Impact of Outside Referral and Dental Extractions on Package Time with Postoperative Radiation Therapy for Head and Neck Cancer

Abstract

Patients with squamous cell carcinoma of head and neck (HNSCC) often receive post-operative radiotherapy (PORT) following surgical cancer removal. It has been shown that a total package time between surgery and completion of PORT of 100 days or less is correlated with lower rates of local and distant recurrence, and longer survival. However, limiting the package time to 100 days can be challenging, as adjuvant RT typically takes 6-7 weeks, leaving 8 weeks or less between surgery and the start of radiation. In this study, we investigate the impact of outside facility referral and dental extractions, both hypothesized to prolong the total treatment package time, with secondary detriment to relapse free survival (RFS) and overall survival (OS). We conducted a retrospective chart review on patients with HNSCC treated at our facility. Inclusion criteria were: HNSCC treated with surgery and PORT within the last five years, age 18 or older upon receiving surgery, and completion of radiation. Patients were excluded from analysis if they had distant metastatic disease at the time of presentation, had received prior radiation to the cancer site, or died during treatment. We then calculated average values for package time and time to recurrence and performed Kaplan-Meier analysis for survival. We performed statistical hypothesis testing via t-test for comparing package time as a continuous variable and via chi-square test for categorical variables. Of 148 patients with HNSCC treated at our facility, 94 met eligibility criteria. 35% of patients experienced local or distant recurrence and 21% of patients died. The median package time was 89.5 days, with 76% of patients achieving a package time of 100 days or less. 44% of patients received PORT at our facility (in-house), and these patients had a shorter package time (85 days vs 101 days, p = 0.0004) and higher likelihood of completion within 100 days (88% vs 66%, p = 0.01). 33% of patients received dental extractions, and this did not affect package time (97 days vs 93 days, p = 0.57) or likelihood of completion within 100 days (74% vs 76%, p = 0.83). A package time of 100 days or less was not associated with significantly lower rates of recurrence (31% vs 48%, p = 0.14) or death (23% vs 17%, p = 0.6), although recurrence was numerically higher with prolonged package times. A Kaplan-Meier analysis was performed to study patient survival over time, and a package time under 100 days was not associated with a change in RFS (p = 0.4) or OS (p = 0.7). In this study, we identified that outside facility referrals for PORT, but not dental extractions, prolong treatment package times. We also saw no effect of package time on RFS or OS, although there was limited variation of package time in this analysis, so our findings do not necessarily contradict previous studies. These results suggest that patients requesting outside facility referrals for PORT may benefit from a streamlined program that expedites the referral process.