Barriers and Timely Postoperative Radiation Therapy in Head and Neck Cancer

Importance Initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery is associated with improved outcomes among patients with head and neck squamous cell carcinoma. However, the relationship of barriers to care with timely PORT is unknown. Objective To categorize barriers to timely PORT, evaluate the association of barriers to care with initiation of timely PORT, and describe the primary reason for delay among patients without timely PORT. Design, Setting, and Participants This prospective cohort study at a US academic medical center included adults with head and neck squamous cell carcinoma undergoing curative-intent surgery with an indication for PORT. Patients were recruited for the study from May 19, 2020, to November 6, 2023. Main Outcomes and Measures The primary outcome was initiation of timely PORT, defined as starting radiation therapy within 6 weeks of surgery. Barriers to PORT were prospectively collected via patient self-report and the electronic health record. Among patients who did not start PORT within 6 weeks of surgery, the primary reason for delay was defined as the singular barrier category that most directly led to the delay. Results Among 78 patients (mean [SD] age, 61.5 [10.8] years; 54 males [69.2%]), 32 patients (41%) initiated PORT within 6 weeks of surgery, and 46 patients (59%) did not initiate PORT within 6 weeks of surgery. Each additional barrier was associated with a decreased odds of initiating timely PORT (adjusted odds ratio, 0.81 [95% CI, 0.63-1.01]); patients with 5 or more barriers had a 76% reduction in the odds of starting PORT within 6 weeks of surgery relative to those with 0 to 2 barriers (adjusted odds ratio, 0.24 [95 CI%, 0.06-0.84]) on multivariable analysis. When analyzed by barrier category, patients with a perioperative adverse effects–related barrier were less likely to initiate timely PORT than patients without a perioperative adverse effects barrier (adjusted odds ratio, 0.17 [95% CI, 0.04-0.66]) on multivariable analysis. Among patients without timely PORT, the most common primary reason for delay was a barrier related to poor care coordination (19/46 [41.3%]). Conclusions and Relevance In this prospective cohort study, patients with a greater number of barriers and those with a barrier related to the perioperative adverse effects category were less likely to initiate timely PORT. Among patients without timely PORT, the most common primary reason for delay was a barrier related to poor care coordination. Efforts to improve timely PORT should focus on decreasing the number of barriers, improving surgical quality, and enhancing care coordination.