2 days ago
Enhanced Navigation Speeds Up Time to Radiotherapy in HNSCC
Enhanced navigation shortens time until guideline-adherent, postoperative radiotherapy (PORT) among patients with head and neck squamous cell carcinoma (HNSCC) compared with standard navigation, according to a study.
The findings of the randomized controlled trial suggest that greater efforts are needed to develop and use enhanced, navigation-based approaches in this patient population, lead author Evan M. Graboyes, MD, of Medical University of South Carolina, Charleston, South Carolina, and colleagues, said.
'Initiation of PORT within 6 weeks of surgery is recommended by National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology and is the only Commission on Cancer-approved quality metric for HNSCC,' the investigators wrote in JCO Oncology Practice . '[D]elays in starting PORT are associated with a 10% absolute decrease in 5-year survival and a 21% increase in the adjusted hazard of mortality.'
Despite the known risks of treatment delay, about half the patients with HNSCC do not receive PORT in a timely, guideline-adherent fashion, Graboyes and colleagues noted, and some patient subgroups are less likely to receive timely treatment than others.
'Delays in starting PORT disproportionately burden racial and ethnic minoritized groups, the underinsured, lower-income, and other medically vulnerable populations,' they wrote. 'These differences in receipt of guideline-adherent care contribute to the persistent and profound disparities in survival for patients with HNSCC.'
Aiming to close this gap, the investigators developed Navigation for Disparities and Untimely Radiation thErapy (NDURE), which includes strategies at the patient, healthcare team, and organizational level. Specifically, NDURE clarifies the navigator's role and defines timepoints for communication and action. For example, under usual care, appointments related to PORT are not tracked; in contrast, the NDURE navigator ensures that appointments are scheduled and attended and logs these events in the patient's electronic health record.
Methods and Results
From May 2020 to November 2023, patients were recruited for the trial from the Medical University of South Carolina and enrolled in NDURE or usual care in a 1:1 ratio. Of the 176 patients enrolled, 145 underwent surgery and had an indication for PORT, of whom 67 were in the NDURE group and 78 were in the usual care group.
Guideline-adherent, timely PORT was delivered in 74% of patients in the NDURE group vs 39% of patients in the usual care group, an absolute risk difference of 35%. Moreover, NDURE was associated with an increased rate of PORT initiation (hazard ratio [HR], 1.82; 90% CI, 1.32-2.50) and treatment package completion (HR, 1.67; 90% CI, 1.22-2.29).
'These data support studying an enhanced, navigation-based approach to improve timely PORT for patients with HNSCC,' the investigators concluded.
Study Powered to Show Risk Reduction in Postoperative Delays
David L. Schwartz, MD, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, and colleagues highlighted the magnitude of the findings.
'The current report provides encouraging results from a follow-on institutional trial,' they wrote in an accompanying editorial. 'Although limited to a modestly sized cohort, it was adequately powered to show a significant 35% absolute risk reduction in postoperative delays in a study population potentially weighted against detection of intervention effect.'
They emphasized that the findings underscore both the progress made and the opportunity for further improvement.
'The fact that more than 60% of control patients treated by an integrated academic practice highly invested in its care coordination still experienced refractory delays speaks volumes as to the [importance] and severity of the problem being addressed here,' they wrote. 'Although treatment delay is a surrogate process measure, there is ample evidence as noted above to suggest the significant downstream impact on disease outcomes.'
Schwartz and colleagues noted how the NDURE program makes each navigator a formal member of the multidisciplinary care team and suggested that the model could more broadly affect future navigator research.
'All told, to our knowledge, this is the first trial to experimentally test a model-informed navigation intervention in any acute multidisciplinary cancer treatment setting beyond uncontrolled quality improvement experiences,' they wrote. 'These are meticulous first steps toward solidifying routine reimbursement for cancer navigation.'
More work remains, Schwartz and colleagues continued, including research into cost-effectiveness research, impact on treatment outcomes, and broader feasibility.
Although they called the 6-week time threshold a 'laudable goal,' they noted that one quarter of the patients in the NDURE group did not hit this mark, suggesting that the target may not be 'a tenable goal across all practice environments in the absence of disruptive systems-level care reorganization and reimbursement reform.'
Still, the editorialists suggested that the presented model offers a valid path forward.
'Navigation is a steady, sensible, and proven way for us to accumulate small patient-level victories which can collectively transform into population-level accomplishments,' they wrote. 'It merits its chance to earn full interventional standing in modern multidisciplinary oncology.'
