Organizing Care Matters: Fragmented Pathways Double Early Local Recurrence Risk in Sarcoma

Background: Early local recurrence (ELR) in musculoskeletal sarcoma is associated with poor oncologic outcomes, yet the relative impact of tumor biology versus system-level factors remains insufficiently understood. This multicenter real-world study within the Swiss Sarcoma Network evaluated whether the initial care pathway influences the risk and timing of ELR. Methods: Patients with histologically confirmed sarcoma and documented local recurrence were classified according to initial management within a Comprehensive Care Pathway (CCP) or a Fragmented Care Pathway (FCP). ELR was defined as recurrence within 12 months after index surgery. Associations were analyzed using restricted Cox proportional hazards models and Firth-penalized logistic regression, adjusting for key clinicopathologic factors. Follow-up was calculated from index surgery to death or administrative censoring (median 88.2 months; interquartile range, 54.9-141.6). Results: Among 158 patients with local recurrence, 96 (60.8%) were treated within CCP, and 62 (39.2%) entered through FCP. ELR occurred in 53 patients (33.5%) and was more frequent in the FCP cohort. Fragmented care was independently associated with ELR in both time-to-event analysis (hazard ratio 2.00, 95% CI 1.14-3.51) and penalized logistic regression (odds ratio 2.83, 95% CI 1.09-6.94). Unplanned ("whoops") procedures and incomplete resection margins were substantially more common in FCP and independently predicted ELR. Tumor grade also contributed to risk, but the magnitude of the pathway effect was comparable. ELR was associated with higher rates of synchronous metastases and inferior survival compared with late local recurrence. Adjuvant therapy did not independently reduce ELR risk after adjustment for surgical quality. Conclusions: These findings indicate that ELR in musculoskeletal sarcoma is strongly influenced by modifiable system-level factors. Early referral, multidisciplinary evaluation, and expert margin-oriented surgery are critical to reducing early recurrence and improving patient outcomes.