Published 9/25/2018

American Academy of Orthopaedic Surgeons endorses the Musculoskeletal Tumor Society’s appropriate use criteria that informs doctors’ monitoring of bone and soft tissue sarcoma survivors

ROSEMONT, Ill. (September 25, 2018)–The American Academy of Orthopaedic Surgeons has endorsed the Musculoskeletal Tumor Society’s (MSTS) new appropriate use criteria (AUC) to help doctors determine when to use X-rays, ultrasounds, CT scans, and other imaging to help patients who have had bone or soft tissue sarcomas surgically removed and are at risk of recurrence.
This AUC—a derivative of the clinical practice guideline (CPG) approved earlier this year—includes a mix of guidelines and expert opinion meant to aid physicians in monitoring patients after they have had surgery to treat bone or soft tissue sarcomas—malignant cancers that grow in bones, muscles, tendons, or other connective tissue.
“The primary goal of surveillance after sarcoma treatment is to identify areas of metastatic spread or local recurrence when they occur, so that an intervention may be performed that will improve patients’ survival or quality-of-life,” said Dr. Benjamin J. Miller, co-chair of the AUC project. “There are two distinct, and somewhat conflicting, goals. First, we want to ensure that we are imaging patients in a way that we will identify recurrent tumors early and accurately. In contrast, we also want to minimize the amount of imaging performed to attain this goal, with the understanding that the majority of patients will survive their disease and not experience disease recurrence. We feel this effort addresses this conundrum, by suggesting imaging protocols that balance accuracy and frequency to identify treatable lesions, when present, but avoiding over-imaging in those who will not benefit.”
“The sarcoma surveillance AUC allows for both clinicians and patients to benefit from the best data available on sarcoma recurrence and metastatic patterns. It provides standardization of practices so that we can know how to best find metastatic disease and local recurrences given a variety of clinical factors,” said Dr. Rajiv Rajani, co-chair of the AUC project and associate professor and vice chair for education at UT Health San Antonio’s Department of Orthopaedic Surgery. “The AUC allows patients to receive the best-known practices for sarcoma surveillance.”

Dr Rajani noted the value of the AUC incorporating the complex aspect of time intervals into the decision process. Three-month, six-month, and one-year intervals are included in the tool, adding significant value for clinicians.

The AUC is accessed via an online tool which rates the appropriateness of certain services depending on patients’ indications and can aid doctors in deciding when and how to use imaging to detect cancer, as well as inform shared decision making with patients.
“Surveillance after removal of sarcoma is an important issue that often is overshadowed by the details of sarcoma diagnosis and treatment,” noted Dr. Miller. “However, regardless of what type of sarcoma a patient has, where it is, or how it is treated, every clinician and patient is faced with questions regarding surveillance. Our group felt that there was little in the literature to guide decision-making in specific clinical scenarios. We worked to think about different patients that we encounter, distinguished by clinical factors such as risk of disease recurrence, origin in the bone or soft tissue, and time since treatment, to make recommendations on the most and least appropriate imaging modalities.” 
The AUC may be used to improve outcomes and reduce unnecessary costs by ensuring the screenings are used appropriately. For example, overusing a screening may drive-up health care costs without any benefits, while underusing a screening may lead to missing a sarcoma recurrence diagnosis.
“The [tool’s] value is in delivering assistance to these practitioners to help determine what studies to order and how often to order them,” explained Dr. Miller. “Just as important, the AUC defines studies that are unlikely to be helpful and should be avoided. This project could potentially reduce unnecessary imaging and result in cost reduction by minimizing over-imaging by frequency and modality. In contrast, if clinicians are not performing surveillance at close enough intervals, it may increase utilization but result in earlier identification of treatable sites of recurrent disease.”

Dr. Rajani notes that while there is potential for select costs to increase, “this AUC will hopefully drive better value in health care by improving patient outcomes.” Dr. Rajani explains that the AUC “sets us up to utilize standardized protocols in the future so that we can determine true value changes.” 
Use of the AUC has the potential to shape future surveillance.
“Currently we have limited data on the practice of surveillance after sarcoma resection,” explained Dr. Rajani. “Most physicians order surveillance studies on their experience in fellowship and we expect to alter the expected surveillance patterns whether it be from a positron emission tomography (PET) scan to a CT scan in some circumstances or from an X-ray to magnetic resonance imaging (MRI) in others. Most importantly, we will be able to examine patient outcomes utilizing the same surveillance modality and therefore improve outcomes in the long run. We will now be able to follow patients longitudinally in standardized time periods with standardized imaging modalities instead of making lower-level evidenced based decisions.”
Dr. Miller sees potential for the AUC to spur additional research: “Truthfully, we need more research on the benefits of early identification of sarcoma metastasis to understand how important postoperative surveillance is for optimizing survival. We view this effort as one that should be repeated periodically as the conclusions may change as more research is performed, imaging studies are improved, costs are reduced, and treatment options increase.”

The AUC was developed by two independent, multidisciplinary groups of experts. It was funded by the MSTS, with partial funding provided by the AAOS’ Quality and Patient Safety Action Fund. The American College of Radiology, Connective Tissue Oncology Society, and the Society of Surgical Oncology participated in the development of the AUC.

The full AUC is available here. The online tool is here.
About the AAOS
With more than 38,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS provides educational programs for orthopaedic surgeons and allied health professionals, champions and advances the highest quality musculoskeletal care for patients, and is the authoritative source of information on bone and joint conditions, treatments and related issues. 
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Disclaimer: Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment. Practitioners are advised to consider management options in the context of their own training and background and institutional capabilities when selecting recommended treatment options.

Contact AAOS Media Relations