Conclusions
A quality gap exists between national guideline recommendations and
delivery of post-operative radiation therapy in patients treated
surgically for HNSCC. A majority of patients do not initiate
post-operative radiotherapy within guideline-recommended 6
weeks.8 Our single academic institution review
mirrored those results. The majority of patients (88.6%) did not start
RT within 6 weeks of surgery, and the average time to initiate of PORT
was 7.9 weeks.
Risk factors for a delay in initiation of PORT include, but are not
limited to, lower seriocomic status, black race, public insurance, or
uninsured, increasing severity of comorbidities, increased
post-operative LOS, 30 day readmissions, fragmented
care8, and receiving adjuvant therapy at a
non-academic center.10,15
Our case-series sought to determine potentially modifiable risk factors
which are associated with a prolonged initiation of PORT. Many patient
related factors that might delay PORT cannot be altered - such as
patient age or tumor stage at presentation. However, there exists some
patient and treatment related factors which offer an opportunity for
quality improvements and thus earlier initiation of PORT. While previous
studies have identified several factors associated with a delay in PORT,
our study assessed additional potentially modifiable risk factors such
as gastrostomy tube placement, rehabilitation facility placement, and
post-operative complications which were all associated with, or at least
showed a trend towards, a delay in PORT (Figure 4). Additionally, our
single-institution study allows for collection of these more granular
data points (such as wound complications and infections), which may not
be available in the larger database studies.
Post-operative length of stay, 30-day readmission and post-operative
complications were associated with delays. Interestingly, patients who
received adjuvant chemotherapy had significantly lower intervals between
surgery and initiation of adjuvant therapy (10 days fewer, p = 0.087).
Additionally, delays were decreased if surgery and adjuvant radiotherapy
were performed at the same institution. Need for dental extractions,
gastrostomy tube placement, and rehabilitation facility placement were
associated with a longer interval to initiation of PORT, but were not
statistically significant.
The finding that the addition of adjuvant chemotherapy to radiation was
associated with earlier initiation of adjuvant therapy seems
counterintuitive. We postulate that the reduced interval for these
patients may be due to earlier recognition for needed adjuvant therapy.
A patient with more advanced clinical disease at initial presentation
may be referred in a timelier fashion than a patient whose need for
adjuvant therapy may be unclear at initial presentation. Referrals in
the latter type of cases are typically made only after final pathology
results are released, and perhaps only after a tumor board discussion;
this decision may not occur until up to 2-3 weeks after surgery.
However, this finding may be in part explained by the fact that adjuvant
chemotherapy is only be offered to a healthier subset of patients. These
patients would be more likely to start therapy sooner than their
unhealthy counterparts.
Fragmented care has previously been associated with delayed initiation
of PORT and poor adherence to treatment regimens,10and poorer outcomes.16,17 We found a statistically
significant decrease in PORT delays for those who received both surgery
and adjuvant therapy at our academic facility. Academic centers may
improve timeliness of care due to ease of intra-institutional referrals,
care coordinators, and multidisciplinary tumor boards which include
surgeons, radiation, and medical oncologists. Additional benefit may
include the patient volume of an academic center,17higher level of comfort with management of HNSCC-related complications,
and fewer treatment interruptions or early terminations. Adjuvant
therapy at an academic center has also been shown to reduce total
“package time” (time from surgery to completion of adjuvant therapy),
likely for the reasons stated above. A reduction of package time is
associated with increased overall and recurrence free
survival.14-15 This difference in fragmented vs.
unfragmented care may be patient related as well. Those who choose to
continue their adjuvant therapy at our institution, often despite
significant commutes, may be more motivated, educated, have better
family support, or better access to transportation.
Improving adherence rates for all patients will be challenging, as there
are often unavoidable delays that push initiation of PORT beyond 6
weeks. Therefore, it is critical to identify those modifiable factors
which may be contributing to PORT delays and directly address those
factors through quality improvement processes.
Divi et al12 demonstrated the utility of a structured
quality improvement project in decreasing the time from surgery to
initiation of adjuvant therapy. Twelve interventions which sought to
address the three key drivers of delay (delayed dental extraction,
delayed referral to radiation oncology, and poor patient or team
engagement) were implemented. They noted a reduction in avoidable delays
from 24 to 9%. Additionally, Janz et al13demonstrated the following care processes improved timeliness of PORT:
preoperative RT consultation, pathology report available within 7 days
of surgery, time from surgery to PORT referral no longer than 10 days,
and time for PORT consultation to its start no longer than 21 days.
In this study, we also noted that patients with longer LOS and those who
had postoperative complications had significant delays in initiating
adjuvant therapy. This presents an opportunity for intervention. The
patients who are at risk for longer stays (e.g. those requiring free
flap reconstruction, those without caregivers at home) or who are at
high risk for complications (e.g., those with multiple comorbidities)
should be identified and preoperative referrals to adjuvant care
providers can be made. If the need for G-tube
placement18 or dental extractions can be anticipated,
these can be accomplished pre- or intra-operatively. However,
complications and length of stay are not always modifiable factors, as
unforeseen events often unfold during patients’ post-operative course,
which may not be predicted. For example, a patient without significant
comorbidities may still develop a wound complication which would prolong
their stay.
We have initiated a structured institutional multidisciplinary process
at our institution in hopes of reducing delays. This initiative will
generate automated referrals and include a checklist led by a Head and
Neck Cancer-specific nurse navigator to identify at-risk patients,
facilitate consult appointments, review of pathology reports, and ensure
timely presentation at tumor board. The specific details of the
initiative are currently in development in conjunction between our
surgeons, radiation oncologists, medical oncologists, and nurse
navigator.
There were limitations to this study. Our sample size was adequate to
determine statistical significance in delay for several risk factors.
However, some risk factors (gastrostomy tube placement, need dental
extractions, rehabilitation facility placement) showed a trend towards
delay, but were not statistically significant, as might have been
expected from prior studies.8
There was also a lack of availability of some outside treatment facility
records, which resulted in exclusion of those patients. Some records did
not include the day of therapy initiation, number of fractions received,
number of fractions completed, or total treatment dose.
Our single academic institutional study also makes the results
challenging to generalize to those not practicing in a similar setting.
Finally, comparing all non-academic centers as a single aggregate to our
academic institution may unfairly generalize their outcomes. It is
possible some non-academic centers have better outcomes than others, or
even our institution, but this was not assessed in the data.
This study is important because it identifies modifiable risk factors
for a delay in initiation of PORT, a known metric for quality care in
HNSCC. Future studies will address the success of a structured
institutional multidisciplinary approach and the use of a dedicated
nurse navigator in reducing delays in adjuvant therapy, and assessing
its effect on outcome measures, such as recurrence rate and disease-free
survival in HNSCC.
In this single institution case series, a majority of patients with
HNSCC did not adhere to recommendation of initiating adjuvant
radiotherapy within 6 weeks of surgery. Identification of modifiable
risks factors/barriers that delay initiation of PORT is crucial to
reduce avoidable delays. A structured quality improvement project, which
directly addresses these modifiable risk factors, would be expected to
improve guideline recommended adherence to post-operative RT time
intervals, and ultimately improve survival outcomes in patients with
HNSCC.