Background

In 2021, the American College of Surgeons Commission on Cancer (CoC) approved the initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery for head and neck cancer (HNC) as its first and only HNC quality metric.¹ This quality metric, which is also included in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers, was selected in part because of the robust association between delays in starting guideline-adherent adjuvant therapy and worse oncologic outcomes for patients with HNC.^2–7 In addition, the metric was selected because there is a quality-of-care gap, with approximately 50% of patients failing to commence PORT within the recommended 6-week interval.^2,3,8,9 Delays in starting guideline-adherent PORT disproportionately burden racial and ethnic minority groups, the underinsured, and other medically vulnerable populations, and contribute to disparities in survival.^2,10,11

Patient navigation (PN) is a patient-centered approach that supports patients in overcoming individual barriers and facilitating timely access to quality health care.^12–19 The implementation of PN can support cancer care delivery systems in their goal of meeting quality metrics and has been linked to improved clinical, patient-reported, and financial outcomes.^{12,13,20–25} There is robust evidence demonstrating that PN improves the timeliness and equity of cancer screening, diagnostic resolution, and treatment initiation.^12,25–33 In addition, emerging data suggest that PN-based interventions may reduce delays in starting adjuvant therapy for patients with HNC, and thus improve adherence to the new CoC quality metric.^34–36

Although PN has the potential to improve the delivery of guideline-adherent PORT for patients with HNC and adherence to this quality metric, the national landscape of PN and barriers to scaling PN-based approaches for patients with HNC undergoing adjuvant therapy are unknown. Therefore, we conducted a national survey to assess the current use of navigators in helping deliver timely, guideline-adherent PORT to patients with HNC, and to identify potential barriers and facilitators to implementing PN as a strategy to improve the delivery of timely PORT.

Materials and Methods

Study Sample

The study sample consisted of health care organizations that participate in the American Cancer Society National Navigation Roundtable (ACS NNRT) email listserv. The ACS NNRT was established in 2017 to advance navigation efforts that eliminate barriers to quality care, reduce disparities, and foster ongoing health equity across the cancer continuum.³⁷ The study was reviewed by the Medical University of South Carolina Institutional Review Board and deemed exempt from human subjects research.

Survey Design and Statistical Analysis

Between September 9, 2022, and November 27, 2022, ACS NNRT disseminated an email invitation to its listserv to complete a survey about the present and future role of navigators in helping cancer centers meet their goal for the new CoC quality metric of time-to-PORT among patients with HNC. The survey consisted of 16 questions (supplemental eAppendix 1, available with this article at JNCCN.org). The survey was pilot-tested and refined by the ACS NNRT Evidence-Based Promising Practices Task Group to assess readability and content accuracy, then disseminated by email to the ACS NNRT listserv. The ACS NNRT listserv includes 186 distinct health care–providing organizations. The email contained instructions and a hyperlink to a web-based data capture tool (REDCap). The survey was anonymous and did not contain any data to link responses to, or identify, the responding institution. Consistent with ACS NNRT best practices, email recipients were instructed to forward the survey link to the person most knowledgeable about navigation services for patients with HNC at their institution. Only one person was instructed to respond from, and on behalf of, each institution. Due to the deidentified nature of the responses and the potential for the survey link to be forwarded to others, the true denominator (and thus response rate) is unknown. Respondents were not compensated for survey completion. Responses were analyzed using descriptive statistics (eg, means and proportions).

Results

Respondent and Facility Characteristics

In total, navigators from 94 institutions responded to the survey. The characteristics of the navigators and the facilities in which they practice are shown in Table 1. Navigators were most commonly located in the South Atlantic (29.8%) or Middle Atlantic (21.3%) regions of the United States. Respondents were from diverse facility types, including comprehensive community cancer programs (35.1%), academic facilities (22.3%), and community cancer programs (21.3%). Most navigators (83.0%) had a nursing background, and nearly half (45.7%) reported 1 to 5 years of experience working as a navigator.

Table 1.

Characteristics of Survey Respondents (N=94)

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Scope of PN

Of the 94 respondents, 84 (89.4%) reported that at least part of their practice was dedicated to navigating patients with HNC. Of those 84 navigators, 54.8%, 26.2%, and 19.0% reported that 1% to 49%, 50% to 99%, and 100% of their practice was devoted to navigating patients with HNC, respectively (Table 2).

Table 2.

Respondent-Reported Scope of PN Services (N=84)

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Of the 83 respondents who navigated patients with HNC and reported their navigation along the continuum, 67.5% (n=56) reported specifically helping navigate the initiation of adjuvant therapy. Only 37.3% (n=31) navigated all phases of the HNC treatment continuum (Table 2). The distribution of HNC-related navigation along the continuum is shown in Figure 1. Navigators reported that their facilities tracked metrics for patients with HNC (Table 2), with time to initiation of adjuvant radiation therapy specifically being tracked by 32.5% of facilities. The most commonly tracked metrics were health-related social needs, such as lack of transportation, housing, or food (62.7%), and barriers to care (61.4%).

Barriers to Navigation From Surgery Through Adjuvant Therapy

For respondents who did not help navigate patients with HNC initiate adjuvant therapy, the most commonly cited reason (66.7%) was that it was not in their job description but that someone else within the institution had this responsibility. The remaining 33.3% reported that providing navigation services to help patients with HNC start adjuvant therapy was not in their job description and that no one else in the institution had the responsibility. None of the navigators reported being too busy with other responsibilities as a barrier to delivering PN services for timely adjuvant therapy for HNC.

Knowledge of Guidelines and Estimated Rates of PORT Delay

Table 3 shows knowledge about NCCN and CoC guidelines for timely PORT and frequency of delays in starting PORT among navigators caring for patients with HNC. Among the 84 respondents who navigated patients with HNC, 44% (n=37) correctly reported that NCCN and CoC guidelines recommend commencing adjuvant radiation within 6 weeks for patients with HNC; 21.4% (n=18) provided a time interval other than within 6 weeks, and 34.5% (n=29) reported that they did not know. When asked to estimate the frequency of delays in starting adjuvant therapy among patients with HNC nationally in the United States, 71.4% (n=60) of respondents who navigated patients with HNC stated that they did not know. Additionally, 63.1% of respondents who navigated patients with HNC (n=53) stated that they did not know the rate of delay at their own institution. Results were similar when data were analyzed only for the 56 respondents who reported navigating PORT initiation for patients with HNC (50% correctly stated the 6-week time-to-PORT interval, 71.4% did not know the national rate of PORT delay, and 57.1% did not know the rate of delays in starting PORT at their institution).

Table 3.

Respondent-Reported Knowledge of Guidelines for Timely PORT and Frequency of PORT Delays (N=84)

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Barriers Encountered and Navigation Services for Timely Adjuvant Therapy

More than two-thirds of HNC navigators (67.5%; 56/83) reported assisting patients with HNC initiate adjuvant therapy. The most commonly reported barriers were challenges with transportation (70.9%), difficulty coordinating timely dental care (69.1%), difficulty coordinating across health systems (54.5%), insufficient health insurance coverage (54.5%), and lack of patient-perceived importance (50.9%) (Table 4). The most frequently reported PN services included placing referrals or providing transportation assistance (89.1%), coordinating care between providers or clinics (87.3%), assessing patient barriers to timely adjuvant therapy (85.5%), and providing referrals or assisting with financial toxicity or health insurance coverage (85.5%).

Table 4.

Respondent-Reported Barriers to Initiation of Adjuvant Therapy Following Surgery (N=56)

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Discussion

In this national landscape survey, we found that most institutions report routinely providing navigation for patients with HNC, and most of those institutions use navigators to help patients with HNC start timely adjuvant therapy. We also found potential gaps in knowledge among navigators regarding NCCN and CoC guidelines for starting PORT among patients with HNC and metrics for tracking delays in starting PORT. Although the delivery of timely PORT for patients with HNC is incorporated into NCCN Guidelines and is a CoC quality metric, more than half of patients with HNC continue to experience delays in starting PORT, and these delays disproportionately burden racial and ethnic minority groups, the underinsured, and other medically vulnerable populations.^2,10,11 Data from this landscape study have important implications for understanding the current and future role of PN in improving the delivery of timely, equitable adjuvant therapy for patients with HNC, thereby improving survival and decreasing disparities in mortality.

As institutions strive to improve the delivery of timely, equitable, guideline-adherent PORT, PN has emerged as one important intervention. There is substantial evidence showing that PN decreases delays in starting adjuvant therapy and enhances equity in access and timeliness of cancer care delivey.^{12,26–31,38} For example, Castaldi et al³⁹ demonstrated that PN improved the delivery of guideline-adherent adjuvant chemotherapy and endocrine therapy to patients with breast cancer. A single-arm clinical trial using a PN-based multilevel intervention resulted in a PORT delay rate of 14%,³⁵ which compared favorably to historical institutional delay rates of 45%.⁸ Similarly, a study from Voora et al³⁴ showed that a PN-based strategy reduced PORT delays from 89.5% to 50% among patients with HNC surgery undergoing free flap reconstruction. Collectively, these studies indicate that PN-based approaches improve the delivery of timely guideline-directed adjuvant therapy for patients with cancer and motivate the hypothesis that PN can also decrease delays for patients with HNC and improve performance on this CoC metric.

Our findings have a number of practical implications for how institutions can harness PN-based approaches to deliver timely, equitable adjuvant therapy for patients with HNC. First, our data suggest that efforts to scale PN in this area should focus on enhancing the effectiveness of existing PN programs, not extending existing PN programs to a new point along the HNC care continuum, because our data suggest that navigators are already widely used in routine clinical practice to facilitate timely adjuvant therapy for patients with HNC. In addition, the implementation of PN for HNC in a number of institutions across the country suggests that there is a model for PN for HNC that is, on some level, financially viable and sustainable. However, it has been well characterized that inadequate hospital resources dedicated to PN services, especially for HNC, are the single largest barrier to implementation, effectiveness, and scaling.^13,40,41 Findings from this landscape study, in alignment with the new CoC quality metric for HNC and existing data about the efficacy of navigation for timely oncology care, provide a compelling basis for the provision of additional resources to support and grow HNC-based patient navigation organizations. In addition, this organizational infrastructure highlights an opportunity for institutions to collaborate and understand the logistics behind these services to enhance access, equity, and quality throughout the country for patients with HNC.

Second, we found that navigators in this study reported low levels of knowledge regarding guidelines for timely PORT and institutional performance with regards to the CoC quality metric. Although the low levels of knowledge about the guidelines for timely PORT and institutional performance on the timely PORT metric could be explained by the fact that the CoC-accredited institutions have only been collecting and reporting data for the CoC quality metric since March 2022, initiation of adjuvant radiation therapy within 6 weeks of surgery has been recommended in the NCCN Guidelines for HNC for nearly 10 years. Capitalizing on the recent approval of the CoC metric, institutions could develop pocket guidelines/cheat sheets or provide focused education and training to address the knowledge gap among navigators, which would, in turn, facilitate education of patients and communication between patients, navigators, and providers. These educational initiatives could occur at the institution level or through collaboration with national navigation (eg, NNRT) and/or HNC (eg, American Head and Neck Society) organizations.

Third, our results suggest a need for better data collection systems and methods of tracking/reporting outcomes back to navigators about the delivery of timely PORT to patients with HNC. In this study, only one-third of respondents who navigated PORT for patients with HNC reported collecting data to track the corresponding CoC metric. It is important to note that there is a difference between navigator awareness of the clinical importance of timely PORT and navigator awareness of the CoC quality metric for timely PORT for patients with HNC. However, because one purpose of quality metrics is to address gaps in clinical care and drive subsequent improvements, the development of enhanced data collection and tracking infrastructure could facilitate the delivery of real-time data that could be leveraged to improve timely PORT. A recent study by Hudson et al⁴² described an intervention incorporating early ancillary referral placement, a metric-tracking tool to identify gaps in patient care along the HNC continuum, and closed-loop communication to intervene at the gaps. They found that the combination of closed-loop communication and real-time tracking was associated with an increase in timely PORT for HNC from a historical 42%⁴³ to 75%.⁴² Similarly, a quality improvement study by Divi et al³⁶ found that an intervention incorporating real-time tracking of a care pathway checklist could improve the delivery of timely, guideline-adherent PORT for patients with HNC. Although these studies did not incorporate patient navigation, it is likely that navigation could enhance, and be enhanced by, a real-time tracking and communication system. Real-time tracking and improved data collection infrastructure around this quality metric could also be leveraged for audit and feedback, a strategy that has been effective for prior quality improvement initiatives in HNC.⁴⁴

Finally, it is also likely that, when feasible, having navigators whose practice is specifically dedicated to patients with HNC could improve the delivery of timely, equitable care. In this study, only 1 in 5 navigators who care for patients with HNC reported navigating exclusively for this patient population. However, delivery of timely, equitable PORT to patients with HNC requires overcoming a unique and complex set of barriers and doing so in a highly compressed time interval. In this study, navigators reported having to address barriers of transportation insecurity, timely dental care, coordinating across health systems, insufficient health insurance coverage, and low patient knowledge. These multilevel barriers align with what has previously been reported^34,45,46 and also reflect barriers targeted in recent PN-based interventions to improve timely PORT in this patient population.^36,47,48 Of these barriers, the challenges associated with preradiation dental care are unique to patients with HNC and thus potentially outside of the standard scope of practices for navigators who have a broad oncology practice. Preradiation dental care could potentially be more efficiently and effectively addressed with PN dedicated to patients with HNC that prioritizes these types of barriers.^35,36,49,50 In addition, navigating timely PORT for patients with HNC requires operating within a highly compressed time interval. Unlike the target 6-week interval between surgery and initiation of PORT for patients with HNC, the time interval for other CoC quality measures for timely adjuvant therapy is much longer, ranging from 4 months to 1 year following diagnosis or surgery for non–small cell lung cancer, colon cancer, and breast cancer.^51–54 Specialization of navigators within HNC might help them understand and work within the more urgent timeline necessary to identify and resolve barriers to timely care in this patient population.

This landscape analysis has multiple strengths, including its national scope and inclusion of navigators from various facility types with different amounts of PN experience. However, there are limitations. First, the true response rate is unknown as survey recipients could have forwarded the link to others. Second, it is likely that there is response bias. Institutions who were included on the ACS NNRT listserv or those who responded may be more heavily invested in PN practices (particularly for patients with HNC) or more inclined to report according to best practices rather than actual practices. As a result, our findings may overestimate the true proportion and scope of PN practices with regard to starting adjuvant therapy for patients with HNC. Third, the study lacked details regarding potentially important characteristics of the navigators or their institutions, including the patient populations served (eg, rurality, insurance coverage, racial or ethnic diversity), geographic location, CoC accreditation status, clinical volume of HNC, program-specific outcomes, or navigator caseload. Therefore, the generalizability of findings to the overall practices of PN for HNC within the United States is unknown. Fourth, although email recipients were instructed to forward the survey to the person with the most knowledge about PN for HNC at their institution, we cannot verify that the respondent was truly the most well informed at the facility. However, it is reassuring that most respondents were HNC navigators, because they would likely be knowledgeable about their own practices. Fifth, the heterogeneous nature of PN as a profession limits our ability to estimate the time dedicated to navigation versus other activities and the amount of time dedicated to initiating PORT versus other HNC continuum intervals. Although we explored whether navigators provided a given service, we did not evaluate the breadth or quality of the navigation.

Conclusions

In this national landscape survey, we identified that PN is already widely used in clinical practice to help patients with HNC begin timely, guideline-adherent adjuvant therapy. To enhance and scale PN within this area and improve the quality and equity of HNC care delivery, institutions could focus on providing better education and support for their navigators. Further research is necessary to evaluate the efficacy and implementation of navigation-based approaches to improving timeliness, equity, and quality for patients with HNC.