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Original Investigation
From the American Head and Neck Society
December 2018

Association of Care Processes With Timely, Equitable Postoperative Radiotherapy in Patients With Surgically Treated Head and Neck Squamous Cell Carcinoma

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
  • 2Hollings Cancer Center, Medical University of South Carolina, Charleston
  • 3Department of Public Health Sciences, Medical University of South Carolina, Charleston
  • 4Department of Radiation Oncology, Medical University of South Carolina, Charleston
  • 5Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston
  • 6Department of Psychiatry, Medical University of South Carolina, Charleston
JAMA Otolaryngol Head Neck Surg. 2018;144(12):1105-1114. doi:10.1001/jamaoto.2018.2225
Key Points

Question  Do key care processes facilitate timely, equitable postoperative radiotherapy after surgery for head and neck squamous cell carcinoma?

Findings  In this cohort study of 197 patients with head and neck squamous cell carcinoma, care processes including preoperative radiotherapy consultation, location of postoperative radiotherapy, timing of pathology report, and timing of referrals and consultation for postoperative radiotherapy were associated with timely, guideline-adherent initiation of therapy within 6 weeks of surgery.

Meaning  Novel strategies appear to be needed to ensure that these processes are performed for all patients with head and neck squamous cell carcinoma, thereby facilitating timely, equitable guideline-adherent initiation of postoperative radiotherapy.

Abstract

Importance  Delays in initiation of postoperative radiotherapy (PORT) after surgery for head and neck squamous cell carcinoma (HNSCC) are common, predominantly affect racial minorities, and are associated with decreased survival. Details regarding the care processes that contribute to timely, equitable PORT remain unknown.

Objective  To determine care processes associated with timely, equitable PORT.

Design, Setting, and Participants  This retrospective cohort study included patients 18 years or older undergoing surgery for HNSCC at the Medical University of South Carolina (MUSC), Charleston, followed by PORT (at MUSC or elsewhere) with or without chemotherapy from January 1, 2014, through December 31, 2016. Data were analyzed from September 15, 2017, through June 28, 2018.

Main Outcomes and Measures  The main outcome measure was the proportion of timely, guideline-adherent initiation of PORT (≤6 weeks postoperatively). Secondary outcome measures included care processes associated with timely PORT. The association between process variables with timely PORT was explored using multivariable logistic regression analysis. Effect modification of the association between receipt of care processes and timely PORT by race was explored using interaction effects.

Results  A total of 197 patients were included in the analysis; they were predominantly white (157 [79.7%]) and male (136 [69.0%]) with a mean age of 59 years (range, 28-89 years). Overall, 89 patients (45.2%) experienced a delay initiating PORT. African American patients had a 13.5% absolute increase in the rate of delayed PORT relative to white patients (21 of 37 [56.8%] vs 68 of 157 [43.3%]). The adjusted multivariable regression showed that the following care processes were associated with timely PORT: preoperative radiotherapy consultation (odds ratio [OR], 8.94; 95% CI, 1.64-65.53), PORT at MUSC (OR, 6.21; 95% CI, 1.85-24.75), pathology report within 7 postoperative days (OR, 4.14; 95% CI, 1.21-15.86), time from surgery to PORT referral of no longer than 10 days (OR, 12.14; 95% CI, 3.14-63.00), time from PORT referral to consultation of no longer than 10 days (OR, 10.76; 95% CI, 3.01-49.70), and time from PORT consultation to its start of no longer than 21 days (OR, 4.80; 95% CI 1.41-18.44). Analysis of interactions revealed no statistically significant differences between African American and white patients in receipt of key processes associated with timely PORT.

Conclusions and Relevance  Specific care processes are associated with guideline-adherent initiation of PORT. Novel strategies appear to be needed to ensure that these processes are performed for all patients with HNSCC, thereby facilitating timely, equitable PORT.

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