The presented findings show that the MRI-report and the provisional diagnosis of the lesion influence the treatment speed of patients with soft tissue swellings. This emphasizes the importance of the radiologist´s role. In the MRI report, a direct reference to a sarcoma center or a recommendation for a biopsy should be given in the case of a suspicious mass [6]. In contrast, a delay of further diagnostics (e.g., biopsy) may allow the development of advanced disease [17]. Usually, no direct flow of information between patient and radiologist exists in the case of publicly insured patients (87% of the total population) in Germany [18]. The radiologist sends the MRI report to the physician, who initially referred the patient to MRI diagnostics. Due to data protection laws, communication is often restricted to letters or FAX leading to further time delay. Direct information of the radiologic findings, at least in cases with a suspicion of a malignant STT, via phone call with the recommendation of a specialized center could dramatically reduce the overall diagnostic time delay. Eventually, the patient himself needs to make the appointment at the UCC and consent to an operation. Personal matters of familial, religious, or financial origin might contribute to a further delay in diagnostics. Altogether, these interfering factors contribute to the overall, large standard deviations within the analyzed cohorts.
OnkoZert, the certification program of the German Cancer Society, requests to offer patients an appointment for a biopsy within five working days after detection of a suspicions mass [14]. In our study, the average time between the first contact of the cancer center and surgery was 14.8 days (SD:17.1) for masses suspicious for sarcoma of the soft tissue. It is very difficult to name the main reason for this delay, some aspects are already discussed above. But delays in appointments due to an over-booked outpatient clinic cannot be ruled out. All biopsies were performed as open incision biopsies. Thus, patients underwent standard preoperative procedures. A computed tomography (CT)-guided fine needle aspiration biopsy might be a quicker alternative because no anesthesiologist and surgical team are necessary. However, fine-needle biopsies deliver less accurate results versus open incision biopsies in sarcomas [19, 20].
Younger et al. reported patients with soft tissue and bone sarcomas in England; 48% of the patients saw a doctor within one month of the development of symptoms, 27% within three months, and 31% within a year [2]. Brouns et al. reported similar findings. Here, 80% of patients consulted a general practitioner as their first medical contact with symptoms [15]. Younger et al. also showed that the symptoms are more likely to be misinterpreted by physicians in younger patients than in older patients [2]. Weaver et al. offered two explanations for this: Young patients are more likely to dismiss their symptoms and have a lesser suspicion of cancer in younger patients than older patients by primary healthcare professionals [21, 22].
Our study examined the time between an MRI scan and contact with a specialized UCC. However, the time interval between first recognition of symptoms and contact to a healthcare professional has not been registered, yet. Buvarp Dyrop et al. reported that this time interval is by far the longest when diagnosing sarcomas [16].
Younger and colleagues report that adolescent and young patients are willing to travel further for specialized sarcoma treatment [2]. No correlation of age and traveled distance was found in our cohort. A thinkable reason is the setting of our study, a metropolitan area in Western Europe. In comparison, Younger et al. analyzed data from the whole National Health Service (NHS) England and thus analyzed a complete country in a multi-center study. The average catchment area of the UCC was 47.5 km. Similar institutions can be reached at a distance of 73 km, 92 km, 156 km, and 185 km. Due to the fairly easy accessibility of a specialized center, a selection towards more malignant tumors being treated at the specialized center has not been observed. Moreover, younger patients did not incur longer traveling distances in comparison to older patients. Other authors report worse oncologic outcomes in rural populations versus urban population [23]. Although overall survival has not been analyzed in our study, there is no evidence of discrimination of patients that lived further away from the center, compared to others nearby.
All general limitations of a retrospective analysis apply to this study. Resolution of the MR-tomographs (slice thickness and magnetic field strength in tesla) was not considered. Higher MRI resolution might have led to a more exact diagnosis influence the further treatment of a patient. This major limitation will always exist as long as different MRI scanners are used for patient examination. Patients´ details such as cancer anamnesis, medical professional knowledge, and income level were not considered. All these circumstances can tremendously affect the patient’s disease awareness and seek medical support. This major limitation will be present in prospective and retrospective studies and can hardly be overcome in a multifaceted society. A heterogeneous group of radiologists performed the imaging at multiple institutions. However, decisions on the surgical procedure were performed in one institution by three experienced surgeons, working in the same department. This limitation should have a minor impact on the study since most healthcare providers act by medical guidelines.
