A new study has revealed racial, socioeconomic, and geographic inequities in the delivery of advanced radiotherapy techniques (ART) for patients with head and neck cancer.  

Findings from the study were presented at the 2022 Multidisciplinary Head and Neck Cancers Symposium by Neal Sean McCall, MD, of Winship Cancer Institute of Emory University in Atlanta.

Dr McCall and colleagues mined data from the National Cancer Database (during 2004-2017) for patients treated with external beam radiotherapy for primary head and neck cancer. The study excluded patients with metastatic disease and early stage glottic larynx cancer. 

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The primary endpoint was use of ART, which included intensity-modulated radiotherapy (IMRT) and proton beam therapy (PBT).

ART Use Over Time

The researchers assessed sociodemographic, facility-specific, and clinical associations with receipt of ART in 177,373 patients. Overall, 94.2% of patients received ART (with 93.3% receiving IMRT and 0.9% receiving PBT), and 5.8% received non-ART (2D or 3D-conformal radiotherapy).

The study showed a steady increase in the use of ART from 2004 through 2012, with use remaining stable from 2012 through 2017. The increased use of ART was primarily due to an increase in the use of IMRT. 

“While the utilization of advanced radiation techniques increased substantially between 2004 and 2017, we were surprised to find that 3.1% of patients were still receiving 3D-conformal radiotherapy or less sophisticated techniques even in 2017,” Dr McCall said in an interview.

Factors Tied to ART Use

Dr McCall and colleagues conducted a multivariate analysis to identify factors associated with receipt of ART. 

The analysis showed that non-Hispanic Black patients were significantly less likely to receive ART (odds ratio [OR], 0.87; P <.001) than non-Hispanic White patients. Asian/Pacific Islander patients were more likely than non-Hispanic White patients to receive ART (OR, 1.44; P <.001), and the same was true for Hispanic patients (OR, 1.31; P <.001).

Other groups who were significantly less likely to receive ART included older patients (continuous OR, 0.95; P <.001), uninsured patients (OR, 0.70; P <.001), those on Medicaid (OR, 0.80; P <.001), and those on Medicare (OR, 0.92; P <.001). 

Patients treated at facilities in the Northeast or Midwest were significantly less likely to receive ART (ORs, 0.83 and 0.92, respectively; P <.001 for both). Increasing facility volume was associated with increased odds of receiving ART (continuous OR, 1.13; P <.001).

Compared with patients treated at academic or research facilities, patients treated at community cancer programs (OR, 0.86; P =.002), comprehensive community cancer programs (OR, 0.71; P <.001), or integrated network cancer programs (OR, 0.88; P <.001) were less likely to receive ART. 

In addition, income and educational levels were significantly associated with receipt of ART. Patients living in areas where a greater proportion of the population does not have a high school degree were less likely to be treated with ART, and patients living in areas of lower census median income were less likely to be treated with ART.

“Race, age, insurance, and census-level measures of income and education were all strongly associated with the receipt of advanced radiotherapy techniques,” Dr McCall said. “I think that this really highlights how patients have not necessarily benefited equally from innovations in our field and that striving toward equity should continue to be a top priority.”  

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


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. Multidisciplinary Head and Neck Cancers Symposium 2022. February 24- 26, 2020. Abstract 17.