Sarcoma Survival: Less Intensive Follow-up Is Appropriate
Elizabeth Hofheinz, M.P.H., M.Ed. • Thu, February 8th, 2018
For patients with limb sarcomas, less may well be more with respect to post treatment surveillance.
The work, “Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb?” appears in the January 31, 2018 edition of The Bone and Joint Journal.
Ajay Puri, M.S. (Orth), co-author on the study and chief of Orthopaedic Oncology at Tata Memorial Centre and Homi Bhabha National University in Mumbai, India, told OTW, “Strategies of surveillance after the resection of sarcomas remain variable and are not evidence-based.”
“The current clinical guidelines for the follow-up of patients with bone and soft tissue sarcomas are based on low-quality evidence. ‘Whether less intensive surveillance protocols would affect sarcoma patient survival’ was recently identified as the highest-ranking research priority in the field of orthopaedic oncology by an international expert panel.”
“The additional radiation exposure to the patient resulting from repeated imaging undertaken for surveillance is a matter of concern. The financial costs incurred by surveillance are considerable and this includes both the cost to the health service and to the patient in terms of hospital visits and lost working days.”
“This is relevant in both resource-challenged societies where patients often travel long distances to access specialized health care and developed countries that are facing increasing healthcare budgetary constraints. In an increasingly ‘‘cost conscious’’ healthcare scenario, allocation of limited health funding is best guided by evidence-based recommendations rather than empirical beliefs.”
“This study, ‘TOSS’ [The Trial for Optimal Surveillance in Sarcomas] (TOSS) is the only prospective randomized trial for surveillance in sarcomas.”
“One of the main strengths of the TOSS study in determining the impact of surveillance is the use of overall survival as an endpoint, rather than the rate of detection, as has been used in other reports. It is important to note that surveillance may not be a critical determinant of survival because there is limited second-line treatment for recurrent sarcomas and because survival may be determined more by the biology of the particular tumor.”
“A total of 500 patients were randomized immediately after surgery to either three-monthly or six-monthly follow-up, and to have either a CT scan or a chest radiograph (CXR) at each visit.”
“88% of the local recurrences were identified by the patients themselves. The overall survival was not significantly worse in the six monthly follow-up group (p = 0.95) and six-monthly follow-up was not significantly poorer at detecting recurrence than three-monthly follow-up (p = 0.99).”
“Although CT scans detected pulmonary metastasis significantly earlier (p = 0.05), it did not result in better survival compared with a CXR as a mode of imaging (p = 0.63).”
“In surgically operated patients with sarcoma of the limb, an increased frequency of follow-up with expensive imaging does not improve overall survival.”
“This study demonstrates that a chest radiograph at six-monthly intervals and patient education regarding local self-examination of the operated area will detect most of the recurrences without deleterious effects on overall survival.”
“There is a need for clinical trials to prospectively evaluate imaging modalities used in follow up and to identify an optimal surveillance strategy, one balancing gains in survival, quality of life, costs, and societal willingness to expend resources as well. This study, ‘TOSS’, the only prospective randomized trial for surveillance in sarcomas is an important step in this direction.”