Cancer Care 2018 Public Reporting of Outcomes
Head and neck cancer is a general category that involves multiple anatomic sites and subsites. Historically, most of these cancers have been associated with tobacco and alcohol abuse, but human papillomavirus (HPV) has emerged as a primary cause of head-and-neck cancer, specifically oropharyngeal cancer, in the United States and elsewhere. Radiation therapy, often in combination with surgery and/or chemotherapy, is an integral part of the management of many cases of head and neck cancer, but radiotherapy to these anatomic areas can be associated with significant treatment-related side effects and complications, such as severe pain, trouble swallowing, and significant weight loss. These side-effects and complications can sometimes lead to treatment breaks, which in turn are associated with worse outcomes and higher rates of cancer recurrence.
To mitigate these side effects, reduce treatment breaks, and optimize outcomes, the National Comprehensive Cancer Network’s guidelines for the management of head-and-neck cancer patients includes the recommendation that head and neck cancer patients be evaluated and treated by both a registered dietician and a speech -swallowing therapist early in their treatment course. We undertook a study to examine whether our patients were consistently being evaluated by registered dieticians and speech-swallowing therapists.
We evaluated the records of all patients treated with radiation therapy for head and neck (including oral cavity, oropharyngeal, nasopharyngeal, laryngeal, hypopharyngeal, and salivary gland) cancer from 2012-2017. The primary objectives were to analyze the proportion of patients referred to dietary services and to speech-swallowing therapy. A secondary objective of our study was to evaluate the proportion of patients who had unplanned breaks, and assess whether a statistical correlation existed between unplanned breaks and referral (or lack thereof) to dietary services and speech–swallowing therapy.
Eighty-nine patients were treated with radiation therapy for head and neck cancer over the study period (2012 – 2017). Over these years, 66 (74%) were referred to dietary services at the initiation of radiation therapy. There was a trend over time towards more frequent referral to dietary services, with the proportion of patients referred equaling 100% in 2016 (Figure 1). Forty-two patients (47%) were referred to speech-swallowing therapy during radiation therapy, also with a general upward trend in the percentage of patients referred over the study period (Figure 2). Over the study period, 22% of patients required an unplanned treatment break due to clinical factors or treatment side-effects, and a positive association was seen between patient requiring a break and both dietary referral (Fischer Exact p<0.05) and speech-swallowing referral (Fischer Exact p<0.001).
For patients who were not referred to dietary services from 2014 onwards, most were undergoing treatment for early-stage glottic cancer, which is generally a low-morbidity treatment compared to other head and neck cancer treatments. Our clinic was also using a screening form during this time to rule-out patients at low risk for treatment related side-effects, and these low-risk patients were not subsequently referred to ancillary services. There were no identifiable patterns for lack of speech-swallowing referral in the dataset. One might note that some proportion of patients were likely offered referral to dietary services and/or speech-swallowing therapy but then refused, and these refusals were not always documented. As for the association between referrals to ancillary services and treatment breaks, we interpret these data to mean that the patients who were most likely to have difficulties with treatment side-effects were more likely to be referred to these ancillary services, which was an encouraging finding.
The radiation oncology departmental goal is for 100% of our head and neck cancer patients to be offered a consultation with dietary services and with speech-swallowing therapy. Although our proportion of patients referred has been trending upward in recent years, we still have room for improvement. We are evaluating a number of actions to help us achieve our goal of 100% referral, which include electronic medical record (EMR) order sets and checklists for head and neck cancer patients which will include automatic referral to ancillary services. We also plan to document patient refusals of referrals more consistently and comprehensively.