Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston.
Hollings Cancer Center, Medical University of South Carolina, Charleston.
JAMA Otolaryngol Head Neck Surg. 2018 Dec 1;144(12):1105-1114. doi: 10.1001/jamaoto.2018.2225.
Delays in initiation of postoperative radiotherapy (PORT) after surgery for head and neck squamous cell carcinoma (HNSCC) are common, predominantly affect racial minorities, and are associated with decreased survival. Details regarding the care processes that contribute to timely, equitable PORT remain unknown.
To determine care processes associated with timely, equitable PORT.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included patients 18 years or older undergoing surgery for HNSCC at the Medical University of South Carolina (MUSC), Charleston, followed by PORT (at MUSC or elsewhere) with or without chemotherapy from January 1, 2014, through December 31, 2016. Data were analyzed from September 15, 2017, through June 28, 2018.
The main outcome measure was the proportion of timely, guideline-adherent initiation of PORT (≤6 weeks postoperatively). Secondary outcome measures included care processes associated with timely PORT. The association between process variables with timely PORT was explored using multivariable logistic regression analysis. Effect modification of the association between receipt of care processes and timely PORT by race was explored using interaction effects.
A total of 197 patients were included in the analysis; they were predominantly white (157 [79.7%]) and male (136 [69.0%]) with a mean age of 59 years (range, 28-89 years). Overall, 89 patients (45.2%) experienced a delay initiating PORT. African American patients had a 13.5% absolute increase in the rate of delayed PORT relative to white patients (21 of 37 [56.8%] vs 68 of 157 [43.3%]). The adjusted multivariable regression showed that the following care processes were associated with timely PORT: preoperative radiotherapy consultation (odds ratio [OR], 8.94; 95% CI, 1.64-65.53), PORT at MUSC (OR, 6.21; 95% CI, 1.85-24.75), pathology report within 7 postoperative days (OR, 4.14; 95% CI, 1.21-15.86), time from surgery to PORT referral of no longer than 10 days (OR, 12.14; 95% CI, 3.14-63.00), time from PORT referral to consultation of no longer than 10 days (OR, 10.76; 95% CI, 3.01-49.70), and time from PORT consultation to its start of no longer than 21 days (OR, 4.80; 95% CI 1.41-18.44). Analysis of interactions revealed no statistically significant differences between African American and white patients in receipt of key processes associated with timely PORT.
Specific care processes are associated with guideline-adherent initiation of PORT. Novel strategies appear to be needed to ensure that these processes are performed for all patients with HNSCC, thereby facilitating timely, equitable PORT.
头颈部鳞状细胞癌（HNSCC）手术后开始进行术后放疗（PORT）的延迟是常见的，主要影响少数族裔，并且与生存率降低有关。关于有助于及时、公平地进行 PORT 的护理过程的详细信息尚不清楚。
确定与及时、公平的 PORT 相关的护理流程。
设计、地点和参与者：这项回顾性队列研究包括 2014 年 1 月 1 日至 2016 年 12 月 31 日期间在南卡罗来纳医科大学（MUSC）接受 HNSCC 手术治疗，随后在 MUSC 或其他地方进行 PORT（伴有或不伴有化疗）的 18 岁或以上的患者。数据于 2017 年 9 月 15 日至 2018 年 6 月 28 日进行分析。
主要结局指标是 PORT 及时启动（≤术后 6 周）的比例。次要结局指标包括与及时 PORT 相关的护理流程。使用多变量逻辑回归分析探索与 PORT 及时相关的过程变量之间的关联。使用交互效应探索种族接受护理流程与及时 PORT 之间关联的效应修饰。
共有 197 名患者纳入分析；他们主要是白人（157 [79.7%]）和男性（136 [69.0%]），平均年龄为 59 岁（范围 28-89 岁）。总体而言，89 名患者（45.2%）出现 PORT 启动延迟。与白人患者相比，非裔美国患者延迟 PORT 的发生率绝对增加了 13.5%（37 名中的 21 名[56.8%]与 157 名中的 68 名[43.3%]）。调整后的多变量回归显示，以下护理流程与 PORT 及时启动相关：术前放疗咨询（优势比[OR]，8.94；95%CI，1.64-65.53）、MUSC 进行的 PORT（OR，6.21；95%CI，1.85-24.75）、术后 7 天内的病理报告（OR，4.14；95%CI，1.21-15.86）、手术至 PORT 转诊时间不超过 10 天（OR，12.14；95%CI，3.14-63.00）、PORT 转诊至咨询时间不超过 10 天（OR，10.76；95%CI，3.01-49.70）、PORT 咨询至开始时间不超过 21 天（OR，4.80；95%CI，1.41-18.44）。交互分析显示，非裔美国患者和白人患者在接受与 PORT 及时启动相关的关键流程方面没有统计学上的显著差异。
特定的护理流程与 PORT 启动的指南一致。似乎需要新的策略来确保为所有 HNSCC 患者提供这些流程，从而促进及时、公平的 PORT。
