Timely Adjuvant Therapy in Head and Neck Cancer: Barriers and Facilitators in Rural Care

Abstract

Importance:

Timely initiation of postoperative radiotherapy (PORT) within six weeks of surgery improves survival for patients with head and neck squamous cell carcinoma. Rural populations experience disproportionate delays, yet contextual drivers remain poorly understood.

Objective:

To identify barriers, facilitators, and themes influencing the receipt of timely PORT in rural settings to inform a future multilevel intervention.

Design, Setting, and Participants:

This qualitative study used a phased, patient-and-caregiver involved design at two rural northern New England cancer center clinics. Phase 1 included two facilitated dialogues with patients, caregivers, and staff followed by participant-led coding. Phase 2 included three facilitated dialogues focused on refining barriers, facilitators and solutions-focused themes (two with patients/caregivers and one with staff). Phase 3 included reviewing preliminary insights at a clinic staff retreat for feedback. The analysts used an inductive–deductive approach guided by Intervention Mapping and the Consolidated Framework for Implementation Research (CFIR) 2.0.

Main Outcomes and Measures:

Barriers, facilitators, and themes related to timely PORT initiation.

Results:

Eleven individuals participated in the Partnership Academies and 18 in the Community Engagement Studios. We identified five barriers – communication, care coordination, access to dental care, transportation, and confronting negative emotions – and four facilitators: key staff as central contacts, caregivers as advocates, rural culture, and leveraging pre-existing resources. Four themes emerged: (1) Leveraging strengths; (2) Managing the steep learning curve after cancer diagnosis; (3) The value of peer support; and (4) The desire for information support was far-reaching.

Conclusions and Relevance:

This study uniquely examines PORT delays in a rural context with patient, caregiver, and staff voices. Findings highlight the importance of community resources, effective communication, and peer support to inform multilevel strategies aimed at reducing delays and improving equity in cancer care.

Introduction

The timely initiation of adjuvant radiotherapy after surgery, also known as surgery to postoperative radiotherapy time (PORT), is a nationally endorsed quality metric in the treatment of head and neck squamous cell carcinoma (HNSCC).^1,2 Starting radiotherapy within six weeks of surgery has been shown to significantly improve tumor control and overall survival.^3–5 Yet, nationally, 50–60% of patients do not receive timely PORT.^6–8 Delays are linked to rural residence,⁹ race,^6,10,11 comorbidities,¹² insurance status,¹³ delayed wound healing,¹⁴ higher stage tumors,¹⁵ patient information overload,^16,17 obtaining dental clearance,^16,18,19 and fragmented care.^6,10 A recent large randomized controlled trial that enrolled patients both within the US and internationally affirmed that fewer than half of the enrolled patients achieved timely PORT,²⁰ underscoring the persistence of this problem.

Existing studies investigating strategies to positively impact PORT timeliness in the United States (US) fall into two groups: pre-implementation studies identifying causal barriers,^16,21–25 and interventional studies addressing those barriers (see eTable1).^{17–19,26–29} Both typically emphasize the importance of addressing clinical processes connected to the initiation of PORT, including dental evaluations, care-team referrals, and communication among staff and between staff and patients.^{16–19,21–29} Other reported contributors to delayed PORT start include postoperative complications,^18,19,27 insufficient awareness of the PORT guideline,^{16,17,22,28,29} transportation difficulties^{16,17,22,28,29}, and limited social support.¹⁶ While some studies have incorporated patient perspectives, none included caregivers; all were single-site, urban, and none were conducted in the Northeast US.

To address this gap, we identified barriers and facilitators to timely PORT in two rural-serving oncology clinics in the Northeast US using patient-and-caregiver involved research methods that were guided by implementation science principles. Our findings will inform the development of a multilevel intervention to reduce PORT delays in rural settings and address survival disparities for rural patients with HNSCC.^30,31

Methods

Overview

We applied community-engaged research principles (classified as patient and caregiver involved research) in three sequential phases: (1) facilitated dialogues that included patients, caregivers, and staff perspectives (Partnership Academies)^32,33; (2) facilitated dialogues with larger numbers of representative participants (Community Engagement Studios)³⁴; and (3) feedback on interim results during a staff research retreat (member checking) (Table 1). Italicized methodologic and analytic terms at first mention in the methods are defined in eSupplement 2, a plain-language reference for terms used in this study. The project was reviewed by the IRB and designated as Quality Improvement, and the CE studios had a separate IRB approval. We provide detailed COREQ guideline reporting, a tool used for qualitative methods, in eTable3.³⁵

Table 1.

Study Overview

	Partnership Academies	Community Engagement Studios	Member Checking
Goal	Identify barriers and facilitators to timely PORT.	Enhance insight into barriers and facilitators with local context.	Refine insights with staff feedback from those directly involved.
Sampling Process	Purposive sampling to engage diverse and involved stakeholders	Patients and caregivers with HNSCC treated at Lebanon, NH, and St. Johnsbury, VT. Staff at both locations.	Staff at an institutional HNSCC retreat. In addition, the study team includes patient and caregiver advocates.
Sampled Participant Roles	• Patient • Caregiver • Nurse navigator • Hospital administrator • Social worker • Dentist • Dental assistant and Public Health Student • Medical oncologist Radiation oncologist	• Patients (9) • Caregivers (3) • Pathology Administrator • Pathology Technician • Dietician • Scheduler • Medical Oncologist • Radiation Oncologist	• Surgeons • Pathologists • Dietician • Radiologist • Nurse Practitioners • Physician Assistant • Medical Oncologist • Radiation Oncologist • Nurse Navigator • Speech Language Pathologist Social Worker • Resident Physicians
Data Collection	Transcribed verbatim dialogue	Summarized dialogue	Written and verbal comments
Analysis	Open coding by eight participants over several sessions	Axial coding (all data) by two analysts.	The study team reviewed barriers, facilitators and themes.

Setting

The two outpatient oncology clinics included in this study are part of the Dartmouth Cancer Center, an NCI-designated comprehensive cancer center. One clinic is located at the main academic medical center in Lebanon, New Hampshire, and the other is a satellite clinic located approximately 70 miles north in St. Johnsbury, Vermont. Both clinics serve rural populations and include medical oncology and radiation oncology services; surgical oncology services are available only at the Lebanon, New Hampshire site.

Sampling

Participants in the Partnership Academies, the first phase of facilitated dialogues, were adults (≥18 years) recruited by purposive sampling for predetermined roles (e.g., patient, caregiver, hospital administrator). Participants from the first session also recommended additional participants for the second session (e.g., dentistry, social work, specific health system leaders).

Two sampling strategies were used for the Community Engagement Studios (CE Studios), the second phase of facilitated dialogues. For the two patient/caregiver CE Studios, participants were eligible if they were ≥18 years, had completed definitive HNSCC treatment (surgery followed by radiation or radiation alone) 6 months–3 years prior or were a caregiver of such a patient, spoke English, had internet-enabled video access, and had completed a REDCap interest form. Each received a $100 stipend. Participants were scheduled into CE Studios according to where they received most of their adjuvant care (St. Johnsbury, VT vs Lebanon, NH). Clinical staff were invited by email or in-person if they were stakeholders in the surgery-to-PORT care pathway and had completed a REDCap form.

Decisions to conclude each data-collection phase (Partnership Academies, CE Studios, member checking) were made by team consensus. Recruitment ceased once the team judged that sufficient content depth and participant diversity were present for the purposes of informing CE Studio design and subsequent analyses.

Data Collection

Each Partnership Academy was facilitated by one researcher trained in this facilitation method (KLF) and co-led by the two principal investigators (GTW, PES). After orienting participants to the format, the session started with a patient vignette and open-ended questions on what participants thought may be causing treatment delays or potential solutions. Sessions were 60 minutes, held virtually, and audio recorded with transcription.

For the CE Studios, an institutional team trained in the CE Studio model led the sessions. Discrete categories of barriers were drafted by the study team (derived from Partnership Academies), which served as a basis for the first half of the session dialogue (review of previously identified barriers). The second half of the session focused on potential solutions to these barriers. The two patient/caregiver CE Studios lasted 120 minutes each; the health system stakeholder CE Studio lasted 75 minutes. These sessions were held virtually, and not recorded; a facilitator took notes and distributed detailed summaries to the study team.

For the off-site staff retreat (member checking), the study team presented the preliminary thematic analysis, and during an interactive, 60-minute session, solicited verbal and written comments from all attendees. One team member took notes and collated all written comments after the session.

Analysis and Interpretation

We used the Consolidated Framework for Implementation Research (CFIR 2.0)³⁷ to organize participant-identified barriers and facilitators across multiple levels; the goal was not one-to-one mapping of each barrier to a specific CFIR domain, but rather to apply the main ideas within a framework used across many implementation studies. We also used principles from Intervention Mapping (IM), a six-step process to design interventions,³⁸ during interpretation to organize determinants (factors, conditions, or drivers of delayed PORT) into solution-oriented themes intended to inform future intervention design; formal, stepwise IM was outside the scope of this manuscript. We identified barriers and facilitators as analytic categories intended to summarize determinants of timely PORT, while reserving thematic analysis for solution-oriented interpretation focused on how participants wished these determinants to be addressed.

We employed an inductive-deductive approach to analyze our participants’ responses during all sessions.³⁹ The specific coding method varied between the Partnership Academy and the CE Studies since the Partnership Academy instructs participants to use a collaborative consensus method that assigns meaning (code) to transcribed quotes. This approach is called the Rapid and Rigorous Qualitative Data Analysis (RADaR) method, and is described in more depth elsewhere.³⁶ Findings from this analysis informed facilitation plans for the CE Studios (Table 1). After the completion of the three CE studios, two analysts (GTW, KS) independently examined all dialogues. Microsoft Excel (Microsoft 365) was used to manage codes across both phases. Findings were iteratively reviewed with the interdisciplinary team during weekly project meetings and further refined at a staff retreat that served as member checking. The decision not to conduct further dialogues was made as a consensus decision among team members after reviewing the derived themes and judged that we achieved sufficient depth. This decision was guided by the concept of information power,⁴⁰ which emphasizes that focused aims, theoretical framing, and rich dialogue support the use of smaller samples.

Results

Participants

Across the two Partnership Academies, 11 individuals participated. Across the three CE Studios, nine patients, three caregivers, and six staff participated; 16 staff contributed during member checking. Participant roles are described in Table 1.

Barriers

We found five barriers to achieving timely PORT: communication, care coordination, access to dental care, confronting negative emotions, and transportation (Figure 1). These are presented as determinant categories rather than fully developed themes. Their ordering is not hierarchical (does not convey importance), and each determinant category was subdivided into subdomains to enhance clarity.

Figure 1.

Fishbone Diagram on Barriers and Facilitators to Timely PORT.

Communication.

Participants cited both staff-patient and staff-staff communication barriers. In staff-patient exchanges, all groups noted high information burden, complexity, and difficulty tailoring the message. Patients and caregivers received extensive new medical information (e.g., feeding tube use, postoperative pain management) that had to be acted on quickly, often without clear instructions. Difficulties in staff-patient communication were not restricted to clinic or hospital encounters. For example, one patient described confusion after seeing unfamiliar appointments in the health portal. A key downstream effect of poor communication was the widespread lack of awareness about the six-week PORT initiation guideline, despite efforts by some to emphasize it in their clinic visits. Staff references to “non-compliant patients” (e.g., declining or delaying visits) likely also reflected underlying communication failures. In many cases, this “non-compliance” may have been the downstream consequence of insufficient education about the purpose of a visit or not fully addressing the root cause of the patient’s reluctance.

Staff–staff communication challenges included limited awareness of timelines outside one’s role (e.g., surgical teams unaware that simulation-to-treatment averaged almost two weeks, not one). Missed meetings and fragmented communication across specialties or external institutions also contributed.

Care coordination.

All groups described internal (within the health system) and external (outside the health system) coordination difficulties. Internal barriers included care transitions (e.g., discharge, rehospitalization) and patients meeting multiple teams (surgery, radiation oncology, medical oncology, oral surgery). Tracking patients from diagnosis to adjuvant therapy was labor-intensive, and electronic health record tools to assist in the labor (e.g., task handoffs, live updates) were limited. In contrast, the Radiation Oncology department relied upon software to manage handoffs on a timeline that was well liked by its users. This system, however, was unavailable to users outside the department. Externally, staff relied on community dentists for clearance since the health system lacked general dentists; referral processes were cumbersome and network knowledge was inconsistent (e.g., which dentists could see patients within 1–2 weeks).

A related subdomain, inflexibility to changing circumstances, involved unanticipated events (e.g., infection, hospitalization, bereavement) that disrupted the multi-week outpatient sequence. Causes spanned clinician scheduling (different clinic days), system constraints (services unavailable), and broader factors (insurance or geographic barriers).

Access to dental care.

Barriers included limited availability (e.g., few dentists in their rural area, long waits, dependence on community providers), financial strain, or no pre-existing dental relationships.

Transportation.

Participants highlighted transportation as a major concern, given that adjuvant radiation often requires daily weekday visits over six weeks. Winter weather compounded the challenge, and public transportation was rarely feasible due to limited routes and misaligned schedules in rural areas.

Confronting negative emotional and physical hardship.

Patients and caregivers described emotional strain (fear, isolation, loss) and physical challenges (symptoms, time-intensive care) persisting for months or years after treatment. Though the severity often waned post-treatment, the nature of the distress evolved – from fear of therapy to managing ongoing uncertainty and adaptation to a “new normal.”

Facilitators

We identified four facilitators to timely PORT: key staff serving as central contacts, caregivers as advocates and knowledge brokers, rural culture, and leveraging pre-existing resources (Figure 1). As with barriers, each included subdomain reflects distinct aspects of the facilitator.

Key staff serving as central contacts.

Patients and caregivers consistently valued clinic staff who functioned as reliable points of contact—often nurses, navigators, or administrative personnel. These staff were described as knowledgeable, engaged, and approachable, providing both information and reassurance. Their presence simplified communication pathways, clarified next steps, and strengthened therapeutic relationships. Participants noted that non-physician staff were particularly effective for routine coordination, allowing physicians to focus on clinical decision-making.

Caregivers as advocates and knowledge brokers.

Caregivers were portrayed as indispensable in navigating complex systems. They actively sought information, coordinated appointments, and managed logistics related to scheduling, transportation, and finances. Their advocacy often compensated for system-level coordination and service gaps. However, participants recognized the emotional labor this required, emphasizing the need to better support caregivers in this role.

Rural culture of resiliency and helping one’s neighbor.

Participants described a strong sense of social cohesion and mutual support as integral to rural life. Many cited community members’ willingness to “step in” for others, especially during treatment. Several noted that messages delivered by individuals perceived as similar to themselves (e.g., community members or cancer survivors) were desirable. This cultural orientation facilitated perseverance but could also foster reluctance to seek help—underscoring its dual potential as strength and barrier

Leveraging pre-existing resources.

Participants highlighted the importance of building on existing assets, including both the health system and community-based organizations. Staff emphasized health system strengths including established dental referral networks, social resource programs, and philanthropic funds that could offset costs. Patients and caregivers emphasized community-based organizations as potential partners to provide transportation, financial support, and psychosocial assistance. All groups valued the current recurring, structured clinic encounters, such as weekly dietitian visits, since they fostered trust and continuity. Together, these examples illustrated how existing infrastructure could be mobilized to support timely PORT.

Consolidated Framework for Implementation Research (CFIR) 2.0

Figure 2 uses CFIR 2.0 as an organizing framework to locate participant-identified determinants of timely PORT within two settings, an “outer setting” related to factors outside of the health system, and an “inner setting” related to factors within the health system. Determinants shown may function as barriers, facilitators, or context-dependent influences; of note, these determinants are not intended to map 1:1 to the list of barriers and facilitators in Figure 1. Consistent with the CFIR 2.0 framework, the “Individuals” domain represents stakeholders involved in the PORT care pathway whose roles and interactions shape implementation. This multilevel mapping highlights how organizational, interpersonal, societal, and contextual influences intersect to shape PORT timeliness and inform the themes described in the following section.

Figure 2. CFIR 2.0–based analytic organization of determinants influencing timely postoperative radiotherapy (PORT).

This figure uses the CFIR 2.0 framework as an organizing lens to situate participant-identified determinants across multiple levels of the implementation context. Determinants shown may function as barriers, facilitators, or context-dependent influences and are not intended to map one-to-one to the list of barriers and facilitators presented elsewhere. Consistent with CFIR 2.0 conventions, the “Individuals” domain reflects characteristics and roles of actors involved in the PORT care pathway rather than discrete implementation determinants

Themes on achieving timely PORT

Participants articulated four themes describing what they sought from a multilevel intervention to improve timely PORT. Table 2 summarizes themes, subthemes, and illustrative quotes.

Table 2.

Themes on barriers and facilitators to timely PORT

Themes	Subthemes	Illustrative quotes
1. Leveraging strengths	Leveraging existing dentistry and health system networks Emulating approaches used in other clinics or professional networks Patient and caregivers like resources based in the community Community health worker to assess and address social needs	“I think the biggest thing that we’ve seen where we’ve kind of tried to help, especially with the transplant team, because our office works pretty close to the transplant team, too, is just making sure the patients are getting their full [dental] evaluations before being picked for a transplant.”   Dentist “Our community health worker tries to outreach as much as she can to a lot of our patients who identify in the social determinants of health and need for transportation.”   Cancer Center Administrator
2. Managing the steep learning curve after cancer diagnosis	Among all stakeholders, there was variable awareness of the 6-week PORT goal Patients noted unclear role delineation among clinicians Written materials that provide simplified short-term and long-term goals Skill among patients in navigating the patient portal is variable	“Needs to be brought to everyone’s attention about the goal of [PORT] in six weeks.”   Patient “The biggest issue was navigating the system. Do I go to primary care, dermatology, or oncology?”   Patient
3. The value of peer support	Lay health navigator Learning from someone with personal experience Value of developing an “advocate”. Learning all that has to happen Better from the community than from the health system	“It was very helpful to hear from people who have been through what I went through. I don’t feel so alone now.”   Patient “I did a lot on Facebook like I found a lot of supports on Facebook. but I think I understand where [he] is coming from is that it can’t just be a Dartmouth thing. It needs to be more of a community-like outreach.”   Caregiver
4. The desire for information support was far-reaching	Patients desire information related to living life to its fullest following cancer treatment Adapting to the new normal immediately after surgery Complexities and challenges in treatment selection	“[I desire] info on the aspects of care after surgery, including speech therapy, lymphedema, thyroid concerns, and stretching the neck.”   Patient “As a patient ‘scared out of my wits’ [I] needed more up-front conversation with doctors who just didn’t tell enough. Could have been more transparent.”   Patient

^*Patient quotes are approximations done by studio facilitator since the sessions not recorded

Theme 1 – Leveraging strengths.

Patients and caregivers identified community-based organizations addressing needs such as transportation and fuel assistance as ideal partners. Staff and leaders cited preexisting health system programs as models to replicate (e.g., existing dental-referral processes used in transplant clinics) or resources to access (e.g., social work, patient support services). Staff widely supported assuming responsibility for connecting patients with needed services; in contrast, some patients emphasized self-reliance and community support.

Theme 2 – Managing the steep learning curve after cancer diagnosis.

Participants described patients and caregivers facing an overwhelming volume of information to integrate within short timeframes (e.g., hour-long visits). The task was further compounded by short timelines (i.e., days to a few weeks) to see the necessary specialists or complete medical procedures or imaging. Awareness of the six-week PORT guideline was often lost, even among staff. Consequences included information overload, difficulty prioritizing, and missed coordination opportunities.

Theme 3 - The value of peer support.

Patients and caregivers desired connections with others who had undergone head and neck cancer treatment. Peer support offered instrumental benefits (practical strategies for navigating care) and emotional benefits (feeling understood, less isolated).

Theme 4 - The desire for information support was far-reaching.

Information needs extended beyond the peri-operative period to long-term recovery and survivorship. Desired topics ranged from surgical recovery to late swallowing outcomes. Participants emphasized the need for tailored, phased information delivery—too much too soon could exacerbate overload, while adaptive, just-in-time access was preferred.

Discussion

The work performed in our study is significant for two main reasons. First, we identified barriers, facilitators, and solutions-focused themes related to timely PORT in a rural context, whereas prior studies performed in the US were conducted at urban centers. Second, we describe the application of two distinct community-engagement methods to obtain knowledge in a rigorous, time-sensitive, and inclusive manner. Of note, the inclusion of the caregiver perspective as it relates to the context of timely PORT is novel. Soliciting the perspective of a diverse group of participants (i.e., patients, caregivers, multidisciplinary staff) provided unique insights into the needs of our community that would not have emerged if we had interviewed only clinical staff. Specifically, the desires for peer support, information support throughout the continuum of cancer survivorship, and a preference for material support from community-based organizations were sourced from the patient and caregiver participants. As the tenets of the co-production suggest, incorporating the lived experiences of patients, their caregivers, and staff together can lead to the design of more effective interventions.^41,42

The barriers and facilitators for timely PORT that we identified are well-supported by existing evidence. There is broad support that clinical care factors like communication barriers, care coordination difficulties, and timely dental care impact the receipt of timely PORT.^{16–19,21–29} Similarly, transportation difficulties as a barrier to timely PORT were identified in multiple studies across different geographic regions,^16,17,22,29 and were the most frequently cited barrier in a national survey of US healthcare organizations that treat HNSCC.²¹ When examining barriers such as communication more granularly, we found incomplete awareness of the PORT metric among staff and patients, consistent with prior research.^16,21,22 Similarly, our participants – like others – cited pathology result turnaround time,^23,28 timing of dental evaluations,^{16–19,22,23,26–29} and timing of radiation oncology visits^{16–19,22,23,26–29} as key drivers for delays.

What set our PORT-focused study apart was its attention to emotional challenges, peer support, caregiver roles, rural culture, and preferences for community-based organizations. There is published evidence supporting these findings, both from timely PORT-focused studies and from the broader cancer care delivery literature. For instance, two separate PORT-focused studies performed at the same cancer center affirm the importance of emotional and peer support: the first interviewed 26 people living with HNSCC and identified the importance of emotional support,¹⁶ and the second used validated survey measures of social support that assessed four subdomains (positive social interaction, affectionate support, tangible support, and emotional/informational support) and each were associated with PORT delays.⁴³ The interview study previously mentioned also identifies the role of the caregiver as an advocate, and when caregiver strain becomes significant, then that strain acts as a barrier to timely PORT.¹⁶ The role of rural culture as a mediator of whether individuals seek or accept support appears unique within the PORT-focused literature, likely because prior work has largely been conducted in urban settings. Interview studies with survivors of HNSCC and other cancers similarly highlight how “rural culture” shapes the willingness to engage with psychosocial support.^44,45 In parallel, although there is no direct evidence in the PORT-focused literature regarding the preference for “community-based organizations” over health system-delivered resources, a recent review found that people “strongly preferred a community outreach approach” for cancer screening and navigational services.⁴⁶ Altogether, these findings deepen understanding of the multilevel factors influencing timely PORT.

While our study had several important strengths that include sampling a variety of perspectives, using established implementation science frameworks to add rigor to the analysis, and conducting the work at two rural-serving cancer clinics, there are also limitations. The study focus on two clinics in rural Northern New England limits generalizability to other geographic areas and cultural contexts. We did not collect demographic data beyond participant role (i.e., patient, caregiver, staff job role) on account of regulatory constraints (i.e., QI designation, specifics of the CE Studio IRB). There is also the possibility of selection bias, as participation in the facilitated dialogues was by invitation and required a substantial time commitment; perspectives of individuals who lacked the time, interest, or ability to participate may therefore be underrepresented. Decisions to conclude data collection were based on team judgments of sufficient content depth and participant diversity, while also considering pragmatic factors such as project timelines and the resources required to reach additional participants. Although further dialogues might have yielded additional insights, qualitative methodologists note that such trade-offs between depth and scope are inherent to qualitative inquiry.⁴⁷ This limitation is most notable for caregiver participants, whose numbers were fewer than patients and staff sampled. We did not ask our participants to rank the importance of the identified barriers or facilitators, as we plan to use alternate means (e.g., electronic health record data, design dialogues, small tests of change) to prioritize intervention targets. Despite these limitations, our findings provide actionable insights into barriers and facilitators to timely PORT in rural settings and highlight opportunities for intervention development.

By including the perspectives of patients, caregivers, and staff in rural oncology clinics, this study provides new insights into barriers and facilitators that contribute to delays in PORT. Our findings underscore the importance of care coordination, communication, and emotional support, while also highlighting the role of rural culture and community resources as both challenges and opportunities. These results will inform the development of multilevel, contextually-grounded interventions aimed at improving the timeliness of PORT and reducing survival disparities in rural head and neck cancer care.

Key Points.

Question

What barriers, facilitators, and themes influence timely postoperative radiotherapy (PORT) for head and neck squamous cell carcinoma in rural cancer clinics?

Findings

In this qualitative, implementation science-informed study at two rural cancer clinics, participants identified five barriers—communication, care coordination, access to dental care, transportation, and confronting negative emotions—and four facilitators: key staff as central contacts, caregivers as advocates, rural culture, and leveraging pre-existing resources. Four themes emerged: (1) Leveraging strengths; (2) Managing the steep learning curve after cancer diagnosis; (3) The value of peer support; and (4) The desire for information support was far-reaching.

Meaning

These findings highlight multilevel factors shaping timely PORT in rural settings and point to specific opportunities for designing interventions that reduce delays and improve equity in HNSCC care.

Access to Data and Data Analysis:

GTW had full access to the data and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Data Sharing Statement:

The data in this study, participants transcripts and facilitation notes, will not be made available as the statements in them could potentially identify individuals and violate expectations of confidentiality.