To The Editor:
We appreciated the article "Initial Symptoms and Clinical Features
in Osteosarcoma and Ewing Sarcoma" (82-A: 667-674, May
2000), by Widhe and Widhe.Their
findings about delays in the diagnosis of primary bone tumors will
be familiar to all orthopaedic oncologists and are very similar
to those that we reported a decade ago1.
Concerned by such long delays in diagnosis, we embarked upon a
vigorous educational campaign to improve awareness of musculoskeletal
tumors. We have monitored this awareness over the years by intermittently repeating
the study on diagnostic delays that we first carried out in the
late 1980s. While there has been some improvement, it is not marked
(TableTable).
What was equally a cause for concern was the fact that, on retrospective
review, 22% of patients in the initial study and 25% in
the second study (unpublished) had had a radiograph which clearly
showed the lesion, yet it had not been detected or its significance
had been misinterpreted.
The main symptom suffered by our patients was an intermittent ache
which progressed to a nonmechanical pain, often worse at night.
In this respect our population differed from that of Widhe and Widhe.
Interest in early diagnosis has recently been heightened in the United
Kingdom by the requirement for any patient with a suspected malignancy
to be seen by an appropriate oncologist within two weeks of the
reported possibility. This has led to the publication of a document,
available on the Internet, entitled "Referral Guidelines
for Suspected Cancer," which highlights the common symptoms
of both bone and soft-tissue malignancy2.
While we agree with Widhe and Widhe’s final comments
about the significance of a mass and the importance of physical examination,
the ideal would still be to detect bone tumors in patients before the
tumor has extended beyond the bone and thus become extracompartmental.
Hence, early referral for further investigation of any suspicious symptoms
must be commended.
We have often addressed the issue of whether delays in diagnosis
affect overall outcome. In our initial study, we found that a missed
tumor on a radiograph usually delayed diagnosis for three months
or more. In this group of patients, 58% had an amputation
compared with 15% of those in whom the radiograph was correctly
interpreted1. We have not been
able to show any excess mortality thus far with the relatively small
numbers available, but, clearly, delays in diagnosis are unsatisfactory
from everyone’s point of view. Continued education and
the vigilance of orthopaedic surgeons, radiologists, and primary-care
physicians are essential.
B. Widhe and T. Widhe reply:
We appreciate the interest of Dr. Grimer and his colleagues in
our paper, and we agree that our findings concerning the initial symptoms
of osteosarcoma and Ewing sarcoma partially differ from those of
Dr. Grimer1 and from the information
given in "Referral Guidelines for Suspected Cancer"2. In our study, pain related to strain
was the most common initial symptom, reported by 85% of
those with osteosarcoma and 64% of those with Ewing sarcoma.
Only 21% of the patients reported pain at night. The purpose
of our study was to identify the initial symptoms and physical
findings as described in the record from the patient’s
very first visit to a physician for symptoms that could be related to
the bone neoplasm. Previous reports have usually relied upon data
given at admission to the tumor center, when the diagnosis was
already known or strongly suspected. Pain at night may be a characteristic
symptom of sarcomas at a later stage, but it is not a typical initial
symptom. The most important clinical feature at the first visit
was a palpable mass, noted in more than one-third of the patients
in our study. This finding emphasizes the value of a careful physical
examination. The high percentage of misinterpreted radiographs,
reported both by Dr. Grimer and in our study, is not generally recognized
by doctors. Reduction in false-negative errors in the interpretation
of radiographs of bone tumors is one important step that would shorten
the delay in diagnosis. However, the extent of the doctor’s
delay depends primarily on the judgment of the first doctor consulted.
Our study has added valuable information about initial
symptoms and physical signs that can increase the doctor’s
awareness of a primary bone tumor.