Prereferral Treatment of Head and Neck Cancer Patients Disregards Guidelines

New findings indicate that prereferral care does not conform to clinical practice guidelines in nearly half of patients with head and neck cancer who are referred to a tertiary care center with persistent or recurrent disease, new findings indicate.

The data also show that inadequate surgical management is the main reason for noncompliance with the guidelines.

"To improve the quality of head and neck cancer care through increased compliance with national guidelines, steps need to be taken toward educating community providers through dissemination of guidelines, implementation of multidisciplinary conferences, and regionalization of the care of this patient population," reported Carol M. Lewis, MD, MPH, and colleagues at the University of Texas MD Anderson Cancer Center in Houston.

For their study, the investigators evaluated all components of prior care in 107 newly referred patients to determine how well prereferral treatment complied with National Comprehensive Cancer Network (NCCN) guidelines.

Assessing the quality of care has been a national priority for roughly a decade, and analyses have been largely based on an examination of mortality, morbidity, and duration of hospital stay. However, clinical practice guidelines, which are drawn from expert consensus and scientific evidence, provide specialty— and disease–specific treatment recommendations that establish the standard of care that clinicians should aim to provide.

Lewis and colleagues stated that, while data on compliance with established clinical practice guidelines are available for axillary lymph node dissection, colorectal cancer care, and the surveillance and management of papillary thyroid cancer, the present study is the first to examine compliance with NCCN guidelines for head and neck cancer outside of tertiary care centers.

Prereferral Treatment of Head and Neck Cancer Patients Disregards Guidelines In the present series, the mean time from first presentation with initial symptoms to diagnosis was 23.8 weeks in patients who presented with persistent disease and 10.1 weeks in patients who presented with recurrent disease.

Overall, 43% of patients presenting with persistent or recurrent disease had some aspect of their prereferral care that did not adhere to NCCN guidelines.

Surgical management deemed to be inadequate on the basis of prereferral imaging, operative notes, and pathology records accounted for 58.7% of cases. Notably, 15.2% of patients were given an incorrect diagnosis, which resulted in inappropriate treatment.

Also, 10.9% of patients received inadequate adjuvant therapy, 10.9% refused recommended treatment, and 4.4% received inadequate radiation therapy.

Lewis and associates said that it is possible that the deviation from guidelines may mean that some prereferral physicians are not aware of the guidelines or they may not implement the guidelines used in the study as the standard of quality.

They also maintained that the large percentage of patients who refused recommended treatment may suggest that these patients were not sufficiently wellinformed when they made their decision to refuse treatment and were also perhaps not sufficiently knowledgeable about the possible consequences of their decisions.

Finally, the researchers said that they were not always able to obtain complete records of prereferral treatment despite trying to contact both the patient and the referring physician. When they were not able to obtain the requisite information and when they were unable to establish that prereferral care was not in sync with NCCN guidelines, the researchers gave providers “the benefit of the doubt” and classified the care as being compliant with guidelines. Thus, deviation from NCCN guidelines is probably more common than seen in their study.