Introduction
Head and neck squamous cell carcinoma (HNSCC) often requires multimodality treatment including surgery, radiation therapy, and chemotherapy. For patients treated surgically for HNSCC, the National Cancer Comprehensive Cancer Network (NCCN) Treatment Guidelines recommend the initiation of post-operative adjuvant radiation therapy (PORT) within six weeks of surgery.1 In fact, timely initiation of post-operative radiation is the only measure of timely care incorporated into the NCCN guidelines for HNSCC.
This recommendation originates from studies that found improved overall survival when adjuvant treatment was initiated within six weeks of surgery.2-5 More recently, Graboyes et al6 conducted a National Cancer Data base review, which identified 41,291 patients requiring PORT, to reevaluate these recommendations. This analysis supported the guidelines, as delays in initiating PORT beyond 6 weeks after surgery was associated with a 10% absolute decrease in overall survival.6 With a push towards healthcare related quality improvement, adjuvant radiation therapy within six weeks has been identified as a quality metric that has a meaningful impact on survival.7
Despite the NCCN guideline recommendations, a majority of patients do not initiate PORT within six weeks. In a separate paper, Graboyes et al, found that only 44.7% of patients initiated PORT within six weeks of surgery. Of additional concern, it appears the proportion of patients experiencing delays is on the rise.8
Risk factors associated with delayed initiation of PORT include patient-, tumor-, and treatment-specific characteristics.8-15 Factors implicated in delayed initiation of PORT include black race, public or no insurance, lower level of education, increasing severity of comorbidities, increased postoperative length of stay, 30-day unplanned readmissions, and undergoing surgery and PORT at different facilities, i.e. “fragmented care.”
In this study, we sought to identify modifiable risk factors associated with delayed initiation of PORT and implement process-related quality improvement metrics to address those factors. Improving compliance to guideline recommendations for timely initiation of PORT would be expected to improve overall survival.