Comment on paper “Bone tumors distribution in diagnostic and excisional biopsies”

This exciting account of the bone tumour biopsies performed over a three-year period in a single institution gives an overview of diagnosis of bone tumours in Jordan.^[1]

Jordan has a population of about 10 million, with 35% of the population aged 15 years or below (the peak age for primary bone tumours).

Around 37% of Hospitals are provided by the Ministry of Health and 24% provided by the Military Royal Medical services. The Jordanian Government has a long-term strategic goal of providing universal health care. This is important in respect of the diagnosis and management of bone tumours as it is well recognised that centralisation of specialist services results in better outcomes for the patient and efficiencies and cost savings for the health services.

Currently, although about 60% of hospitals are provided outside the private health system, this paper identifies that the authors institute are only seeing a small proportion of primary bone tumours that would be expected.

Primary bone tumours are rare, accounting for less than 1% of all malignancies but occur in young age groups. The incidence of primary osteosarcoma is about 3 cases per million of the population annually; therefore, there should have been, over the three-year period of this study, 90 cases, yet the authors record only 16 cases. Similarly, for Ewing’s sarcoma only two cases were diagnosed, but 87 cases should have been anticipated. For chondrosarcoma, one case was seen against an anticipated 84.

I am aware that there are racial and geographic variations in the incidence of bone tumours; Ewings sarcoma, is rare in people of African heritage and Giant Cell Tumour of bone become more frequent in Eastern countries.

Interestingly the authors diagnosed six chordomas during the study period, making it the second commonest primary bone tumour diagnosed. Chordoma has a published incidence of one case per million of the population, and therefore, there does seem to be either an unusual incidence of Chordoma in Jordan or that chordomas are more frequently referred to the authors institute. (I suspect the latter).

Another interesting finding is that there were only 19 cases of metastatic disease to bone diagnosed (all secondary to lung cancer). As all Orthopaedic Surgeons are aware, bone metastases are the final common pathway of many carcinomas; lung, great kidney, prostate and thyroid in particular and that our Oncology colleagues are providing better treatments enabling patients with these conditions to have a longer survival and therefore, a greater chance of developing and having to live with bone metastases.

This paper highlights the need in Jordan (and possibly other countries) to arrange for centralisation of the management of Bone Tumours. This will allow for a proper assessment of the incidence and number of cases. Centralisation will allow for greater accuracy in the pathological diagnosis of Bone Tumours (a notoriously difficult pathological field). Once the incidence and diagnosis are established, then centralisation of treatment should be organised as in a country with a population of 10 million a single centre should be able to provide care for the entire population.

Such centralisation should produce better outcomes for all parties, as mentioned above and allow for research and treatment developments.

As discussed, it would appear that many bone metastases are not presenting. This, in my opinion, is a disaster. Imagine undergoing treatment for cancer and gaining remission only to have pain and disability from a bone metastasis. There is ample evidence that if such a patient has a life expectancy of greater than 6–12 months, management of that bone metastasis involves surgical methods similar to that of primary bone tumours. Again, centralisation of treatment would offer benefits in terms of patient outcomes and a considerable financial benefit for the health providers as remaining independent and mobile takes less resource than being confined to bed and suffering. A further advantage of having centralisation of Bone Tumour management is that lessons learnt can be transferred to the management of soft tissue sarcomas, which are ten times as frequent as primary bone tumours.

This paper, therefore, is really important as a first step in organisation of Bone tumour treatment in Jordan and I hope that this was the objective of the authors in putting this paper forwards for publication. I wish the authors well in their endeavour.