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

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 PARTICIPANTSRetrospective 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 MEASURESOverall 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 RELEVANCEDelaying 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.

Changes in head and neck oncologic practice during the COVID‐19 pandemic

“…This is likely related to the known risk morbidity and mortality among patients with head and neck cancer that results from treatment delays. 7,8 In a systematic review of 51 studies, Schutte et al found that treatment delays led to reduced overall survival and disease specific survival, as well worsened functional and psychosocial outcomes. They recommended timely treatment to improve outcomes in HNSCC.…”

“…7 Similarly, in 956 patients, Liao et al found that delays in treatment led to lower overall survival and higher risk of recurrence. 8 This highlights the importance of timely intervention, even in the era of COVID-19, to maintain a high level of care. The need for timely intervention must be weighed with opposing concerns that necessitate delays or alterations in treatment paradigms to protect health care workers due to a lack of PPE or availability of preoperative COVID-19 testing.…”

“…5,6 Additionally, reasonable alternative treatment options are lacking for many head and neck malignancies and treatment delay leads to increased morbidity and mortality. 7,8 Head and neck cancer is unique in that oral cavity cancers, human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC), and advanced laryngeal cancers are considered aggressive malignancies and there is no widely-accepted neoadjuvant treatment option that can allow definitive surgery to be delayed. Other subtypes such as HPV-mediated OPSCC and early laryngeal squamous cell carcinoma can be treated either with radiation-based or surgical-based therapy, which offer equivalent oncologic outcomes.…”

“…This can be expected to alter the management strategies as head and neck surgeons and radiation oncologists weigh the risks and benefits of viral exposure both to the patient and to operating room and clinic staff. Furthermore, patients who unknowingly have surgery during the incubation period of COVID-19 infection appear to be at extremely high risk of morbidity and may have approximately 20% risk of mortality 8 . There is also a high level of concern over the risk of immunosuppression with systemic chemotherapy during the ongoing pandemic.…”

“…[10][11][12] It has been established in the literature that increases in the duration of time between diagnosis and definitive therapy is associated with decreased overall and disease-free survival. 7,8 In addition, delays in surgery may result in increased morbidity due to disease progression necessitating more extensive tumor resection.…”