Where Are We Now?
Medicolegal exposure is an unwelcome yet all-too-present part of contemporary healthcare. This can lead to the practice of so-called defensive medicine in an attempt to limit liability. Medicolegal exposure may be especially severe in high-risk situations and conditions outside a physician’s area of regular practice, as well as when caring for patients with rare illnesses. The subspecialty of musculoskeletal oncology involves all of those elements, particularly when an oncologic diagnosis is made (or missed) by a primary care provider or a non-oncology-trained orthopaedic surgeon. As reported in the current study by Hwang et al. , the most-common reason for medicolegal claims related to sarcoma care is a delay in diagnosis, and primary care providers and non-oncology-trained orthopaedic surgeons are the providers most-frequently named in these claims. Progression to metastatic disease as a result of the alleged delay in diagnosis was a commonly reported injury. Ultimately, the allegation of a delayed diagnosis resulting in disease progression may result in the perception that the care received by the patient was not ideal.
The findings of Hwang et al.  are important because they provide insight into the allegations leading to medicolegal claims regarding sarcoma care. The findings lead me to consider whether improved access to specialty sarcoma care might decrease the frequency of claims and cause the patient to perceive that they have received a higher level of care. As reported by Mankin et al. , even after only a biopsy of a bone or soft-tissue sarcoma performed at a non-sarcoma center, there is an increased risk of obtaining an incorrect diagnosis, a higher likelihood of complications from treatment, and ultimately, poorer disease-specific outcomes, such as local recurrence and survival. Given the rarity of these illnesses, the potential severity of disease, and the improved outcome (local control and survival) when treatment is provided in a multidisciplinary context, it is tempting to recommend that all patients with a suspected bone or soft-tissue tumor be initially evaluated by oncology-trained providers. Unfortunately, this is not feasible and would easily overwhelm the relatively few multidisciplinary sarcoma centers in any country, even a well-resourced one such as the United States. Oncology training for providers who do not work in such a clinical setting is not a viable strategy either, particularly owing to the rarity of these diseases.
Where Do We Need To Go?
As a result, we need to find ways to provide a level of care for patients with suspected sarcomas in community settings that is comparable to the level of care they might receive at tertiary care centers, at least when making the initial diagnosis. For patients in whom a sarcoma diagnosis is made, definitive care should be provided at a center that is expert in the treatment of this diverse, challenging set of illnesses. These centers need to look beyond disease-specific treatment and consider the many important and complementary aspects of patients’ lives, including stress and anxiety management, sleep, and nutrition. The understandable emphasis on disease-specific treatment sometimes leads to less attention on the comprehensive care of the patient.
How Do We Get There?
To provide patients who have a bone or soft-tissue sarcoma with the highest possible level of care from the time of initial presentation through definitive treatment and surveillance, two predominant strategies can be integrated into the existing healthcare system. First, we need to improve access to care, and second, we need to provide comprehensive care to each patient.
Most patients will initially present to a nononcology-trained provider. Improved access to care will ensure that the initial evaluation of these patients is improved. Resources to allow for this should include identification of clinical findings that increase the concern for the presence of a malignant tumor, integration of specialist-level care at the initial point of care, and ready access to coordinate care with a multidisciplinary sarcoma center for further evaluation and treatment of these patients. Given the advancing state of technology, these initiatives could be provided digitally through a telehealth platform that would be readily accessible to all providers. This would provide the patient with the advantages of having access to sarcoma specialists without having to travel to a sarcoma center until necessary for further care.
This strategy has already been implemented in different settings and has further undergone recent expansion because of the coronavirus disease 2019 (COVID-19) pandemic. There are many benefits to the more-widespread use of telehealth, including improved access to care and specialists for patients in remote areas, decreased cost, and increased availability of second opinions to ensure the best initial care. During the COVID-19 pandemic, many unrelated in-person health services were temporarily stopped; however, the need for ongoing cancer care persists. This situation led to the expansion of the use of telehealth for this purpose . In addition, the use of telehealth has been shown to improve access to specialty care for patients with cancer, irrespective of a pandemic . Because of the increased availability of telehealth to oncology specialists for either the initial treatment or a second opinion, the initial evaluation can be improved and delayed diagnosis can be decreased, resulting in fewer medicolegal cases.
The second strategy is to incorporate the vast knowledge base of complimentary fields to provide holistic care to patients with bone or soft-tissue sarcomas, thereby providing comprehensive care. Treating the patient, in addition to his or her family, will be beneficial in the overall management of his or her sarcoma. Without question, many patients have increased stress and anxiety, difficulty sleeping, and frequently, poor nutrition. Improving each of these areas will benefit patients and their families because it will allow for improved recovery from the stresses inherent in the diagnosis and treatment of sarcoma. In addition, there may be disease-specific benefits. It has been demonstrated in a mouse model that sleep deprivation results in more-rapid growth of the primary tumor and signs of increased aggressive growth, including metastatic spread . Although the benefits of these strategies have not been proven in patients with sarcomas, there is little to no risk in incorporating stress management, sleep hygiene, and nutrition improvement into the paradigm of care, and at a minimum, this might lead to improved health-related quality of life. In other areas of cancer care, the benefit of mindfulness training on reducing anxiety and depression have been demonstrated [7, 11]. Sleep duration has also been linked to increased tumor aggressiveness in breast cancer .
Incorporation of the well-established principles of meditation and mindset training [1, 4, 10], sleep hygiene, and nutrition can contribute to the holistic treatment of patients with sarcomas. At a minimum, these initiatives can improve the patient’s quality of life and may have an impact on a given disease-specific outcome; for example, the link between the primary tumor’s growth and sleep deprivation . Integration of providers who can provide education and training of these skills to patients and their families, either in-person or through telehealth, might become a regular component of multidisciplinary sarcoma care. Such integration would complement disease-specific treatment and provide a holistic approach to treating a patient with a bone or soft-tissue sarcoma.
1. Goleman D, Davidson RJ. Altered Traits: Science Reveals How Meditation Changes Your Mind, Brain, and Body.
Avery: New York; 2017.
2. Hakim F, Wang Y, Zhang SX, Zheng J, Yolcu ES, Carreras A, Khalyfa A, Shirwan H, Almendros I, Gozal D. Fragmented sleep accelerates tumor growth and progression through recruitment of tumor-associated macrophages and TLR4 signaling. Cancer Res.
3. Hwang R, Park HY, Sheppard W, Bernthal NM. Delayed diagnosis is the primary cause of sarcoma litigation: analysis of malpractice claims in the United States. Clin Orthop Relat Res.
[Published online ahead of print June 2, 2020]. DOI: 10.1097/CORR.0000000000001340
4. Kelly JD. CORR Insights: Does a brief mindfulness exercise improve outcomes in upper extremity patients? A randomized controlled trial. Clin Orthop Relat Res. 2018;476:799-800.
5. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am.
6. Sabesan S. Specialist cancer care through telehealth models. Aust J Rural Health.
7. Sarenmalm EK, Martensson LB, Andersson BA, Karlsson P, Bergh I. Mindfulness and its efficacy for psychological and biological responses in women with breast cancer. Cancer Med. 2017;6:1108-1122.
8. Soucise A, Vaughn C, Thompson CL, Millen AE, Freudenhheim JL, Wactawski-Wende J, Phipps AI, Hale L, Qi L, Ochs-Balcom HM. Sleep quality, duration, and breast cancer aggressiveness. Breast Cancer Res Treat. 2017;164:169-178.
9. Spiess PE, Greene J, Keenan RJ, Paculdo D, Letson GD, Peabody JW. Meeting the challenge of the 2019 novel coronavirus disease in patients with cancer. Cancer.
10. Westenberg RF, Zale EL, Heinhuis TJ, Ozcan S, Nazzal A, Lee SG, Chen NC, Vranceanu AM. Does a brief mindfulness exercise improve outcomes in upper extremity patients? A randomized controlled trial. Clin Orthop Relat Res. 2018;476:790-798.
11. Zhang MF, Wen YS, Liu WY, Peng LF, Wu XD, Liu QW. Effectiveness of mindfulness-based therapy for reducing anxiety and depression in patients with cancer: a meta-analysis. Medicine (Baltimore).