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Original Investigation
April 2, 2020

Development and Validation of Nomograms for Predicting Delayed Postoperative Radiotherapy Initiation in Head and Neck Squamous Cell Carcinoma

Author Affiliations
  • 1Department of Otolaryngology–Head & Neck Surgery, Medical University of South Carolina, Charleston
  • 2Department of Public Health Sciences, Medical University of South Carolina, Charleston
  • 3Hollings Cancer Center, Medical University of South Carolina, Charleston
  • 4Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston
  • 5Department of Radiation Oncology, Medical University of South Carolina, Charleston
  • 6Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston
  • 7American Board of Otolaryngology–Head & Neck Surgery, Houston, Texas
  • 8Arnold School of Public Health, Department of Epidemiology and Biostatistics, University of South Carolina, Columbia
JAMA Otolaryngol Head Neck Surg. 2020;146(5):455-464. doi:10.1001/jamaoto.2020.0222
Key Points

Question  What variables are associated with delayed initiation of postoperative radiotherapy after surgical treatment for head and neck squamous cell carcinoma that could be incorporated into clinically useful nomograms for pretreatment counseling and risk adjustment?

Findings  In this cohort study of 60 776 patients with head and neck squamous cell carcinoma, delayed postoperative radiotherapy initiation was associated with race/ethnicity, insurance type, tumor site, US region, facility type, clinical stage, length of stay, and care fragmentation. Presurgical and postsurgical nomograms based on these variables were developed and externally validated.

Meaning  Findings of this study suggest that a nomogram using presurgical information can improve pretreatment counseling and targeted intervention delivery for patients at high risk for postoperative radiotherapy initiation delay, whereas a nomogram also using postsurgical data can drive institutional quality improvement initiatives and enhance risk-adjusted comparisons of delay rates across facilities.

Abstract

Importance  The standard of care for initiation of postoperative radiotherapy (PORT) in head and neck squamous cell carcinoma (HNSCC) is within 6 weeks of surgical treatment. Delays in guideline-adherent PORT initiation are common, associated with mortality, and a measure of quality care, but patient-specific tools to estimate the risk of these delays are lacking.

Objective  To develop and validate 2 nomograms (that use presurgical and postsurgical data) for predicting delayed PORT initiation.

Design, Setting, and Participants  This cohort study obtained patient data from January 1, 2004, to December 31, 2015, from the National Cancer Database. Adults aged 18 years or older with a newly diagnosed HNSCC who underwent surgical treatment and PORT at a Commission on Cancer–accredited facility were included. Data analysis was conducted from June 2, 2019, to January 29, 2020.

Exposures  Surgical treatment and PORT.

Main Outcomes and Measures  The primary outcome measure was PORT initiation more than 6 weeks after the surgical intervention. Multivariable logistic regression models were created in a random selection of 80% of the sample (derivation cohort) and were internally validated with bootstrapping, assessed for discrimination by calibration plots and the concordance (C) index, and externally validated in the remaining 20% of the sample (validation cohort).

Results  The study included 60 766 adults with HNSCC who were grouped into derivation and validation cohorts. The derivation cohort comprised 48 625 patients (mean [SD] age, 59.59 [11.3] years; 36 825 men [75.7%]) selected randomly from the full sample, whereas 12 151 patients (mean [SD] age, 59.63 [11.2] years; 9266 men [76.3%]) composed the validation cohort. The rate of PORT delay was 55.8% (n=27140) in the derivation cohort and 56.7% (n=6900) in the validation cohort. Both nomograms created to predict the risk of PORT initiation delay used variables, including race/ethnicity, insurance type, tumor site, and facility type. The nomogram based on presurgical variables included clinical stage and severity of comorbidity, whereas the nomogram with postsurgical variables included US region, length of stay, and care fragmentation between surgical and radiotherapy facilities. For the presurgical nomogram, the concordance indices were 0.670 (95% CI, 0.664-0.676) in the derivation cohort and 0.674 (95% CI, 0.662-0.685) in the validation cohort. For the nomogram with postsurgical variables, the concordance indices were 0.691 (95% CI, 0.686-0.696) in the derivation cohort and 0.694 (95% CI, 0.685-0.704) in the validation cohort.

Conclusions and Relevance  This study found that a nomogram developed with presurgical data to generate personalized estimates of PORT initiation delay may improve pretreatment counseling and the delivery of interventions to patients at high risk for such a delay. A nomogram including postsurgical data can drive institutional quality improvement initiatives and enhance risk-adjusted comparisons of delay rates across facilities.

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