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

Abstract

QUESTION ASKED: Can multilevel barriers to timely, guideline-adherent postoperative radiation therapy (PORT) after surgery for head and neck squamous cell carcinoma (HNSCC) be identified and organized into a conceptual model? SUMMARY ANSWER: Barriers causing delays starting guideline-adherent PORT following HNSCC surgery occur at the intrapersonal-, interpersonal-, healthcare team-, organizational-, and community levels. These barriers inform a theory-based, multilevel conceptual model for understanding the delivery of timely, guideline adherent PORT to patients with HNSCC. WHAT WE DID: Semi-structured interviews with key in-formants were conducted with a purposive sample of patients with HNSCC and oncology providers across diverse practice settings (n 5 45); thematic analysis was performed to identify the themes that explain barriers to timely PORT and develop a conceptual model. WHAT WE FOUND: Five themes explain the mechanisms underlying delayed, guideline-non-adherent PORT following surgery for HNSCC: (1) inadequate education about timely PORT, (2) post-surgical se-quelae that interrupt the tight treatment timeline, (3) insufficient care coordination and communication during care transitions, (4) fragmentation of care across healthcare organizations impeding care delivery, and (5) travel for HNSCC care as a burden for socioeconomically disadvantaged patients. Our conceptual model, by organizing themes at levels of healthcare delivery, reflects 1) individual behaviors of patients and providers, 2) reciprocal interactions between patients and providers and providers with each other, 3) that clinicians are embedded within and across numerous healthcare teams (surgical oncology, radiation oncology , etc.), 4) that teams are situated within and across healthcare systems, and 5) that healthcare systems are located within communities. BIAS, CONFOUNDING FACTORS: Although we included patients and providers across diverse practice settings, an important study limitation is that all patients underwent HNSCC surgery at a single tertiary academic medical center. Additional qualitative work in other settings is therefore necessary establish the general-izability of our findings. We identified 5 themes that explain the mechanisms underlying delays starting guideline-adherent PORT after HNSCC surgery. REAL-LIFE IMPLICATIONS: Our conceptual model provides a framework to understand the multilevel barriers to timely sequential multimodal cancer care delivery (e.g. surgery followed by PORT). These foundational qualitative data will enable future studies to gather prospective quantitative data about barriers to timely PORT to characterize the frequency, number, timing, and dynamic evolution of barriers as patients progress through treatment. In addition, interventions targeting these barriers could improve the delivery of timely, guideline-adherent PORT and decrease mortality for patients with HNSCC. 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 5 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 in-trapersonal 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.