What do we know about survivorship after treatment for extremity sarcoma? A systematic review

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.

A Qualitative Study of the Factors Influencing Patients' Experience of Soft Tissue Sarcoma in the United Kingdom

BACKGROUND

Treatment of soft tissue sarcoma frequently involves extensive surgery, loss of mobility, and complex rehabilitation programs. Poorer patient-reported outcomes are reported in comparison to those from patients with other cancer types. Understanding patient experience is therefore important to support patients and improve care.

OBJECTIVE

The aim of this study was an in-depth exploration of patients' experience of being diagnosed with soft tissue sarcoma.

METHODS

Semistructured interviews and focus groups were conducted with 68 patients with soft tissue sarcoma (59% female; aged 23-82 years). These were analyzed using adapted framework analysis.

RESULTS

Two overarching themes explained the factors influencing patients' experiences: individual and social factors to manage the impact of soft tissue sarcoma; and context and processes of care. Access to professionals with sarcoma expertise and services in specialist hospitals had an impact on patients' well-being. Lack of access to specialist services and coordinated care were associated with worse experiences. These were influenced by age and support from family/friends/other patients and were crucial in patients' adaptation to living with and beyond a sarcoma diagnosis.

CONCLUSION

We describe factors that both negatively and positively influenced the experience of patients with soft tissue sarcoma. Access to specialist soft tissue sarcoma and rehabilitation services and support tailored to patients' age and disease trajectory are needed to improve these experiences.

IMPLICATION FOR PRACTICE

Nurses are important for helping patients manage the long-term effects and directing them to supportive care services. Rehabilitation services need to be available and easily accessible.

Return to sports following lower limb musculoskeletal tumor surgery-A systematic review

BACKGROUND

Survivors of primary malignant musculoskeletal tumors often face long-term disability. Clinicians at present are unable to provide evidence-based advice about returning to sports, which is important for active patients.

PURPOSES

Identify patients returning to sports. Describe the sporting activities in which patients participate. Identify the outcome measures used to assess return to sport. Identify barriers preventing return to sports.

STUDY DESIGN

Systematic review.

METHODS

A comprehensive search strategy was used to identify relevant studies combining the following concepts: (1) Bone/Soft tissue tumor, (2) Lower limb, (3) Surgical interventions, and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors (MTB, FS, and CG).

RESULTS

Twenty-two studies were selected, published between 1985 and 2020, including 1005 patients. Fifteen of the 22 studies had valid data on return to sports, with 705 participants, of which 412 (58.4%) returned to some form of sport such as swimming and cycling, at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing surgery and amputation; none of these were able to identify a difference in sports participation or ability.

CONCLUSION

There is insufficient published research to provide guidance for patients with respect to return to sports following musculoskeletal tumors. Future prospective studies are needed to collect better pre- and post-treatment data at multiple time intervals. Validated clinical and patient sports participation outcomes such as type of sports, level, frequency, and validated sports-specific outcome scores should be recorded. In particular, more comparison between limb sparing surgery and amputation would be welcome.

Determining functional outcomes after resection and reconstruction of primary soft tissue sarcoma in the lower extremity: A review of current subjective and objective measurement systems

The surgical management of soft-tissue sarcoma has evolved significantly over the last two decades due to the routine use of adjunct therapies, with an increased focus on postoperative functional outcome. The literature suffers from methodological inconsistency and use of low quality outcome measures to assess an already heterogeneous population. This article aims to review the most frequently used subjective and objective methods of functional outcome assessment and highlight the current benefits and limitations of these.

Working situation and burden of work limitations in sarcoma patients: results from the multi-center prospective PROSa study

PURPOSE

We investigated predictors of limitations in work performance, odds of drop out of work, and odds of receiving disability pension in sarcoma patients.

METHODS

We measured clinical and sociodemographic data in adult sarcoma patients and recorded if the patients received a (1) disability pension at baseline or (2) had dropped out of work 1 year after initial assessment. (3) Work limitations were assessed using the Work-limitations questionnaire (WLQ^©). We analyzed exploratively.

RESULTS

(1) Amongst 364 analyzed patients, odds to receive a disability pension were higher in patients with abdominal tumors, older patients, high grade patients and with increasing time since diagnosis. (2) Of 356 patients employed at baseline, 21% (n = 76) had dropped out of work after 1 year. The odds of dropping out of work were higher in bone sarcoma patients and in patients who received additive radiotherapy ± systemic therapy compared with patients who received surgery alone. Odds of dropping out of work were less amongst self-employed patients and dropped with increasing time since diagnosis. (3) Work limitations were higher in woman and increased with age. Patients with bone and fibrous sarcomas were more affected than liposarcoma patients. Patients with abdominal tumors reported highest restrictions. Sarcoma treatment in the last 6 months increased work limitations.

CONCLUSION

Work limitations, drop out of work and dependence on a disability pension occurs frequently in patients with sarcoma adding to the burden of this condition. We were able to identify vulnerable groups in both the socioeconomic and disease categories.

Cancer Survivors’ Disability Experiences and Identities: A Qualitative Exploration to Advance the Cancer Equity

Eliminating cancer-related disparities is a global public health priority. Approximately 40% of cancer survivors experience long-term effects of cancer which can lead to activity limitations and participation restrictions; yet discussions of disability are largely absent from clinical and research cancer health equity agendas. The purpose of this study was to explore how cancer survivors experience and make sense of the long-term disabling effects of cancer and its treatments. In this qualitative study, data were collected via in-depth semi-structured interviews with survivors of breast cancer, head and neck cancer, and sarcoma (n = 30). Data were analyzed thematically using a 2-phase iterative process proceeding from descriptive to conceptual coding. Survivors experienced a wide range of long-term physical, sensory, cognitive, and emotional effects, that intertwined to restrict their participation in self-care, work, leisure, and social roles. While the interaction between impairments and participation restrictions meets the definition of disability; participants articulated a range of responses when asked about their disability identity, including (1) rejecting, (2) othering, (3) acknowledging, and (4) affirming. Findings may be indicative of structural and internalized ableism which can impede cancer care and survivorship. To support cancer survivors’ transition to post-treatment life, cancer care providers should implement anti-ableist practices and engage in frank discussions about cancer’s long-term impacts.

Predicting length of stay after proximal femoral endoprosthetic replacement for oncological conditions

BACKGROUND

Endoprosthetic replacement of the proximal femur plays a vital role in managing metastatic and primary bone tumours¹. Length of stay (LOS) has important resource implications but is driven by patient and disease factors over and above the procedure itself. The aim of this project was to identify factors that drive LOS in patients undergoing proximal femoral replacement (PFR).

METHODS

This was a retrospective analysis of clinical records from a single centre (RNOH). 144 cases were identified over a 4 year-period. These were divided into 3 diagnostic categories: primary bone tumour with chemotherapy, primary bone tumour without chemotherapy and metastatic bone disease. Several factors were considered that could influence the length of stay including age, ASA grade, gender, admission to the high dependency unit (HDU), diagnosis, saving the greater trochanter, pre-operative radiotherapy, admission with a fracture and return to theatre.

RESULTS

The median LOS for PFR was 15 days, with 79% admitted to HDU. LOS was almost doubled for patients returning to theatre (P = 0.04). Patients with ASA grades of 3 and 4 had a 75% longer LOS compared to those with grade 1. Additionally, a 10-year increase in age was associated with a 6-8% increase in LOS. Incorporating these factors produced a model which explained 27% of the variability of LOS.

CONCLUSION

Majority of the variables which were tested were significantly associated with LOS. However, factors other than those in our model drive length of stay. This analysis can support conversations with patients and service planning around LOS.

Financial toxicity in sarcoma patients and survivors in Germany: results from the multicenter PROSa study

Purpose

Cancer patients have been shown to frequently suffer from financial burden before, during, and after treatment. However, the financial toxicity of patients with sarcoma has seldom been assessed. Therefore, the aim of this study was to evaluate whether financial toxicity is a problem for sarcoma patients in Germany and identify associated risk factors.

Methods

Patients for this analysis were obtained from a multicenter prospective cohort study conducted in Germany. Using the financial difficulties scale of the EORTC QLQ-C30, financial toxicity was considered to be present if the score exceeded a pre-defined threshold for clinical importance. Comparisons to an age- and sex-matched norm population were performed. A multivariate logistic regression using stepwise backward selection was used to identify factors associated with financial toxicity.

Results

We included 1103 sarcoma patients treated in 39 centers and clinics; 498 (44.7%) patients reported financial toxicity. Sarcoma patients had 2.5 times the odds of reporting financial difficulties compared to an age- and sex-matched norm population. Patient age < 40 and > 52.5 years, higher education status, higher income, and disease progression (compared to patients with complete remission) were associated with lower odds of reporting financial toxicity. Receiving a disability pension, being currently on sick leave, and having a disability pass were statistically significantly associated with higher odds of reporting financial toxicity.

Conclusion

Financial toxicity is present in about half of German sarcoma patients, making it a relevant quality of life topic for patients and decision-makers.

The Health-Related Quality of Life of Sarcoma Patients and Survivors in Germany-Cross-Sectional Results of a Nationwide Observational Study (PROSa)

Simple Summary

Sarcomas are a rare cancer with many different subtypes. They can occur anywhere in the body and are treated in a multi-disciplinary manner. Large studies on the quality of life of sarcoma patients are rare, so little is known about how patients are doing compared to the general population and which groups of sarcoma patients are particularly affected by quality of life limitations. We assessed the quality of life of 1113 sarcoma patients from Germany. The majority were particularly restricted in their emotional functioning, physical functioning, and the exercise of everyday demands (role function). Many of them experienced pain (56%) and fatigue (51%). We found that patients with leg or bone sarcomas were especially affected by quality of life limitations. We also found that patients who received a retirement pension were less affected by quality of life restrictions than patients who had not retired.

Abstract

Sarcomas are rare cancers with high heterogeneity in terms of type, location, and treatment. The health-related quality of life (HRQoL) of sarcoma patients has rarely been investigated and is the subject of this analysis. Adult sarcoma patients and survivors were assessed between September 2017 and February 2019 in 39 study centers in Germany using standardized, validated questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)). Associated factors were analyzed exploratively using multivariable linear regressions. Among 1113 patients, clinically important limitations and symptoms were most pronounced in emotional (63%, 95% CI 60–66%), physical (60%, 95% CI 57–62%), role functioning (51%, 95% CI 48–54%), and pain (56%, 95% CI 53–59%) and fatigue (51%, 95% CI 48–54%). HRQoL differed between tumor locations with lower extremities performing the worst and sarcoma types with bone sarcoma types being most affected. Additionally, female gender, higher age, lower socioeconomic status, recurrent disease, not being in retirement, comorbidities, and being in treatment were associated with lower HRQoL. Sarcoma patients are severely restricted in their HRQoL, especially in functioning scales. The heterogeneity of sarcomas with regard to type and location is reflected in HRQoL outcomes. During treatment and follow-up, close attention has to be paid to the reintegration of the patients into daily life as well as to their physical abilities and emotional distress.

A Prospective Observational Study of Multivisceral Resection for Retroperitoneal Sarcoma: Clinical and Patient-Reported Outcomes 1 Year After Surgery

BACKGROUND

Primary retroperitoneal sarcoma (RPS) may require multivisceral resection (MVR). Clinical outcome (morbidity and renal function) and quality of life (QoL) are not as well reported as the oncologic outcome.

METHODS

Patients with primary RPS who underwent surgery between 2014 and 2016 were prospectively enrolled in an observational longitudinal study. At baseline, then at 4 and 12 months, the study measured Clavien-Dindo morbidity, estimated glomerular filtration rate (EGFR), EORTC QLQ-C30, QLQ-CR29, DN4 (neuropathic pain [NP]), lower-extremity functional scale (LEFS), and the brief pain inventory. The primary end point was the difference in global health status (GHS/QoL). The secondary end points were EGFR changes, difference in other QLQ-C30 scales, pain intensity, NP, and LEFS. The study is registered at ClinTrials.gov (NCT03480399).

RESULTS

Of 74 patients, 58 were evaluable. Morbidity grade 3 or higher was 24.1%, and mortality was 1.3%. After nephrectomy, the mean 1-year EGFR change was -33.9%. The GHS/QoL at baseline was 58.6 and had increased of 6.9 points at 1 year, comparable with that of the general population. A transient worsening in pain and diarrhea had recovered at 12 months. Average pain was mild and did not differ at 12 months. However, NP was found in 41.4% of the patients and was significantly associated with resection of the psoas muscle. At baseline, LEFS was already lower than the normative value, and worsening after surgery was not clinically relevant.

CONCLUSION

A QoL measure after MVR in primary RPS is complex and requires multiple tools. Whereas overall MVR is safe and associated with an improvement in GHS/QoL, chronic NP is frequent and deserves specific attention. Pre-surgery rehabilitation tracks may help to prevent or reduce chronic NP.

A multidisciplinary approach to soft-tissue sarcoma of the extremities

INTRODUCTION

Soft-tissue sarcoma (STS) denotes a group of rare and highly heterogeneous malignant tumors of mesenchymal origin. Accurate histological diagnosis is critical for selecting appropriate treatment. Complete tumor resection is the primary treatment for STS, and the efficacies of radiotherapy and chemotherapy have been tested in the adjuvant setting to improve oncological outcomes. Because most STS lesions arise in the extremities, preserving limb function and managing limb impairment after radical local treatment represent significant challenges.

AREAS COVERED

This article reviews the current front-line treatments for patients with extremity STS and discusses the multidisciplinary team-based efforts needed to improve oncological outcomes and survivorship.

EXPERT OPINION

Given the rarity, variety, and complexity of STS, a multidisciplinary approach involving experts in various disciplines is vital for improving outcomes in patients ranging from diagnosis to survivorship. A major challenge is building a sustainable system in each region permitting all patients with extremity STS to be treated at high-volume centers with multidisciplinary teams dedicated to this rare and complex disease.

Return to Work and Employment Situation of Young Adult Cancer Survivors: Results from the Adolescent and Young Adult-Leipzig Study

Purpose: Although cancer often impacts work issues in patients, little is known about changes in the employment situation of adolescent and young adult (AYA) cancer survivors. Materials and Methods: We surveyed AYA cancer patients (18-39 years at diagnosis, diagnosis ≤4 years) using as set of validated self-report measures. By using multivariate and regression analyses, we analyzed employment status prediagnosis (in retrospect) and return to work (RTW) rate about 2 years postcancer diagnosis and related predictors. We compared work-related characteristics (occupational position, weekly working hours, and type of employment contract) at both time points. Cancer-related financial distress (European Organization for Research Treatment of Cancer-Quality of Life Questionnaire [EORTC QLQ-C30]) was assessed. Results: A total of 505 AYAs (mean age at diagnosis 29.7 years) completed the questionnaire. After an average of 2 years postcancer diagnosis, 83.4% among those being employed at the time of diagnosis (n = 355) had returned to work, 2.8% were on vocational training, 4.5% were unemployed, 4.2% were disabled due to reduced work capacity, and 5.1% were not employed for other reasons. For 158 of 505 AYAs (31.3%), employment status had changed since diagnosis. Significant changes of work-related characteristics were found for the weekly working hours (M_atdiagnosis = 35.8; standard deviation [SD] = 7.4; M_t2 = 34.7; SD = 8.2; p = 0.004). Twenty-four percent of the RTW patients and 68% of patients not RTW reported cancer-related financial distress. Patients with comorbid diseases, having hematological cancer or sarcoma, were less likely to RTW. Conclusion: Most AYAs returned to work in the medium term, often by reducing weekly working hours. Since AYAs state significant cancer-related financial distress, even after RTW, it seems particularly relevant to provide financial support and occupational counseling.

[Physiotherapy in early rehabilitation of patients with bone sarcomas after arthroplasty of large bones and joints]

ACTUALITY

The modern method of treating patients with tumor lesions of the bones is the replacement of large bones and joints with the inclusion of reconstructive plastic component. The main functional postoperative disorders of this method (limitation of mobility in the operated joint, pain, muscle hypotrophy and edema of the operated limb) obstruct the ability of patients to return to a full life, which makes their early rehabilitation extremely urgent. Orthopedics uses a number of physical factors for this. The literature presents data on the absence of negative effects of low-frequency electro- and magnetotherapy in the treatment of late complications of oncopedic surgery on a number of bone sarcomas, which allowed them to be included in early rehabilitation for the first time.

AIM OF STUDY

Development of a complex of early rehabilitation of patients with bone tumors after arthroplasty of large bones and joints and evaluation of its effectiveness.

MATERIALS AND METHODS

A prospective, open, nonrandomized, controlled study included 36 patients aged 19-67 years (Me 42 years old) with primary malignant and metastatic bone tumors who underwent endoprosthesis replacement of large bones and joints with the inclusion of reconstructive plastic component (plastic by displaced muscles, synthetic mesh) and received local low-frequency magnetotherapy, low-intensity infrared laser radiation, electroneuromyostimulation and therapeutic exercises. Physiotherapy began from the first day after the operation and lasted for 10 days. To assess the functional result, the international MSTS scale was used.

RESULTS

The combined use of the reconstructive plastic component during radical surgery and physiotherapy made it possible to obtain good functional result at 63,9% of patients, satisfactory functional results in 36.1% of patients according to the MSTS scale at the time of discharge. The function of the saved limb in 10 patients after distal femoral resection with knee replacement was 80% of normal function, in 7 patients after proximal tibia resection - 72%; in 13 patients after proximal resection of the femur with hip replacement - 59%; in 5 patients after proximal resection of the humerus with endoprosthetics of the shoulder joint - 61.3%; and in 1 patient after proximal resection of the ulna with endoprosthetics of the elbow joint - 70%.

CONCLUSION

The multidisciplinary approach to the early rehabilitation of patients with bone tumors made it possible to achieve functional results in a short time, reduce the time spent by patients in the surgical department without increasing the number of postoperative complications. Based on the preliminary obtained results, it is necessary to continue the study on a larger number of patients and with a longer follow-up period.

Development of a patient-reported experience questionnaire for patients with sarcoma: the Sarcoma Assessment Measure (SAM)

PURPOSE

The aim of the study was to develop a patient-reported outcome measure for patients with sarcoma-the Sarcoma Assessment Measure (SAM).

METHODS AND RESULTS

The systematic development of SAM included a three-stage, mixed-methods study using semi-structured interviews, focus groups and questionnaires, with all stages involving patients from across the United Kingdom. In-depth interviews were conducted with 121 patients (50% male; aged 13-82; with soft tissue sarcoma (62%), bone tumours (28%) and gastrointestinal stromal tumours (10%)). Content analysis of the interview transcripts identified 1415 post-diagnosis experience statements. Experience statements were reviewed, repetition was removed and sentences were refined to form 395 'items' which were included in an Item Reduction Questionnaire (IRQ) grouped as physical, emotional, social and financial wellbeing and sexuality. The IRQ was completed by 250 patients who rated each item on importance and worry. Items with a mean score above 5 (6 in the emotional domain) were removed, which reduced the list to 166 items. After review by the research team, 23 clinicians and 34 patients, 66 items were retained to test content validity. Items with a content validity ratio of < .33 were removed. Cognitive interviews were conducted with 10 patients on the final 22 items to test comprehension. Minor changes were made to four.

CONCLUSION

SAM comprises of 22 items reflecting physical, emotional, social, financial wellbeing and sexuality. This systematic process of using patient experience to develop the content of SAM will ensure that it measures what is important to patients.

Rehabilitation to Improve the Function and Quality of Life of Soft Tissue and Bony Sarcoma Patients

Sarcomas are bone and soft tissue tumors that can have significant effects on patient function and quality of life. Like most malignancies, treatment includes a combination of chemotherapy, radiation, and surgical resection, all of which also carry risks and long-term effects. A multidisciplinary rehabilitation plan can help minimize symptoms and sequelae which negatively affect the patient function and quality of life, including pain, chemotherapy-induced peripheral neuropathy, radiation fibrosis, activity restrictions following surgical excision, amputation, bowel and bladder dysfunction, and lymphedema. Patients should be evaluated by a rehabilitation specialist at any point during their diagnosis, treatment, and survivorship phase to determine appropriate interventions to minimize the impact of sarcomas and their treatment on patient function and quality of life.

Qualitative study exploring patients experiences of being diagnosed and living with primary bone cancer in the UK

OBJECTIVE

The aim of this study is to explore the experiences of patients with primary bone cancer.

DESIGN

Qualitative study design using semistructured interviews and focus groups.

SETTING

Hospitals across the UK and recruitment through UK sarcoma charities and support groups.

METHODS

Semistructured telephone/face-to-face interviews and focus groups with a purposive sample of 26 participants. Data were analysed using Framework Analysis.

PARTICIPANTS

Patients (n=26) with primary bone cancer aged 13-77 years. The majority were male (69%), white (85%); diagnosed within 4 years (54%); and had lower limb sarcoma (65%). Ten participants had undergone an upper/lower limb amputation (39%).

RESULTS

The health-related quality-of-life domains of physical, emotional and social well-being and healthcare professionals' role were the overarching themes of analysis. The physical domain anchored patient experiences. The intensity and length of treatment, the severity of side-effects, the level of disability after surgery and the uncertainty of their prognosis had an impact on patient's self-image, confidence, mood and identity, and caused disruption to various aspects of the patients' social life, including their relationships (emotional and sexual) and participation in work/school and leisure activities. Adaptation was influenced by the way patients dealt with stress and adversity, with some finding a new outlook in life, and others struggling with finding their 'new normal'. Family and friends were the main source of support. Healthcare professional's expertise and support was critical. Rehabilitation services had a considerable role in patient's physical and emotional well-being, but inequitable access to these services was apparent.

CONCLUSIONS

This study described the impact of primary bone cancer on patients' well-being and adjustment over time with the identification of influencing factors of better/worse experiences. It showed that impact was felt after end of treatment and affected patients at different life stages. Holistic models of survivorship care are needed.

A Critical Review of the Impact of Sarcoma on Psychosocial Wellbeing

Background

Previous reviews of outcomes in specific sarcoma populations suggest patients have poor quality of life. In most of these reviews, there is a predominant focus on physical function rather than psychosocial outcome. The aim of this review was to describe the psychosocial impact of diagnosis and treatment on patients with all types of sarcoma.

Methods

Searches were conducted through six electronic databases for publications of any study design using a validated patient-reported outcome measure reporting the psychosocial impact in this population.

Results

Eighty-two studies fulfilled the inclusion criteria. Most (65%) were assessed of being of reasonable quality. The most common aspect of psychosocial wellbeing measured was quality of life (80%). Due to the heterogeneity of methods, outcomes, and populations, it was not possible to make definitive conclusions. It seems there is an improvement in the physical aspects of quality of life over time but not in psychosocial function or mental health. There was no change in mental health scores, but patients reported an improvement in adjusting to normal life. There are no differences according to the type of surgery patients receive, and psychosocial outcomes tend to be poorer than the general population. There is no consistency in identifying the factors that predict/influence psychosocial wellbeing.

Conclusion

The published literature does not provide a clear understanding of the impact of sarcoma diagnosis and treatment on psychosocial wellbeing. Instead, the review demonstrates a need for well-designed studies in this area and a more consistent approach to the measurement of patient-reported outcomes, which include psychosocial domains. Recommendations for future research have been proposed.

Factors influencing people's ability to maintain their activity levels during treatment for soft tissue sarcoma - A qualitative study

BACKGROUND AND PURPOSE

Soft tissue sarcoma (STS) is a rare connective tissue cancer treated with chemotherapy in the advanced stages. Emerging evidence suggests that physical activity (PA) improves symptom management and quality of life for people undergoing chemotherapy for advanced cancer. However, little research reports their perspective. Method: Semi-structured interviews were used within a phenomenological approach to explore factors that affect people's ability to be physically active while undergoing treatment. Six participants were recruited with purposive sampling. Thematic analysis was used to analyze the data. Results: Three themes identified that PA was seen as an indicator of a persons' own sense of normality; a feeling of loss and uncertainty for the future had impacts on peoples' ability to be physically active, and finally, participants found it challenging to recognize their support needs as their activity levels reduced. Motivation to remain active was individual, and numerous barriers affected participants' ability to remain active as their disease advanced; this included a lack of specific guidance while undergoing chemotherapy. Participants expressed uncertainty generally in identifying and expressing their support needs as they faced multiple complex issues. Conclusion: Health professionals should be proactive in exploring possibilities for PA to mitigate the expected physical decline, and support symptom management while undergoing palliative chemotherapy.

Long-term survivors of childhood bone and soft tissue sarcomas are at risk of hospitalization

BACKGROUND

Childhood cancer survivors can have a high burden of chronic conditions related to cancer treatment, some of which are debilitating or potentially life-threatening. Much remains to be learned about late effects in bone and soft tissue sarcoma survivors.

PROCEDURES

The Utah Cancer Registry was used to identify survivors of bone (N = 71) and soft tissue sarcomas (N = 98) who were diagnosed at ages 0-20 years between 1973 and 2007 and were alive at least 5 years after diagnosis. We selected an age-sex-matched comparison cohort (N = 934). Hospitalizations from 1996 to 2012 were extracted from the Utah Department of Health statewide inpatient hospitalization discharge records. Cox, Poisson, and Gamma regressions were used to evaluate the risk of hospitalization, rate of admission, and length of stay for survivors versus the comparison cohort. Primary ICD-9 codes defined the most common reasons for hospitalizations.

RESULTS

The hazard ratio (HR) of any hospitalization was higher for survivors in reference to the comparison cohort (HR = 2.12, 95% confidence interval [CI] 1.51-2.97). Survivors experienced more hospital admissions (rate ratio [RR] = 4.58, 95% CI 3.92-5.35) and longer length of stay (RR = 1.28, 95% CI 1.12-1.46) compared with the comparison cohort. Survivors treated with any chemotherapy were at three-fold higher risk (HR = 3.37, 95% CI 1.94-5.83) of hospitalization compared with survivors who received surgery and/or radiation alone. Among hospitalized survivors, the most common reason was injury for bone tumor (26.8%) and neoplasm for soft tissue sarcoma (12.2%).

CONCLUSION

Childhood survivors of bone tumor and soft tissue sarcoma face ongoing risk of hospitalization for years after diagnosis.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues, and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location means that developing evidence-based guidelines is complicated by the limitations of the data available. However, this makes it more important that STS are managed by teams, expert in such cases, to ensure consistent and optimal treatment, as well as recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous version published in 2010 (Grimer et al. in Sarcoma 2010:506182, 2010). The original guidelines were drawn up following a consensus meeting of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This current version has been updated and amended with reference to other European and US guidance. There are specific recommendations for the management of selected subtypes of disease including retroperitoneal and uterine sarcomas, as well as aggressive fibromatosis (desmoid tumours) and other borderline tumours commonly managed by sarcoma services. An important aim in sarcoma management is early diagnosis and prompt referral. In the UK, any patient with a suspected soft tissue sarcoma should be referred to one of the specialist regional soft tissues sarcoma services, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging, plus a biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon. In tumours at higher risk of recurrence or metastasis pre- or post-operative radiotherapy should be considered. Systemic anti-cancer therapy (SACT) may be utilized in some cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late-effects of treatment. For local recurrence, and more rarely in selected cases of metastatic disease, surgical resection would be considered. Treatment for metastases may include radiotherapy, or systemic therapy guided by the sarcoma subtype. In some cases, symptom control and palliative care support alone will be appropriate.

Physical functioning, pain and quality of life after amputation for musculoskeletal tumours

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision.

Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores.

This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs.

Cite this article: Bone Joint J 2015;97-B:1284–90.