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Program Number: B083
Session Name: Poster Session

Association of Barriers to Care with Failure to Initiate Timely Guideline-Adherent Post-Operative Radiation Therapy Among Patients with Head and Neck Squamous Cell Carcinoma: A Prospective Cohort Study

Megan T Nguyen, BA¹; Emily Kistner-Griffin, PhD¹; Reid DeMass, MS²; Bhisham S Chera, MD¹; Chanita Hughes Halbert, PhD³; Katherine R Sterba, PhD, MPH¹; Elizabeth G Hill, PhD¹; Brian Nussenbaum, MD, MHCM⁴; Anthony J Alberg, PhD, MPH³; Vlad C Sandulache, MD, PhD⁵; Ryan S Jackson, MD⁶; Sidharth V Puram, MD, PhD⁶; Russel Kahmke, MD, MMCi⁷; Nosayaba Osazuwa-Peters, PhD, MPH, BDS⁷; Evan M Graboyes, MD, MPH¹; ¹Medical University of South Carolina; ²University of South Carolina; ³University of South California; ⁴American Board of Otolaryngology-Head and Neck Surgery; ⁵Baylor College of Medicine; ⁶Washington University School of Medicine; ⁷Duke University

Background: More than half of patients with head and neck squamous cell carcinoma (HNSCC) experience a delay in starting postoperative radiation therapy (PORT) according to National Comprehensive Cancer Network Guidelines and the Commission on Cancer. Although demographic and clinical factors underlying PORT delays have been characterized, the multilevel barriers (e.g., patient-, healthcare team-, organization-level) along the care continuum from presentation through PORT initiation have not been prospectively evaluated.

Objective: To characterize multilevel barriers to timely PORT and their association with initiating guideline-adherent PORT among patients with HNSCC.

Study Design: Prospective cohort study.

Setting: US academic medical center.

Participants: Adults with locally advanced HNSCC undergoing surgery and PORT from May 2020 to November 2023.

Main Outcomes and Measures: Barriers to timely PORT were prospectively assessed by abstraction from the electronic health record and patient self-report via a validated assessment modified for timely PORT. Barriers were assessed at 4 timepoints corresponding to key care transitions: (1) surgical consultation, (2) hospital discharge, (3) first postoperative clinic visit, and (4) start of PORT. Based on an existing conceptual framework, 16 discrete multilevel barriers to timely PORT were categorized into 5 domains: (1) patient education, (2) communication/care coordination, (3) care fragmentation across healthcare organizations, (4) transportation, and (5) recovery from surgery. Patients were categorized into tertiles based on number of barriers (<2, 3-4, ≥5); the association of number and type of barrier with PORT initiation ≤6 weeks of surgery was evaluated with multivariable logistic regression analysis adjusting for age, sex, race, health insurance, severity of comorbidity, cancer subsite, and overall AJCC stage.

Results: Among 78 patients who underwent surgery and PORT, the mean age was 61.5 years; 69% of patients were male, 76% were White, 56.4% had oral cavity SCC, and 85.9% had pathologic overall AJCC 8th edition stage III or IV HNSCC. Overall, 96.2% of patients reported >1 barrier to timely PORT and 35.9% of patients reported >5 barriers. The most common barriers were education (73.1%), recovery from surgery (69.2%), and communication/care coordination (64.1%). The distribution of barrier type varied from surgical consultation through PORT initiation (Figure). Overall, 58.9% of patients failed to initiate PORT <6 weeks of surgery. Patients with 3-4 barriers (aOR 0.26; 95% CI: 0.06 to 0.96) and >5 barriers (aOR 0.29; 95% CI 0.08 to 0.96) were less likely to initiate timely PORT relative to patients with <2 barriers on multivariable analysis. When considering barrier type, patients reporting barriers to recovery from surgery (e.g., surgical complications, prolonged length of stay, unplanned readmission) were 83% less likely to initiate timely PORT relative to patients with no barriers in a separate multivariable model (aOR 0.17; 95% CI: 0.04 to 0.66).

Conclusions: In this prospective cohort of patients with HNSCC undergoing surgery and PORT, patients experiencing multiple barriers were less likely to initiate timely PORT, as were those experiencing barriers related to recovering from surgery. Further research is needed to identify optimal strategies to identify and resolve these barriers to timely PORT.

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