Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma

Factors associated with adjuvant treatment delays in patients treated surgically for head and neck cancer

OBJECTIVE

To determine the patient and treatment characteristics associated with delay in post-operative radiation therapy (PORT) for patients treated surgically for head and neck squamous cell cancer (HNSCC) at our institution.

DESIGN

Single institution retrospective review.

SETTING

Tertiary care academic medical centre.

PARTICIPANTS

Patients treated surgically for HNSCC who underwent PORT between 2013 and 2016.

MAIN OUTCOME MEASURES AND RESULTS

One hundred forty patients met inclusion criteria. A majority did not start radiotherapy within 6 weeks. Factors associated with a delayed initiation of PORT included length of stay >8 days, 30-day readmission, no adjuvant chemotherapy, post-operative complications and fragmented care.

CONCLUSIONS

A majority of patients did not initiate PORT within the guideline-recommended 6 weeks. Modifiable risks factors that delay initiation of PORT were identified.

Timely delivery of PORT for head and neck squamous cell carcinoma in a county hospital

Objectives

The objective of this study was to compare the rate of post-operative radiation therapy (PORT) initiation within 6 weeks for head and neck squamous cell carcinoma patients treated at a safety net, academic institutio between 2019 and 2021 versus those treated in 2022 after implementation of a new clinical pathway.

Methods

A retrospective case-control study was performed at a single tertiary care, safety-net, academic institution. Patient demographics, tumor characteristics, dates of surgery, and other treatment dates were collected from the electronic medical record. The time from surgery to PORT was calculated. Patients who started radiation treatment within 42 days of surgery were regarded as having started PORT on time. The demographics, tumor characteristics, and rate of timely PORT for the two cohorts of patients were compared.

Results

From 2018 to 2021, our rate of PORT initiation within 6 weeks of surgery was 12% (n = 57). In 2022, our rate of timely PORT was 88% (n = 16), p < 0.5. Patient demographics and characteristics were similar with the exception of marital status and use of free-flap reconstruction. The 2022 cohort was more likely to be single (p < 0.5), and all patients underwent free-flap reconstruction in 2022 (p < 0.05).

Conclusion

Early referrals, frequent communication, and use of a secure registry were the key to the success found by our group despite the socioeconomic challenges of our underserved, safety-net hospital patient population. The changes made at our institution should serve as a template for other institutions seeking to improve the quality of care for their HNSCC patients.

Operationalizing a Free Flap Program for Head and Neck Reconstruction at a Veterans Affairs Hospital

Objectives

We aimed to operationalize a head and neck microvascular free tissue transfer (MVFTT) program at a Veterans Affairs (VA) hospital with the emphasis on initiating radiotherapy within 6 weeks of surgery for cancer patients and minimizing readmissions.

Study Design

Case series.

Setting

Tertiary care VA hospital.

Methods

A retrospective analysis was performed on consecutive head and neck MVFTT patients from May 1, 2017 and April 30, 2022. Demographics, patient and disease characteristics, per-operative data and postoperative outcomes were recorded from the electronic medical record. We sought to compare our rate of 30-day readmissions with those published in the literature.

Results

One hundred and forty-one procedures were performed in the queried timeframe. Eighty-four percent (119) were performed after oncologic resections and 16% (22) were for nononcologic procedures. The rate of total flap loss was <1% and the rate of partial flap loss was 3.5%. For mucosal defects, the fistula rate was 2.3%. The rate of return to the OR for any reason within 30 days was 7.8%. The 30-day readmission rate was 6.4% while the rates reported in the literature range from 13% to 20%. One hundred and four patients required postoperative radiotherapy (PORT) and 76% started PORT within 42 days of surgery.

Conclusion

Operationalizing a head and neck MVFTT program with a VA hospital is safe and allows for the successful delivery of multimodality treatment to cancer patients. These resources can be expanded for the care of head and neck cancer treatment sequelae, such as osteoradionecrosis, and other nononcologic patient needs.

Evaluating delays in patients treated with post-operative radiation therapy for head and neck squamous cell carcinoma

Introduction

Delays in commencing post‐operative radiation therapy (PORT) and prolongation of overall treatment times (OTT) are associated with reduced overall survival and higher recurrence rates in patients with head and neck squamous cell carcinoma (HNSCC). The objective of this study was to evaluate treatment delays, factors contributing to those delays and to explore strategies to mitigate them.

Methods

This retrospective study included patients with mucosal HNSCC at Townsville University Hospital treated with curative intent surgery and PORT between June 2011 and June 2019. The proportion of patients who experienced delays in commencing PORT (>6 weeks) and OTT were evaluated and reasons for these delays were explored.

Results

The study included 94 patients of which 70% experienced PORT delay. Surgery at an external facility (81% vs 56%, P = 0.006) and longer post‐operative length of stay (P = 0.011) were significantly associated with a higher incidence of PORT delay. Aboriginal and Torres Strait Islander patients had a higher rate of PORT delay (89% vs 68.2%, P = 0.198). Significant delays were noted from time of surgery to radiation oncology (RO) consult and from RO consult to commencement of radiation treatment.

Conclusion

This study demonstrates that the prevalence of PORT delay for patients with HNSCC remains high with room for improvement. Potential strategies to improve delays include developing effective care coordination, addressing specific needs of Indigenous patients, implementing reliable automated tracking and communication systems between teams and harnessing existing electronic referral systems.