In a study reported in the Journal of Oncology Practice, Thomas et al found that interruption of radiotherapy for head and neck cancer was more frequent and treatment outcomes were poorer among indigent populations vs commercially or Medicare-insured populations within a single academic health system.
In this retrospective cohort study, electronic medical and billing records were used to analyze treatment interruptions between January 2011 and December 2014 among 564 patients referred from clinics run by the University of Texas Southwestern Medical Center (UTSW; n = 347) and Parkland Health and Hospital System (PHHS; n = 217), the latter of which provides indigent care to Dallas County. Payer type was private/Medicare for 90%, county/Medicaid for 7%, and self-pay for 3% of the UTSW cohort vs 18%, 82%, and 0% of the PHHS cohort.
Treatment Delays and Outcomes
Overall, 316 patients (56%) had a treatment delay, with 114 (20%) missing a single session and 202 (36%) missing multiple sessions. Treatment delay occurred in 70% of the PHHS cohort vs 47% of the UTSW cohort (P < .001). PHHS patients had 837 delays for any reason, with a mean of 3.9 delays per patient, compared with 742 delays among UTSW patients, with a mean of 2.1 delays per patient. PHHS patients most commonly missed sessions for nonmedical or logistical reasons (34.7% vs 19.8% for UTSW patients, P < .001). On multivariable analysis, disease stage (P = .016) and payer type (P < .001) were significantly associated with treatment interruption.
On multivariable analysis, treatment delay was associated with a greater risk for local recurrence (hazard ratio [HR] = 1.877, P = .0396) and poorer overall survival (HR = 3.534, P < .001). Among compliant patients, there was no significant difference in local recurrence (P = .43) or overall survival (P = .27) between cohorts. Among noncompliant patients, those in the PHHS cohort had a greater risk of local recurrence (P = .016) and nonsignificantly greater risk of mortality (P = .18). UTSW patients with delays had local control (P = .11) and overall survival (P = .07) similar to those among PHHS patients without delays, whereas PHHS patients with delays had significantly worse local control and overall survival outcomes (both P < .001) compared with compliant UTSW patients.
The investigators concluded: “Survival outcomes in our at-risk population were inferior to those in patients insured by commercial carriers or Medicare. Treatment interruption predicted for poor outcome across all patients but was disproportionately experienced by at-risk patients. These results highlight cancer control needs specific to disadvantaged communities at risk for poor treatment compliance.”
Kimberly Thomas, MD, of Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, is the corresponding author of the Journal of Oncology Practice article.
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