An equity‐based narrative review of barriers to timely postoperative radiation therapy for patients with head and neck squamous cell carcinoma

Abstract

Objectives: The majority of patients with head and neck squamous cell carcinoma (HNSCC) do not commence postoperative radiation treatment (PORT) within the recommended 6 weeks. We explore how delayed PORT affects survival outcomes, what factors are associated with delayed PORT initiation, and what interventions exist to reduce delays in PORT initiation. Methods: We conducted a PubMed search to identify articles discussing timely PORT for HNSCC. We performed a narrative review to assess survival outcomes of delayed PORT as well as social determinants of health (SDOH) and clinical factors associated with delayed PORT, using the PROGRESS-Plus health equity framework to guide our analysis. We reviewed interventions designed to reduce delays in PORT. Results: Delayed PORT is associated with reduced overall survival. Delays in PORT disproportionately burden patients of racial/ethnic minority backgrounds, Medicaid or no insurance, low socioeconomic status, limited access to care, more comorbidities, presentation at advanced stages, and those who experience postoperative complications. Delays in PORT initiation tend to occur during transitions in head and neck cancer care. Delays in PORT may be reduced by interventions that identify patients who are most likely to experience delayed PORT, support patients according to their specific needs and barriers to care, and streamline care and referral processes. Conclusions: Both SDOH and clinical factors are associated with delays in timely PORT. Structural change is needed to reduce health disparities and promote equitable access to care for all. When planning care, providers must consider not only biological factors but also SDOH to maximize care outcomes.

Update on adherence to guidelines for time to initiation of postoperative radiation for head and neck squamous cell carcinoma

“…Persistent associations with treatment delay included black race, public insurance, lower educational attainment, oral cavity tumor site, increased postoperative length of stay or unplanned readmissions, treatment at an academic center, and fragmented surgery and PORT at different locations. The parallels of our findings 5 years after the initial report underscores inadequate interventions to rectify this disparity despite expanding evidence dedicated to understanding patient and system‐level barriers to timely PORT 3–6 . Additionally, temporal trends are suggestive of worsening adherence over time.…”

“…A National Cancer Database (NCDB) analysis spanning 2006 through 2014 reported that greater than half of patients with HNSCC requiring PORT initiated treatment after 6 weeks from surgery 3 . Several subsequent publications attempt to further elucidate reasons for treatment delay and measures to implement targeted quality improvement interventions 4–6 …”

“…3 Several subsequent publications attempt to further elucidate reasons for treatment delay and measures to implement targeted quality improvement interventions. [4][5][6] In January of 2022, the American College of Surgeons (ACS) Commission on Cancer (CoC) released a national quality metric for patients with HNSCC to initiate PORT within 6 weeks. 7 Given that 8 years passed since the last large-scale analysis of timeliness of care, this study provides an update on adherence to guidelines for time to initiation of PORT for patients with HNSCC.…”

Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy

“…The interval between primary surgery and initiation of PORT is the primary driver of total treatment package time, affecting survival independent of diagnosis-to-treatment interval or duration of radiation therapy . Delays in PORT initiation disproportionately affect racial and ethnic minorities, those with Medicaid insurance, and those in medically underserved areas …”

Closing the Achievement Gap: An Analysis of Equity-Based Educational Interventions

“…There is some evidence that equity-based interventions can help reduce the achievement gap, but more research is needed to determine their precise effect and optimal implementation (Noyes et al, 2021). The purpose of this research is to investigate whether or not equity-based educational interventions are helpful in reducing the achievement gap, and if so, to what extent, and what kinds of obstacles and benefits schools may face when trying to implement such programs (Wald et al, 2019).…”