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Original Investigation |

Influence of Physician Specialty on Treatment Recommendations in the Multidisciplinary Management of Soft Tissue Sarcoma of the Extremities

Nabil Wasif, MD, FACS1; Caitlin A. Smith, MD2; Robert M. Tamurian, MD3; Scott D. Christensen, MD4; Arta M. Monjazeb, MD5; Steve R. Martinez, MD, FACS2; Robert J. Canter, MD, FACS2
[+] Author Affiliations
1Department of Surgery, Mayo Clinic Arizona, Scottsdale
2Department of Surgery, University of California at Davis Health System, Sacramento
3Department of Orthopedic Surgery, University of California at Davis Health System, Sacramento
4Department of Internal Medicine, University of California at Davis Health System, Sacramento
5Department of Radiation Oncology, University of California at Davis Health System, Sacramento
JAMA Surg. 2013;148(7):632-639. doi:10.1001/jamasurg.2013.113.
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Importance  Although prospective randomized data are available to guide the multidisciplinary management of soft tissue sarcoma (STS) of the extremities, controversy exists regarding adjuvant chemotherapy and radiation therapy.

Objective  To determine if clinical specialty introduces bias in recommendations for multimodality treatment of STS.

Design  Electronic survey.

Setting  Database of active members of the American Society of Clinical Oncology, the Society of Surgical Oncology, and the Connective Tissue Oncology Society.

Participants  Members of specialty oncology societies with an active interest in STS.

Exposure  Physician specialty.

Main Outcomes and Measures  Survey responses regarding the multidisciplinary management of STS were scored on a 5-point Likert scale and analyzed using analysis of variance.

Results  The questionnaire was completed by 320 of 490 potential respondents (65%), including medical (18%), radiation (8%), orthopedic (22%), and surgical oncologists (45%). Respondents concurred on the use of radiation therapy for margins positive for tumor, for high-grade tumors, for improvement in local control, for tumors larger than 10 cm, and for tumors in close proximity to a neurovascular bundle. Respondents diverged on the use of radiation therapy for tumors 5 to 10 cm in size, for low-grade tumors, for radiation-associated STS, and for survival benefit. Only radiation oncologists felt that radiation therapy was underutilized as a treatment modality (mean [SEM] Likert scale score, 2.44 [0.12]; P < .001). There was agreement on the use of chemotherapy for synovial sarcoma, for high-grade tumors, for tumors larger than 10 cm, for patients younger than 50 years of age, and for survival benefit. Medical oncologists were more likely to recommend chemotherapy for margins positive for tumor (mean [SEM] score, 3.12 [0.12]; P = .03) and for improvement in local control (mean [SEM] score, 2.91 [0.12] P = .08). Surgical oncologists placed the least emphasis on chemotherapy in the overall treatment plan (mean [SEM] score, 2.60 [0.07]; P = .001).

Conclusions and Relevance  Specialty bias exists in adjuvant treatment recommendations for STS. This highlights the importance of multidisciplinary STS tumor boards and interdisciplinary care to facilitate consensus decision making for individual patients.

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Figures

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Figure 1.
Questions About the Importance of Radiation Therapy

Questions about the importance of radiation therapy in the treatment of soft tissue sarcoma (A; 320 respondents) and the utilization of radiation therapy in the treatment of soft tissue sarcoma (B; 317 respondents), stratified by physician specialty. Questions were scored on a 5-point Likert scale. For each question, mean values were calculated to generate a single response score (a range from 1 indicating not essential to 5 indicating essential). Error bars indicate SEM.

Graphic Jump Location
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Figure 2.
Questions About the Importance of Chemotherapy

Questions about the importance of chemotherapy in the treatment of soft tissue sarcoma (A; 320 respondents) and the utilization of chemotherapy in the treatment of soft tissue sarcoma (B; 315 respondents), stratified by physician specialty. Questions were scored on a 5-point Likert scale. For each question, mean values were calculated to generate a single response score (a range from 1 indicating not essential to 5 indicating essential). Error bars indicate SEM.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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