Barriers and Facilitators to Timely Adjuvant Therapy for Head and Neck Cancer in Rural Care

Abstract

Importance: Timely initiation of postoperative radiotherapy (PORT) within 6 weeks of surgery improves survival for patients with head and neck squamous cell carcinoma. Rural populations experience disproportionate delays, yet contextual drivers remain poorly understood. Objective: To identify barriers, facilitators, and themes influencing the receipt of timely PORT in rural settings to inform a future multilevel intervention. Design, Setting, and Participants: This qualitative study used a phased, patient-And caregiver-involved design at 2 rural northern New England cancer center clinics at Dartmouth Health. Phase 1 included 2 facilitated dialogues with patients, caregivers, and staff, followed by participant-led coding (referred to as Partnership Academies). Phase 2 included 3 facilitated dialogues focused on refining barriers, facilitators, and solutions-focused themes (2 with patients/caregivers and 1 with staff; referred to as Community Engagement Studios). Phase 3 included reviewing preliminary insights at a clinic staff retreat for feedback. Data were collected from November 2024 to April 2025 and analyzed from November 2024 to May 2025. Main Outcomes and Measures: Barriers, facilitators, and themes related to timely PORT initiation. Analysts used an inductive-deductive approach guided by Intervention Mapping and the Consolidated Framework for Implementation Research, version 2.0. Results: Eleven individuals participated in the Partnership Academies and 18 in the Community Engagement Studios. Five barriers were identified (communication, care coordination, access to dental care, transportation, and confronting negative emotions), and 4 facilitators were identified (key staff as central contacts, caregivers as advocates, rural culture, and leveraging preexisting resources). Four themes emerged: (1) leveraging strengths, (2) managing the steep learning curve after cancer diagnosis, (3) the value of peer support, and (4) the desire for information support was far-reaching. Conclusions and Relevance: This qualitative study examines PORT delays in a rural context with patient, caregiver, and staff voices. Findings highlight the importance of community resources, effective communication, and peer support to inform multilevel strategies aimed at reducing delays and improving equity in cancer care.