Delayed Initiation of Postoperative Radiotherapy in Head and Neck Cancer

Introduction: The Commission on Cancer (CoC) recently approved initiation of postoperative radiotherapy (PORT) within 6 weeks of surgery as the first and only quality metric for head and neck squamous cell carcinoma (HNSCC). To date, no study has systematically reviewed the literature nor synthesized the data to establish national benchmarks for PORT delay.

Methods: Following PRISMA guidelines, we performed a systematic review of PubMed, Scopus, and CINAHL. Studies that described time-to-PORT or PORT delays in patients with HNSCC treated in the US in 2004 or later were included. A meta-analysis of proportions was performed on non-overlapping datasets to examine the pooled frequency of PORT delays. Heterogeneity was assessed using Q test and I2 statistic.

Results: Of 672 unique abstracts screened, 37 studies were included in the systematic review. Eighteen (48.6%) were single-institution studies (15 academic centers, 2 urban community hospitals, 1 VA medical center), 3 (8.1%) were multi-institutional, and 16 (43.2%) utilized cancer registry data. Sample sizes ranged from 14 to 60,776 patients. Twenty-six studies (70.3%) defined PORT delay as > 6 weeks after surgery (the definition utilized by the CoC and NCCN Guidelines), 4 (10.8%) defined PORT delay as a time interval other than > 6 week after surgery, and 7 (18.9%) characterized time-to-PORT without defining delay. Thirteen studies included patients with all HNSCC subsites, 10 were subsite-specific (eg, oral cavity), 8 were treatment-specific (eg, transoral robotic surgery), 3 analyzed other patient populations (eg, specific health insurance), and 3 described interventions to reduce PORT delays. Meta-analysis revealed a frequency of PORT delay (> 6 weeks after surgery) of 48.6% (95% CI 41.4% to 55.9%). Median time-to-PORT was 43.8 days (95% CI 41.2 to 46.4 days). Mean time-to-PORT was 46.5 days (95% CI 42.7 to 50.2 days).

Conclusions: Delays in initiating guideline-adherent PORT occur in about half of patients with HNSCC. These meta-analytic data can be used to set current national benchmarks and assess progress regarding strategies to reduce PORT delays.