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Original Investigation
September 12, 2019

Association of Delayed Time to Treatment Initiation With Overall Survival and Recurrence Among Patients With Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population

Author Affiliations
  • 1Medical student at the Albert Einstein College of Medicine, Bronx, New York
  • 2Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
  • 3Department of Epidemiology & Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
  • 4Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, New York
  • 5Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Bronx, New York
JAMA Otolaryngol Head Neck Surg. 2019;145(11):1001-1009. doi:10.1001/jamaoto.2019.2414
Key Points

Question  What are the consequences of delaying treatment initiation in an urban underserved population of patients with head and neck squamous cell carcinoma?

Findings  In this cohort study of 956 patients with head and neck squamous cell carcinoma, delayed treatment initiation beyond 60 days was associated with worse survival and greater risk of recurrence independent of other relevant factors. Associated patient factors and reasons for treatment delay were also identified.

Meaning  Delayed treatment initiation contributes to worsened outcomes, and risk factors and reasons for delay should be targeted with intervention.

Abstract

Importance  Delay in time to treatment initiation (TTI) can alter survival and oncologic outcomes. There is a need to characterize these consequences and identify risk factors and reasons for treatment delay, particularly in underserved urban populations.

Objectives  To investigate the association of delayed treatment initiation with outcomes of overall survival and recurrence among patients with head and neck squamous cell carcinoma (HNSCC), to analyze factors that are predictive of delayed treatment initiation, and to identify specific reasons for delayed treatment initiation.

Design, Setting, and Participants  Retrospective cohort study at an urban community-based academic center. Participants were 956 patients with primary HNSCC treated between February 8, 2005, and July 17, 2017, identified through the Montefiore Medical Center Cancer Registry.

Exposures  The primary exposure was TTI, defined as the duration between histopathological diagnosis and initial treatment. The threshold for delayed treatment initiation was determined by recursive partitioning analysis.

Main Outcomes and Measures  Overall survival, recurrence, and reasons for treatment delay.

Results  Among 956 patients with HNSCC (mean [SD] age, 60.8 [18.2] years; 72.6% male), the median TTI was 40 days (interquartile range, 28-56 days). The optimal TTI threshold to differentiate overall survival was greater than 60 days (20.8% [199 of 956] of patients in our cohort). Independent of other relevant factors, patients with HNSCC with TTI exceeding 60 days had poorer survival (hazard ratio, 1.69; 95% CI, 1.32-2.18). Similarly, TTI exceeding 60 days was associated with greater risk of recurrence (odds ratio, 1.77; 95% CI, 1.07-2.93). Predictors of delayed TTI included African American race/ethnicity, Medicaid insurance, body mass index less than 18.5, and initial diagnosis at a different institution. Commonly identified individual reasons for treatment delay were missed appointments (21.2% [14 of 66]), extensive pretreatment evaluation (21.2% [14 of 66]), and treatment refusal (13.6% [9 of 66]).

Conclusions and Relevance  Delaying TTI beyond 60 days was associated with decreased overall survival and increased HNSCC recurrence. Identification of predictive factors and reasons for treatment delay will help target at-risk patients and facilitate intervention in hospitals with underserved urban populations.

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