Adolescent survival rates for osteosarcoma have not improved for 20 years

More research is urgently needed says cancer surgeon

New treatments and more research are urgently needed in order to increase the numbers of adolescents who survive bone cancer, according to a leading cancer surgeon.

Osteosarcoma is the third most common cancer in young people*, yet during the past 20 years little research has been carried out into developing improved therapies, and survival rates have remained unchanged with only 54 per cent of patients alive after five years, says Robert Grimer, a consultant orthopaedic oncologist at The Royal Orthopaedic Hospital NHS Trust in Birmingham.

He will tell the Teenage Cancer Trust’s Third International Conference on Cancer and the Adolescent today (Monday 1 March): “Osteosarcoma arises most often in teenagers, yet treatments have not improved during the past 20 years. Chemotherapy and removing part or all of the affected limb are still the standard therapies available. There is an urgent need for new treatments to be developed that are more effective, but kinder to the patients themselves.

“It is a sad fact that, while survival rates in many other cancers have been improving, they have remained static for so long for osteosarcoma.”

Fifty per cent of osteosarcomas in adolescents and young adults occur in the bones around the knee, but they can occur in any bone. “The symptoms are very non-specific and delays in diagnosis are common,” said Mr Grimer. “This is a problem because if the tumour has had time to spread to other parts of the body, it is very difficult to treat successfully. GPs need to be aware of this, and to refer patients immediately for further investigation if they have symptoms such as pain and swelling of a bone or in the area of a bone.

He said that more research needed to be done not only on improving and evaluating treatments, but also on the best ways to explain risks adequately to adolescents so that they could make properly informed decisions.

“In adolescents there are a number of dilemmas that need to be explored and which may affect decision-making for the individual. Firstly, can the tumour be safely resected (cut out) with a low risk of the cancer recurring? In many, this will be the case, but in some there will be a true dilemma between resection and limb salvage versus amputation. In this situation the risks and benefits need to be clarified.

“If there has been a poor response by the tumour to chemotherapy and it is not possible to leave a clear margin of unaffected bone around the diseased area, then the risk of local recurrence of the tumour may be as high as 30 per cent. Tumour recurrence is dangerous, with a high risk of amputation and also of metastatic disease developing. The alternative procedure is an amputation – something that is not attractive to the vast majority of patients. Thus there is a conflict between a ‘safe’ amputation and a ‘risky’ limb salvage operation. Adolescents take risks and many will accept this risk of local recurrence to keep their limb. Limb salvage surgery is not without problems, however, including poor function, infection, breakages and the almost certain need for further surgery in the future.

“Exploring how these risks and benefits can be conveyed to adolescents to help them make sensible choices is part of the art and challenge of dealing with adolescents.”

Dr Jeremy Whelan, a consultant medical oncologist at The Meyerstein Institute of Oncology, Middlesex Hospital in London, will tell the conference that it is vital that osteosarcoma in adolescents should be treated by specialists who not only understand the disease but also their patients. He agreed with Mr Grimer that more research was urgently needed, especially as there was evidence from clinical trials to suggest that osteosarcoma was not treated so well in the UK as in other European countries and the USA. But he highlighted the problems that researchers encountered in setting up clinical trials.

“I am involved in setting up a new trial for osteosarcoma with groups in Europe and the US as we all recognise that we need better results from treatment and that solutions will come quicker by working together. However, such trials are very difficult to establish, fund and run, mostly because of the tightening of regulations; we have spent two and a half years so far trying to set up this trial, and it is still not opened,” he said.

Notes
* New figures for the year 2000 show that between 1979 and 2000 in England there were 1,057 cases of osteosarcoma in young people between the ages of 13 and 24. This represents a rate of 0.59 cases per 100,000 of the population in this age group.