Barriers to the Delivery of Timely, Guideline-Adherent Adjuvant Therapy Among Patients With Head and Neck Cancer

Abstract

PURPOSE: Delays initiating guideline-adherent postoperative radiation therapy (PORT) in head and neck squamous cell carcinoma (HNSCC) are common, contribute to excess mortality, and are a modifiable target for improving survival. However, the barriers that prevent the delivery of timely, guideline-adherent PORT remain unknown. This study aims to identify the multilevel barriers to timely, guideline-adherent PORT and organize them into a conceptual model. MATERIALS AND METHODS: Semi-structured interviews with key informants were conducted with a purposive sample of patients with HNSCC and oncology providers across diverse practice settings until thematic saturation (n = 45). Thematic analysis was performed to identify the themes that explain barriers to timely PORT and to develop a conceptual model. RESULTS: In all, 27 patients with HNSCC undergoing surgery and PORT were included, of whom 41% were African American, and 37% had surgery and PORT at different facilities. Eighteen clinicians representing a diverse mix of provider types from 7 oncology practices participated in key informant interviews. Five key themes representing barriers to timely PORT were identified across 5 health care delivery levels: (1) inadequate education about timely PORT, (2) postsurgical sequelae that interrupt the tight treatment timeline (both intrapersonal level), (3) insufficient coordination and communication during care transitions (interpersonal and health care team levels), (4) fragmentation of care across health care organizations (organizational level), and (5) travel burden for socioeconomically disadvantaged patients (community level). CONCLUSION: This study provides a novel description of the multilevel barriers that contribute to delayed PORT. Interventions targeting these multilevel barriers could improve the delivery of timely, guideline-adherent PORT and decrease mortality for patients with HNSCC.

An equity‐based narrative review of barriers to timely postoperative radiation therapy for patients with head and neck squamous cell carcinoma

“…Place of residence • Residing further from facility (>20 miles) and experiencing barriers to travel 2,25 Race/ethnicity/culture/ language…”

“…• Black race, Asian race, Hispanic ethnicity Patients of color are more likely to have lower socioeconomic status (SES), reduced access to care, and present with more advanced stage cancer 2,3,[26][27][28][29][30][31] Occupation/insurance status • Medicaid/Medicare, health maintenance organization, or no insurance 2,3 People who are under-or unemployed have limited access to health insurance 50 People of color and of lower SES are more likely to be under-or unemployed and have Medicaid or no insurance 26,33,[46][47][48][49] Gender/sex • There is not enough evidence to declare a relationship between gender/sex and delayed PORT 2,3 Education • Lower levels of education 2,3,31,48,54 • Most patients are unaware of the 6-week guideline and clinical consequences of delaying radiation treatment 25…”

“…25 Providers face cumbersome patient handoffs, having to reconcile differing electronic health records or fax over hundreds of pages of records, leading to further delays in care. 25 On the other hand, receiving PORT at the same center can facilitate timely care due to improved communication and accessibility of medical records. 26 Delayed dental evaluations and extractions were strongly associated with delayed PORT.…”

Barriers to Comprehensive Multidisciplinary Head and Neck Care in a Community Oncology Practice

“…13 Analyses by various groups identify travel/transportation issues as a major cause of patients not receiving guidelineadherent radiotherapy in head and neck cancers. 14,15 In a comprehensive root cause analysis of radiotherapy initiation timing in postoperative radiotherapy in head and neck cancers, multiple factors were identified related to communication, process, and social support. Specifically identified in the social support area was the lack of transportation support as a cause of increased time to initiation of postoperative radiotherapy.…”

“…15 Delays in receiving postoperative radiotherapy are known to negatively impact overall survival in head and neck squamous cell carcinomas. [14][15][16] Solution Employ a head and neck nurse navigator. These can be helpful in coordination between offices.…”