomplished by providing quality medical education and populating dedicated specialty centers of excellence by optimizing (not necessarily increasing) the number of orthopaedic oncologists.
1. Duchman KR, Miller BJ. Are recently trained tumor fellows performing less tumor surgery? An analysis of 10 years of the ABOS part II database. Clin Orthop Relat Res. 2017;475:221-228.
2. Malik AT, Voskuil RT, Baek J, Alexander JH, Scharschmidt TJ. Has the volume and variability of procedures reported by fellows in ACGME-accredited musculoskeletal oncology fellowship programs changed over time? Clin Orthop Relat Res. 2021;479:60-68.
3. Tumor Society Musculoskeletal. Fellowships. Available at: MSTS.org/index.php/fellowships
. Accessed August 5, 2020.
4. Wera GD, Eisinger S, Oreluk H, Cannada LK. Trends in the orthopaedic surgery fellowship match 2013 to 2017. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e080.
5. White J, Toy P, Gibbs P, Enneking W, Scarborough M. The current practice of orthopaedic oncology in North America. Clin Orthop Relat Res. 2010;468:2840-2853.