Advanced radiotherapy techniques may reduce the risk of severe and debilitating toxicity associated with radiation, but not all patients have equal access to these modalities, according to data presented at the 2022 Multidisciplinary Head and Neck Cancers Symposium.¹ Retrospective analysis of the National Cancer Database between 2004 and 2017 has identified multiple racial, socioeconomic, and geographic disparities in the delivery of advanced radiotherapy techniques such as intensity-modulated radiotherapy or proton-beam therapy.

Results of the study showed that older patients, Black patients, patients living in less-educated areas, and patients living in areas of lower census median income were significantly less likely to receive advanced radiotherapy modalities. Underinsured patients were also less likely to receive advanced techniques, authors of the study reported.

“These disparities in the delivery of advanced radiotherapy techniques for head and neck cancer place our most disadvantaged patients at risk of severe toxicities and overall worse quality of life as a result of the treatment we deliver,” said lead author of the study, Neal S. McCall, MD, a PGY4 resident in the Department of Radiation Oncology at Winship Cancer Institute of Emory University, Atlanta.

The disparities we identified in this study suggest that our most disadvantaged patients are more likely to endure quality-of-life insults related to less-advanced radiation treatment.

— Neal S. McCall, MD

Tweet this quote

Background and Study Details

As Dr. McCall explained, sparing normal tissue through advanced radiotherapy techniques such as intensity-modulated radiotherapy or proton-beam therapy can reduce the risk of severe toxicities as compared with less-advanced techniques such as two-dimensional or three-dimensional conformal radiotherapy. Although advanced radiotherapy techniques are considered standard-of-care by consensus guidelines, he added, the implementation of this modality and the corresponding patterns of care in the United States remain unclear.

For this study, Dr. McCall and colleagues extracted data from the National Cancer Database between 2004 and 2017 for patients with any malignancy of the head and neck that was treated with definitive-intent external-beam radiation therapy. Patients with early-stage glottic cancers, cutaneous primaries, or metastatic disease; patients treated with palliative intent; and patients with a missing variable in terms of radiation modality were excluded from the analysis. Sociodemographic, facility-specific, and clinical associations with receipt of treatment were assessed by logistic regression.

Disparities in Treatment of Older, Black, and Underinsured Patients 

As Dr. McCall reported, utilization of advanced radiotherapy techniques increased substantially between 2004 and 2012, driven largely by the adoption of intensity-modulated radiotherapy. In 2004, intensity-modulated radiotherapy comprised approximately 77% of pertinent head and neck cancer cases, but by 2017, the proportion of such cases had risen to 95%.

Although there have been incremental increases in intensity-modulated radiotherapy utilization since 2012, Dr. McCall noted that more recent adoption of advanced radiotherapy has been impacted by the growth and expansion of proton-beam therapy. Of the 177,373 patients with head and neck cancer eligible for analysis during the study period, 94.2% received advanced radiation techniques, including intensity-modulated radiotherapy (93.3%) and 0.9% proton-beam therapy. In 2017, however, approximately 2.7% of patients received proton therapy.

“It is still a small minority of patients who receive proton therapy, but there has been a significant jump over the past decade,” added Dr. McCall.

Despite the increased utilization of advanced radiation therapy techniques, however, the researchers identified racial and socioeconomic disparities in the adoption of these ­modalities nationally. Multivariate analysis of radiotherapy utilization showed that Black patients, patients residing in areas of lower census median income, and patients living in areas with low rates of high school graduation were less likely to be treated with advanced radiotherapy techniques. Similarly, Medicare and Medicaid beneficiaries and uninsured patients were significantly less likely to receive either intensity-
modulated radiotherapy or proton-beam therapy.

“Not all patients have benefited equally from technical advances in radiation delivery. The disparities we identified in this study suggest that our most disadvantaged patients are more likely to endure quality-of-life insults related to less-advanced radiation treatment,” Dr. McCall said.

With respect to disease-related factors, patients with oropharyngeal and nasal pharyngeal primaries were much more likely to be treated with an advanced radiotherapy modality. Higher T stages, higher-end stages, concurrent chemotherapy, and higher radiation dose also correlated with advanced radiotherapy use.

Geographic Factors

The researchers also identified geographic disparities in the adoption of advanced techniques. Patients treated in the Northeast and Midwest were less likely to receive an advanced radiotherapy modality as compared with patients treated in the South. Patients treated at higher-volume academic centers and those who traveled a greater distance from their residence to their treatment facility, on the other hand, were more likely to receive advanced radiotherapy techniques.

“I would have expected patients who lived farther from their treatment center would have been more likely to be treated with older techniques, but that wasn’t the case,” Dr. McCall observed. “Patients who traveled distances were more likely to receive advanced treatment techniques. This argues that many patients are seeking out advanced technology.” 

DISCLOSURE: Dr. McCall reported no conflicts of interest.

REFERENCE

1. McCall NS, Liu Y, Janopaul-Naylor J, et al: Standard but not equal: Disparities in advanced radiotherapy techniques for head and neck cancer in the United States. 2022 Multidisciplinary Head and Neck Cancers Symposium. Abstract 17. Presented February 25, 2022.