Does referral to a specialist centre improve outcomes?

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Does referral to a specialist centre improve outcomes in BSTTs?


It is estimated that a busy general practitioner will only see one to two patients with sarcoma in their clinical practice lifetime.[1][2][3]. National registries also reveal that a general orthopaedic surgeon can expect to see less than one patient with a primary bone tumour every three years.[4][5] Figures do not exist for the rates of sarcoma patients seen initially by other types of surgeon.

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Referral to specialist centres

As it will never be possible to conduct a randomised trial on this topic evidence can only be gained from analysis of series of patients treated within and outside specialist centres. This leads to significant bias in the cases reported as those patients with a good prognosis (for example a patient with a superficial tumour that is readily widely excised) are often not referred whereas those with complex treatment requirements or suspected poorer prognosis are.[6] However, even with these caveats published series consistently report that outcomes are worse when treatment is initiated in non-specialist centres.[5][7][8][9][10][11][12] Unfortunately, current estimates are that up to half of all patients with soft-tissue sarcoma (STS) are managed outside specialist centres.[1]

As sarcomas are rare, but benign soft tissue tumours are very common, surgery is often undertaken with a plan to perform enucleation or marginal excision. This usually occurs prior to any imaging or biopsy.[13][14][15] These procedures have come to be known as “unplanned surgery”.[16] There is residual tumour found at re-excision in 39-68% of these patients.[17][18][19][20] Re-excision is often a more complex and complicated procedure and the chance for optimal treatment may have been lost by unplanned surgery.[2][21][22][23][24][25] Reported local recurrence rates after unplanned surgery are in the range of 60 to 90%.[16][26][6][27][28] There is also evidence that disease-specific survival is higher in patients treated in specialist centres.[29][30][2][10][6][18]

Reported series often only consider a few of the possible outcomes of non-referral for specialist treatment. These include the effect of delayed diagnosis, the need for repeated procedures and ultimately the effects on local and distant recurrence.

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Evidence summary and recommendations

Evidence summary Level References
The rate of preoperative diagnosis in non-specialist centres ranges from 17-60%. This greatly increases the chances of incomplete resection. IV [13], [14], [15], [31]
When biopsies are performed in non-specialist units the errors in diagnosis, non-representative samples and biopsy site complications resulting in alterations in treatment or outcome, have been shown to be between 2–12 times greater than when the biopsy is performed in a specialist centre. Referral of patients to specialist centres results in less unplanned surgery and fewer biopsy-related complications. IV [5], [7], [8], [9], [10], [11], [12], [31]
The rates of positive excision margins in patients treated in non-specialist centres are often reported to be as high as 67-93%. Specialist centres generally report rates below 35%. IV [13], [14], [21], [5], [15], [4], [22], [16], [31]
Reoperation reveals residual disease in 39-68% of patients referred after their primary excision. Current imaging modalities are unable to reliably predict the presence of residual microscopic disease. III-2, IV [10], [4], [15], [17], [18], [19], [20]
Reoperation becomes increasingly complex due to inappropriately placed incisions, contamination of uninvolved tissue planes and wound complications. The costs associated with treatment are significantly increased. IV [17], [21], [23], [2], [24], [22], [25], [19]
Treatment recommendations by the referring physician have been reported to cause anxiety and confusion as they agree with the recommendation of specialists on less than 50% of occasions. IV [17]
Local recurrence rates are higher following incomplete primary excision. Rates in non-specialist units are generally two to four times higher than those achieved in specialist centres. III-2, IV [27], [23], [18], [28], [13], [29], [7], [2], [19], [26]
Disease-specific survival is greater in patients treated in specialist centres. III-2, IV [18], [2], [6], [15], [29], [10], [30], [32]
Evidence-based recommendationQuestion mark transparent.png Grade
Patients with suspected sarcoma to be referred to a specialist sarcoma unit prior to diagnosis in order to reduce the rates of incomplete excision, reoperation, local recurrence and to improve survival.

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Issues requiring more clinical research study

  • What are the economic implications of referral and non-referral for specialist care?

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  1. 1.0 1.1 Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences, University of Leicester. Referral Guidelines for Suspected Cancer in Adults and Children (Internet). National Institute for Health and Clinical Excellence: Guidance 2005 Jun Abstract available at
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