Oncologic outcomes for patients with head and neck squamous cell carcinoma (HNSCC) are impacted by time to treatment initiation (TTI) and adherence to therapy. Our patient population is composed primarily of residents from Bronx, NY: one of the poorest counties in the country. Previous data from our institution demonstrated that patients who experience TTI more than 60 days had approximately double the risk of mortality and disease recurrence. The results also demonstrated that those patients who were at highest risk for TTI delay were African American and Medicaid patients. In an effort to address these issues, we planned an intervention utilizing an oncology nurse navigator with a customized navigation portal within the electronic health record starting in June 2020. We measured the impact of this intervention on treatment timelines and prescribed therapeutic completion rates.
Methods: This was a retrospective study examining two cohorts: 1) newly diagnosed HNSCC patients from 2019 prior to implementing the nurse navigator and newly diagnosed HNSCC patients from June 2020 to July 2021 - the first year during which navigation was implemented. The first 6 months of 2020 were not included due to the COVID pandemic significantly altering care delivery at our institution. The following outcomes were measured: time to diagnosis, TTI, time to medical and radiation oncology appointments, time to adjuvant treatment, time to PET CT scan, and total no show appointments. Patients’ race, ethnicity, and county of residence were also recorded.
Results: There were 84 patients in the pre-navigation group and 60 patients in the post-navigation group. Four outcomes showed statistically significant differences: TTI - mean 40.1 days (SD 34.6, 95% CI 27.0, 42.1) vs 28.5 days (SD 17.8, 95% CI 13.1, 22.5) in the pre- vs post-navigation group (p = 0.01), time to PET CT - mean 32.9 days (SD 38.0, 95% CI 27.6, 48.5) vs 19.1 days (SD 15.3, 95% CI 9.8, 18.9) in the pre- vs post-navigation group (p = 0.02), total missed appointments - mean 8.4 days (SD 7.7, 95% CI 6.0, 9.3) vs 4.8 days (SD 4.6, 95% CI 3.4, 5.7) in the pre vs post-navigation group (p = 0.001), and time to medical oncology (MO) - mean 41.8 days (SD 43.5, 95% CI 32.3, 54.7) vs 27.7 days (SD 20.0, 95% CI 14.0, 26.1) in the pre vs post-navigation group (p = .03). Additionally, after navigation was implemented, the number of patients who experienced TTI>60 days was reduced from 11/84 (13%) to 1/60 patients (1.6%).
Conclusion: Our data suggests that with the implementation of an oncology nurse navigator, there was a significant decrease in TTI, time to PET CT and MO, and total no show appointments. Additionally, there was a significant decrease in patients that experienced a TTI > 60 days. Given the socioeconomic and racial disparities associated with treatment delay, an oncology navigator can serve as a valuable resource for supporting patients with newly diagnosed head and neck cancer through their complicated treatment courses and potentially help address inequalities in head and neck cancer outcomes.