VOLUME 32 䡠 NUMBER 35 䡠 DECEMBER 10 2014
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
Time to Diagnosis of Ewing Tumors in Children and Adolescents Is Not Associated With Metastasis or Survival TO THE EDITOR: Ewing=s sarcoma is special in several ways, first of all because most of the patients are young children or adolescent and second because a perfect coordination between chemotherapy, surgery, and radiotherapy must be implemented to achieve the high percentage of cure that we can see presently.1 The experience of the French group of pediatricians at the Institute Gustav Roussy has been fundamental to setting the algorithm of treatment and the outcome in this tumor.2-3 Brasme et al4 summarize this experience but from a new perspective, analyzing the association between epidemiologic variables and patient characteristic, tumor variables, and survival. The conclusion is that time to diagnosis (TtD) expressed in days, and defined as the time from onset of symptoms to the date of diagnosis, is not associated with a worse outcome in terms of metastases or survival. But we believe that to assume this conclusion as a rule can be risky for several reasons: first, the study is based on a group of patients from two different clinical trials with different treatment, even a consolidation arm, and we do not know how this variable was included in the multivariable model. Also, the authors assume a nondifferential misclassification for TtD, but this is difficult to prove because they do not show, for instance, some other possible indirect measures such as the number of visits before diagnosis. In the study by Brasme et al,4 the only prognostic factors independently associated with characteristic of the patients are site location and older age. The authors considered that the worst prognosis for children older than 12 years could be related to a different clinical behavior, but we think that it is also worthy to consider as an explana-
tion a cognitive bias in the clinical reasoning process of the clinicians attending these patients. A “representativeness bias”5 drives the doctor=s mind to a prototypical situation where bone pain is associated with growth, which results in a longer TtD, or in other words, a diagnostic delay.6 We want to congratulate the authors for the clear explanations, but we think that there is still room to reduce TtD of Ewing=s sarcoma and that the clinical reasoning process in pediatricians and doctors involved in treating these patients can be improved.
Lorenzo Alonso, Victor Navarro-Perez, Alfonso Sanchez-Muñoz, and Emilio Alba University Hospital Regional and Virgen de la Victoria of Malaga, Malaga, Spain
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Balamuth NJ, Womer RB: Ewing=s sarcoma. Lancet Oncol 11:184, 2010 2. Oberlin O, Le Deley MC, N=Guyen Bui B, et al: Prognostic factors in localized Ewing’s tumours and peripheral neuroectodermal tumours: The third study of the French Society of Paediatric Oncology (EW88 study). Br J Cancer 85:1646-1654, 2001 3. Taque S, Munzer M, Vannier JP, et al: Risk adapted chemotherapy for localised Ewing’s sarcoma of bone: The French EW93 study. Eur J Cancer 48:1376-1385, 2012 4. Brasme JF, Chalumeau M, Oberlin O, et al: Time to diagnosis of Ewing tumors in children and adolescents is not associated with metastasis or survival: A prospective multicenter study of 436 patients. J Clin Oncol 32:1935-1940, 2014 5. Croskerry P: The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 78:775-780, 2003 6. Graber M, Gordon R, Franklin N: Reducing diagnostic errors in medicine: What’s the goal? Acad Med 77:981-992, 2002
DOI: 10.1200/JCO.2014.58.4466; published online ahead of print at www.jco.org on November 10, 2014
■ ■ ■
4020
© 2014 by American Society of Clinical Oncology
Journal of Clinical Oncology, Vol 32, No 35 (December 10), 2014: pp 4020
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Correspondence
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Time to Diagnosis of Ewing Tumors in Children and Adolescents Is Not Associated With Metastasis or Survival The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Lorenzo Alonso No relationship to disclose
Alfonso Sanchez-Muñoz No relationship to disclose
Victor Navarro-Perez No relationship to disclose
Emilio Alba No relationship to disclose
www.jco.org
© 2014 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
Time to Diagnosis of Ewing Tumors in Children and Adolescents Is Not Associated With Metastasis or Survival TO THE EDITOR: Ewing=s sarcoma is special in several ways, first of all because most of the patients are young children or adolescent and second because a perfect coordination between chemotherapy, surgery, and radiotherapy must be implemented to achieve the high percentage of cure that we can see presently.1 The experience of the French group of pediatricians at the Institute Gustav Roussy has been fundamental to setting the algorithm of treatment and the outcome in this tumor.2-3 Brasme et al4 summarize this experience but from a new perspective, analyzing the association between epidemiologic variables and patient characteristic, tumor variables, and survival. The conclusion is that time to diagnosis (TtD) expressed in days, and defined as the time from onset of symptoms to the date of diagnosis, is not associated with a worse outcome in terms of metastases or survival. But we believe that to assume this conclusion as a rule can be risky for several reasons: first, the study is based on a group of patients from two different clinical trials with different treatment, even a consolidation arm, and we do not know how this variable was included in the multivariable model. Also, the authors assume a nondifferential misclassification for TtD, but this is difficult to prove because they do not show, for instance, some other possible indirect measures such as the number of visits before diagnosis. In the study by Brasme et al,4 the only prognostic factors independently associated with characteristic of the patients are site location and older age. The authors considered that the worst prognosis for children older than 12 years could be related to a different clinical behavior, but we think that it is also worthy to consider as an explana-
tion a cognitive bias in the clinical reasoning process of the clinicians attending these patients. A “representativeness bias”5 drives the doctor=s mind to a prototypical situation where bone pain is associated with growth, which results in a longer TtD, or in other words, a diagnostic delay.6 We want to congratulate the authors for the clear explanations, but we think that there is still room to reduce TtD of Ewing=s sarcoma and that the clinical reasoning process in pediatricians and doctors involved in treating these patients can be improved.
Lorenzo Alonso, Victor Navarro-Perez, Alfonso Sanchez-Muñoz, and Emilio Alba University Hospital Regional and Virgen de la Victoria of Malaga, Malaga, Spain
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Balamuth NJ, Womer RB: Ewing=s sarcoma. Lancet Oncol 11:184, 2010 2. Oberlin O, Le Deley MC, N=Guyen Bui B, et al: Prognostic factors in localized Ewing’s tumours and peripheral neuroectodermal tumours: The third study of the French Society of Paediatric Oncology (EW88 study). Br J Cancer 85:1646-1654, 2001 3. Taque S, Munzer M, Vannier JP, et al: Risk adapted chemotherapy for localised Ewing’s sarcoma of bone: The French EW93 study. Eur J Cancer 48:1376-1385, 2012 4. Brasme JF, Chalumeau M, Oberlin O, et al: Time to diagnosis of Ewing tumors in children and adolescents is not associated with metastasis or survival: A prospective multicenter study of 436 patients. J Clin Oncol 32:1935-1940, 2014 5. Croskerry P: The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 78:775-780, 2003 6. Graber M, Gordon R, Franklin N: Reducing diagnostic errors in medicine: What’s the goal? Acad Med 77:981-992, 2002
DOI: 10.1200/JCO.2014.58.4466; published online ahead of print at www.jco.org on November 10, 2014
■ ■ ■
4020
© 2014 by American Society of Clinical Oncology
Journal of Clinical Oncology, Vol 32, No 35 (December 10), 2014: pp 4020
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Correspondence
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Time to Diagnosis of Ewing Tumors in Children and Adolescents Is Not Associated With Metastasis or Survival The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Lorenzo Alonso No relationship to disclose
Alfonso Sanchez-Muñoz No relationship to disclose
Victor Navarro-Perez No relationship to disclose
Emilio Alba No relationship to disclose
www.jco.org
© 2014 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
