CORR Insights®: Soft Tissue Sarcoma of the Extremities: What Is the Value of Treating at High-volume Centers?
Year: 2018
Type: article
Abstract: Where Are We Now? A strong body of evidence has indicated that patients with cancer have better oncologic outcomes when they are treated at high-volume centers [2, 6]. Lazarides and colleagues [9] have contributed to the accumulating evidence regarding this phenomenon specifically for patients with sarcomas, finding that patients with soft-tissue sarcomas of the extremities may benefit from treatment at high-volume centers, while also determining that the vast majority of patients with that diagnosis in the United States are treated at low-volume centers. Other research points to a related problem: Many subspecialty-trained orthopaedic oncologists do not encounter sufficient volume to support the development of full-time tumor practices [5]. Where Do We Need To Go? There is evidence supporting the importance of centralized care for patients with sarcomas [1, 3], and I believe the research is robust enough to begin to inform healthcare policy in terms of identifying and supporting high-volume national centers of excellence in sarcoma care. National guidelines can direct referring physicians to these high-volume centers of and indicate what work-up studies and interventions are required prior to referral (ie, cross-sectional imaging and in some cases image-guided biopsy). Future studies should determine the causes for poorer oncologic outcomes for patients with sarcomas who are treated at lower-volume centers. Are the differences in oncologic outcomes related to individual surgeon experience and expertise or are the differences the result of less-developed or incohesive multidisciplinary care? Clear and regular communication among multidisciplinary sarcoma experts is critical to maximize oncologic outcomes [8]. Countries and jurisdictions where health care is centrally funded are more likely to have developed patterns of centralized care for rare diseases [7]. For example, Cancer Care Ontario has developed a sarcoma treatment paradigm in which three Host Centers are responsible for the care of all patients with sarcoma in the province of Ontario [4]. The prerequisites to be a Host Center include the ability to provide all associated multidisciplinary services. These centers are afforded additional provincial funding to support centralized sarcoma care. Similarly, the National Health Service of the United Kingdom (UK) provides online information to patients and referring physicians regarding the specialized sarcoma treatment centers in the UK and the available surgical and multidisciplinary services available at each [10]. However, in countries where the healthcare system is not nationalized, there will be significant challenges to centralized care. These would include the need for financial support for patients to travel to sarcoma centers. Sarcoma care is intense and multidisciplinary, and require many trips to the center for radiation, chemotherapy, surgery, and followup. These financial concerns are compounded by the fact that socioeconomic disparities are likely to affect the ability of patients to travel to high-volume sarcoma centers for all of the necessary care. One possible to solution would be partnering high-volume centers that offer complete multidisciplinary services with other sites in the provision of certain aspects of care. For example, a patient can undergo preoperative radiation at a partner site closer to home, but undergo surgery at the high-volume center. Long-term followup can be carried out at the partner center with occasional visits to the high-volume center. This teamwork solution would require regular and clear communication between the sarcoma teams at both centers. How Do We Get There? The current study is a population-based registry review, and therefore, it cannot identify individual-patient causes for oncologic relapse and/or patient death. A smaller, more-focused audit of individual centers could inform hospitals of the services and expertise missing at low-volume centers. In addition, a comparison of overall outcomes for patients with sarcoma between those treated at government-identified sarcoma centers in the UK or Canada and low-volume centers in the United States would provide more definitive conclusions. Finally, specialty orthopaedic oncology societies such as the Musculoskeletal Tumor Society (MSTS) could work to educate prospective and current fellows regarding the importance of pursuing a position at large referral centers where services and expertise for sarcoma management are present without any critical multidisciplinary gaps. Since such positions are not always available, the MSTS can focus on educating new independent surgeons on the importance of communication and collaboration with MSTS colleagues at higher volume centers. Because centralized care would be impractical in the current US healthcare system, other solutions such as developing relationships with partner sites and collaboration among MSTS surgeons would help improve oncologic outcomes for sarcoma patients. An interesting and beneficial study would be a comparative cost analysis of various combinations of US sarcoma center collaborations that could, as a unit, provide full access and complete sarcoma care within geographical jurisdictions. Such a study would help inform healthcare policy aimed at improving cost-effective care and oncologic outcomes for all sarcoma patients.
Author: Michelle Ghert
Institutions: Hamilton Health Sciences, McMaster University
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W3021894318