Integrated Care in Specialized Networks: Leveraging Early Referrals to Reduce Local Recurrence in Soft Tissue Sarcoma

Abstract

This study evaluated the impact of care pathways on the incidence of local recurrence (LR) in patients with soft tissue sarcomas (STS) and identified factors predictive of LR. It compared outcomes between patients managed entirely within a comprehensive care pathway (CCP) at the Swiss Sarcoma Network (SSN) and those who experienced fragmented care pathways (FCPs), where initial treatment occurred outside specialized centers. This prospective study utilized real-world-time data from the SSN-Sarconnector, capturing quality indicators through weekly Multidisciplinary Team/Sarcoma-Board (MDT/SB) meetings. The overall incidence of LR was 17.6% (n = 68/386), higher than rates typically reported in sarcoma center-based studies due to the inclusion of patients with prior inadequate management from real-world referrals. In a univariable logistic regression analysis, the FCP was significantly associated with higher LR rates, unplanned "whoops" resections (25.4%, n = 96), and positive surgical margins, emphasizing the detrimental impact of suboptimal initial management outside of specialized centers. Multivariable analysis confirmed that the FCP (aOR 2.7, 95% CI [1.41, 5.12], p = 0.003), tumor size (aOR 1.49, 95% CI [1.1, 2.02], p = 0.01), and biological behavior (aOR 5.84 95% CI [1.8, 18.86], p = 0.0003) are independent predictors of LR. Notably, patients referred to sarcoma centers after an initial FCP presented with inadequately managed disease, such as incomplete resections and unplanned surgeries, leading to increased complexity of subsequent treatments. These findings underscore the critical role of referral patterns on sarcoma center outcomes, highlighting the significant disparity in LR rates between institutions. The need for improved education and standardized early referral strategies at the spoke level is paramount to optimize patient outcomes and reduce the burden of LR. Enhanced spoke-level education and standardized referral protocols are critical to ensuring effective initial management and optimizing patient outcomes within specialized sarcoma networks like the SSN.

Keywords: Multidisciplinary Team/Sarcoma Board (MDT/SB); centralized care; fragmented care pathway (FCP); local recurrence (LR); real-world-time data (RWTD); soft tissue sarcomas (STS).

Figure 1

Definition of comprehensive (CTP) and fragmented (FTP) treatment pathway of patient management. The figure illustrates the definition of the different patient pathways: comprehensive care pathway at SSN (CCP) versus fragmented care pathway at SSN (FCP).

Figure 2

Decision tree on patient inclusion criteria. N, number of patients; SSN, Swiss Sarcoma Network.

Figure 3

Local recurrence according to anatomical region. Distribution of local recurrence by anatomical region, with data presented as absolute patient numbers and percentages by region, along with percentages relative to the total number of patients with soft tissue sarcoma (STS) in brackets; LR, local recurrence; n, number.

Figure 4

Analysis of treatment pathways (comprehensive vs. fragmented care pathway) for patients presented to the sarcoma board, distinguishing between deep soft-tissue sarcoma and superficial soft-tissue sarcoma, with a focus on local recurrence outcomes. Data presented in numbers (n) and percentage (%); CCP, comprehensive care pathway; FCP, fragmented care pathway; LR, local recurrence; n, number of patients.

Figure 5

Patients with a fragmented care pathway: reasons for secondary referral towards a sarcoma hub (left) and decision of the sarcoma board (right). On the left, other reasons include metastasis or requests for a second opinion. “Complete treatment outside SSN” refers to patients treated outside a sarcoma hub but referred for follow-up at a sarcoma hub. “Incomplete treatment outside” includes patients whose treatment was not completed outside the sarcoma hub. (Right) Decisions and treatments determined by the sarcoma board.