The old adage, “I feel it in my bones,” is oftentimes associated with an intuition or resolute gut feeling about something. That catch phrase is fitting for Wakenda Tyler, MD, MPH, who knew early on in medical school that she wanted to specialize in cancer and orthopedics. Her motivation was partly personal.

“I witnessed a close friend and close family member pass away from breast cancer as I was starting to embark on my journey towards medical school,” says Dr. Tyler, division chief of orthopedic oncology at Columbia University Vagelos College of Physicians & Surgeons. “It was tough watching how they suffered towards the end. I’ve had a passion ever since for caring for that particular population of patients. It just meant something more to me.”

Wakenda Tyler, MD, MPH, division chief of orthopedic oncology

A physician-scientist, Dr. Tyler focuses on treating primary soft tissue and bone cancers, sarcomas, and metastatic bone cancer. Her basic science research concentrated on investigating tumor growth and drivers of bone metastasis—examining how cancer cells target bones, attach, and proliferate, and studying ways to block them. More recently Dr. Tyler and her collaborators have been interested in cancer disparities research, studying the access barriers to oncological care for low-income communities, underrepresented minorities, and patients who live in rural communities.

Last June, she was tapped to serve as vice chair of diversity, equity, and inclusion in the Department of Orthopedics and has since established a committee dedicated to promoting racial and social justice at Columbia and in the orthopedic field.

“We have to start with dialogue, we have to engage, and we have to talk about it,” she says. “Instead of seeing people squirm in their seats whenever you bring up race or racism, we have to get to a point where people feel more comfortable talking about it. We have to start making it a less awkward conversation and more of a daily conversation.”

Tell us about how orthopedics and cancer intersect.

People don't immediately think of orthopedics as part of the cancer field. I would say we’re more quickly associated with sports medicine and the like. But the reality is that we have thousands of patients in the United States each year that get diagnosed with metastatic cancer, cancer that has spread from one part of their body to other parts, and 85% to 90% of those patients, have bone metastases, or ‘ bone mets’. Many times, the bone met is not symptomatic. Patients aren’t aware of it. But it is very common and very frequent for those bone metastases to become symptomatic. As orthopedic surgeons, that's one of our main roles—caring  for patients who have metastatic bone disease. There used to be a time when we would say that patients with metastatic bone disease meant they had very limited treatment options. Thankfully that is no longer the case.

What has changed?

Metastatic bone disease does not mean it is the end of the line for a patient. It becomes a little tricky because it often means we can't cure the patient’s cancer, but we now have such good treatments available to us that we can put the disease into a remission state, and keep people in that remission state for a very long time. A lot of credit goes to the medical oncologists who have really moved the dial in researching targeted therapies, and these therapies in their vastness have allowed for us to take a cancer that 10 to 15 years ago would have meant a patient had a six-month life expectancy and turn that into a six-year life expectancy or longer.

What have been some of the key advancements in orthopedic oncology?

We've made a lot of incremental improvements in the field, and a lot of those incremental improvements have come in the type of implants we now have that enable us to give patients better function, and also in the way we conduct our surgeries. We have better implants that are more durable and more lasting for the patient. Patients may now get 30 to 40 years out of an implant. We’ve also come up with implants that allow us to work with less bone and soft tissue. When we have a short segment of bone or we don't have a lot of bone, we have new implants now that we can use that will allow us to still give somebody a functional outcome with that short segment of bone. That's one area of surgical orthopedics where we've made some really big improvements.

We've also moved towards computer-assisted or navigation-assisted surgeries. While we can't use this technique in each surgical case, for some of these more complicated surgeries now we can use intraoperative CT imaging scan to help us actually navigate the borders of a tumor and allow us to more accurately resect the tumor without getting too close to the margins. As an example, I use the intraoperative CT scanner in many of my pelvic cases, and it can more accurately help us see what we need to do in terms of making our cuts and doing what is appropriate for a patient.

What is your focus in cancer disparities research?

There have been a lot of studies that looked at  underserved communities—low-income communities, minority populations, and those who live in rural locations where the nearest cancer center might be miles and miles away. Overall, what we've seen from these studies is that these patients are getting not as good care as they should be getting. They're having higher mortality rates. They're having higher complication rates, and they're having delays in diagnoses. We see that in our own studies, and now that we’ve observed the problem the obvious next step is whether we can create a solution to that problem. Are there ways to improve care so that there are fewer delays for a patient living in a rural community, for instance, or a way to give patients access to a primary doctor who can better detect a cancer diagnosis before it's too late?

One of the things we should implement is educating those community or local doctors that are out there, who are in the thick of things in those rural communities. We need to better educate them so that they know the red flags, so they have a checklist that gives them better guidance on when a patient might need to be referred on to the bigger medical center right away and not hold on to them and delay their cancer care.

Tell us about your role as diversity, equity, and inclusion vice chair in orthopedics.

I have to say, if there was one thing good that has come out of the George Floyd event and other events that have since taken place and sparked so much outrage is that institutions have started to take real action. Some institutions have said, ‘we've sat here with the blindfolds on for decades and centuries, and it's time to take the blindfolds off and be more proactive.’ And Columbia has done that, and I give them credit for that. Columbia has launched multiple diversity, equity, and inclusion groups throughout the greater hospital setting to spearhead this change.

My goal is to start with educating the orthopedic department and my fellow colleagues throughout orthopedics in this country, and quite honestly, it is a tough subject to tackle but it is good—and necessary—to have to start these conversations. One key goal of Columbia’s initiative is to spark recruitment and retention of more young minorities and underrepresented community members. Columbia does have representation of women and minorities in their ranks, but not so much in the leadership roles as it should. And part of that is a pipeline issue, and that's an issue we are dealing with in orthopedics. We now have our diversity, equity, and inclusion committee established in our department and we are at a good starting point.

Are you optimistic?

When you see the George Floyd video, of course, you sit there going, ‘I feel like I'm in the 1950s again,’ but the reality of it is that we have made gains since the 1950s. First of all, this is a gain—that the division chief of orthopedic oncology at Columbia is a brown female. That’s big. I wouldn't even be allowed in the hospital door outside of just being the cleaning person in the 1950s. We need to continue the dialogue on race and racism. It’s an awkward dialogue, but that’s the starting point, and we need to continue to engage in this dialogue no matter how uncomfortable it is.

-Interview by Melanie A. Farmer