Defining sarcoma specialist center: revisiting the volume effect
Authors: Dimitrios Moris, Dan G Blazer
Journal: Annals of Oncology (2019)

We read with great interest the recent publication by Blay et al. [1.Blay J.-Y. Honoré C. Stoeckle E. et al.Surgery in reference centers improves survival of sarcoma patients: a nationwide study.Ann Oncol. 2019; Abstract Full Text Full Text PDF Scopus (15) Google Scholar] showing that surgical management of sarcomas in sarcoma specialist centers led to better outcomes. The authors presented data from a large network (NETSARC) of 26 sarcoma reference centers with specialized multidisciplinary tumor boards. The study included the full spectrum of soft tissue malignant tumors, including retroperitoneal sarcomas (RPS). National Comprehensive Cancer Network guidelines on RPS confirm the findings of the study and currently recommend that all patients should be managed by a multidisciplinary team with expertise in sarcoma [2.Adam M.A. Moris D. Behren S. et al.Hospital volume threshold for the treatment of retroperitoneal sarcoma.Anticancer Res. 2019; 39: 2007-2014Crossref PubMed Scopus (15) Google Scholar]. However, hospital volume is also considered as a factor correlating with improved clinical outcomes for several cancers [3.Sheetz K.H. Dimick J.B. Nathan H. Centralization of high-risk cancer surgery within existing hospital systems.J Clin Oncol. 2019; Crossref PubMed Scopus (57) Google Scholar]. Emerging literature clearly demonstrates that treatment of extremity and retroperitoneal sarcomas in high-volume centers is associated with significant reduction in short-term mortality and improved long-term survival, setting the threshold of 10 cases/year to define high-volume centers [2.Adam M.A. Moris D. Behren S. et al.Hospital volume threshold for the treatment of retroperitoneal sarcoma.Anticancer Res. 2019; 39: 2007-2014Crossref PubMed Scopus (15) Google Scholar, 4.Keung E.Z. Chiang Y.J. Cormier J.N. et al.Treatment at low-volume hospitals is associated with reduced short-term and long-term outcomes for patients with retroperitoneal sarcoma.Cancer. 2018; 124: 4495-4503Crossref PubMed Scopus (75) Google Scholar, 5.Abarca T. Gao Y. Monga V. et al.Improved survival for extremity soft tissue sarcoma treated in high-volume facilities.J Surg Oncol. 2018; 117: 1479-1486Crossref PubMed Scopus (40) Google Scholar]. Given the unique operative challenges with RPS and the importance of volume-outcomes with this disease, it would be of paramount importance if the authors provided more information on how they defined sarcoma specialist centers besides the presence of robust multidisciplinary sarcoma tumor boards. It is not clear in the article whether the number of referrals also was used to support the ‘sarcoma specialist’ definition. The authors reported that only 9% of the total sarcoma cases were defined as RPS. Also, our review of the center volume provided in supplement suggests that each center had to carry out around 80 cases during the study period in order to be considered as high volume. As a result, based on the volume analysis, most hospitals in the study are low-volume centers for RPS. Finally, we would like to ask the authors if they have data reflecting the number of patients managed at any point of their treatment outside NETSARC network, received evidence-based treatment. In other words, who many patients had received guideline-compliant management before getting treated at a NETSARC hospital or how many of the patients managed at NETSARC and continued their management outside the network continued to receive evidence-based treatment. That seems to be really important since treating sarcomas outside NETSARC was related to worse outcomes. All in all, we strongly believe that the quality of surgical care is a timely topic-because surgical outcomes can vary widely among hospitals and surgeons. Centralization of care for complex surgical diseases is compulsory in order to optimize outcomes. None declared.