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Disadvantaged Patients Less Likely to Receive Advanced Radiotherapy Techniques for Head and Neck Cancer


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Advanced radiotherapy techniques can 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 by Neal S. McCall, MD, at the 2022 Multidisciplinary Head and Neck Cancers Symposium (Abstract 17). 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 (IMRT) 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 median income (according to the census) were significantly less likely to receive advanced radiotherapy modality. 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.
— Neal S. McCall, MD

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“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 Dr. McCall, a PGY4 resident in the Department of Radiation Oncology at Winship Cancer Institute of Emory University.

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

Study Details

For this study, Dr. McCall and colleagues extracted data from the National Cancer Database between 2004 and 2017 for patients with any malignancy in 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, as well as patients treated with palliative intent and those 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 the 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 IMRT. In 2004, IMRT comprised approximately 77% of radiotherapy cases among patients with head and neck cancer, but by 2012, the proportion of IMRT cases had risen to 95%.

Although there have been incremental increases in IMRT utilization since 2012, Dr. McCall noted that more recent adoption of advanced radiotherapy has been driven by the growth and expansion of proton-beam therapy.

Of the 177,373 patients with head and neck cancer eligible for analysis, 94.2% received advanced radiotherapy techniques, including 93.3% who received IMRT and 0.9% who received 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,” said Dr. McCall.

Multivariate analysis of radiotherapy utilization showed that Black patients, patients residing in areas of lower median income, and patients living in areas with low rates of high school graduation were less likely to be treated with an advanced radiotherapy modality. Similarly, Medicare and Medicaid beneficiaries and uninsured patients were significantly less likely to receive advanced radiotherapy techniques.

With respect to disease-related factors, patients with oropharyngeal and nasopharyngeal primary tumors 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.

The researchers also identified geographic disparities in the adoption of advanced techniques. Patients treated in the Northeast and Midwest areas of the United States were less likely to receive an advanced radiotherapy modality as compared to 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 an advanced radiotherapy technique.

“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 concluded.

Disclosure: For full disclosures of the study authors, visit astro.confex.com.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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