Adherence to Quality Metrics Could Improve Head and Neck Cancer Survival

Adherence to each of five quality metrics for head and neck squamous cell carcinoma (HNSCC) was associated with a reduced risk for death, making them suitable candidates for endorsement as quality metrics by national healthcare quality organizations, according to the results of a study published recently in Cancer.

The five metrics were negative surgical margins, neck dissection yield of 18 or more lymph nodes, appropriate adjuvant radiation, appropriate adjuvant chemoradiation, and adjuvant therapy within 6 weeks of surgery.

“If validated in other data sets and/or endorsed by societies that care for patients with HNSCC, then the implications of our findings are substantial,” wrote John D. Cramer, MD, of the department of otolaryngology–head and neck surgery at Feinberg School of Medicine in Chicago, and colleagues. “These quality metrics could be rapidly implemented into existing Commission on Cancer quality reporting tools to provide timely and actionable information to cancer centers.”

According to the study, there are currently no nationally endorsed quality metrics for head and neck cancer. In order to establish possible quality metrics, the researchers identified 76,853 patients with surgically treated, invasive, HNSCC in the National Cancer Data Base from 2004 to 2014. They compared the rate of adherence to five different quality metrics and whether compliance with these metrics affected overall survival.

For the first measure, negative surgical margins, there was 80% adherence among patients. Median survival was 9.3 years among patients with negative margins compared with 7.6 years in patients with positive margins. Negative surgical margins were associated with a reduced risk for death (hazard ratio [HR], 0.73; 95% CI, 0.71–0.76).

“Although this was the highest adherence rate of all the quality metrics studied, there is still significant room for national improvement, especially within nonacademic cancer centers,” the researchers wrote.

Adherence to neck dissection yield of 18 lymph nodes or more was 73.1%. The risk-adjusted model predicted a reduced mortality rate among those patients with a yield of 18 or more lymph nodes (HR, 0.93; 95% CI, 0.89–0.96).

Sixty-nine percent of patients achieved the quality metric for appropriate use of adjuvant radiation. The median survival for patients with radiation was 7.4 years compared with 2.9 years in the no radiation group. Use of adjuvant radiation reduced the risk of morality (HR, 0.67; 95% CI, 0.64–0.69).

Among patients with positive margins or extracapsular extension, 42.6% received adjuvant chemoradiation. Median survival among patients with adjuvant chemoradiation was 8.4 years compared with 4.5 years in those without. Adjuvant chemoradiation was associated with a reduced risk for death (HR, 0.84; 95% CI, 0.79–0.88).

“We also noted that academic cancer centers had lower adherence to both adjuvant radiation and adjuvant chemoradiation compared with other types of cancer facilities,” the researchers wrote. “This is the opposite of what we observed for the surgical quality indicators.”

Finally, 44.5% of patients who required adjuvant radiation met the metric and received that therapy within 6 or fewer weeks from surgery, which was associated with a reduced risk for mortality (HR, 0.92; 95% CI, 0.89–0.96). The median survival among this group was 10.8 years compared with 8.3 years in people who started therapy greater than 6 weeks from surgery.

“High-quality care must meaningfully impact patient outcomes; and, in support of this, we observed that overall high-quality care was associated with a 19% reduced hazard of mortality,” the researchers wrote. “It is noteworthy that the strongest variable associated with an increased likelihood of receiving high-quality care was the receipt of treatment at a high-volume center.”