Introduction
Head and neck squamous cell carcinoma (HNSCC) often requires
multimodality treatment including surgery, radiation therapy, and
chemotherapy. For patients treated surgically for HNSCC, the National
Cancer Comprehensive Cancer Network (NCCN) Treatment Guidelines
recommend the initiation of post-operative adjuvant radiation therapy
(PORT) within six weeks of surgery.1 In fact, timely
initiation of post-operative radiation is the only measure of timely
care incorporated into the NCCN guidelines for HNSCC.
This recommendation originates from studies that found improved overall
survival when adjuvant treatment was initiated within six weeks of
surgery.2-5 More recently, Graboyes et
al6 conducted a National Cancer Data base review,
which identified 41,291 patients requiring PORT, to reevaluate these
recommendations. This analysis supported the guidelines, as delays in
initiating PORT beyond 6 weeks after surgery was associated with a 10%
absolute decrease in overall survival.6 With a push
towards healthcare related quality improvement, adjuvant radiation
therapy within six weeks has been identified as a quality metric that
has a meaningful impact on survival.7
Despite the NCCN guideline recommendations, a majority of patients do
not initiate PORT within six weeks. In a separate paper, Graboyes et al,
found that only 44.7% of patients initiated PORT within six weeks of
surgery. Of additional concern, it appears the proportion of patients
experiencing delays is on the rise.8
Risk factors associated with delayed initiation of PORT include
patient-, tumor-, and treatment-specific
characteristics.8-15 Factors implicated in delayed
initiation of PORT include black race, public or no insurance, lower
level of education, increasing severity of comorbidities, increased
postoperative length of stay, 30-day unplanned readmissions, and
undergoing surgery and PORT at different facilities, i.e. “fragmented
care.”
In this study, we sought to identify modifiable risk factors associated
with delayed initiation of PORT and implement process-related quality
improvement metrics to address those factors. Improving compliance to
guideline recommendations for timely initiation of PORT would be
expected to improve overall survival.