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Controversies in the Management of Sarcoma Survey (Eur J Cancer 2023)
'As clear as mud'
Obligatory—This is not medical advice
I wouldn’t say that this article necessarily heralds a revolution in treatment, but given this is somewhat of a consensus statement, it does show where most of the sarcoma community in Europe stands. Amongst the authors here are big names in sarcoma, including many we’ve seen as first or last authors in major papers that have defined the treatment landscape for our patients.
What is this?
62 sarcoma experts from 12 countries occupied a panel and reviewed a number of areas within Sarcoma (220 questions in all). When 75% of panelists agreed, this was called a consensus. When >95% agreed, this was a strong consensus. It’s a fancy survey and therefore observational.1
How do I read this as an oncologist who cares for patients with Sarcomas?
There’s little new information in here for me. It does, however, serve to consolidate many things, and portray the direction of the field. Think of it as reading a holiday card from a family you know well (let’s say the Smiths). You’ve kept up with the Smiths, you know about their pets, vacations, and all the like. Here is a summary of it all in front of you that’s comforting in a way, part of a ritual you expect at this time of the year. Let’s read about the Smiths.
What did it show?
There were plenty of obvious remarks within this document—patients should not undergo attempted resection without diagnosis, there should be increased awareness of sarcoma in the medical community, people should look at guidelines, patient representatives should be involved, etc.
Approximately half of panelists utilize the SARCULATOR to define high risk. This has shown an increase in uptake over time and is the most commonly employed method amongst sarcoma experts in Europe.
I have discussed this separately in my neoadjuvant post, but it has been externally validated (retrospectively) with thousands of patients, and is our most qualified tool at the moment.2 We should continue to hone it, and it should be used for stratification of future trials if possible.
Given I am simply a medical oncologist, I will avoid topics that directly incorporate the preferences of other disciplines for the sake of this post. That stated, I will include this guideline for oligometastatic disease (meaning few metastatic lesions). The lack of consensus is evident in the field, and has led to varied recommendations center to center. It seems that in the majority of cases, oncologists do not recommend local therapy (eg radiation or surgery) over systemic treatment for oligometastatic recurrence that happens less than 6 months after diagnosis.
Panelists also shared their preferences for order of treatment, on which there was consensus for chemotherapy followed by radiation, and then surgery. This is what’s typically used, but understand that this is also in the ideal circumstances. There are times, and plenty in sarcoma, when we find out after definitive local therapy that the histologic subtype will require treatment. This is just to say, when all information is in front of you, and neoadjuvant treatment is merited, what is the preferred order?
There was also a belief amongst 64% of respondents that subtype agnostic (meaning all comer) trials were no longer appropriate.
A tabulation of the following medications for select subtypes of sarcoma was also included:
So what’s the takeaway? Nothing particularly novel. This formalizes a lot of the more recent literature that’s been published in prior years and gives a glimpse into treatment related trends. I would argue that within this parallels what we would see in the United States at reference centers, but we’re all different. As you’ll note, for more nuanced questions, there is a lack of strict consensus. When it comes to less well defined treatment recommendations, even Europe is variable.