Guideline-Concordant Care Is Associated With Reduced Risk of Death in Metastatic Osteosarcoma

R. Lor Randall, MD, FACS

Although guideline-concordant care was associated with improved survival in patients with metastatic osteosarcoma in California, disparities exist in the delivery of this care, pointing to the need for interventions to improve its utilization, according to data from a population-based analysis on the relationship between guideline-concordant care and survival.

In the analysis published in the JCO Oncology Practice, investigators accessed data from the California Cancer Registry, garnering information on patients diagnosed with osteosarcoma between 2004 and 2019. Of the 1716 patients included in the study, 47% received guideline-concordant care. Notably, children (67%) and adolescent young adults (43%) were more likely to receive guideline-concordant care compared with adults (30%).

Subsequently, patients with metastatic osteosarcoma who did not receive guideline-concordant care were associated with an increased risk of death (HR, 2.02; 95% CI, 1.55-2.63); however, no statistical differences for the risk of death were found in patients diagnosed at earlier stages (HR, 1.15; 95% CI, 0.92-1.43).

“I would encourage [medical oncologists] within their own groups at their centers to look into whether there are guidelines for their specific types of diseases that they're treating. If not, find ways by which they can start to build those frameworks for these patients,” R. Lor Randall, MD, FACS, said in an interview with OncLive^®.

In the interview, Randall, the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at University of California (UC) Davis Comprehensive Cancer Center in Sacramento, detailed the research into the relationship between guideline-concordant care and survival outcomes in patients with metastatic osteosarcoma in California, and highlighted the importance of following guidelines in place when treating patients with sarcomas.

OncLive: What led to the investigation of guideline-concordant care in relation to survival outcomes in patients with osteosarcoma in California?

Randall: Guideline-concordant care in patients with osteosarcoma in California, primarily steered by Elysia Marie Alvarez, MD, MPH, who is a pediatric oncologist and runs the Pediatric Division of our Sarcoma Services Program at UC Davis. We are a National Cancer Institute [NCI] comprehensive cancer center and have very robust population sciences as well as mechanistic research efforts. [ Guideline-concordant care] is something she's been doing with her population-based study, and she has several grants that have funded her research.

What this study looked at was the application of guideline-concordant care, which is essentially National Comprehensive Cancer Network [NCCN] Guidelines for the way patients with osteosarcoma should be treated or stewarded. We looked at the California database under Dr Alvarez's leadership to see how often patients were getting guideline-concordant care.

What patient population was investigated throughout the study and what findings were derived?

We had [data for] 1716 patients and just under half of those patients [47%] received guideline-concordant care. The age of diagnosis [spanned] all ages, but the majority [who received guideline-concordant care] were children [67%]; 43% were adolescent young adults, which is defined as ages 15 to 39; and 30% were adults.

What we found was that for patients who did not receive guideline-concordant care and had a metastatic osteosarcoma diagnosis had a greater hazard ratio [HR] for death, meaning that these patients went on to die sooner from their disease than those who [did] have guideline-concordant care. Interestingly, in patients with earlier detected and treated disease, [the HR for death] was not statistically significant. We did find that children and adolescent young adults were more likely [to receive] guideline-concordant care compared with adults. Adults were not getting the NCCN standard roadmap for osteosarcoma care.

[These findings] highlight the disparities in the delivery of guideline-concordant care in patients with osteosarcoma. Our next steps are to look at national databases to see if [these patterns] are true beyond the state of California.

What are some of the areas where there is a lack of data to support certain guidelines? How would you navigate these areas with a lack of data?

Not just in osteosarcoma, but in all sarcomas, because of the rarity and the orphan status of sarcomas, there are not much robust data. As a subset, osteosarcoma and those that involve pediatric patients, are the vanguard of getting level 1 prospective clinical trial data on these patients. Having said that, if you're looking for guideline-concordant care, you need expert panels, and that's what the NCCN does.

What the NCCN does is bring together this cohort of experts, and when the data are not robust enough to have level 1 or level 2 evidence, they get expert opinions. Although opinions are not as good as level 1 or level 2 data, it does affirm that there are certain standards that should be met when patients are faced with these less common types of aggressive cancers.

What are some areas where physicians shouldn't stray from recommendations? What data are supporting each approach?

Physicians who are [treating patients with] sarcomas are, for the most part, at these academic medical centers or NCI-designated centers. where they have a group of content experts. These [physicians] don't necessarily need the guidelines because they're so entrenched with the development of the guidelines, and they don't have to stray from them. When the sarcoma experts do stray from the guidelines, it's usually because [patients] have had disease progression and need to get on to a phase 1 or phase 2 trial.

For non-experts who may be referring to the guidelines, if they do feel for whatever reason that they need to step aside from the guidelines, they still should pick up the proverbial phone and speak to a compatriot at a sarcoma program who has familiarity with the disease and the clinical course of these patients. It is important to consult with those content experts.

What is the value of guidelines, particularly in these diseases that require multidisciplinary management?

For many of the [sarcoma] centers, we have weekly or monthly tumor boards where we will present all of our patients with sarcoma, and those [boards] bring together all of the content experts.

However, for centers that don't have robust disease-specific tumor boards, they're not afforded that ability to speak in real-time with their other disciplinarians. The surgeons, medical oncologists, radiation therapists, and others, are not able in real time to navigate these patients. They must therefore refer to guidelines. That's why it's a real charge of ours to get this information out there that there should be guideline-concordant care if you don't have a multidisciplinary tumor board.

What else can be done to rectify this issue to help increase the use of guideline-concordant care?

[It is important to] raise awareness and make sure that people know that [these guidelines] exist. Most medical oncologists, who are the most frequent users of mediums such as OncLive, are aware of the NCCN Guidelines and other sorts of guidelines; however, others are not.

We need to afford every opportunity, whether it be through the American Cancer Society, ASCO, or some of the subspecialty cancer societies to make sure people are raising awareness for those who might be blind to the fact that these guidelines are out there.

Reference

Abrahão R, Keegan THM, Maguire FB, et al. Receipt of guideline-concordant care is associated with improved survival in patients with osteosarcoma in California: a population-based analysis. JCO Oncol Pract. Published online February 21, 2024. doi:10.1200/OP.23.00591