Sarcomas are rare cancers that develop in the body’s connective tissues, including bones, cartilage, muscles, tendons, blood vessels, nerves and fatty tissue. But that is the only thing these rare cancers have in common. There are more than 150 subtypes of sarcoma, and they all behave differently at the molecular level, making sarcoma a very complex disease to treat. Some sarcomas respond to chemotherapy, but others do not. Some can be treated with radiation, but others are better treated with oral drugs and surgery.
“Because of the nuance of treating such a varied cancer, it’s important for patients to seek out a Sarcoma Center of Excellence, such as Fred Hutch,” said Stephanie Schaub, MD, a sarcoma radiation oncologist who treats patients at Fred Hutch Cancer Center – Proton Therapy as well as the Sloan Clinic. “It’s imperative to come to a place like Fred Hutch, where many patients with sarcomas are treated, so we can provide evidence-based treatment methods within a personalized care plan. Sarcoma is best approached from a multidisciplinary angle with many experts weighing in.”
At Fred Hutch, Schaub treats adult sarcoma patients using radiation, along with her colleagues Michael Folkert, MD, PhD, and Ed Kim, MD.
According to Schaub, if a patient has an undiagnosed mass and their provider suspects sarcoma, they should get a referral for a biopsy. Fred Hutch providers can perform a biopsy so that it doesn’t compromise the surrounding tissues, cutting out the area surrounding the biopsy tract when possible. Pathologists at Fred Hutch are also experts in bone and soft tissue cancers and will examine the histological and molecular structure of tumor cells to better determine the disease subtype. This can lead to the most efficient confirmation of a diagnosis and creation of a multidisciplinary treatment team.
“Patients are sometimes referred to us for a suspected sarcoma and when we review the pathology, we actually find that it is a different cancer,” Schaub said. “That’s how uncommon and nuanced this disease is. It all comes down to having extensive experience in the field.”
Once a patient has been diagnosed with sarcoma, their Fred Hutch care team will discuss their case at a sarcoma tumor board. A tumor board is a group of providers, including medical oncologists, radiation oncologists, surgeons, radiologists, pathologists, medical students, resident trainees and fellows, advanced practice providers and nurse navigators, who meet weekly to review patient cases and formulate treatment plans together, and if necessary, revise existing plans.
“By reviewing cases together, we can make sure all the relevant experts weigh in to provide the best treatment plan for the best outcomes,” said Schaub.
A tumor board may also include colleagues and peers from other institutions, who are requesting expert input about their patient’s case.
“For a radiation oncologist, reviewing the case may lead to decisions on whether any radiation is warranted or what type of radiation therapy is most appropriate to a patient’s specific needs,” said Folkert, a radiation oncologist who specializes in sarcomas.
“While many patients are well served with conventional radiation therapy, for others, treatment could use heavy particles such as protons or neutrons or adaptive radiation therapy where the treatment plan is modified over the course of therapy to adjust to changes in the tumor and/or patient anatomy,” he said.
Along with the benefit of having multiple specialists in one room reviewing a patient’s case, a tumor board also offers an opportunity for providers to assess if clinical trials are an option.
“Before we meet, a research nurse will have determined available clinical trial options in order to cast as broad a treatment net as possible,” said Schaub. “At times, we may reach out to other institutions running a clinical trial, if we believe our patient may be a good candidate. At Fred Hutch, providers are more likely to know what trials are going on locally as well as at other institutions and to be able to give the best opinion.”
Schaub is involved in a preoperative radiation therapy clinical trial developed at Fred Hutch for high-risk liposarcoma patients led by sarcoma surgical oncologist Jeremy Sharib, MD. The trial focuses on a specific type of sarcoma called adipocytic retroperitoneal sarcoma (dedifferentiated liposarcoma) — a type that arises from fat tissue near the kidneys, adrenal glands, pancreas, parts of the intestines and in major blood vessels like the aorta and vena cava. It is testing the safety and effectiveness of pre-surgical radiation therapy in combination with a drug called abemaciclib. The trial is currently enrolling patients. Depending on the location of the tumor and medical necessity, some patients on this trial could receive proton therapy.
“Clinical trials are important because we want to consistently improve treatment to help patients live longer and to decrease toxicity,” Schaub said. “Clinical trials help advance our options and hope for patients with sarcoma.”
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