Specialized teams or specialist networks for rare cancers?

Achievements of international rare cancers networks and consortia in the neuro-oncology field

PURPOSE OF REVIEW

In this review, we investigated the role of European oncological networks on management and care of patients with central nervous system (CNS) malignancies.

RECENT FINDINGS

Within this universe of tumors, malignancies of the central nervous system (CNS) malignancies represent a challenge because of several reasons such as biological complexity, the need of dedicated experienced physicians (surgeons, pathologists, radiologists and neuro-oncologists) and tertiary healthcare providers. Limits to the development of effective and innovative care are represented by the rarity of these tumors and their extreme heterogeneity in terms of clinical presentation, course of the disease, genetic assessments and site of presentation. The oncological networks are societies or associations, which make possible to connect patients, scientists, doctors and researchers together allowing to obtain several improvements.

SUMMARY

Oncological networks can cooperate to increase accrual rate and speed in clinical trials, share data about CNS malignancy management and improve knowledge toward this class of tumors within patients and health operators promoting equity and high standard of care.

Descriptive epidemiological study of rare, less common and common cancers in Western Australia

Background

There are no epidemiological studies describing rare cancers in Western Australia (WA). We aimed to fill this gap by estimating the incidence and five-year survival of rare, less common and common cancers in WA, based on definitions for rarity used by the Australian Institute of Health and Welfare and cancer groupings from the project on Surveillance of Rare Cancers in Europe (RARECARE). This research will enable policy- and decision-makers to better understand the size and nature of the public health problem presented by rare cancers in WA. It is anticipated that this study will inform improved health service design and delivery for all WA cancer patients, but particularly those with rare and less common cancers.

Methods

We estimated incidence and five-year survival rates of rare, less common and common cancers in WA using data sourced from the WA Cancer Registry for the 2013–2017 period. Cancers were defined as rare (< 6), less common (6–12), or common (> 12) based on their crude incidence rate per 100,000 people per year.

Results

Rare cancers make up 21.5% of all cancer diagnoses in WA, with a significantly poorer five-year survival of 58.2% (95% confidence interval (CI) 57.3–59.1%), compared to patients diagnosed with a common cancer, whose five-year survival was 87.8% (95% CI 87.3–88.3%). Survival for less common cancers was significantly poorer than both rare and common cancers, at 48.1% (95% CI 47.3–49.0%). Together, rare and less common cancers represent 48.4% of all cancer diagnoses in WA.

Conclusions

While rare cancers are individually scarce, collectively over one in five cancer patients in WA are diagnosed with a rare cancer. These patients experience significantly worse prognoses compared to patients with common cancers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08501-4.

The sarcoma diagnostic interval: a systematic review on length, contributing factors and patient outcomes

Sarcomas are rare and heterogeneous mesenchymal tumours of soft tissue or bone, making them prone to late diagnosis. In other malignancies, early diagnosis has an impact on stage of disease, complexity of therapeutic procedures, survival and health-related quality of life (HRQoL). Little is known about what length of diagnostic interval should be considered as delay in patients with bone (BS) or soft tissue sarcomas (STS). To quantify total interval (defined as time from first symptom to histological diagnosis) and its components, identify contributing factors to its length and determine the impact on patients’ outcome in terms of mortality and HRQoL. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventy-six articles out of 2310 met the predefined inclusion criteria. Total intervals, varied broadly; 9–120.4 weeks for BS and 4.3–614.9 weeks for STS. Older age and no initial radiological examinations were contributing factors for a long interval in BS, while in STS results were conflicting. The impact of length of total interval on clinical outcomes in terms of survival and morbidity remains ambiguous; no clear relation could be identified for both BS and STS. No study examined the impact on HRQoL. The length of total interval is variable in BS as well as STS. Its effect on outcomes is contradictory. There is no definition of a clinically relevant cut-off point that discriminates between a short or long total interval. Prospero: CRD42017062492.

Histopathologic challenges: The second OPINION issue

Classification and definition criteria for rare cancer is still an open issue in clinical practice due to several factors, which include the limited available molecular data to better defining specific tumor groups or "families" of interest. An important issue related to the proper management of these entities is the correct diagnosis and subtyping of a given entity. The high complexity associated with the histopathologic diagnosis and eventual molecular analysis may suggest the use of a histopathologic second opinion from a specialized pathologist. Diagnostic inaccuracies and difference between primary diagnosis and second opinion are expected at the population level: however, the magnitude of this difference is remarkably high and calls for implementation of second opinion in routine practice outside reference centers.

Centers of excellence or excellence networks: The surgical challenge and quality issues in rare cancers

There are several suggestions that centralization of care improves outcome for rare cancers, particularly when optimal treatment requires complex surgery or high-technology radiotherapy equipment. Diagnosis and treatment in reference centers are expected to be more accurate because they benefit from large numbers of cases discussed in a multidisciplinary tumor board with a well-run pathway. However, centralization is sometimes moderately perceived by oncologists as a solution to be endorsed for rare cancer patients; disadvantages of centralization are the need for patients to move and the risk of a longer waiting list, with discomfort and possible negative effects on outcome. It is difficult to find single experts on rare cancers: all the more it will be difficult to find a multidisciplinary panel of experts, and the role of the surgeon is to be a functional part of it. On the other side, from a surgical point of view, the quality of the initial management of many rare cancers directly impacts the final outcome; surgery of rare cancers may not necessarily be more demanding than the average from a technical point of view, but the lack of cultural knowledge about the disease can well lead to inappropriateness even in the lack of major technical challenges. Care for rare cancer patients must be organized in pathways that cover the patient's journey from their point of view rather than that of the healthcare system, and pathways must follow the best evidence on diagnosis, treatment and follow-up.

Improved survival using specialized multidisciplinary board in sarcoma patients

BACKGROUND

Sarcomas are rare but aggressive diseases. Specialized multidisciplinary management is not implemented for all patients in most countries. We investigated the impact of a multidisciplinary tumor board (MDTB) presentation before treatment in a nationwide study over 5 years.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized MDTB, funded by the French National Cancer Institute to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and second pathological review are mandatory for sarcoma patients in France. Patients' characteristics and follow-up are collected in a database regularly monitored and updated. The management and survival of patients presented to these MDTB before versus after initial treatment were analyzed.

RESULTS

Out of the 12 528 patients aged ≥15 years, with a first diagnosis of soft tissue and visceral sarcoma obtained between 1 January 2010 and 31 December 2014, 5281 (42.2%) and 7247 (57.8%) were presented to the MDTB before and after the initiation of treatment, respectively. The former group had generally worse prognostic characteristics. Presentation to a MDTB before treatment was associated with a better compliance to clinical practice guidelines, for example, biopsy before surgery, imaging, quality of initial surgery, and less reoperations (all P < 0.001). Local relapse-free survival and relapse-free survival were significantly better in patients presented to a MDTB before initiation of treatment, both in univariate and multivariate analysis.

CONCLUSION

The compliance to clinical practice guidelines and relapse-free survival of sarcoma patients are significantly better when the initial treatment is guided by a pre-therapeutic specialized MDTB.

Treatment challenges in and outside a network setting: Soft tissue sarcomas

Patients with soft tissue sarcoma (STS) experienced better outcomes when treated according to existing clinical practice guidelines either at reference institution or dedicated treatment networks. Despite increasing evidence supporting referral to sarcoma specialised units, up to half of patients are not managed according to guidelines, particularly those in the early stage of their disease requiring surgery. Also, criteria to certify expertise of institutions, such as the treatment volume, are debated and health authorities have only recently started identification of these centres and creation of treatment networks in Europe as well as in several countries. This process have important implications for both patient outcomes and innovation of existing treatment strategies through clinical research, making improvement of clinical pathways a priority for health care authorities. This article will discuss issues with management of patients with STS, such as pathological diagnosis and adherence to guidelines, and the definition of referral centres and networks will be illustrated along with existing experiences and population-based data.

The BRASS (BReast Angiosarcoma Surveillance Study): Protocol for a retrospective multicentre cohort study to evaluate the management and outcomes of angiosarcoma of the breast and chest wall

•Multicentre retrospective study involving breast and plastic units across the UK.•Will produce valuable data regarding management and outcomes.•Will inform decision making and help shape a future definitive study.