Evaluating delays in patients treated with post‐operative radiation therapy for head and neck squamous cell carcinoma

Abstract

Introduction: Delays in commencing post-operative radiation therapy (PORT) and prolongation of overall treatment times (OTT) are associated with reduced overall survival and higher recurrence rates in patients with head and neck squamous cell carcinoma (HNSCC). The objective of this study was to evaluate treatment delays, factors contributing to those delays and to explore strategies to mitigate them. Methods: This retrospective study included patients with mucosal HNSCC at Townsville University Hospital treated with curative intent surgery and PORT between June 2011 and June 2019. The proportion of patients who experienced delays in commencing PORT (>6 weeks) and OTT were evaluated and reasons for these delays were explored.Results: The study included 94 patients of which 70% experienced PORT delay. Surgery at an external facility (81% vs 56%, P = 0.006) and longer postoperative length of stay (P = 0.011) were significantly associated with a higher incidence of PORT delay. Aboriginal and Torres Strait Islander patients had a higher rate of PORT delay (89% vs 68.2%, P = 0.198). Significant delays were noted from time of surgery to radiation oncology (RO) consult and from RO consult to commencement of radiation treatment. Conclusion: This study demonstrates that the prevalence of PORT delay for patients with HNSCC remains high with room for improvement. Potential strategies to improve delays include developing effective care coordination, addressing specific needs of Indigenous patients, implementing reliable automated tracking and communication systems between teams and harnessing existing electronic referral systems.

Assessing the Risk of Adjuvant Radiotherapy Initiation Delays With Social Support Surveys

“…Other variables associated with delays in our cohort with univariate analysis included stage III/IV cancer and PORT at another institution, consistent with prior studies 33 . The association between outside facilities and delays suggests that fragmentation of care is a contributing factor.…”

“…34 While other studies have found the length of postoperative hospital stay to be associated with delays in treatment, it did not modify the risk of PORT delay for the present cohort. 20,33 These findings, while important, do not provide meaningful information in the preoperative setting that can help guide earlier patient intervention. Furthermore, distinguishing variables that may mediate delays through association, such as length of stay, from variables that directly moderate delays, such as social support, is important when creating targeted interventions.…”

“…31,32 Other variables associated with delays in our cohort with univariate analysis included stage III/IV cancer and PORT at another institution, consistent with prior studies. 33 The association between outside facilities and delays suggests that fragmentation of care is a contributing factor. As expected, patients with ECS and positive margins had their PORT course accelerated, potentially due to their high-risk features and knowledge that these factors can substantially impact disease outcome.…”

Influence of time between surgery and adjuvant radiotherapy on prognosis for patients with head and neck squamous cell carcinoma: A systematic review

“…44,45 A time delay in one or more steps on the pathway to therapy may result in an eventual delay in patient receiving ultimate care. 46 At the patient level, those with advanced disease or underlying medical complications may require more postoperative recovery time for wounds to heal. The time required for wound healing is patient-specific and involves many factors, including presence of chronic comorbidities such as diabetes.…”

“…Moreover, patient's access to radiotherapy maybe disrupted by issues such as travel distance and insurance referral 44,45 . A time delay in one or more steps on the pathway to therapy may result in an eventual delay in patient receiving ultimate care 46 . At the patient level, those with advanced disease or underlying medical complications may require more postoperative recovery time for wounds to heal.…”