A new tool to predict delays in post-surgical radiotherapy for head and neck cancer

More than 65,000 Americans are diagnosed annually with head
and neck cancer, which most often occurs inside the mouth and throat. For
patients who undergo surgery to treat this cancer, guidelines recommend that prompt
initiation of radiotherapy — within six weeks — is critical for best outcomes.

Unfortunately, delays in initiating post-operative radiotherapy
(PORT) are far too common. Patients do not always understand the importance of
prompt initiation of radiotherapy and may have to overcome other barriers, such
as lack of social support and insurance. In addition, health care providers do
not always communicate with one another or coordinate care. These avoidable
delays have a negative impact on outcomes in a disease that claims almost
15,000 lives in the U.S. each year.

To ameliorate this crisis, a research team at the Medical
University of South Carolina has developed and validated tools known as
nomograms to help predict treatment delays in high-risk patients based on
individualized risk factors. The team was led by Evan Graboyes, M.D., an
assistant professor in the Department of Otolaryngology-Head & Neck Surgery
at MUSC and a member of the Cancer Control Program at Hollings Cancer Center. The
results of the nomogram study were reported in JAMA Otolaryngology-Head & Neck Surgery.

“A nomogram is a
graphical representation of a mathematical model that we are using to predict
how likely it is that a patient with head and neck cancer may have a treatment
delay,” explained Graboyes. “We hope that these nomograms can be used to
identify patients at highest risk for treatment delays so that we can target
interventions to them to decrease the risk of delay.”

Standard-of-care treatment for patients with head and neck
cancer combines surgery, radiation and chemotherapy. However, treatment outcomes
remain very poor, and only about 50% of head and neck cancer patients with advanced
disease will survive after 5 years.

With the goal of improving the survival rate of patients
with head and neck cancer, Graboyes and his team developed and validated two
types of nomograms for predicting delays in PORT. The study examined pre- and
post-surgical data from 60,766 adult patients with head and neck cancer,
grouped into different cohorts.

The first nomogram is based on information available to both
the clinician and patient during the surgical consultation. At this point, the
patient will know whether he or she is likely going to have surgery followed by
radiation therapy.

“This type of nomogram will provide a personalized estimate
of the risk of delay commencing PORT and can be used to enhance counseling and guide
interventions for patients with higher risks of delay,” explained Graboyes.

The findings of Graboyes’ study suggest that stage 4 cancer
and oral cavity sites are two of the main variables associated with delayed
PORT initiation. Knowing this type of information beforehand will enable
patients to obtain pre-surgical dental oncologic treatment referrals and may
greatly improve timely PORT introduction.

The second nomogram incorporates information from before and
after surgery. According to Graboyes, this nomogram can be used by health care
systems to compare their rates of PORT delay in a risk-adjusted fashion that
acknowledges differences in the types of patients being treated.

In addition, the nomogram may guide quality improvement
initiatives. For example, one of the key factors associated with delayed PORT
was prolonged length of stay after surgery. This information may help physicians
to reduce the length of time patients stay in the hospital after surgery, eliminating one hurdle to prompt initiation of radiation treatment.

Although the two nomograms were developed in one cohort of
patients and validated in a second cohort of patients with head and neck cancer
from across the U.S., the study still had some key limitations. The nomogram
didn’t account for individual patient education, income, social support, dental
disease, smoking or alcohol consumption. Therefore, more research will be
needed to understand the degree to which these factors lead to delays in PORT
initiation. A future study will help to address some of these limitations.

Graboyes believes that the current study will help head and
neck cancer patients get the treatment they need and improve their chance of survival.

“I would love it if patients and clinicians would be able to
use the nomogram website to get more precise, quantitative information about
the risk of PORT delay and use it to educate patients, counsel them before
treatment and communicate risk precisely,” said Graboyes. “We know that getting
patients timely head and neck cancer care that follows guidelines is a
promising strategy to improve survival among these patients. I hope these
nomograms will be a practical and useful tool as we work toward the goal of
decreasing treatment delays.”