Clinical Outcomes and Costs Following Unplanned Excisions of Soft Tissue Sarcomas in the Elderly

J Surg Res. 2019 Jul;239:125-135. doi: 10.1016/j.jss.2019.01.055. Epub 2019 Feb 27.

Abstract

Background: Surgical guidelines for soft tissue sarcoma (STS) emphasize pretreatment evaluation and reports of the perils of unplanned excision exist. Given the paucity of population-based data on this topic, our objective was to analyze clinical outcomes and costs of planned versus unplanned STS excisions in the Medicare population.

Methods: We analyzed 3913 surgical patients with STS ≥66 y old from 1992 to 2011 using the Surveillance, Epidemiology, and End Results-Medicare datafiles. Planned excisions were classified based on preoperative MRI and/or biopsy, whereas unplanned excisions were classified by excision as the first procedure. Inverse probability of treatment weighting with propensity scores was used to adjust for clinicopathologic differences. Re-excisions, complications, and Medicare payments were compared with multivariate models. Overall survival and disease-specific survival were analyzed using Cox proportional hazards and competing risk models.

Results: Before the first excision, 24.3% had an MRI and biopsy, 27.3% had an MRI, 11.4% had a biopsy, and 36.9% were unplanned. Re-excision rates were highest for unplanned excisions: 46.3% compared to 18.1%, 36.4%, and 29.7% for other groups (P < 0.0001). There was no difference in disease-specific survival or overall survival between groups (P > 0.05). Planned excisions were associated with increased Medicare costs (P < 0.05), with the first resection contributing to the majority of costs. Subgroup analyses by histologic grade and tumor size revealed similar results.

Conclusions: Survival was comparable with greater health care costs in elderly patients undergoing planned STS excision. Although unplanned excisions remain a quality of care issue with high re-excision rates, these data have important implications for the surgical management of STS in the elderly.

Keywords: Biopsy; Cost; MRI; Sarcoma; Survival.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Biopsy / economics
  • Biopsy / statistics & numerical data
  • Cost-Benefit Analysis
  • Female
  • Health Care Costs / statistics & numerical data*
  • Humans
  • Magnetic Resonance Imaging / economics
  • Magnetic Resonance Imaging / statistics & numerical data
  • Male
  • Margins of Excision
  • Medicare / economics
  • Medicare / statistics & numerical data
  • Postoperative Complications / economics*
  • Postoperative Complications / epidemiology
  • Preoperative Care / economics*
  • Preoperative Care / statistics & numerical data
  • Reoperation / economics*
  • Reoperation / statistics & numerical data
  • Retrospective Studies
  • SEER Program / statistics & numerical data
  • Sarcoma / diagnostic imaging
  • Sarcoma / mortality
  • Sarcoma / surgery*
  • Survival Analysis
  • Treatment Outcome
  • United States / epidemiology