Sometimes we need to think of zebras: An observational study on delays in the identification of bone tumors in children

Background: Pediatric bone sarcomas are rare and difficult to diagnose. Osteosarcoma is the most common and Ewing sarcoma is the second most common of these. Most cases are identified in individuals age 13 to 16 years. Common sites for osteosarcoma include the distal femur and proximal tibia. Patients typically present with chronic localized pain that is intermittent. There is often no fever, no weight loss, and no malaise. Because the presentation can be similar to what a clinician would expect for tendonitis and other benign pathologies, patients frequently receive physiotherapy rather than referral to a tertiary care centre for further workup. A quality improvement observational study was proposed to address a lack of research on delays in appropriate management of pediatric bone tumor and to increase awareness of osteosarcoma and Ewing sarcoma. Methods: Six pediatric patients at BC Children's Hospital who were diagnosed with either osteosarcoma or Ewing sarcoma in 2018 were identified from the oncology database. The dates of their interactions with the health care system were used to create patient journey maps. Results: Each patient saw an average of four health care professionals before referral to BC Children's Hospital, and three patients spent 4 to 9 weeks receiving physiotherapy. On average, 114 days elapsed from the time patients had their first symptoms to when they received chemotherapy, and 81% of this time was spent within the primary care system. Conclusions: The study reveals an overall delay in diagnosis and treatment of pediatric bone tumors and highlights the need for general practitioners to further consider sarcomas in the differential diagnosis when patients present with chronic localized pain, especially when patients are in the at-risk age group and the pain is localized to one of the common sites. Practitioners should be even more suspicious if there is a history of night pain, an atypical pain pattern following minor trauma, or a soft tissue mass on examination.