Prescribing patterns for management of newly diagnosed squamous cancers of the head and neck (HNSCC) and opportunities to improve quality.

Abstract

e17701 Background: Variability in prescribing and deviations from evidence-based (EB) standards contribute to the high cost of cancer care and affect quality. We sought to evaluate prescribing patterns for curative treatment of HNSCC in a commercially insured population of 1.8 million covered lives. Methods: The eviti web-based decision-support platform database of chemotherapy (CT) and radiation therapy (RT) treatment plans submitted for insurance pre-authorization between Feb 2011 and Nov 2013 was queried for analysis of patient characteristics and first line curative treatment of HNSCC. Results: A total of 902 individual RT and CT treatment plans were submitted constituting 426 pt episodes of curative treatment (single or multimodality); 414 had sufficient detail for analysis. Primary sites were: oral cavity(OC)- 53, oropharynx(OP)- 198, unknown- 19, larynx- 91, nasopharynx (NPC)- 27, other- 26; stage III/IV(M0) comprised 85%. Notably, only 9 of 414 pts were enrolled in a clinical trial. Approaches to definitive treatment by site were: OC-surgery + adjuvant RT +/- CT in 89% of pts, chemoradiation(CRT) 11%; OP & unknown primary: CRT 63%, surgery + adjuvant RT+/- CT 17%, RT alone 8.7%; larynx stage III/IV(M0)- CRT 73%, laryngectomy 17%, RT alone 10%; NPC- 92% of pts were prescribed the EB standard cisplatin/RT, 61% adjuvant cisplatin/5-FU, and 27% an induction regimen. CT regimens and variability: CRT was prescribed as definitive therapy in 215 pts. Single agent cisplatin prescribed in 63.7%, cetuximab 13.4%, carboplatin 8.8%, platinum + taxane 6.9%, other 6.9%. Induction CT was prescribed infrequently, total 69 pts of which 37 (53.6%) had T4 or N3 tumors. Combination taxane, cisplatin, 5-FU, the EB standard was prescribed in 57%. Conclusions: Too few HNSCC pts are enrolled in clinical trials. The treatment of NPC usually conforms to the level 1 EB standard. Single agent cisplatin (Level 1 EB) was prescribed for CRT in 64%, regimens with less evidence used in approx. 25% potentially over or under treat. When induction CT is prescribed, the EB regimen is often not used. Prescribing based on the highest level of evidence provides an opportunity to reduce variability and improve quality.