(P 308) REFERRAL DELAYS OF QUEBEC SARCOMA POPULATION : A PROSPECTIVE COHORT STUDY

Objective: In order to better understand the issues surrounding referral patterns and delays of all musculoskeletal tumors requiring treatment in tertiary sarcoma center a prospective cohort study was implanted in Quebec (Canada) in 2011. The primary goal of this study was to determine referral times and identify elements that contributed to unacceptable delays, particularly for the high-grade sarcoma sub-group. The second objective was to correlate delay in referral time to oncological outcomes. We hope that this would enable us to make constructive recommendations to improve sarcoma patient outcomes by implanting defined provincial referral pathways .

Methods: A analysis of a prospective cohort study was conducted in one of three sarcoma centers in Quebec, from September 2011 until March 2020. The study received institutional ethic review board approval. We included patients who were referred from any source for a suspected sarcoma that needed a follow-up appointment by our team, control imagery or surgical treatment. Patients with one of the following criteria were excluded : age < 12 years old; nononcologic final diagnosis; benign lipoma < 5 cm; estimated survival < 6 months; Inability to consent, refused to participate. After diagnosis, tumors were graded as benign or malignant, and the later as low (grade 1) or high (grade 2-3). Non oncological condition at final diagnosis, that needed musculoskeletal surgeon expertise and treatment, were included in this study and assigned as benign. All participants completed a dedicated questionnaire that included: Dates of initial symptoms, first medical consultation and first imaging study, Number of consultations with 2nd line specialists, prior treatments to referral and report of number and type of imaging studies (MRI, CT scan, ultrasound, PET scan). Clinical data were extracted from medical records. Histology subtypes and oncological status were recorded initially and for the Following 5 years. Results were categorized in two groups: a low-risk group (benign lesions and grade 1 lesions), and a high-risk group (grade 2 and 3 lesions).

Results: Delays from first medical consultation to sarcoma center referral of >25 weeks were found in 45% of patients, >52 weeks in 26% of patients. Time from first medical consultation to first imaging study was the most important source of delay (39.7 weeks for low-grade and 36.9 weeks for high-grade tumors) representing 45% of the total delay. 67% of patients were inappropriately directed to more than one specialist before referral to the sarcoma center. Inadequate imaging had to be repeated in 51% of MRI exams and 18% of CT scans. In the high-risk group, 21% of patients were already metastatic at the initial orthopedic-oncology consultation. Another 22% developed metastases during the 5-year followup period. In 17% patients in the high-risk group, an unplanned primary excision (‘’Whoops’’ surgery) occurred. For this subgroup, revision surgery was needed in 87% of cases.

Conclusion: This study is the first to analyze referral delays of patients with musculoskeletal tumors in Quebec. Its strengths are in its prospective nature and long (9 year) surveillance period. We were able to quantify referral times and locate sources of delays. Our findings revealed two main reasons for unacceptable delays: Time to obtain the first imaging study, and inappropriate referrals to other specialists or centers. To address these issues a Quebec sarcoma referral network was created and guidelines for patient evaluation and imaging with defined timelines were published. We expect these measures will improve patient outcomes and health care resource utilization.