In Reply

Abstract

Authors of the recently published article from the Spanish Group for Research in Sarcoma respond to comments on the results of their study.

We thank Dr. Valenti for comments[1] on our recent published work [2], and we would like to address them in the next lines.

As stated in the article, our work focused on prospectively recorded cases. It is true that a percentage of cases were excluded from the present analysis because of incomplete data. Contrary to other countries, such as Scandinavian countries or France, Spain does not yet count on a mandatory national registry for sarcoma, and the present work is an academic initiative from the Spanish Group for Research on Sarcoma (GEIS). Academic research always faces important challenges, and we prioritized the quality of data over the number of cases.

Reference Centers for Sarcoma in adult patients in Spain were accredited by the Spanish Health Ministry for the first time in July 2017. Up to now, five centers have obtained the official designation, and another two centers are in the process of achieving the accreditation. Our work refers to a previous period in which there were no centers officially designated as reference centers (RCs). We prespecified in the Methods section what the characteristics defining RCs were in our study. At that time, only two centers among participants reached the criteria for being considered RCs. None of the current official RCs in Spain, except for Sant Pau Hospital (defined as RC in the paper), participated in the reported work. However, this does not mean that every patient managed in those centers was included in the current work, as it was not mandatory, which explains the achieved numbers.

It is true that in our series the median overall survival of metastatic patients managed in reference centers exceeds that expected for this population. There could be several explanations for this phenomenon: discussion in the multidisciplinary setting, integrating the best sequence of therapy, including local therapies of the metastatic disease, and access to clinical trials. In the period of the study, clinical trials with trabectedin and pazopanib were ongoing and open in some Spanish centers, including the RC in this paper.

Regarding the last comment, ESMO‐EURACAN soft‐tissue sarcoma guidelines [3], recently updated, state “Management should be carried out in reference centres for sarcomas and/or within reference networks sharing multidisciplinary expertise and treating a high number of patients annually.” This is stated in this and other guidelines [4], [5], [6] given the evidence showing a better outcome for those patients managed in centers with expertise [7], [8], [9]. This expertise in such a rare group of diseases cannot be achieved in centers managing few cases per year. In addition, it is highly unlikely for these centers to have a sarcoma multidisciplinary team trained for such a complex management.

Dr. Valenti referred to a recently published paper whose authors found a prognostic impact in the compliance with guidelines and survival, but they were not able to find an independent prognostic value of hospital volume [10]. These conclusions must be carefully interpreted. Interestingly, those high‐volume hospitals accomplished better compliance with guidelines when compared with low‐volume centers, and this was only significant in patients with stage III tumors (59% vs. 49%; p < .001). In addition, high‐volume centers received more patients with tumors >10 cm. In summary, high‐volume hospitals received patients with a worse prognosis and they managed them better than low‐volume centers. This article, however, uses a definition of high‐volume center (>10 soft‐tissue sarcoma surgeries per year) that is quite far from the minimum criteria for reference centers in sarcoma by our National Health Ministry (>70 new patients with soft tissue sarcoma (STS) per year) and the European Reference Network for Rare Tumors, in which a minimum of 80 new patients with STS per year was necessary to obtain the European accreditation. This “high‐volume hospital” group then encompasses different realities, as it is clear that a center managing 11 patients with STS per year does not have the same expertise as a center with more than 70 patients with sarcoma per year.

In summary, if clinical guidelines on sarcoma care advise the need for referring patients to centers with expertise and multidisciplinary management, then those professionals working in centers not fitting in with these characteristics cannot comply with clinical guidelines if they do not refer patients.

Disclosures

The authors indicated no financial relationships.