Timely Initiation of Radiation Treatment for Primary Head and Neck Squamous Cell Carcinoma in an Urban Safety Net Hospital during the COVID-19 Pandemic

Abstract

Delayed initiation of radiation treatment for head and neck squamous cell cancer (HNSCC) may lead to worse survival, higher recurrence, and increased financial burden on patients. In times of limited resources, timely treating underserved population of HNSCC patients pose a special challenge to a safety net setting. This single-institutional study aims to characterize and compare treatment delays in HNSCC before and during the COVID-19 pandemic at an urban safety net hospital in Los Angeles to assess the success of efforts made to deliver timely care. Patients who received definitive or post-operative radiotherapy for treatment of primary HNSCC at LAC+USC Medical Center between 2010-2021 were retrospectively reviewed. Time to treatment initiation (TTI) was defined as date of histopathological diagnosis to date of first radiation treatment for definitive and date of surgery to date of first radiation treatment for post-operative patients. Among 70 patients with HNSCC (mean age at diagnosis 55 years, 79% male), 31 patients (18 pre-pandemic, 13 peri-pandemic) were treated definitively with chemoradiation, and 39 patients (24 pre-pandemic, 15 peri-pandemic) were treated post-operatively. Overall, the median TTI was 50 days (interquartile range, IQR 42-74 days); median TTI for pre-pandemic HNSCC patients was 49 days (IQR 43-70 days) and median TTI for peri-pandemic HNSCC patients was 51 days (IQR 43-75 days). The median TTI for definitive radiation was 52 days (IQR 42-93) for pre-pandemic and 52 days (IQR 44-61) for peri-pandemic patients. The median TTI for post-operative radiation was 47 days (IQR 41-75) for pre-pandemic and 50 days (IQR 48-73) for peri-pandemic patients. During the pandemic, there were fewer (38% vs 44%) definitive patients whose TTI exceeded 60 days, whereas more (40% vs 33%) post-operative patients had TTI >60 days. By prioritizing treatment of definitive and high-risk post-operative HNSCC patients according to ASTRO-ESTRO consensus guidelines, expanding the use of telephone follow-up to ensure continuity of care, teleconferencing for multidisciplinary tumor board discussions, and initiating COVID-19 protocols in which mildly symptomatic patients were treated at the end of the day, we were able to maintain timely initiation of radiation treatment not compromised by the pandemic.