Saving Limbs and the Urgent Need for Equity in Sarcoma Treatment

A man sits with next to prosthetic leg

Systemic and structural inequity in healthcare can profoundly influence patient outcomes, particularly in specialized fields like sarcoma care where access to quality care may mean amputation or not. Jarrod T. Bogue, MD, plastic surgeon and specialist in orthoplastic surgery, recently co-authored a pivotal study exploring how factors like race, income, and geographic location impact access to limb-sparing surgery versus amputation for lower extremity sarcomas. 

In this insightful Q&A, Dr. Bogue shares the motivations behind his research, discusses key findings, and outlines potential policy changes to improve equitable access to life-altering surgical options.

What inspired you to investigate socioeconomic factors in limb-sparing surgery?

At Columbia, we serve a large, underserved population, and there is limited research on how socioeconomic disparities impact access to limb-sparing surgery versus amputation. While there is existing literature on outcomes, little attention has been given to the plastic and reconstructive surgery aspect of sarcoma care. By using a database study, we could capture data across various settings—urban, rural, and beyond—to analyze how these factors influence patient care and identify areas for potential policy change.

What are some of the most significant barriers to limb-sparing surgery?

Access to plastic surgery is a major barrier. Studies on other areas, like breast reconstruction, show that when patients have access to plastic surgeons, they’re more likely to receive reconstructive surgery. The same pattern holds here: patients treated at centers with access to reconstructive surgeons are more likely to receive limb-sparing procedures. Unfortunately, marginalized patients often lack this access, and some present at stages where amputation is the only option.

How do you think health policy can address these disparities?

A potential model is the New York State law requiring every breast cancer patient to consult with a plastic surgeon about reconstruction. A similar policy could mandate that patients with soft tissue or bony cancers requiring extensive resection be evaluated by a reconstructive surgeon. This would ensure that all patients are informed about their options and have access to appropriate care.

Proximity seems to be a major factor as rural patients face additional challenges in accessing care. Realistically, what can be done to alleviate this burden?

Telehealth could play a significant role. While I can’t currently conduct out-of-state video visits due to licensing restrictions, expanding telehealth capabilities would allow initial consultations and follow-ups to happen virtually, reducing travel for rural patients. Additionally, partnerships with local surgeons could help provide continuity of care post-surgery.

Your study highlights the link between race, ethnicity, and advanced cancer stages, another data point in the systemic crisis across medicine. Were there any unexpected findings?

While it wasn’t surprising, it was so disheartening to see this trend reflected in sarcoma care. Earlier diagnosis usually leads to better outcomes, but systemic inequities contribute to delays in care for minority populations. This issue is well-documented in other cancers, like breast cancer, and remains a significant challenge.

Amputation rates slightly declined during the study period. What do you think contributed to this trend?

Advances in microsurgery have played a significant role. Over the past decade, we’ve seen growth in the number of microsurgeons and the complexity of cases they can manage. Resecting surgeons are also performing more precise resections, reducing the need for amputation. The combination of these advancements has improved reconstructive outcomes.

Are there resources or support networks available to patients and families navigating these decisions?

One organization I’m aware of is Sarcoma Strong, which provides support and advocacy for patients. My colleague Dr. Wakenda Tyler might have additional recommendations for resources tailored to patients’ needs, but to your point, increasing awareness of these networks is crucial.

What’s next in research or advocacy to actually reduce these disparities?

Advocacy is key. We need broader reform and greater visibility for reconstructive surgery’s role in sarcoma care. Additionally, increasing training opportunities in reconstructive techniques and expanding the presence of plastic surgeons in underserved areas will help address access issues. 

I’ve also been involved in international work with a group called ReSurge International, where we teach reconstructive techniques in countries with limited resources. Initiatives like this can have a global impact.

You used a database called SEER for this study. What limitations could that have created?

The SEER database provides a valuable bird’s-eye view of trends, but it lacks granular details on patient comorbidities and reconstructive approaches. To address this, we’re analyzing data from our patients at Columbia to gain more specific insights. And preliminary findings show no significant outcome differences between privately insured patients and those on Medicare or Medicaid, which is encouraging.

Let’s close with goals—What is your greatest hope for the impact of this study?

My hope is that every patient with a sarcoma requiring surgical intervention has access to the right care, including limb-sparing options. The ability to preserve a limb profoundly impacts quality of life, mobility, and the ability to return to work. Ensuring equitable access to reconstructive surgery is a small change that can significantly improve patients’ lives.

 

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