# Organizing Care Matters: Fragmented Pathways Double Early Local Recurrence Risk in Sarcoma

## TL;DR

Early local recurrence in sarcoma is strongly linked to fragmented care pathways, highlighting the need for coordinated treatment in specialized centers.

## Contribution

The study identifies fragmented care pathways as a major modifiable risk factor for early local recurrence in sarcoma patients.

## Key findings

- Fragmented care pathways independently increase the risk of early local recurrence in sarcoma patients.
- Unplanned surgery and incomplete tumor removal are key factors in fragmented care leading to early recurrence.
- Adjuvant treatments do not compensate for the increased risk from fragmented care.

## Abstract

Sarcomas are rare malignancies in which outcomes strongly depend on early management according to established guidelines in specialized centers. Nevertheless, many patients receive initial treatment outside structured sarcoma care pathways, where diagnostic and surgical standards are often not fully met. In this study, we analyzed patients with local recurrence within the Swiss Sarcoma Network to assess how the initial care pathway influences the risk of early recurrence. We found that fragmented initial management was independently associated with a higher risk of early local recurrence, mainly due to unplanned surgery and incomplete tumor removal. This increased risk was not compensated for by adjuvant treatments. Our findings highlight the importance of early referral and coordinated, center-based care to improve outcomes in patients with musculoskeletal sarcoma.

Background: Early local recurrence (ELR) in musculoskeletal sarcoma is associated with poor oncologic outcomes, yet the relative impact of tumor biology versus system-level factors remains insufficiently understood. This multicenter real-world study within the Swiss Sarcoma Network evaluated whether the initial care pathway influences the risk and timing of ELR. Methods: Patients with histologically confirmed sarcoma and documented local recurrence were classified according to initial management within a Comprehensive Care Pathway (CCP) or a Fragmented Care Pathway (FCP). ELR was defined as recurrence within 12 months after index surgery. Associations were analyzed using restricted Cox proportional hazards models and Firth-penalized logistic regression, adjusting for key clinicopathologic factors. Follow-up was calculated from index surgery to death or administrative censoring (median 88.2 months; interquartile range, 54.9–141.6). Results: Among 158 patients with local recurrence, 96 (60.8%) were treated within CCP, and 62 (39.2%) entered through FCP. ELR occurred in 53 patients (33.5%) and was more frequent in the FCP cohort. Fragmented care was independently associated with ELR in both time-to-event analysis (hazard ratio 2.00, 95% CI 1.14–3.51) and penalized logistic regression (odds ratio 2.83, 95% CI 1.09–6.94). Unplanned (“whoops”) procedures and incomplete resection margins were substantially more common in FCP and independently predicted ELR. Tumor grade also contributed to risk, but the magnitude of the pathway effect was comparable. ELR was associated with higher rates of synchronous metastases and inferior survival compared with late local recurrence. Adjuvant therapy did not independently reduce ELR risk after adjustment for surgical quality. Conclusions: These findings indicate that ELR in musculoskeletal sarcoma is strongly influenced by modifiable system-level factors. Early referral, multidisciplinary evaluation, and expert margin-oriented surgery are critical to reducing early recurrence and improving patient outcomes.