Intervention improves timely postoperative treatment for people with head and neck cancer
Key takeaways:
- An enhanced patient navigation-based intervention improved delivery of timely postoperative radiation for head and neck cancer vs. usual care.
- The approach also narrowed racial disparities in care delays.
A multilevel, navigation-based intervention led to more timely initiation of postoperative radiation therapy vs. usual care-based patient navigation for people with head and neck squamous cell carcinoma.
Timely initiation of postoperative radiation therapy is a Commission on Cancer quality metric for HNSCC.
Researchers conducted a randomized trial to evaluate the efficacy of the enhanced patient navigation intervention — Navigation for Disparities and Untimely Radiation ThErapy (NDURE) — among 176 adults (64.8% men; 79.3% white, 20.7% Black) with locally advanced HNSCC.
Investigators randomly assigned participants planning to undergo surgery and postoperative radiation therapy (PORT) 1:1 to standard multidisciplinary head and neck cancer oncology care and NDURE (n = 88) or usual care patient navigation (n = 88).
Elements of the NDURE intervention included patient education about timely PORT; screening for and addressing PORT-relevant health-related social risks, such as housing or transportation needs to ensure the ability to receive radiation for 6 weeks; clinical documentation to improve coordination and communication between care teams; and active referral and appointment tracking by a navigator to ensure timely completion of key steps in care needed to initiate PORT.
Initiation of timely PORT — defined by National Comprehensive Cancer Network (NCCN) Guidelines and the Commission on Cancer as 6 weeks or less after surgery — served as the primary endpoint.
The NDURE intervention improved initiation of timely PORT compared with usual care (model-based initiation of timely PORT, 74% vs. 39%; risk difference = 35%). Additionally, NDURE increased the rate of PORT initiation (HR =1.82; 90% CI, 1.32-2.5) and treatment package completion — defined as the time from surgery to the completion of PORT — compared with usual care (HR = 1.67; 95% CI, 1.22-2.29).
“The goal of this research, in the long arc of things, is to change the standard of care for how patients with head and neck cancer are navigated, and how we deliver care that is coordinated, multidisciplinary and timely,” Evan M. Graboyes, MD, MPH, associate professor in the department of otolaryngology-head and neck urgery and public health sciences at Medical University of South Carolina (MUSC), told Healio. “Hopefully, our ongoing, multicenter randomized clinical trial will help confirm that this enhanced, navigation-based intervention is a new standard for improving timely and coordinated care in this patient population.”
Healio spoke with Graboyes about the motivation for developing the NDURE program, the efficacy observed so far, the intervention’s impact on racial disparities and the next steps in research.
Healio: How problematic are treatment delays in head and neck cancer?
Graboyes: Unlike some cancers — breast, lung, colon or prostate, for example — there is no screening test for head and neck cancer. Most patients present with advanced disease, for which combinations of treatment — surgery, radiation and systematic therapy — are recommended. For most solid cancers such as breast cancer and colon cancer, there is a general treatment paradigm of sequential, multimodal care. Within head and neck cancer, there is currently only one Commission on Cancer-approved quality metric — the timeliness of starting postoperative radiation therapy or adjuvant radiation.
NCCN Guidelines and the Commission on Cancer recommend initiating PORT within 6 weeks of surgery. When patients don’t get radiation started in a timely fashion, they are more likely to have their cancer recur and less likely to survive. Improving this aspect of care could help improve outcomes and also improve equity.
Despite the importance of timely PORT, delays affect approximately 50% of patients with head and neck cancer, so it’s a common problem. Like most health care problems, it doesn’t burden everyone equally. Racial and ethnic minority groups, those with Medicaid or no insurance, those with rural residence, and other medically vulnerable patient populations are more likely to experience delays. These disparities in care delivery drive differences in outcomes.
Healio: What motivated you to conduct this study?
Graboyes: The motivation for this study was a recognition that these delays in starting PORT are common and important, and they impact oncologic outcomes. We wanted to develop an intervention that could help improve outcomes for patients. There is a robust evidence base around navigators — be they nurse navigators or lay navigators — in terms of getting people into screening and helping resolve uncertainties in screening to start cancer-directed therapy. However, navigation has been less studied in the active cancer treatment space like coordinating timely surgery and adjuvant therapy.
In addition to studying this specifically to help improve outcomes for patients with head and neck cancer, we also pursued this study with the idea that the NDURE intervention could help improve outcomes for patients with other cancers, such as breast or colon cancers, for which timely adjuvant therapy is important.
Healio: What did you find?
Graboyes: In this single-site randomized trial, the enhanced navigation intervention improved timely, guideline-adherent radiation by 35% relative to usual care patient navigation. In addition, we looked at time to radiation as a continuous measure. Those in the NDURE arm started radiation 8 days earlier on average than those in the usual care arm. Each week of delay beyond 6 weeks is associated with a dose-dependent increase in mortality, so the 8 days of timeliness is quite important in this aspect of care.
Healio: What did you find in terms of health disparities in delays to care?
Graboyes: When comparing white patients to Black patients with head and neck cancer, the disparities in the rate of delays were basically gone in the enhanced navigation arm but persisted by approximately 20% in the usual care arm. So, it did seem that the NDURE intervention has the potential to improve care for everyone and also decrease racial disparities in care.
Healio: What are the next steps in research?
Graboyes: We are conducting a study funded by NCI at four other sites — Duke University, Baylor University, Washington University and MUSC — to confirm these findings.
We also will study how to implement this into clinical care outside the context of a clinical trial. We want to figure out what enhanced navigation means in all of these different care delivery contexts. Our study sites are all very different, and we want to understand the contextual factors that might affect implementation.
We were very careful to design the intervention in a way that should be scalable and lead to adoption and uptake across cancer centers. We chose navigation as the backbone of this intervention because most cancer centers already have navigators. It doesn’t require a lot in terms of additional resources. It’s just changing the way care is delivered, and that seems very scalable and feasible.
Reference:
For more information:
Evan M. Graboyes, MD, MPH, can be reached at graboyes@musc.edu.
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