Background: Previous work has suggested that treatment delays are associated with worse overall survival in head and neck cancer (HNC), however oropharyngeal squamous cell carcinoma (OPSCC) is often human papilloma virus (HPV)-associated and behaves differently than other types of HNC. It is unclear if delays are associated with survival.
Objectives: This study characterized treatment delays in OPSCC patients treated with primary surgery, with or without adjuvant radiation. Specifically, this study identified median durations and factors predictive of treatment delays and associated treatment delays with overall survival (OS).
Methods: The National Cancer Database (NCDB) was used to identify a retrospective cohort of OPSCC patients treated 2010-2013 with primary surgery with or without adjuvant treatment. Five treatment intervals were examined: diagnosis-to-treatment initiation (DTI), surgery-to-radiation (SRT), RT duration (RTD), treatment initiation-to-end (total treatment package, TTP), and diagnosis-to-treatment end (DTE). Patients treated with surgery without RT were only included in the analysis examining DTI. For each interval, delayed patients (fourth quartile) were compared to non-delayed patients (first and second quartile). Median durations were identified for each interval. Patient, tumor, and treatment factors predictive of delays were identified via multivariable binary logistic regression. Delays were associated with OS via cox proportional hazards regression, controlling for clinically-relevant patient, tumor, and treatment factors.
Results: 3708 patients were included in the final cohort. Median durations for DTI, SRT, RTD, TTP, and DTE were 14, 42, 47, 90, and 106 days, respectively (Figure 1). Overall HPV incidence was 75%. HPV-positive tumors were associated with decreased delays in DTI, RTD, and DTE (OR=0.69 (0.56-0.85), p<0.001; OR=0.73 (0.58-0.91), p=0.003; OR=0.66 (0.52-0.83), p<0.001, respectively). Overall 5-year OS was 84%. On multivariable analysis, delayed DTI, TTP, and DTE were associated with decreased survival (HR=1.63 (1.22-2.17), p=0.001; HR=1.81 (1.29-2.54), p=0.001; and HR=1.97 (1.39-2.78), p<0.001, respectively) (Table 1; Figure 2). Delayed SRT was associated with survival for HPV-negative, but not positive, patients (HR=2.05 (1.19-3.52), p=0.010 and HR=1.15 (0.74-1.80), p=0.535, respectively). Delays in RTD were not associated with OS.
Conclusions: The median treatment interval durations provided here can be used for national benchmarking. Delays are linked to a variety of patient-, tumor-, and treatment-related factors. Delays in DTI, TTP, and DTE are associated with decreased OS and could be considered quality indicators in OPSCC.
Table 1. Association of Treatment Delays with Survival.
||First and Second Quartiles
||HR (95% CI)