Advanced Radiotherapy Across a Multi-Geography Referral Network for Children With Ewing Sarcoma and Rhabdomyosarcoma: Treatment Delivery and Early Outcomes-A Single-Centre Experience.
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BACKGROUND: Children with Ewing sarcoma (ES) and rhabdomyosarcoma (RMS) across Asia, the Middle East and Africa often require cross-border referral for advanced radiotherapy, risking a disruption of multimodality care. We evaluated whether a structured referral network could deliver advanced radiotherapy while preserving treatment continuity. METHODS: This retrospective single-centre study included 54 consecutive children (27 ES, 27 RMS) treated in India between 2019 and 2025, referred from 13 countries and 11 Indian states. Primary endpoints were radiotherapy completion, treatment interruptions, chemotherapy continuity, treatment abandonment and follow-up retention. Survival outcomes were secondary endpoints. RESULTS: Median age was 7 years (range, 1-18), and 87% received proton beam therapy. All patients completed planned radiotherapy; interruptions occurred in only three patients, all ≤4 days. There was no treatment abandonment, and loss to follow-up was 2%. Planned chemotherapy was completed in all patients, with shared delivery between referring and treating centres in 80%. Median time from chemotherapy initiation to radiotherapy was 23.3 weeks for ES and 17.7 weeks for RMS. Among patients receiving definitive radiotherapy, treatment began within 15 weeks of chemotherapy start in 72% of ES and 88% of RMS patients. After radiotherapy, 63% resumed chemotherapy within 14 days and 78% within 21 days. Three-year overall survival and progression-free survival were 89.7% and 55.0% for ES (100% and 66.4% in localised disease) and 82.5% and 69.7% for RMS (90.0% and 74.2% in localised disease). CONCLUSIONS: In a single-centre cohort of children referred across state and national borders, a structured referral network enabled the delivery of advanced radiotherapy while preserving multimodality treatment continuity. Although survival outcomes are descriptive and derived from a selected cohort, this model may inform access strategies in regions without local advanced radiotherapy capability.