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Sarcoma

About

What is covered

This interactive flowchart covers the guidance that NICE has produced on sarcoma. It includes a link to NICE cancer service guidance on improving outcomes for people with sarcoma.

Updates

Updates to this interactive flowchart

8 August 2017 Olaratumab in combination with doxorubicin for treating advanced soft tissue sarcoma (NICE technology appraisal guidance 465) added to management.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on sarcoma in an interactive flowchart

What is covered

This interactive flowchart covers the guidance that NICE has produced on sarcoma. It includes a link to NICE cancer service guidance on improving outcomes for people with sarcoma.

Updates

Updates to this interactive flowchart

8 August 2017 Olaratumab in combination with doxorubicin for treating advanced soft tissue sarcoma (NICE technology appraisal guidance 465) added to management.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Mifamurtide for the treatment of osteosarcoma (2011) NICE technology appraisal guidance 235
Trabectedin for the treatment of advanced soft tissue sarcoma (2010) NICE technology appraisal guidance 185
Sarcoma (2015) NICE quality standard 78

Quality standards

Sarcoma

These quality statements are taken from the sarcoma quality standard. The quality standard defines clinical best practice for sarcoma and should be read in full.

Quality statements

Diagnostic pathways

This quality statement is taken from the sarcoma quality standard. The quality standard defines clinical best practice in sarcoma care and should be read in full.

Quality statement

Sarcoma advisory groups and sarcoma multidisciplinary teams (MDTs) have pathways for referral and diagnosis in place for people with suspected sarcoma.

Rationale

Because malignant sarcomas are rare, they are often diagnosed late, resulting in poorer patient outcomes. To improve diagnosis, people with suspected sarcoma need to be recognised early and quickly referred to services that can confirm the diagnosis. However, because sarcomas often can’t be reliably distinguished from benign conditions using clinical judgement, a large number of benign cases will also be referred to diagnostic services, creating a large diagnostic workload. To prevent specialist sarcoma services from becoming overwhelmed by referrals to confirm diagnosis, diagnostic pathways will need to be developed by sarcoma advisory groups in conjunction with sarcoma MDTs. These pathways will need to be agreed with the services providing the referrals, including GPs, general diagnostic imaging services and other secondary care providers.

Quality measures

Structure
a) Evidence that sarcoma advisory groups and sarcoma MDTs have pathways for referral and diagnosis in place for people with suspected sarcoma.
Data source: Local data collection.
b) Evidence of local arrangements to agree and communicate diagnostic pathways with primary and secondary care providers.
Data source: Local data collection.
Outcome
Stage of sarcoma at diagnosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Sarcoma advisory groups and sarcoma MDTs establish and implement pathways for referral and diagnosis for people with suspected sarcoma, ensuring that primary and secondary care providers are involved in their design.
Primary and secondary service providers (hospitals, sarcoma specialist centres, diagnostic clinics, GPs) follow pathways for referral and diagnosis for people with suspected sarcoma that have been agreed by sarcoma advisory groups and sarcoma MDTs. They should also ensure information about these pathways is easily accessible to staff.
Healthcare professionals ensure that they follow pathways for referral and diagnosis for people with suspected sarcoma that have been agreed by sarcoma advisory groups and sarcoma MDTs.
Commissioners (clinical commissioning groups and NHS England) ensure that all sarcoma advisory groups and sarcoma MDTs work with primary and secondary care providers to establish and implement pathways for referral and diagnosis for people with suspected sarcoma.

What the quality statement means for patients, service users and carers

People with symptoms that suggest sarcoma (a rare type of cancer that develops in a bone or in soft tissue such as muscle or fat) are referred and have investigations carried out by healthcare professionals who follow advice on diagnosing sarcoma from specialists in sarcoma.

Source guidance

  • Sarcoma (2006) NICE cancer service guidance, Section 3: Improving diagnosis of bone and extremity soft tissue sarcoma (page 37)

Definitions of terms used in this quality statement

Suspected sarcoma
The NICE guideline suspected cancer: recognition and referral includes recommendations for referral for suspected sarcoma.

Multidisciplinary teams for sarcoma

This quality statement is taken from the sarcoma quality standard. The quality standard defines clinical best practice in sarcoma care and should be read in full.

Quality statement

Adults, children and young people with bone sarcoma and adults with soft tissue sarcoma have their care plan confirmed by a sarcoma multidisciplinary team (MDT) and treatment delivered by services designated by the sarcoma advisory group.

Rationale

A sarcoma MDT should confirm care plans for adults, children and young people with bone sarcoma and adults with soft tissue sarcoma, although they might not deliver all of their care. Treatment may be provided by other services if agreed by the sarcoma MDT and sarcoma advisory group. Children with soft tissue sarcoma, for example children with rhabdomyosarcoma, would usually be managed by paediatric oncology MDTs.

Quality measures

Structure
a) Evidence of written protocols and local arrangements for adults, children and young people with bone sarcoma and adults with soft tissue sarcoma to have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group.
Data source: Local data collection.
b) Evidence of written protocols and pathways agreed between sarcoma MDTs and site-specific cancer MDTs clarifying the circumstances in which patient care should be transferred from one team to the other.
Data source: Local data collection. National Cancer Peer Review Manual for cancer services: sarcoma measures, measure 14-2L–112.
Process
a) Proportion of adults, children and young people with bone sarcomas who have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group.
Numerator – the number in the denominator who have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group.
Denominator – the number of adults, children and young people with bone sarcomas.
Data source: Local data collection. National Cancer Intelligence Network Cancer outcomes and services dataset.
b) Proportion of adults with soft tissue sarcomas who have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group.
Numerator – the number in the denominator who have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group.
Denominator – the number of adults with soft tissue sarcomas.
Data source: Local data collection. National Cancer Intelligence Network Cancer outcomes and services dataset.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, sarcoma MDTs and cancer MDTs) ensure that adults, children and young people with bone sarcomas and adults with soft tissue sarcomas have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group. Site-specific cancer MDTs that are not specifically for sarcoma should liaise with sarcoma MDTs when people with sarcoma are referred to them.
Healthcare professionals ensure that adults, children and young people with bone sarcomas and adults with soft tissue sarcomas have their care plan confirmed by a sarcoma MDT and treatment delivered by services designated by the sarcoma advisory group.
Commissioners (such as NHS England and clinical commissioning groups) ensure that adults, children and young people with bone sarcomas and adults with soft tissue sarcomas receive a care plan that is confirmed by a sarcoma MDT and treatment that is delivered by services designated by the sarcoma advisory group.

What the quality statement means for patients, service users and carers

Adults with soft tissue or bone sarcoma (a rare type of cancer that develops in a bone or in soft tissue such as muscle or fat) and children and young people with bone sarcoma are cared for with the help of a sarcoma multidisciplinary team (a specialist team of healthcare professionals who have training and experience in caring for people with sarcoma) who will advise on their care plan. Children with soft tissue sarcoma are usually cared for by a team that specialises in children’s cancers (a paediatric oncology multidisciplinary team).

Source guidance

  • Sarcoma (2006) NICE cancer service guidance, Section 5: Improving treatment: sarcoma multidisciplinary teams (pages 54 and 56)

Definitions of terms used in this quality statement

Sarcoma multidisciplinary team (MDT)
The core membership of a sarcoma MDT is defined in the National Cancer Peer Review Manual for cancer services: sarcoma measures.
Sarcoma MDTs can also have extended team members, some of whom may work as part of the core team. Extended team members can work at sites distant from the sarcoma MDT. Extended team members should participate in sarcoma MDT meetings when appropriate. Extended team roles include:
  • specialist sarcoma physiotherapist
  • specialised allied health professionals (such as therapy radiographers, occupational therapists, prosthetists, orthotists, dietitians, social workers, counsellors or psychologists)
  • paediatric oncologist (specifically for MDTs that treat children and young people with bone and/or soft tissue sarcoma)
  • specialist nurse(s) (including palliative care nurses and appropriately trained ward staff)
  • designated medical or clinical oncologist from a linked cancer centre
  • affiliated diagnostic service clinicians
  • other professionals including orthopaedic, thoracic, plastic, head and neck, gynaecological, gastrointestinal and vascular surgeons.
[Adapted from Sarcoma (NICE cancer service guidance), Section 5: Improving treatment: sarcoma multidisciplinary teams and National Cancer Peer Review Manual for cancer services: sarcoma measures]

Equality and diversity considerations

When referring people to a sarcoma MDT, potential difficulties in access such as age, travelling distance, disability or financial barriers should be taken into account.

Publishing information about areas of expertise

This quality statement is taken from the sarcoma quality standard. The quality standard defines clinical best practice in sarcoma care and should be read in full.

Quality statement

Sarcoma multidisciplinary teams (MDTs) publish information about their shared pathways, activity and patient outcomes, including information on site-specific sarcomas.

Rationale

Sarcoma MDTs should increase awareness of their pathways and arrangements to treat sarcomas, and their patient outcomes and activity. This will demonstrate their expertise and help commissioners to identify which sarcoma MDTs are best suited to treat particular sarcoma types and help in making decisions about referrals.

Quality measures

Structure
Evidence of local arrangements for sarcoma MDTs to publish information about shared pathways, activity and patient outcomes, including information on site-specific sarcomas.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (sarcoma MDTs) ensure arrangements are in place for the publication of information about their shared pathways, activity and patient outcomes, including information for site-specific sarcomas. This may involve working in collaboration with NHS England specialised services, specialist centres and the NHS England Sarcoma Clinical Reference Group.
Healthcare professionals ensure that they collect data and publish activity and patient outcome data, including information for site-specific sarcomas.
Commissioners (NHS England and clinical commissioning groups) ensure that they commission services that publish details of their arrangements with site-specific cancer MDTs to manage site-specific sarcomas, and that also collect and publish activity and patient outcome data, including information for site-specific sarcomas.

What the quality statement means for patients, service users and carers

People with sarcoma (a rare type of cancer that develops in a bone or in soft tissue such as muscle or fat) can see how different sarcoma multidisciplinary teams (specialist teams of healthcare professionals who have training and experience in caring for people with sarcoma) treat their particular type of sarcoma, which may help them decide on the best sarcoma multidisciplinary team to treat them.

Source guidance

  • Sarcoma (2006) NICE cancer service guidance, Section 5: Improving treatment: sarcoma multidisciplinary teams (page 54) and Section 10: Improving knowledge (page 96)

Definitions of terms used in this quality statement

Activity and patient outcomes
Activity and patient outcomes for sarcoma MDTs include:
  • number of new cases per annum
  • local recurrence rates
  • patient experience of care
  • treatment morbidity and physical function
  • survival rates.
[Definition developed from expert consensus; adapted from Sarcoma, NICE cancer service guidance].
Site-specific sarcomas
Site-specific sarcomas include gynaecological sarcomas, head and neck sarcomas, retroperitoneal and pelvic sarcomas, chest wall or intrathoracic sarcomas, skin sarcomas, central nervous system sarcomas, gastrointestinal stromal tumours, urological sarcomas and breast sarcomas. [Definition developed from expert consensus; adapted from Sarcoma, NICE cancer service guidance].

Retroperitoneal sarcoma

This quality statement is taken from the sarcoma quality standard. The quality standard defines clinical best practice in sarcoma care and should be read in full.

Quality statement

People with a retroperitoneal sarcoma are referred before having any treatment to a sarcoma treatment centre with special expertise in managing this type of tumour.

Rationale

Treating retroperitoneal sarcomas poses particular challenges, and experience of treating this tumour type will vary between sarcoma treatment centres. Outcomes for people with retroperitoneal sarcoma will be improved by concentrating their treatment at centres with staff who are experienced in managing this type of tumour.

Quality measures

Structure
Evidence of local arrangements and protocols to ensure that people with a retroperitoneal sarcoma are referred before having any treatment to a sarcoma treatment centre with special expertise in managing this type of tumour.
Data source: Local data collection.
Process
Proportion of people with a retroperitoneal sarcoma who are referred before having any treatment to a sarcoma treatment centre with special expertise in managing this type of tumour.
Numerator – the number in the denominator who are referred before having any treatment to a sarcoma treatment centre with special expertise in managing this type of tumour.
Denominator – the number of people with a retroperitoneal sarcoma.
Data source: Local data collection.
Outcome
Retroperitoneal sarcoma survival rate.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as such as hospitals, sarcoma multidisciplinary teams (MDTs) and cancer MDTs) ensure that protocols are in place to refer people with a retroperitoneal sarcoma before they have any treatment to an identified treatment centre with special expertise in treating this type of sarcoma.
Healthcare professionals ensure that they refer people with retroperitoneal sarcoma before they have any treatment to a treatment centre with special expertise in treating this type of sarcoma.
Commissioners (NHS England Sarcoma Clinical Reference Group) may wish to consider including a definition for retroperitoneal sarcoma centres with special expertise in national service specifications. Clinical commissioning groups ensure that they commission services that have protocols in place to refer people with a retroperitoneal sarcoma before they have any treatment to an identified treatment centre with special expertise in treating this type of sarcoma.

What the quality statement means for patients, service users and carers

People with retroperitoneal sarcoma (a rare type of cancer that develops in the soft tissues of the abdomen or pelvis) are referred to a centre that has special expertise in treating this type of sarcoma before being offered any treatment.

Source guidance

  • Sarcoma (2006) NICE cancer service guidance, Section 7: Improving treatment: soft tissue sarcomas (page 73)

Definitions of terms used in this quality statement

Sarcoma treatment centre with special expertise in managing this type of tumour
Treatment centres with special expertise in treating retroperitoneal sarcoma should be identified locally by taking into account case volumes and patient outcomes for retroperitoneal sarcoma. [Definition developed from expert consensus]

Equality and diversity considerations

When referring people to a sarcoma treatment centre, potential difficulties in access such as travelling distance, age, disability or financial barriers should be taken into account.

Surgical skills

This quality statement is taken from the sarcoma quality standard. The quality standard defines clinical best practice in sarcoma care and should be read in full.

Quality statement

Surgeons performing planned resections of sarcomas are core or extended members of a sarcoma multidisciplinary team (MDT).

Rationale

Sarcoma resection carried out by a specialist sarcoma surgeon, who is a core member of the sarcoma MDT, is generally more likely to result in improved patient outcomes. However, in some cases the most appropriate surgeon to carry out a sarcoma resection may not be a sarcoma specialist, but a surgeon with skills relevant to the age of the patient or the site of the tumour. In these cases the surgeon should be an extended member of a sarcoma MDT.

Quality measures

Structure
Evidence of local arrangements and protocols to ensure that people who have planned resection of their sarcoma have it performed by a surgeon who is a core or extended member of a sarcoma MDT.
Data source: Local data collection.
Process
Proportion of planned sarcoma resections that are performed by a surgeon who is a core or extended member of a sarcoma MDT.
Numerator – the number in the denominator that are performed by a surgeon who is a core or extended member of a sarcoma MDT.
Denominator – the number of planned sarcoma resections.
Data source: Local data collection. National Cancer Intelligence Network Cancer outcomes and services dataset.
Outcome
a) 30-day mortality rate post-sarcoma resection.
Data source: Local data collection.
b) Recurrence within 2 years of initial surgery.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, sarcoma specialist centres) ensure that operational policies and procedures are in place for people having planned resection of their sarcoma to either have it carried out by a surgeon who is a core member of a sarcoma MDT or, when appropriate, by a surgeon who is an extended member of a sarcoma MDT with tumour site-specific or age-appropriate skills.
Healthcare professionals ensure that people having planned resection of their sarcoma have it carried out by a surgeon who is a core member of a sarcoma MDT or, when appropriate, by a surgeon with tumour site-specific or age-appropriate skills who is an extended member of a sarcoma MDT.
Commissioners (NHS England and clinical commissioning groups) should ensure that policies and procedures are in place for people who are having planned resection of their sarcoma to either have it carried out by a surgeon who is a core member of a sarcoma MDT or, when appropriate, by a surgeon who is an extended member of a sarcoma MDT with tumour site-specific or age-appropriate skills.

What the quality statement means for patients, service users and carers

People with sarcoma (a rare type of cancer that develops in a bone or in soft tissue such as muscle or fat) who are having surgery to remove their tumour have their operation done either by an experienced surgeon who specialises in sarcomas and is part of the sarcoma multidisciplinary team (a specialist team of healthcare professionals who have training and experience in bone or soft tissue sarcoma) or by a surgeon who has other suitable specialist skills and works with a sarcoma multidisciplinary team.

Source guidance

  • Sarcoma (2006) NICE cancer service guidance, Key recommendations (page 8) and Section 5: Improving treatment: sarcoma multidisciplinary teams (page 56)

Equality and diversity considerations

When considering appropriate surgeons for referrals, any potential difficulties in accessing services, which may include distance, age, disability and financial barriers, should be taken into account.

Key workers

This quality statement is taken from the sarcoma quality standard. The quality standard defines clinical best practice in sarcoma care and should be read in full.

Quality statement

People with sarcoma are supported by an allocated key worker with specialist knowledge of sarcomas and their treatment.

Rationale

Because sarcoma is such a rare cancer, specialist knowledge of the condition and its treatment is not widespread. It is important that people with sarcoma are able to contact a key worker who can provide specialist guidance and support at all stages of their care and treatment, including during follow-up. Key workers can also act as a link to local support groups. In addition, care for people with sarcoma may encompass services outside a sarcoma treatment centre, such as rehabilitation, prosthetics, psychological support and palliative care. A key worker is integral in ensuring that people with sarcoma are aware of and able to access such services, and in providing necessary clinical information to these services.

Quality measures

Structure
Evidence of local arrangements to provide a designated key worker with specialist knowledge of sarcomas and their treatment for all people with sarcoma.
Data source: Local data collection. National Cancer Peer Review Manual for cancer services: sarcoma measures, measure 14-2L–115.
Process
Proportion of people with sarcoma who have an allocated key worker with specialist knowledge of sarcomas and their treatment.
Numerator – the number in the denominator who are allocated a key worker with specialist knowledge of sarcomas and their treatment.
Denominator – the number of people with sarcoma.
Data source: Local data collection.
Outcome
a) Coordination of care.
Data source: Local data collection.
b) Patient satisfaction and availability of key worker.
Data source: Local data collection. National Cancer Intelligence Network National cancer patient experience survey.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as sarcoma specialist centres and hospitals) ensure that sufficient key workers with specialist knowledge of sarcomas and their treatment are available to support people with sarcoma, and that cover is available for illness or annual leave.
Healthcare professionals ensure that people with sarcoma are allocated a key worker with specialist knowledge of sarcomas and their treatment.
Commissioners (NHS England Sarcoma Clinical Reference Group) may wish to consider including in national service specifications that people with sarcoma are allocated a key worker with specialist knowledge of sarcomas and their treatment.

What the quality statement means for patients, service users and carers

People with sarcoma (a rare type of cancer that develops in a bone or in soft tissue such as muscle or fat) are supported by a ‘key worker’, who is a healthcare professional with specialist knowledge of sarcoma. People with sarcoma should be able to contact their key worker for information and support throughout their care.

Source guidance

  • Sarcoma (2006) NICE cancer service guidance, Section 8: Supportive and palliative care (page 82)

Definitions of terms used in this quality statement

Key workers with specialist knowledge of sarcomas
Key workers are usually specialist nurses or allied health professionals who have an in-depth or specialist knowledge of sarcomas and their treatment. They can act as advocates for the patient, helping to coordinate the diagnostic and treatment pathway, providing continuity and ensuring the patient knows how to access information and advice. [Sarcoma (NICE cancer service guidance)]

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Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Why we made the recommendations on olaratumab

People with advanced soft tissue sarcoma having doxorubicin alone are expected to live for 12 to 16 months after starting treatment. Evidence suggests that having olaratumab plus doxorubicin increases the length of time people live by 11.8 months. This amount of survival gain in advanced sarcoma is unprecedented and potentially represents a step-change in its treatment. However, there are not enough long-term data to know the overall length of time people having olaratumab plus doxorubicin live compared with doxorubicin alone because a confirmatory phase III trial (ANNOUNCE) is still ongoing.
Olaratumab plus doxorubicin met NICE's criteria to be considered a life-extending treatment at the end of life. The criteria are that life expectancy for people with the condition should be less than 24 months and that the treatment should extend life by more than 3 months.
The estimate of the cost effectiveness of olaratumab plus doxorubicin varied primarily because of the uncertainties in the data. The incremental cost-effectiveness ratios (ICERs) ranged between £46,000 and £60,000 per quality-adjusted life year (QALY) gained. The most plausible ICER is likely to be close to £60,000 per QALY gained. This is not cost effective based on what NICE normally considers acceptable for end-of-life treatments.
More long-term data would reduce uncertainty in the clinical effectiveness of olaratumab plus doxorubicin and allow a more certain cost effectiveness estimate. The ongoing ANNOUNCE trial is expected to address the uncertainty in the data. Olaratumab is therefore recommended for use within the Cancer Drugs Fund while further data are collected.
For more information see the committee discussion in the NICE technology appraisal on olaratumab in combination with doxorubicin for treating advanced soft tissue sarcoma.

Glossary

Paths in this pathway

Pathway created: January 2015 Last updated: August 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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