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. Author manuscript; available in PMC: 2025 Oct 4.
Published in final edited form as: JAMA Otolaryngol Head Neck Surg. 2025 Dec 1;151(12):1186–1195. doi: 10.1001/jamaoto.2025.2824

Barriers and Timely Postoperative Radiation Therapy in Head and Neck Cancer

Megan T Nguyen 1, Emily Kistner-Griffin 2,3, Reid DeMass 4,5, Bhisham S Chera 6,7, Chanita Hughes Halbert 8,9, Katherine R Sterba 10,11, Elizabeth G Hill 12,13, Brian Nussenbaum 14, Anthony J Alberg 15, Vlad C Sandulache 16,17, David J Hernandez 18, Ryan S Jackson 19,20, Sidharth V Puram 21,22, Russel Kahmke 23, Nosayaba Osazuwa-Peters 24,25,26, Gail Jackson 27, Sue S Yom 28,29, Evan M Graboyes 30,31,32,33
PMCID: PMC12426859  NIHMSID: NIHMS2110949  PMID: 40932734

Abstract

IMPORTANCE

Initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery is associated with improved outcomes among patients with head and neck squamous cell carcinoma. However, the relationship of barriers to care with timely PORT is unknown.

OBJECTIVE

To categorize barriers to timely PORT, evaluate the association of barriers to care with initiation of timely PORT, and describe the primary reason for delay among patients without timely PORT.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study at a US academic medical center included adults with head and neck squamous cell carcinoma undergoing curative-intent surgery with an indication for PORT. Patients were recruited for the study from May 19, 2020, to November 6, 2023.

MAIN OUTCOMES AND MEASURES

The primary outcome was initiation of timely PORT, defined as starting radiation therapy within 6 weeks of surgery. Barriers to PORT were prospectively collected via patient self-report and the electronic health record. Among patients who did not start PORT within 6 weeks of surgery, the primary reason for delay was defined as the singular barrier category that most directly led to the delay.

RESULTS

Among 78 patients (mean [SD] age, 61.5 [10.8] years; 54 males [69.2%]), 32 patients (41%) initiated PORT within 6 weeks of surgery, and 46 patients (59%) did not initiate PORT within 6 weeks of surgery. Each additional barrier was associated with a decreased odds of initiating timely PORT (adjusted odds ratio, 0.81 [95% CI, 0.63–1.01]); patients with 5 or more barriers had a 76% reduction in the odds of starting PORT within 6 weeks of surgery relative to those with 0 to 2 barriers (adjusted odds ratio, 0.24 [95 CI%, 0.06–0.84]) on multivariable analysis. When analyzed by barrier category, patients with a perioperative adverse effects–related barrier were less likely to initiate timely PORT than patients without a perioperative adverse effects barrier (adjusted odds ratio, 0.17 [95% CI, 0.04–0.66]) on multivariable analysis. Among patients without timely PORT, the most common primary reason for delay was a barrier related to poor care coordination (19/46 [41.3%]).

CONCLUSIONS AND RELEVANCE

In this prospective cohort study, patients with a greater number of barriers and those with a barrier related to the perioperative adverse effects category were less likely to initiate timely PORT. Among patients without timely PORT, the most common primary reason for delay was a barrier related to poor care coordination. Efforts to improve timely PORT should focus on decreasing the number of barriers, improving surgical quality, and enhancing care coordination.

National Comprehensive Cancer Network guidelines and the Commission on Cancer recommend that patients with head and neck squamous cell carcinoma (HNSCC) undergoing postoperative radiation therapy (PORT) initiate PORT within 6 weeks of surgery.1,2 Despite these guidelines and the association of guideline-adherent PORT with improved overall and recurrence-free survival,3–5 more than 50% of patients with HNSCC do not undergo PORT within the recommended timeframe.6 To improve the delivery of timely PORT, studies have identified demographic and clinical risk factors associated with PORT delay.7 Although limited by their retrospective design, a few studies have also used data in the electronic health record (EHR) to describe the primary reason for delayed PORT initiation.8–11 Understanding the risk factors for PORT delay and the primary reason for delay can help target scarce resources to those at greatest risk to address the most significant problems.

In addition to focusing on risk factors for PORT delay and the underlying reasons, an approach that focuses on proactively assessing barriers to care may provide complementary insights. For example, a barrier-focused paradigm allows for the prospective assessment of events as they occur during clinical care, whereas a reasons-focused approach is limited to understanding events only after they occur. A barrier-focused approach may reveal that patients experience multiple barriers over time, and that the cumulative burden of barriers contributes to delays. Finally, a barrier-focused approach provides a vocabulary to understand these events as modifiable and aligns with strategies that focus on barrier resolution.

Our team and others have conducted in-depth semistructured interviews with patients and clinicians to qualitatively characterize barriers and facilitators to timely PORT.12–14 These studies, and the subsequent conceptual models based on them, suggest that barriers to PORT exist across multiple levels (eg, patient, clinician, system) and include patient knowledge and uncertainty, surgical complications, poor care coordination, care fragmentation, and health-related social risks (eg, transportation problems).12,14,15 To date, however, strategies to quantitatively characterize barriers to timely PORT among patients with HNSCC are lacking, and the quantitative relationship between barriers and timely PORT is unknown.

Although the EHR may be used to identify some clinical barriers to PORT (eg, surgical complications), strategies to evaluate the patient’s perspective about barriers to PORT are lacking. To incorporate the patient’s perspective into identifying barriers to PORT, we developed the Perceived Barriers Questionnaire (PBQ) by adapting a widely used assessment of barriers to cancer screening16 to align with existing conceptual models of PORT delay among patients with HNSCC.12,17 When combined with clinical data from the EHR, the PBQ represents a promising tool to aid in the comprehensive evaluation of multilevel barriers to PORT.

To address the gaps in our understanding about the relationship of barriers to care with timely PORT among patients with HNSCC, this study aims to prospectively (1) describe the barriers to PORT; (2) evaluate the association of barriers to care with the initiation of timely PORT and time to PORT; and (3) among patients who did not start PORT within 6 weeks of surgery, describe the primary reason for delay.

Methods

Study Design and Participants

This prospective cohort study included adults with locoregionally advanced HNSCC undergoing surgery and PORT from the usual care (UC) arm of a randomized clinical trial (RCT) evaluating an enhanced navigation-based intervention to improve the delivery of timely PORT.18 Patients were recruited for this RCT from May 19, 2020, to November 6, 2023. The methods and primary outcomes of the RCT have previously been published.18 This study was approved by the institutional review board at the Medical University of South Carolina. All participants provided written informed consent. Results are presented according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Development of the PBQ

To address the lack of a quantitative measure of the patient’s perspective about barriers to timely PORT, we developed the PBQ through the following steps. First, we conducted a comprehensive literature review to identify patient-reported measures of barriers to oncology care. Second, we identified relevant health behavior theories and an underlying conceptual framework for understanding barriers to timely PORT.12 Third, we performed semistructured interviews with a purposive sample of patients undergoing surgery and PORT and members of the head and neck oncology team to determine key barrier domains.12 Based on existing measures,16 our conceptual framework,12,17 and our qualitative data,12 we developed the specific PBQ items. We then performed cognitive interviews with patients and clinicians using standard techniques19 to optimize item content, relevance, complexity, and readability. Finally, the PBQ was refined based on participant feedback from within our single-arm trial evaluating an enhanced navigation-based intervention.20 As the PBQ item responses are yes/no instead of rating scale categories, psychometric validation using Rasch analyses was not performed.

Identifying Barriers to PORT

Barriers to PORT were prospectively collected from 2 sources: the PBQ and the EHR. Inclusion of the patient’s perspective (via the PBQ) and the clinician’s perspective (via the EHR) enhances the study of barriers to timely PORT because this approach aligns with existing multilevel conceptual models12,14,15 and maximizes the accuracy of data collection by ensuring that the most trusted source is used for each barrier. The PBQ (eFigure 1 in Supplement 1) is a patient-reported measure of barriers to PORT consisting of 16 yes/no items. In this study, patients completed the PBQ at 4 time points: surgical consultation (baseline), hospital discharge, their first postoperative clinic appointment, and the start of PORT (end of study). To complement the patient’s perspective, the research coordinator prospectively gathered data on the following clinical barriers from the EHR: lack of preradiation dental evaluation and/or extractions, delayed pathology reporting (ie, >10 days), care fragmentation, perioperative complications (eg, surgical site infection, wound dehiscence, fistula, hemorrhage, and partial or total flap failure), prolonged hospital length of stay (ie, >10 days), and hospital readmission. Each of the EHR-based barriers to care was collected as part of the parent RCT.18 Data from the PBQ and EHR were merged to create one comprehensive and singular set of barriers to PORT for each patient over the treatment continuum from surgical consultation through the start of PORT.

Characterizing Barriers to Timely PORT

For each patient, we calculated the number of barriers as the sum of the number of unique barriers between surgery and the start of PORT. If a patient experienced the same barrier at multiple time points (eg, a transportation-related barrier at baseline and again at the first postoperative clinic visit), only the first occurrence was counted. Thus, for each patient, the total number of unique barriers (henceforth, the number of barriers) ranged from0 to 16.

To determine the barrier category, we grouped the 16 barriers into 5 categories aligned with existing conceptual models for characterizing PORT delays.12,14 Barrier categories included the following:

  1. Patient knowledge and uncertainty (2 questions regarding knowledge about timely PORT and uncertainty regarding PORT);

  2. Care coordination and communication (5 questions regarding contacting, scheduling, attending, and receiving care from the multidisciplinary team);

  3. Care fragmentation (2 questions regarding fragmentation of care between the primary team and outside hospital, if patients received their surgical and radiation care at separate facilities);

  4. Perioperative adverse effects (3 questions regarding recovery from surgery, including needing more time to recover, complications, prolonged length of stay, hospital readmission); and

  5. Travel (3 questions regarding transportation, distance, and social support).

A patient was considered to have experienced a barrier within a category if they experienced 1 or more unique barriers from within that category during the study period. We classified barriers based on their timing in relation to key care transitions: after surgical consultation (baseline), hospital discharge (reflecting new barriers since surgical consultation), first postoperative clinic appointment (reflecting new barriers since hospital discharge), and start of radiation therapy (reflecting new barriers since the postoperative clinic appointment).

Primary Reason for PORT Delay

Among patients who did not start PORT within 6 weeks of surgery, we conducted an exploratory investigation to understand the primary reason for PORT delay. For each patient, the study coordinator prospectively supplemented information about barriers to care from the PBQ and EHR (clinical notes and care coordination documentation) for each patient with contextual information about each patient’s clinical course from members of the HN oncology team. The primary reason for delay was then defined in relation to the singular barrier category that most directly led to the delay. For patients who experienced a barrier in only 1 category, that category was assigned as the primary reason for PORT delay. For patients who experienced a barrier across more than 1 category, the unique barrier most directly responsible for the delay was determined through discussions between the research team and clinical teams (and the associated barrier category ascribed as the primary reason). For example, if a patient had a minor wound dehiscence (a perioperative adverse effects–related barrier) that resolved with antibiotics and wound care by 3 weeks after surgery but did not have a postoperative visit with radiation oncology scheduled until 5 weeks after surgery (a care coordination and communication barrier), the primary reason for delay was attributed to the poor care coordination and communication barrier because the wound dehiscence that resolved in a timely manner was not directly related to the PORT delay.

Sample Size

The sample size calculation for the RCT has been described18 and was based on a targeted difference in initiation of PORT within 6 weeks of surgery (primary end point) between the intervention and UC arms. In total, 78 patients from the UC arm were included in the analysis for this cohort study, all of whom completed the PBQ at least twice. Missing data (ie, unit non-response) were minimal as 67 patients (86%) completed the PBQ at all 4 time points, 9 patients (12%) completed the PBQ at 3 time points, and 2 patients (3%) completed the PBQ at only 2 time points. The analytic population for the end points in this study (initiation of PORT within 6 weeks of surgery; time to PORT) consisted of all patients enrolled in the UC arm who underwent surgery and had a pathologic indication for PORT (n = 78).18

Statistical Analysis

We analyzed the association between the number of barriers (covariate) and the initiation of timely PORT (primary end point) with barriers modeled as a continuous variable (0–16 barriers). Based on the observed nonlinear relationship between number of barriers and timely PORT, we also modeled the number of barriers as a categorical variable based on barrier tertiles (0–2, 3–4, and ≥5 barriers). To evaluate the association between the number of barriers and initiation of timely PORT, we constructed an unadjusted logistic regression model and multivariable logistic regression model adjusting for age, self-reported race, health insurance, Charlson Comorbidity Index, cancer subsite, and overall American Joint Committee on Cancer (AJCC) clinical stage. To evaluate the association of the barrier category with initiation of timely PORT, we constructed an unadjusted logistic regression model and multivariable logistic regression model adjusting for the same covariates. Although a harmonized dataset including the patient’s perspective (via the PBQ) and the clinician’s perspective (via the EHR) represents the most conceptually accurate and robust method of understanding the multilevel relationship of barriers to care and initiation of timely PORT, it is possible that analyzing only patient-reported barriers may be informative. To that end, we repeated all analyses, restricting barriers to only those directly reported by the patient on the PBQ.

A secondary analysis evaluating the association of (1) number of barriers with time to PORT and (2) the association of barrier category with time to PORT was conducted using a Fine-Gray competing risk model, with death considered a competing risk. Patients who reached the protocol-defined maximum follow-up time were censored at 18 weeks, as described previously.18 We reported 95% CIs around odds ratios (ORs) and hazard ratios (HRs). Median time to PORT in both timely PORT and delayed PORT groups was reported using a Kaplan-Meier approach. Analyses were conducted using RStudio, version 4.4.1 (R Project for Statistical Computing).

Results

Patient Characteristics

The characteristics of the 78 patients included in the study are summarized in Table 1. The mean (SD) age was 61.5 (10.8) years; 54 (69.2%) were male, and 24 (30.8%) were female. Seventy patients (89.7%) had AJCC clinical stage III or IV disease, and 52 patients (66.7%) underwent a free flap reconstructive surgery. Overall, 32 of 78 patients (41%) initiated PORT within 6 weeks of surgery. The median (IQR) time to PORT was 47 (40–56) days; 38 (35–41) days for those who initiated PORT within 6 weeks of surgery; and 55 (49–63) days for those without timely PORT.

Table 1.

Demographic and Clinical Characteristics

Characteristic No. (%)
Timely PORT (n = 32) PORT delay (n = 46) Total (N = 78)
Age, mean (SD), y 59.9 (11.5) 62.6 (10.2) 61.5 (10.8)
Sex
 Female 8 (25.0) 16 (34.8) 24 (30.8)
 Male 24 (75.0) 30 (65.2) 54 (69.2)
Race
 Black 5 (15.6) 14 (30.4) 19 (24.4)
 White 27 (84.4) 32 (69.6) 59 (75.6)
Health insurance
 Private 16 (50.0) 15 (32.6) 31 (39.7)
 Medicare 8 (25.0) 21 (45.7) 29 (37.2)
 Medicaid 3 (9.4) 6 (13.0) 9 (11.5)
 Uninsured 3 (9.4) 3 (6.5) 6 (7.7)
 Veterans Affairs 2 (6.2) 1 (2.2) 3 (3.8)
Partnership status
 Married or current partner 17 (53.1) 25 (54.3) 42 (53.8)
 Single 7 (21.9) 9 (19.6) 16 (20.5)
 Separated/divorced 5 (15.6) 8 (17.4) 13 (16.7)
 Widowed 3 (9.4) 4 (8.7) 7 (9.0)
Highest level of education
 <High school 3 (9.4) 7 (15.2) 10 (12.8)
 High school graduate 14 (43.8) 12 (26.1) 26 (33.3)
 Some college 10 (31.2) 14 (30.4) 24 (30.8)
 College graduate 3 (9.4) 8 (17.4) 11 (14.1)
 Graduate school 1 (3.1) 3 (6.5) 4 (5.1)
 Missing 1 (3.1) 2 (4.3) 3 (3.8)
Employment
 Full time 12 (37.5) 13 (28.3) 25 (32.1)
 Part time 1 (3.1) 1 (2.2) 2 (2.6)
 Unemployed 5 (15.6) 3 (6.5) 8 (10.3)
 Disability 2 (6.2) 6 (13.0) 8 (10.3)
 Retired 12 (37.5) 22 (47.8) 34 (43.6)
 Home 0 (0) 1 (2.2) 1 (1.3)
Charlson Comorbidity Index
 0 24 (75.0) 27 (58.7) 51 (65.4)
 1 3 (9.4) 14 (30.4) 17 (21.8)
 2 1 (3.1) 2 (4.3) 3 (3.8)
 ≥3 4 (12.5) 3 (6.5) 7 (9.0)
Smoking history
 Never 9 (28.1) 13 (28.3) 22 (28.2)
 Former 14 (43.8) 24 (52.2) 38 (48.7)
 Current 9 (28.1) 9 (19.6) 18 (23.1)
Cancer subsite
 Oral cavity 17 (53.1) 27 (58.7) 44 (56.4)
 Oropharynx p16-positive 6 (18.8) 3 (6.5) 9 (11.5)
 Oropharynx p16-negative 1 (3.1) 1 (2.2) 2 (2.6)
 Larynx/hypopharynx 6 (18.8) 9 (19.6) 15 (19.2)
 Paranasal sinuses 2 (6.2) 6 (13.0) 8 (10.3)
AJCC clinical T category
 0–1 9 (28.1) 2 (4.3) 11 (14.1)
 2 5 (15.6) 3 (6.5) 8 (10.3)
 3 5 (15.6) 6 (13.0) 11 (14.1)
 4 13 (40.6) 35 (76.1) 48 (61.5)
AJCC clinical N category
 x-0 7 (21.9) 15 (32.6) 22 (28.2)
 1 13 (40.6) 14 (30.4) 27 (34.6)
 2 10 (31.2) 16 (34.8) 26 (33.3)
 3 2 (6.2) 1 (2.2) 3 (3.8)
Overall AJCC clinical stage
 I 5 (15.6) 2 (4.3) 7 (9.0)
 II 1 (3.1) 0 (0.0) 1 (1.3)
 III 6 (18.8) 7 (15.2) 13 (16.7)
 IV 20 (62.5) 37 (80.4) 57 (73.1)
Ablative surgerya
 Mandibulectomy 5 (15.6) 17 (37.0) 22 (28.2)
 Glossectomy 13 (40.6) 23 (50.0) 36 (46.2)
 Maxillectomy 3 (9.4) 8 (17.4) 11 (14.1)
 Radical tonsillectomy 1 (3.1) 5 (10.9) 6 (7.7)
 Total laryngectomy 6 (18.8) 9 (19.6) 15 (19.2)
 Transoral robotic surgery 5 (15.6) 2 (4.3) 7 (9.0)
 Skull base resection 1 (3.1) 5 (10.9) 6 (7.7)
Neck dissection
 No 1 (3.1) 4 (8.7) 5 (6.4)
 Yes 31 (96.9) 42 (91.3) 73 (93.6)
Reconstructive surgerya
 Primary closure, allograft, skin graft, local flap, or obturator/prosthesis 13 (40.6) 10 (21.7) 23 (29.5)
 Regional flap 1 (3.1) 5 (10.9) 6 (7.7)
 Free flap 18 (56.2) 34 (73.9) 52 (66.7)
Concurrent therapies
 None 19 (59.4) 22 (56.4) 41 (57.7)
 Chemotherapy 12 (37.5) 15 (38.5) 27 (38.0)
 Immunotherapy 1 (3.1) 2 (5.1) 3 (4.2)
Travel distance to MUSC, median (IQR), miles 69.5 (21.8–121.2) 97.5 (69.8–134.4) 88.2 (36.5–134.4)
Fragmentation of care between surgical and radiation facilities
 No (PORT at MUSC) 22 (68.8) 10 (25.6) 32 (45.1)
 Yes (PORT at non-MUSC facility) 10 (31.2) 29 (74.4) 39 (54.9)
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Abbreviations: AJCC, American Joint Committee on Cancer; MUSC, Medical University of South Carolina; PORT, postoperative radiation therapy.

a

Totals may sum to greater than 100 due to patients having more than 1 concurrent type of ablative surgery and more than 1 concurrent reconstructive surgery.

Barriers to PORT

Table 2 shows the distribution of the number of barriers and their associated barrier category. Overall, 26 patients (33.3%) experienced 0 to 2 barriers, 25 patients (32.1%) experienced 3 to 4 barriers, and 27 patients (34.6%) experienced 5 or more barriers. When grouped into categories, barriers were most often related to patient knowledge and uncertainty (57 patients [73.1%]) and perioperative adverse effects (54 patients [69.2%]). The most common unique barriers were patient lack of knowledge about guidelines for starting PORT within 6 weeks of surgery, prolonged hospital admission, and delayed pathology reporting (eTable 1 in Supplement 1). The distribution of unique patient-reported barriers to PORT (PBQ without EHR data) is shown in eTable 2 in Supplement 1. When evaluating the temporal distribution of barriers, the total number of barriers was highest at hospital discharge (eFigure 2 in Supplement 1).

Table 2.

Barriers to Timely Postoperative Radiation Therapy (PORT) by Number of Barriers and Associated Barrier Categorya

Variable No. (%)
Timely PORT (n = 32) Delayed PORT (n = 46) Total (N = 78)
No. of barriers
 0–2 (Lowest tertile) 16 (50) 10 (21.7) 26 (33.3)
 3–4 (Middle tertile) 8 (25.0) 17 (37.0) 25 (32.1)
 ≥5 (Highest tertile) 8 (25.0) 19 (41.3) 27 (34.6)
Barrier category
 Patient knowledge and uncertainty
  No 8 (25.0) 13 (28.3) 21 (26.9)
  Yesb 24 (75.0) 33 (71.7) 57 (73.1)
 Care coordination and communication
  No 13 (40.6) 15 (32.6) 28 (35.9)
  Yesc 19 (59.4) 31 (67.4) 50 (64.1)
 Care fragmentation
  No 30 (93.7) 41 (89.1) 71 (91.0)
  Yesd 2 (6.3) 5 (10.9) 7 (19.6)
 Perioperative adverse effects
  No 16 (50.0) 8 (17.4) 24 (30.8)
  Yese 16 (50.0) 38 (82.6) 54 (69.2)
 Travel
  No 22 (68.8) 32 (69.6) 54 (69.2)
  Yesf 10 (31.2) 14 (30.4) 24 (30.8)
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a

For each barrier category, a brief description of the corresponding individual barriers is provided. A full description of the unique barriers (as synthesized from the electronic health record and Perceived Barriers Questionnaire) is provided in eTable 1 in Supplement 1. The frequency of unique barriers to PORT as measured by individual Perceived Barriers Questionnaire items is noted in eTable 2 in Supplement 1. The Perceived Barriers Questionnaire is included as eFigure 1 in Supplement 1.

b

Patient lack of knowledge about guidelines or referral process for starting PORT; patient indecision about need for PORT or radiation oncology facility.

c

Poor communication by head and neck clinicians about plan for starting PORT; challenges getting timely preradiation dental care; challenges getting appointments with head and neck oncology team scheduled in a timely fashion; lack of a point person for questions about starting PORT; pathology report returned more than 10 days after surgery.

d

Challenges getting information from Medical University of South Carolina (MUSC) team to non-MUSC radiation oncology team; non-MUSC radiation oncology team lacks relevant clinical information.

e

Patient perceived need for more time to recover from surgery before starting PORT; postoperative surgical complications; postoperative length of stay >10 d; unplanned hospital readmission.

f

Lack of reliable transportation for appointments; excessive travel distance for appointments; lack of social support or competing caregiver responsibilities.

Association Between the Number of Barriers and Timely PORT

The unadjusted and adjusted (multivariable) logistic regression analyses examining the association between number of barriers and the initiation of timely, guideline-adherent PORT are shown in Table 3. Each additional barrier was associated with a 19% decrease in the odds of initiating PORT within 6 weeks of surgery on multivariable analysis adjusted for demographic and clinical characteristics (adjusted OR, 0.81 [95% CI, 0.63–1.01]). Patients with 5 or more barriers (highest tertile) had a 76% reduction in the odds of initiating PORT within 6 weeks of surgery relative to patients with 0 to 2 barriers (lowest tertile) on multivariable analysis (adjusted OR, 0.24 [95% CI, 0.06–0.84]). When analyzed using time to PORT as an end point, findings were similar (eTable 3 in Supplement 1). Each additional barrier was associated with a 10% reduction in the rate of PORT initiation in a competing risks model adjusted for demographic and clinical characteristics (adjusted HR, 0.90 [95% CI, 0.80–1.01]). eTable 4 in Supplement 1 shows the association between the number of patient-reported barriers (PBQ without EHR data) and initiation of timely PORT.

Table 3.

Unadjusted and Adjusted Logistic Regression Models Evaluating the Association Between the Number of Barriers and the Initiation of Timely, Guideline-Adherent Postoperative Radiation Therapy

Unadjusted OR (95% CI) Adjusted OR (95% CI)a
No. of barriers 0.82 (0.65–1.00) 0.81 (0.63–1.01)
No. of barriers by tertile
 0–2 (Lowest) 1 [Reference] 1 [Reference]
 3–4 (Middle) 0.29 (0.09–0.91) 0.31 (0.08–1.11)
 ≥5 (Highest) 0.26 (0.08–0.80) 0.24 (0.06–0.84)
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Abbreviation: OR, odds ratio.

a

Models adjusted for age, race, health insurance, Charlson Comorbidity Index, cancer subsite, and overall American Joint Committee on Cancer clinical stage.

Association of Barrier Category With Timely PORT

The unadjusted and adjusted (multivariable) logistic regression analyses examining the association of barrier category with the initiation of timely PORT are shown in Table 4. There was a reduction in the odds of timely PORT initiation for patients with a perioperative adverse effects–related barrier compared to those without a perioperative adverse effects barrier on multivariable analysis (adjusted OR, 0.17 [95% CI, 0.04–0.66]). Findings were similar when evaluating time to PORT as an end point (eTable 5 in Supplement 1). The rate of PORT initiation was decreased among patients with a perioperative adverse effects barrier relative to patients without a perioperative adverse effects barrier (adjusted HR, 0.31 [95% CI, 0.18–0.53]). The association of patient-reported barrier category (PBQ without EHR data) and initiation of timely PORT is shown in eTable 6 in Supplement 1.

Table 4.

Unadjusted and Adjusted Logistic Regression Models Evaluating the Association of Barrier Category with Initiation of Timely, Guideline-Adherent Postoperative Radiation Therapy

Barrier category Unadjusted OR (95% CI) Adjusted OR (95% CI)a
Patient knowledge and uncertainty
 No 1 [Reference] 1 [Reference]
 Yes 1.18 (0.43–3.40) 1.13 (0.36–3.75)
Care coordination and communication
 No 1 [Reference] 1 [Reference]
 Yes 0.71 (0.28–1.81) 0.66 (0.22–1.95)
Care fragmentation
 No 1 [Reference] 1 [Reference]
 Yes 0.55 (0.07–2.73) 0.16 (0.01–1.31)
Perioperative adverse effects
 No 1 [Reference] 1 [Reference]
 Yes 0.21 (0.07–0.57) 0.17 (0.04–0.66)
Travel
 No 1 [Reference] 1 [Reference]
 Yes 1.04 (0.38–2.75) 1.44 (0.42–4.99)
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Abbreviation: OR, odds ratio.

a

Models adjusted for age, race, health insurance, Charlson Comorbidity Index, cancer subsite, and overall American Joint Committee on Cancer clinical stage.

Primary Reason for PORT Delay

The primary reasons for PORT delay among the 46 patients who did initiate PORT within 6 weeks of surgery are shown in the Figure. The most common reasons for PORT delay were due to poor care coordination and communication (19/46 [41.3%]), perioperative adverse effects (16/46 [34.8%]), and patient knowledge and uncertainty (8/46 [17.4%]) barriers. Collectively, nonperioperative adverse effects–related reasons accounted for 30 of 46 patients (65.2%) for whom PORT was not initiated within 6 weeks of surgery (eTable 7 in Supplement 1).

Figure. Pareto Chart Demonstrating the Primary Reasons for Delay Among Patients Who Did Not Initiate Postoperative Radiation Therapy (PORT) Within 6Weeks of Surgery.

Figure.

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The x-axis lists the primary reasons for PORT delay among the 46 patients who did not initiate PORT within 6 weeks of surgery, organized in descending order of prevalence. The y-axis at left lists the frequency count of the underlying primary reason. The y-axis at right indicates the cumulative percentage, in which the blue line represents the cumulative percentage of reasons for PORT delay, reading left to right across the x-axis.

Discussion

Four key findings emerged from this prospective cohort study of patients with HNSCC undergoing surgery and PORT. First, a barrier-focused approach can identify and classify multilevel barriers to timely PORT among these patients. Second, the cumulative number of barriers is associated with a decrease in initiating timely, guideline-adherent PORT and prolonged time to PORT. Third, among patients who did not start PORT within 6 weeks of surgery, the most common primary reason for delay was a barrier related to poor care coordination and communication. Fourth, when considering the category of barriers, perioperative adverse effects–related barriers had the strongest association with timely PORT and time to PORT.

To our knowledge, this is the first study to prospectively characterize barriers to timely PORT among patients with HNSCC and describe the relationship between barriers to care and PORT delay. Our approach draws on the robust barrier-focused approach used in the cancer screening and patient navigation literature21–27 and extends it to a novel patient population and aspect of the treatment continuum. In the future, this barrier-focused approach combining data from the EHR and the PBQ could be implemented into clinical care to screen patients for barriers to care in real time and guide the deployment of resources to address them.

Our finding that an increasing number of barriers was associated with treatment delays aligns with and extends findings from the cancer screening literature. In one study of 2600 people undergoing screening for breast cancer and 1387 people undergoing screening for cervical cancer, a greater number of barriers was associated with delays in cancer screening and prolonged time to diagnostic resolution.26,27 On a practical level, our results suggest that efforts to improve the delivery of timely PORT should focus on reducing the number of barriers that each patient experiences. Accordingly, for a patient to start PORT in a timely manner, it does not appear necessary to remove every single barrier. Rather, each barrier that the health care team addresses has the potential to decrease time to PORT and increase the likelihood of starting PORT in a guideline-adherent manner.

Our prospective cohort study confirms the importance of health care team-level factors such as care coordination in determining timely PORT9,11,14,28 and provides empirical support for existing multilevel conceptual models.12,15,29 Care coordination and communication barriers, such as submitting timely referrals to radiation oncology, scheduling timely postoperative appointments with radiation oncology, delayed preradiation dental evaluation, and lengthy time intervals between CT simulation and PORT start, are all modifiable targets, and quality improvement (QI) projects have shown the potential to address these factors and improve timely PORT.9,28,30 Furthermore, patient navigation, which is available at many facilities caring for patients with HNSCC,31 is an evidence-based strategy to enhance patient-centered care coordination and communication.32,33 Specifically for patients with HNSCC, there is a growing literature from QI study,11 a single-arm trial,20 and an RCT18 that enhanced navigation-based approaches focusing on care coordination and communication can improve timely PORT.

Finally, our study reinforces the importance of perioperative adverse effects as an important barrier to PORT. In this study, perioperative adverse effects–related barriers included surgical complications, prolonged length of stay, and unplanned hospital readmission, all of which are generally agreed on as modifiable and important QI targets.34,35 For patients with cancer, however, these QI targets take on important additional oncologic relevance. Viewed through this lens, return to intended oncologic therapy is an emerging quality indicator that helps underscore the importance of minimizing perioperative adverse effects in patients with cancer that can derail the package of cancer-directed therapy.36 Although it is unreasonable to expect to eliminate postsurgical complications, the field of head and neck surgery should not be complacent in accepting a high rate of PORT delay due to postsurgical complications. When considering strategies to improve timely PORT, head and neck surgeons should engage deeply with the robust literature on QI and enhanced recovery after surgery37,38 to improve postoperative healing, minimize postsurgical complications, and ensure the readiness of postsurgical patients for the timely initiation of PORT.34

Limitations

Our findings should be interpreted within the context of important limitations. The single institution design limits generalizability, while the relatively small sample size reduces the precision of point estimates. Future studies should therefore confirm our findings in a large, multi-institutional study inclusive of diverse patients and health care delivery characteristics. Although a number of studies have documented that patients with cancer are willing to report barriers to care39,40 and potentially stigmatizing conditions like health-related social risks in the clinical and research settings,41 the potential remains that patients in our study did not fully disclose perceived barriers to care to research staff, potentially biasing study findings. While the PBQ was developed in alignment with existing conceptual models for delivery of timely PORT at the time,12,14,15 important barriers (eg, health literacy,15 social support42) were not included, and we did not directly capture the perspective of informal caregivers or members of the health care team in understanding barriers. Finally, determining the primary reason for PORT delay remains inherently subjective. Our study, with its prospective design and inclusion of patient-centered data, represents an improvement over prior studies, which were retrospective in nature and relied solely on information in the EHR.8–11 Nevertheless, the validity, interrater reliability, and intrarater reliability of our approach should be evaluated in other settings.

Conclusions

In this prospective cohort study, our novel barrier-focused approach revealed that patients with a greater number of barriers were less likely to initiate timely PORT, as were those with a perioperative adverse effects–related barrier. Among patients who did not initiate PORT within 6 weeks of surgery, the most common primary reason for PORT delay was a barrier related to poor care coordination. Efforts to improve timely PORT should focus on decreasing the number of barriers, improving surgical quality, and enhancing care coordination.

Supplementary Material

Supplement 1
Supplement 2

Key Points.

Question

How do barriers to care affect the initiation of timely postoperative radiation therapy (PORT) among patients with head and neck cancer?

Findings

In this prospective cohort study of 78 patients with head and neck cancer, an increasing number of barriers and a perioperative adverse effects–related barrier were each associated with a decreased likelihood of initiating timely, guideline-adherent PORT. Among patients who did not start PORT within 6 weeks of surgery, the most common primary reason for PORT delay was a barrier related to poor care coordination.

Meaning

Efforts to improve timely PORT should focus on decreasing the number of barriers, improving surgical quality, and enhancing care coordination.

Funding/Support:

This work was supported by the National Cancer Institute at the National Institutes of Health (K08 CA237858 and R01 CA282165 to Dr Graboyes), the Triological Society/American College of Surgeons to Dr Graboyes, the Biostatistics Shared Resource, Hollings Cancer Center, Medical University of South Carolina (P30 CA138313) and the National Center for Advancing Translational Sciences (UL1 TR000062).

Role of the Funder/Sponsor:

The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnotes

Conflict of Interest Disclosures: Mr DeMass reported personal fees from MountainPass Technology outside the submitted work. Dr Sandulache reported consulting fees Femtovox consulting outside the submitted work. Dr R. Jackson reported honoraria from Intuitive Surgical outside the submitted work. Dr Osazuwa-Peters reported personal fees from Merck and Navigating Cancer outside the submitted work. Dr Yom reported grants from Bristol Myers Squibb, Merck, Johnson & Johnson, and EMD Serono outside the submitted work. Dr Graboyes reported personal fees from Merck, grants from Stryker, and travel support from Stryker outside the submitted work. No other disclosures were reported.

Disclaimer: Drs Osazuwa-Peters and Graboyes are Deputy Editors of JAMA Otolaryngology–Head & Neck Surgery but were not involved in any of the decisions regarding review of the manuscript or its acceptance.

Meeting Presentation: This study was presented at the AHNS 2025 Annual Meeting; May 15, 2025; New Orleans, Louisiana.

Contributor Information

Megan T. Nguyen, Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston.

Emily Kistner-Griffin, Department of Public Health Sciences, Medical University of South Carolina, Charleston; Hollings Cancer Center, Medical University of South Carolina, Charleston.

Reid DeMass, Department of Public Health Sciences, Medical University of South Carolina, Charleston; Hollings Cancer Center, Medical University of South Carolina, Charleston.

Bhisham S. Chera, Hollings Cancer Center, Medical University of South Carolina, Charleston; Department of Radiation Oncology, Medical University of South Carolina, Charleston.

Chanita Hughes Halbert, Department of Population and Public Health Sciences, University of Southern California, Los Angeles; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles.

Katherine R. Sterba, Department of Public Health Sciences, Medical University of South Carolina, Charleston; Hollings Cancer Center, Medical University of South Carolina, Charleston.

Elizabeth G. Hill, Department of Public Health Sciences, Medical University of South Carolina, Charleston; Hollings Cancer Center, Medical University of South Carolina, Charleston.

Brian Nussenbaum, American Board of Otolaryngology–Head and Neck Surgery, Houston, Texas.

Anthony J. Alberg, Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia.

Vlad C. Sandulache, Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas; ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.

David J. Hernandez, Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas.

Ryan S. Jackson, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri; The Robert Ebert and Greg Stubblefield Head and Neck Tumor Center at Siteman, Washington University School of Medicine, St Louis, Missouri.

Sidharth V. Puram, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri; The Robert Ebert and Greg Stubblefield Head and Neck Tumor Center at Siteman, Washington University School of Medicine, St Louis, Missouri.

Russel Kahmke, Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina.

Nosayaba Osazuwa-Peters, Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina; Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina; Deputy Editor, JAMA Otolaryngology–Head & Neck Surgery.

Gail Jackson, Head and Neck Cancer Alliance, Charleston, South Carolina.

Sue S. Yom, Department of Radiation Oncology, University of California, San Francisco; Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco.

Evan M. Graboyes, Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston; Department of Public Health Sciences, Medical University of South Carolina, Charleston; Hollings Cancer Center, Medical University of South Carolina, Charleston; Deputy Editor, JAMA Otolaryngology–Head & Neck Surgery.

Data Sharing Statement:

See Supplement 2.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1
NIHMS2110949-supplement-Supplement_1.pdf (729.5KB, pdf)
Supplement 2
NIHMS2110949-supplement-Supplement_2.pdf (17.3KB, pdf)

Data Availability Statement

See Supplement 2.

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