14-day Pathway from Decision to Treat to Radiotherapy for Head and Neck Cancer in the National Health Service: An Evaluation of Feasibility and Outcomes at Torbay Hospital.
Purpose/Objective
In squamous cell carcinoma of the head and neck there is significant evidence that a prolonged time to treatment initiation results in worse overall survival and loco-regional control1-6. This is also evidenced in the adjuvant setting: Patients receiving radiotherapy within 11 weeks of surgery had significant improvement in loco-regional control, compared to those who waited more than 13 weeks7-11. This is reflected in NHS England and JCCO guidance12.
The primary objective of this audit was to evaluate compliance to a 14-day pathway from decision to treat (DTT) to radical radiotherapy, over a 5-year period at Torbay Hospital, UK 13. We also evaluated compliance for patients receiving postoperative radiotherapy: aiming for all patients to start adjuvant treatment within 35 days of surgery. Our secondary objective was to review survival and recurrence rates within these patients.
Material/Methods
A 14-day pathway from DTT to start of radiotherapy was developed following a quality improvement project which identified common causes of delay. Key preparatory steps are scheduled to enable timely radiotherapy delivery. The pathway is demonstrated in Figure 1.
From January 2017 to December 2022, data on DTT date, site of disease, radiotherapy start date, date of surgery, date of recurrence and date of death was prospectively collected for all patients undergoing definitive radiotherapy or post-operative radiotherapy with curative intent for squamous cell carcinoma of the head and neck. Patients undergoing radiotherapy with palliative intent, patients with non-squamous cell cancers, benign pathologies and patients receiving neoadjuvant chemotherapy or targeted systemic treatment were excluded. 187 patients were included in total over the period.
Results
117 (62.6%) patients underwent radical radiotherapy within 14 days of DTT, 55 (29.4%) patients started within 15 to 21 days and 15 (8.0%) patients started after more than 22 days. Of the 75 patients receiving radiotherapy adjuvantly, 39 (52%) received radiotherapy within 35 days of surgery and 49 (65%) patients received radiotherapy within the national target of 42 days.
158 (84.5%) patients of the 187 treated within the 5-year period were alive at the end of the study period. 9 (4.8%) patients had had a local recurrence of their disease only, 17 (9.1%) patients had metastatic disease. Recurrence by site was; Larynx: 3 of 25 (12%), P16 positive oropharynx: 5 of 84 (6%), P16 negative oropharynx: 4 of 10 (40%), Oral Cavity: 7 of 26 (26.9%), Nasopharynx: 2 of 4 (50%), Parotid: 4 of 15 (26.7%), CUP: 1 of 12 (8.3%). 10 (38.4%) of the 26 patients who developed loco-regional recurrence or metastatic disease had a treatment time of more than 14 days. There was one treatment-related death due to neutropenic sepsis.
Conclusion
This audit demonstrates that a 14-day pathway for the radical treatment of squamous cell cancers of the head and neck is achievable for the majority of patients. Whilst local recurrence and survival data is not mature it is thus far in-keeping with published outcomes. Adherence to the pathway has been maintained over a prolonged period despite workload pressures within the NHS, at no extra financial cost and throughout the Covid-19 pandemic. We therefore believe this would be transferrable to other treatment centres.
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