Abstract
Objectives:
In this study, we aim to determine the frequency of adherence to National Comprehensive Cancer Network follow-up guidelines in a population of head and neck cancer patients who received curative treatment. We will also assess the impact of race, ethnicity, socioeconomic status, and treatment setting on utilization of follow-up care.
Methods:
This study included patients with biopsy-proven, nonmetastatic oropharyngeal or laryngeal cancer treated with radiotherapy between January 1, 2014, and June 30, 2016, at a safety-net hospital or adjacent private academic hospital. Components of follow-up care analyzed included an appointment with a surgeon or radiation oncologist within 3 months and post-treatment imaging of the primary site within 6 months. Univariable and multivariable analyses were conducted using a logistic regression model to estimate odds ratios and corresponding 95% confidence intervals.
Results:
Two hundred and thirty-four patients were included in this study. Of those, 88.8% received posttreatment imaging of the primary site within 6 months; 88.5% attended a follow-up appointment with a radiation oncologist within 3 months; and 71.1% of patients attended a follow-up appointment with a surgeon within 3 months. On multivariable analysis, private academic hospital treatment versus safety-net hospital treatment was associated with increased utilization of both surgical and radiation oncology follow-up. Non-Hispanic black (NHB) patients, Hispanic patients, and those with a low socioeconomic status were also less likely to receive follow-up.
Conclusion:
Safety-net hospital treatment, socioeconomic status, Hispanic ethnicity, and NHB race were associated with decreased follow-up service utilization. Quality improvement initiatives are needed to reduce these disparities.
Level of Evidence:
2b
Keywords: Head and neck cancer, follow-up care, healthcare disparities, Hispanic
INTRODUCTION
The National Comprehensive Cancer Network (NCCN) follow-up guidelines on head and neck cancer include, but are not limited to, a history and physical within 3 months of treatment conclusion and repeat baseline imaging of the primary site within 6 months.1 Previously reported barriers to adequate follow-up in other primary cancers include African American race, Spanish language preference, and safety-net hospital treatment.2–4
To our knowledge, a study examining the utilization of follow-up care in head and neck cancer has not been previously performed. The Hispanic population in the United States is growing rapidly and is responsible for over half of the U.S. population growth between 2000 and 20145; therefore, it is especially important to examine follow-up disparities in this cohort. This study has the benefit of taking place in an ethnically diverse population within a dual hospital system that harbors both a safety-net and private academic hospital. The purpose of this study is two-fold: first, to determine the frequency of adherence to NCCN follow-up guidelines in a population of head and neck cancer patients; and second, to assess the impact of race, ethnicity, language preference, socioeconomic status, and treatment setting on receipt of follow-up care.
MATERIALS AND METHODS
This study was approved by the University of Miami Institutional Review Board. Eligible patients were ≥ 18 years old, treated with radiotherapy (RT) between January 1, 2014, and June 30, 2016, and diagnosed with biopsy-proven nonmetastatic oropharyngeal or laryngeal cancer. Patients with persistent disease after treatment were not eligible for inclusion in this study. Only oropharynx and larynx patients were included to examine a more homogenous cohort with similar referral, workup, and treatment patterns; other commonly treated head and neck cancers, such as oral cavity cancer, have a different pathway of referral and follow-up and therefore were excluded. Patients were treated at either Jackson Memorial Hospital (safety-net hospital) or the University of Miami Sylvester Comprehensive Cancer Center (private academic hospital). Patients must have received definitive cancer treatment and continuous care within either of these hospital systems.
Demographic, staging, treatment details, and follow-up documentation were collected retrospectively from electronic medical records. Demographic variables included age at diagnosis, gender, zip code, race, ethnicity, and preferred language. Staging/prognostic variables included tumor-node-metastasis stage (with stage 1 and 2 disease classified as low, and stage 3 and 4 disease classified as high), American Joint Committee on Cancer, Seventh Edition, group stage, and Adult Comorbidity Evaluation (ACE-27) score. Treatment details included treatment with chemotherapy and/or surgery with RT.
Follow-up Care
Follow-up measures collected after RT conclusion included a visit with an otorhinolaryngologist (ENT) within 3 months, a visit with a radiation oncologist (RO) within 3 months, and follow-up imaging of the primary site within 6 months. Early stage glottic cancers (stage I and II) were not included in the imaging follow-up cohort due to variability in provider practice within our institution regarding follow-up. These follow-up variables were binary, with a threshold of one physician visit or imaging session necessary to document receipt of each respective service.
Comorbidity Classification
Comorbidity was assessed using the ACE-27 model.6 In the ACE-27 system, medical comorbidity is classified on a 0 to 3 scale, with 0 indicating no comorbidity and 3 indicating severe comorbidity. In this study, comorbidity was classified as a binary variable, with a score of 0 to 1 indicating low comorbidity and a score of 2 to 3 indicating high comorbidity. ACE-27 score was defined retrospectively from comorbidities listed in clinical documentation prior to treatment initiation.
Socioeconomic Status Composite Score
Socioeconomic status (SES) was characterized using education, poverty, and income to create a score for each census tract in Florida. We did not categorize an SES score for patients living outside of Florida. These three variables were weighted equally and used to develop an SES composite score based on previously published methodologies.7 Socioeconomic status was stratified into five equal categories. An SES of 1 represented the highest economic status, and an SES of 5 represented the lowest. Each patient was assigned an SES score based on their last documented living address.
Statistical Methods
For this study, univariable and multivariable analyses (MVA) were conducted to estimate odds ratios (ORs) and hazard ratios, corresponding 95% confidence intervals, and P values using a logistic regression model.
RESULTS
Patient Characteristics
Two hundred and thirty-four patients were included in this study (182 at the private academic hospital and 52 from the safety-net hospital). The larynx was the primary disease site in 51.3% of patients and the oropharynx was the primary site in 48.7% (Table I). Treatments received included RT plus chemotherapy (CRT) (44.0%), surgery plus RT or CRT (31.6%), and RT only (24.4%). The two most common language preferences among patients were English (60.3%) and Spanish (37.2%). Overall, 43.6% of patients were non-Hispanic white (NHW); 41.9% of patients were Hispanic; and 12.0% of patients were non-Hispanic black (NHB).
TABLE I.
Patient Demographic and Clinical Treatment Characteristics.
| Category | All (n = 234) | Safety-Net Hospital (n = 52) | Private Academic Hospital (n = 182) | P Value |
|---|---|---|---|---|
| Treatment, n. (%) | 0.792 | |||
| RT alone | 56 (23.9) | 11 (21.2) | 45 (24.7) | |
| CRT | 105 (44.9) | 23 (44.2) | 82 (45.1) | |
| Surgery + RT/CRT | 73 (31.2) | 18 (34.6) | 55 (30.2) | |
| Gender, n. (%) | 0.533 | |||
| Female | 40 (17.1) | 7 (13.5) | 33 (18.1) | |
| Male | 194 (82.9) | 45 (86.5) | 149 (81.9) | |
| Marital status, n. (%) | < 0.001 | |||
| Single | 54 (23.1) | 28 (53.8) | 26 (14.3) | |
| Married | 122 (52.1) | 18 (34.6) | 104 (57.1) | |
| Divorced | 47 (20.1) | 6 (11.5) | 41 (22.5) | |
| Widowed | 8 (3.4) | NA | 8 (4.4) | |
| No response | 3 (1.3) | NA | 3 (1.6) | |
| Documentation status, n. (%) | < 0.001 | |||
| Documented | 224 (95.7) | 42 (80.8) | 182 (100) | |
| Undocumented | 10 (4.3) | 10 (19.2) | NA | |
| Race/ethnicity, n. (%) | < 0.001 | |||
| Non-Hispanic white | 102 (43.6) | 7 (13.5) | 95 (52.2) | |
| Non-Hispanic black | 28 (12.0) | 10 (19.2) | 18 (9.9) | |
| Hispanic | 98 (41.9) | 35 (67.6) | 63 (34.6) | |
| Other | 6 (2.6) | NA | 6 (3.3) | |
| Preferred language, n. (%) | < 0.001 | |||
| English | 141 (60.3) | 20 (38.5) | 121 (66.5) | |
| Spanish | 87 (37.2) | 29 (55.8) | 58 (31.9) | |
| Other | 6 (2.6) | 3 (5.8) | 3 (1.6) | |
| Insurance status, n. (%) | < 0.001 | |||
| Insured | 203 (86.8) | 23 (44.2) | 180 (98.9) | |
| Uninsured | 31 (13.2) | 29 (55.8) | 2 (1.1) | |
| Socioeconomic score, n. (%) | <0.001 | |||
| Unknown | 15 (6.4) | 2 (3.8) | 13 (7.1) | |
| 1 | 32 (13.7) | 1 (1.9) | 31 (17.0) | |
| 2 | 28 (12.0) | 1 (1.9) | 27 (14.8) | |
| 3 | 28 (12.0) | 3 (5.8) | 25 (13.7) | |
| 4 | 43 (18.4) | 13 (25.0) | 30 (16.5) | |
| 5 | 88 (37.6) | 32 (61.5) | 56 (30.8) | |
| Comorbidity, n. (%) | 0.901 | |||
| None | 72 (30.8) | 16 (30.8) | 56 (30.8) | |
| Mild | 100 (42.7) | 23 (44.2) | 77 (42.3) | |
| Moderate | 51 (21.8) | 10 (19.2) | 41 (22.5) | |
| Severe | 11 (4.7) | 3 (5.8) | 8 (4.4) | |
| Diagnosis at outside hospital, n. (%) | 0.003 | |||
| No | 156 (66.7) | 44 (84.6) | 112 (61.5) | |
| Yes | 78 (33.3) | 8 (15.4) | 70 (38.5) | |
| Primary site, n. (%) | 0.002 | |||
| Laryngeal | 120 (51.3) | 37 (71.2) | 83 (45.6) | |
| Oropharyngeal | 114 (48.7) | 15 (28.8) | 99 (54.4) | |
| HPV, n. (%) | < 0.001 | |||
| No | 38 (16.2) | 16 (30.8) | 22 (12.1) | |
| Yes | 106 (45.3) | 8 (15.4) | 98 (53.8) | |
| Unknown | 90 (38.5) | 28 (53.8) | 62 (34.1) | |
| T stage, n. (%) | < 0.001 | |||
| 1 | 58 (24.8) | 11 (21.2) | 47 (25.8) | |
| 2 | 66 (28.2) | 5 (9.6) | 61 (33.5) | |
| 3 | 54 (23.1) | 12 (23.1) | 42 (23.1) | |
| 4 | 56 (23.9) | 24 (46.2) | 32 (17.6) | |
| N stage, n. (%) | 0.248 | |||
| N0 | 103 (44.0) | 23 (44.2) | 80 (44.0) | |
| N1 | 26 (11.1) | 9 (17.3) | 17 (9.3) | |
| N2 | 98 (41.9) | 20 (38.4) | 78 (42.9) | |
| N3 | 7 (3.0) | NA | 7 (3.8) | |
| AJCC 7th Edition group stage, n. (%) | 0.157 | |||
| I | 32 (13.7) | 9 (17.3) | 23 (12.6) | |
| II | 26 (11.1) | 2 (3.8) | 24 (13.1) | |
| III | 45 (19.2) | 8 (15.4) | 37 (20.3) | |
| IV | 131 (56.0) | 33 (63.5) | 98 (53.8) |
AJCC = American Joint Committee on Cancer; CRT = chemoradiation; HPV = human papilloma virus; (n.) = number; N = node; RT = radiation therapy; T = tumor.
Follow-up Imaging
Overall, 88.8% of patients received posttreatment imaging of the primary site within 6 months, with the majority (58.2%) of these performed using CT. On MVA, NHB race (83.3% utilization, OR 0.05, P = 0.015), Hispanic ethnicity (82.4% utilization, OR 0.10, P = 0.044), and other race (75.0% utilization, OR 0.01, P = 0.008) versus NHW ethnicity (97.6% utilization) had an association with decreased likelihood of posttreatment imaging (Table II).
TABLE II.
Multivariable Analysis Demonstrating Factors Associated With Follow-up Imaging.
| Category | OR (95% CI) | P Value |
|---|---|---|
| Treating hospital | ||
| Safety-net hospital | Reference | |
| Private hospital | 0.92 (0.26–3.33) | 0.899 |
| Race/ethnicity | ||
| Non-Hispanic white | Reference | |
| Non-Hispanic black | 0.05 (0.01–0.57) | 0.015 |
| Hispanic | 0.10 (0.01–0.94) | 0.044 |
| Other | 0.01 (0.00–0.27) | 0.008 |
| Language | ||
| English | Reference | |
| Spanish | 0.51 (0.09–3.05) | 0.461 |
| Other | NE | |
| Socioeconomic status | ||
| 5 | Reference | |
| 1 | 2.02 (0.13–31.41) | 0.617 |
| 2 | 0.48 (0.05–4.61) | 0.523 |
| 3 | 0.34 (0.04–3.32) | 0.354 |
| 4 | 4.38 (0.86–22.39) | 0.076 |
| Comorbidity | ||
| High | Reference | |
| Low | 0.68 (0.16–2.91) | 0.601 |
| Primary site | ||
| Laryngeal | Reference | |
| Oropharyngeal | 2.35 (0.62–8.88) | 0.207 |
| Cancer stage | ||
| IV | Reference | |
| I | NE | |
| II | NE | |
| III | 0.89 (0.21–3.71) | 0.877 |
| Treatment | ||
| RT | Reference | |
| CRT | 3.12 (0.31–31.47) | 0.335 |
| Surgery + RT | 0.86 (0.07–11.37) | 0.912 |
| Surgery + CRT | 1.44 (0.10–20.45) | 0.790 |
CI = confidence interval; CRT = chemoradiation; NE = not estimable; OR = odds ratio; RT = radiation therapy.
Radiation Oncology Follow-up
A total of 88.5% of patients attended a follow-up RO appointment within 3 months. On MVA, private academic hospital treatment (92.3% utilization, OR 7.34, P = 0.002) versus safety-net hospital treatment (76.9% utilization) was correlated with increased likelihood of RO follow-up (Table III).
TABLE III.
Multivariable Analysis Demonstrating Factors Associated With Radiation Oncology Follow-up.
| Category | OR (95% CI) | P Value |
|---|---|---|
| Treating hospital | ||
| Safety-net hospital | Reference | |
| Private academic hospital | 7.34 (2.15–25.04) | 0.002 |
| Race/ethnicity | ||
| Non-Hispanic white | Reference | |
| Non-Hispanic black | 1.60 (0.32–7.89) | 0.566 |
| Hispanic | 3.57 (0.87–14.64) | 0.077 |
| Other | NE | |
| Language | ||
| English | Reference | |
| Spanish | 0.84 (0.24–3.02) | 0.792 |
| Other | NE | |
| Socioeconomic status | ||
| 5 | Reference | |
| 1 | NE | |
| 2 | 0.67 (0.13–3.38) | 0.624 |
| 3 | 0.33 (0.08–1.33) | 0.118 |
| 4 | 0.98 (0.29–3.36) | 0.978 |
| Comorbidity | ||
| High | Reference | |
| Low | 0.85 (0.29–2.48) | 0.760 |
| Cancer type | ||
| Laryngeal | Reference | |
| Oropharyngeal | 1.40 (0.45–4.32) | 0.562 |
| Cancer stage | ||
| IV | Reference | |
| I | 3.09 (0.21–45.80) | 0.412 |
| II | 1.03 (0.10–10.67) | 0.980 |
| III | 0.81 (0.22–3.02) | 0.749 |
| Treatment | ||
| RT | Reference | |
| CRT | 1.29 (0.13–12.79) | 0.827 |
| Surgery + RT | 1.10 (0.11–10.70) | 0.938 |
| Surgery + CRT | 0.57 (0.06–5.73) | 0.630 |
CI = confidence interval; CRT = chemoradiation; NE = not estimable; OR = odds ratio; RT = radiation therapy.
Otorhinolaryngology Follow-up
A total of 71.1% of patients attended a follow-up ENT appointment within 3 months. On MVA, private academic hospital treatment (76.8% utilization, OR 3.07, P = 0.008) versus safety-net hospital treatment (50% utilization), the highest SES quintile (SES 1, 90.3% utilization, OR 6.01, P = 0.034) versus the lowest SES quintile (SES 5, 65.2% utilization), and treatment with surgery + CRT (90.5% utilization, OR 8.25, P = 0.019) versus RT alone (58.9% utilization) had an association with increased likelihood of ENT follow-up (Table IV).
TABLE IV.
Multivariable Analysis Demonstrating Factors Associated With ENT Follow-up.
| Category | OR (95% CI) | P Value |
|---|---|---|
| Treating hospital | ||
| Safety-net hospital | Reference | |
| Private academic hospital | 3.07 (1.34–7.00) | 0.008 |
| Race/ethnicity | ||
| Non-Hispanic white | Reference | |
| Non-Hispanic black | 0.60 (0.18–2.04) | 0.416 |
| Hispanic | 0.70 (0.27–1.84) | 0.473 |
| Other | 0.11 (0.01–1.12) | 0.062 |
| Language | ||
| English | Reference | |
| Spanish | 0.45 (0.18–1.12) | 0.087 |
| Other | NE | |
| Socioeconomic status | ||
| 5 | Reference | |
| 1 | 6.01 (1.15–31.41) | 0.034 |
| 2 | 1.36 (0.40–4.59) | 0.626 |
| 3 | 0.99 (0.31–3.15) | 0.984 |
| 4 | 1.61 (0.68–3.81) | 0.283 |
| Comorbidity | ||
| High | Reference | |
| Low | 0.85 (0.39–1.85) | 0.677 |
| Cancer type | ||
| Laryngeal | Reference | |
| Oropharyngeal | 0.64 (0.28–1.46) | 0.286 |
| Cancer stage | ||
| IV | Reference | |
| I | 1.75 (0.30–10.11) | 0.529 |
| II | 1.14 (0.24–5.36) | 0.867 |
| III | 0.69 (0.26–1.81) | 0.445 |
| Treatment | ||
| RT | Reference | |
| CRT | 1.90 (0.46–7.80) | 0.373 |
| Surgery + RT | 4.1 (0.93–23.69) | 0.060 |
| Surgery + CRT | 8.25 (1.42–47.89) | 0.019 |
CI = confidence interval; CRT = chemoradiation; ENT = ear, nose, and throat; NE = not estimable; OR = odds ratio; RT = radiation therapy.
Otorhinolaryngology or Radiation Oncology Follow-up
A total of 95.7% of patients attended a follow-up appointment with a surgeon or RO within 3 months. On MVA, private academic hospital (98.3% utilization, OR 16.93, P = 0.007) versus safety-net hospital treatment (86.5% utilization) was correlated with increased likelihood of follow-up (Table V).
TABLE V.
Multivariable Analysis Demonstrating Factors Associated With ENT and/or Radiation Oncology Follow-up.
| Category | OR (95% CI) | P Value |
|---|---|---|
| Treating hospital | ||
| Safety-net hospital | Reference | |
| Private academic hospital | 16.93 (2.18–131.68) | 0.007 |
| Race/ethnicity | ||
| Non-Hispanic white | Reference | |
| Non-Hispanic black | 1.43 (0.16–12.94) | 0.752 |
| Hispanic | 3.25 (0.44–24.29) | 0.251 |
| Other | NE | |
| Language | ||
| English | Reference | |
| Spanish | 1.17 (0.16–8.55) | 0.878 |
| Other | NE | |
| Socioeconomic status | ||
| 5 | Reference | |
| 1 | NE | |
| 2 | 1.10 (0.08–15.92) | 0.942 |
| 3 | NE | |
| 4 | 0.90 (0.17–4.81) | 0.900 |
| Comorbidity | ||
| High | Reference | |
| Low | 0.30 (0.06–1.40) | 0.126 |
| Cancer type | ||
| Laryngeal | Reference | |
| Oropharyngeal | 0.24 (0.03–1.83) | 0.169 |
| Cancer stage | ||
| IV | Reference | |
| I | NE | |
| II | 0.42 (0.01–18.68) | 0.656 |
| III | 0.64 (0.09–4.86) | 0.670 |
| Treatment | ||
| RT | Reference | |
| CRT | 2.06 (0.04–102.83) | 0.717 |
| Surgery + RT | 0.48 (0.01–14.96) | 0.675 |
| Surgery + CRT | 1.25 (0.02–86.30) | 0.917 |
CI = confidence interval; CRT = chemoradiation; NE = not estimable; OR = odds ratio; RT = radiation therapy.
Supplemental Data
The above analyses were repeated with follow-up as a continuous variable rather than discrete. The results were similar (Supporting Tables SI–SIV, available online), with safety-net hospital treatment associated with significant delays in ENT and RO follow-up. Hispanic ethnicity was associated with delayed imaging follow-up; however, whereas NHB race was associated with numerically longer delays in our categorical data, the difference was not statistically significant when treating follow-up as a continuous variable.
DISCUSSION
This study was designed to assess adherence to head and neck cancer follow-up guidelines and to examine risk factors that decrease utilization of follow-up care. Within this cohort, follow-up services were not always appropriately utilized. A total of 88.8% of patients received post-treatment imaging of the primary site within 6 months; 88.5% of patients attended a follow-up RO appointment within 3 months; and 71.1% of patients attended a follow-up surgery appointment within 3 months. Treatment at a safety-net hospital was shown to be a major risk factor for not receiving a follow-up with a RO or a follow-up with an ENT. Non-Hispanic black race, Hispanic ethnicity, low SES, and lack of surgical treatment were other risk factors associated with lower rates of certain follow-up services.
For head and neck cancers, NCCN guidelines emphasize the importance of early and repeated physical examination, along with imaging of the primary site.1 Of note, imaging guidelines have recently changed; earlier guidelines recommended further reimaging based on signs and symptoms, but current guidelines recommend only one posttreatment baseline imaging scan within 6 months.8 Other guidelines and reviews make similar examination and imaging recommendations.9–12 These guidelines were developed from studies documenting the recurrence rate for head and neck cancers and the ideal diagnostic tests for evaluating recurrence. One study showed that 95% of larynx, oropharynx, and hypopharynx recurrences occurred within 4.7, 2.7, and 2.3 years, respectively.11 Other studies demonstrate that a substantial majority of head and neck recurrences occur within 3 years of treatment completion.13–15 The importance of physician follow-up examinations and imaging studies in this timeframe is paramount. One study showed that 62.7% of early stage cancer (stages I and II) recurrences are detected by physician examination, whereas 42.0% of advanced-stage cancer (stages III and IV) recurrences are detected by imaging studies.16 Another study found that 39% of all head and neck cancer recurrences are found through the physical exam.13
Previous studies have shown high levels of adherence to NCCN follow-up guidelines in the first year following treatment completion; however, this level falls over time. In one survey, head and neck surgeons followed published guidelines 97% of the time in the first postoperative year, but only 62% of the time in the fifth postoperative year.12 For ROs, a survey showed that 97% provided follow-up care for more than 6 months, but only 83% and 43% provided follow-up care after 2 and 5 years, respectively.17 Patient compliance is also an important consideration because one out of five patients attended ≤ 50% of all scheduled follow-up appointments in one intensive head-and-neck cancer follow-up program.18 Although some studies have found that follow-up schedules do not necessarily correlate with overall survival,19,20 gross negligence in follow-up—or having no follow-up—is likely to impact survival.
Select strategies can improve follow-up efficacy. Studies have demonstrated that patients can often identify new symptoms or physical findings before a physician discovers a recurrence; however, despite these findings, a physical examination typically does not occur at an earlier time than previously scheduled.21–23 Pilot studies have examined the effectiveness of electronic applications to monitor posttreatment symptoms for lung cancer patients and to intervene at an earlier time.23 Similar applications may be worthwhile to further integrate all head and neck patients into a follow-up network and facilitate the receipt of all baseline follow-up services. In our study, follow-up care was suboptimal; therefore, such an application may be beneficial.
To our knowledge, disparities in follow-up care after definitive head and neck cancer treatment have not been previously studied. The multidisciplinary nature of head and neck cancer care can make arranging appropriate follow-up challenging. However, the high rates of toxicities with head and neck cancer treatment coupled with the potential for early detection of local recurrence make evidence-based follow-up critically important. One study of patients treated with stereotactic radiosurgery for brain metastases showed that patients treated at a safety-net hospital had fewer neuroimaging studies and were at higher risk for complications.2 Another study showed that compared to white breast-cancer survivors, African American breast cancer survivors were more likely to report barriers to follow-up care.3 Spanish-speaking versus English-speaking Latina breast cancer survivors were also less likely to report receiving follow-up care at a doctor’s office.4 In our study, patients treated at a safety-net hospital had less utilization of RO and ENT follow-up services. Hispanic patients and NHB patients had less utilization of follow-up imaging. These disparities need to be addressed in quality-improvement initiatives to ensure that all patients receive evidence-based follow-up.
Our study had some limitations that are worth exploring, most notably a lack of generalizability given that patients were limited to two institutions within a single hospital system. Additionally, we were unable to assess insurance status as an independent marker of follow-up frequency given that all uninsured self-payors were treated at the safety-net hospital. More patients were diagnosed with laryngeal cancer at the safety-net hospital in comparison to the private academic hospital; this difference may have influenced patients’ perception of the need for follow-up care. In addition, factors such as patient transportation issues, change in address necessitating follow-up at a different facility, or simple nonad-erence to recommendations are difficult to collect in a retrospective review. Also, NCCN guidelines recommend a similar follow-up regimen for patients who received surgery + RT/CRT versus RT/CRT alone; further investigation is necessary to determine whether different treatments require different intervals of follow-up. At this institution, medical oncologists do not perform fiberoptic examinations and thus do not replace ENT or radiation oncology follow-up. Therefore, we did not include medical oncology follow-up in this study. Moreover, although this is a study of immediate follow-up, studies evaluating longer follow-up trends are also needed. One strength of this study is the high percentage of Hispanic- and Spanish-speaking patients. The same faculty staff both hospitals, allowing for an assessment of systematic differences between hospitals. Furthermore, the study evaluates multiple components of follow-up care and notes trends in factors associated with reduced utilization of follow-up services. Finding decreased follow-up utilization among patients treated at a safety-net hospital was a particularly important finding that can be used to spearhead quality improvement initiatives not only within this hospital system but likely in other safety-net institutions as well.
CONCLUSION
In this study, utilization of multiple head-and-neck cancer follow-up services was less than 100%, ranging from 71.1% to 88.8%. Treatment location, low SES, Hispanic ethnicity, and NHB race were associated with decreased utilization of follow-up services. Quality improvement measures may involve targeted improvements in interprovider or provider–patient communication. Patient navigators and social workers could potentially help with transportation, financial, and other social issues to help bridge the disparity gap. The development of a follow-up electronic application, along with automated phone call, text, or e-mail reminders, may be beneficial. Additionally, assessing patient understanding of the importance of follow-up may represent an area for further study.
Supplementary Material
Footnotes
Additional supporting information may be found in the online version of this article.
Dr. Stephen Ramey received travel accommodations from Intellisphere, LLC, to attend a conference. The authors have no other funding, financial relationships, or conflicts of interest to disclose.
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