CORRInsights®: Developing an Evidence-Based Followup Schedule for Bone Sarcomas Based on Local Recurrence and Metastatic Progression

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Creativity and flexibility are expected for the surgical management of bone sarcomas, but we should not expect those same qualities for our approach to sarcoma surveillance after the surgery is complete. Cipriano and colleagues address an unanswered question within orthopaedic oncology: “How frequently do I need to obtain followup imaging on my patients?”
In the office we routinely discuss treatment options for sarcoma and provide our patients with data to support our treatment recommendations. We then move to the next room and examine patients who are months or years removed from their surgery, and we advise them to return in 3 months, 6 months, or 1 year with new imaging studies that can include radiographs, MRI, CT, positron emission tomography (PET) CT, bone scan, or a combination of several studies. Very few of these patients ask what data we have to support surveillance recommendations. Oncologic societies such as National Comprehensive Cancer Network, National Cancer Institute, and European Society for Medical Oncology provide general guidelines for local and systemic surveillance, but even terms like “chest imaging” lack specificity [1, 2]. While this gives the orthopaedic oncologist some autonomy for medical decision making, it fails to address the unintended consequences such as radiation exposure, rising healthcare costs, unnecessary subsequent testing for false-positive results, and patient anxiety related to the aforementioned effects.
Cipriano and colleagues refine the existing guidelines based upon tumor grade, with low-grade tumors receiving a less-aggressive surveillance plan and high-grade tumors following a more-intensive surveillance plan. Their research provides Level-3 recommendations that include less-frequent chest imaging for low- and intermediate-grade sarcomas and suggests that a shorter period of total surveillance for low-grade bone sarcomas is appropriate without adverse impact on overall survival. These recommendations favor less-cumulative radiation exposure to patients.
Evidence exists that healthcare providers do not appreciate the amount of radiation associated with tests ordered on a daily basis [4]. A chest radiograph exposes a patient to approximately 0.14 mSv, whereas the radiation from a chest CT is 8 mSv to 10 mSv [3]. How many of us disclose to our patients that we have ordered the equivalent of 500 chest radiographs in order to obtain a CT scan for routine surveillance? Although the perceived overall risk for secondary malignancy is low, modest evidence supports an increased risk of cancer in patients with protracted exposure to 50 mSv to 100 mSv [5]. Puri's Trial for Optimal Surveillance in Sarcomas [6] provides Level 1 evidence that chest radiograph is not inferior to chest CT at a median followup of 42 months for detecting pulmonary metastases, and 3-year overall survival rates were similar in the chest radiography and chest CT cohorts.
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