Research

JAMA Otolaryngology–Head & Neck Surgery | Original Investigation

Association of Social-Ecological Factors With Delay in Time to Initiation

of Postoperative Radiation Therapy
A Prospective Cohort Study
Tuleen Sawaf, BS; Celina G. Virgen, MD, MPH; Bryan Renslo, BS; Nathan Farrokhian, MD; Katherine M. Yu, MD;
Shaan N. Somani, MD; Andrés M. Bur, MD; Kiran Kakarala, MD; Yelizaveta Shnayder, MD;
Gregory N. Gan, MD, PhD; Evan M. Graboyes, MD, MPH; Kevin J. Sykes, PhD, MPH

Supplemental content
IMPORTANCE Timely initiation of postoperative radiation therapy (PORT) is associated with
reduced recurrence rates and improved overall survival in patients with head and neck
squamous cell carcinoma (HNSCC). Measurement of the association of social-ecological
variables with PORT delays is lacking.

OBJECTIVE To assess individual and community-level factors associated with PORT delay
among patients with HNSCC.

DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study carried out between
September 2018 and June 2022 included adults with untreated HNSCC who were enrolled in
a prospective registry at a single academic tertiary medical center. Demographic information
and validated self-reported measures of health literacy were obtained at baseline visits.
Clinical data were recorded, and participant addresses were used to calculate the area
deprivation index (ADI), a measure of community-level social vulnerability. Participants
receiving primary surgery and PORT were analyzed. Univariable and multivariable regression
analysis was performed to identify risk factors for PORT delays.

EXPOSURES Surgical treatment and PORT.

MAIN OUTCOMES AND MEASURES The primary outcome was PORT initiation delay (>42 days
from surgery). Risk of PORT initiation delay was evaluated using individual-level
(demographic, health literacy, and clinical data) and community-level information (ADI and
rural-urban continuum codes).

RESULTS Of 171 patients, 104 patients (60.8%) had PORT delays. Mean (SD) age of
participants was 61.0 (11.2) years, 161 were White (94.2%), and 105 were men (61.4%).
Insurance was employer-based or public among 65 (38.5%) and 75 (44.4%) participants,
respectively. Mean (SD) ADI (national percentile) was 60.2 (24.4), and 71 (41.8%) resided in
rural communities. Tumor sites were most commonly oral cavity (123 [71.9%]), with 108
(63.5%) classified as stage 4 at presentation. On multivariable analysis, a model incorporating
individual-level factors with health literacy in addition to community-level factors was most
predictive of PORT delay (AOC= 0.78; R2, 0.18).

CONCLUSIONS AND RELEVANCE This cohort study provides a more comprehensive assessment
of predictors of PORT delays that include health literacy and community-level measures.
Predictive models that incorporate multilevel measures outperform models with Author Affiliations: Department of
individual-level factors alone and may guide precise interventions to decrease PORT delay for Otolaryngology–Head and Neck
Surgery, University of Kansas Medical
at-risk patients with HNSCC.
Center, Kansas City (Sawaf, Virgen,
Renslo, Farrokhian, Yu, Somani, Bur,
Kakarala, Shnayder, Sykes);
Department of Radiation Oncology,
University of Kansas Medical Center,
Kansas City (Gan); Department of
Otolaryngology–Head and Neck
Surgery, Medical University of South
Carolina, Charleston (Graboyes).
Corresponding Author: Tuleen
Sawaf, BS, Department of
Otolaryngology–Head and Neck
Surgery, University of Kansas Medical
JAMA Otolaryngol Head Neck Surg. 2023;149(6):477-484. doi:10.1001/jamaoto.2023.0308 Center, 3901 Rainbow Blvd, Kansas
Published online April 20, 2023. City, KS 66160 (tsawaf@kumc.edu).

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 Research Original Investigation Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy
T
imely initiation of radiation therapy following primary
surgical ablation of head and neck squamous cell car-
cinoma (HNSCC) is critical to achieving locoregional con-
trol and improved survival in patients with advanced-stage and
high-risk disease.1,2 Although initiation of postoperative ra-
diation therapy (PORT) within 6 weeks of surgery is the stan-
dard to achieve optimal oncologic outcomes, most patients do
not begin adjuvant therapy within this window.3-5 In early
2022, the Commission on Cancer made initiation of radiation
within 6 weeks of surgery its first and only head and neck can-
cer quality measure.6 Factors associated with an increased risk
of PORT delay in prior studies include oral cavity and advanced-
stage tumors, PORT outside the surgical facility, Medicaid in-
surance or uninsured status, minority race and ethnicity,
rural geographic location, lower education level, lack of inter-
disciplinary care coordination, and lower social support.7-11
Prior studies12-14 have demonstrated that delays in initi-
ating PORT are associated with worse overall survival and in-
creased recurrence. The interval between primary surgery and
initiation of PORT is the primary driver of total treatment pack-
age time, affecting survival independent of diagnosis-to-
treatment interval or duration of radiation therapy.12,15,16 De-
lays in PORT initiation disproportionately affect racial and
ethnic minorities, those with Medicaid insurance, and those
in medically underserved areas.13,17-19
To guide targeted interventions to improve the delivery of
timely, equitable, guideline-adherent PORT, better predic-
tive tools are needed to identify patients at risk for delay. The
social-ecological model, originally developed to guide vio-
lence prevention, recognizes the influence of individual char-
acteristics, interpersonal or relationship influences, commu-
nity factors, and society-level influences on health behavior
and outcomes.20,21 The influence of individual contexts and
community environments on health behaviors has been
studied extensively over the past several decades.22 Like-
wise, the social-ecological model has been applied across stud-
ies in public health and otolaryngology, including understand-
ing disparities in human papilloma virus (HPV) vaccination
uptake.23,24 Prior qualitative work has even referenced the so-
cial-ecological model to evaluate and conceptualize barriers
to timely PORT in head and neck cancer.25 By identifying dis-
parities in PORT delay at the individual, interpersonal, com-
munity, and society level, the social-ecological model may
guide how to address key drivers of prevention, timely diag-
nosis, timely completion of treatment, and support for survi-
vorship at each level of influence. Although a number of stud-
ies have identified individual-level factors associated with
PORT delay using data from national databases,5 they have
been limited in their consideration of community-level fac-
tors affecting delays. Moreover, to our knowledge, no studies
have applied these measures in a prospective cohort to quan-
titatively assess factors associated with PORT delay in pa-
tients with head and neck cancer. The aim of this study was
to evaluate factors from multiple levels of influence among pa-
tients with HNSCC treated at a single Midwestern institution
to develop a more comprehensive baseline risk assessment for
PORT delay. We hypothesize that based on the social-
ecological framework, a model that incorporates baseline
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Key Points
Question How are individual and community-level factors
associated with risk for postoperative radiation (PORT) delays in
patients with head and neck squamous cell carcinoma (HNSCC)?
Findings In this prospective cohort study of 171 participants who
received primary surgery and PORT for HNSCC, lower levels of
written health literacy were significantly associated with PORT
delays when controlling for demographic and clinical factors. The
addition of health literacy and the community-level area deprivation
index improved the model’s prediction of PORT delay risk.
Meaning Precise measures of baseline risk for PORT delay at
multiple social-ecologic levels are necessary to develop and
implement precise resource-conscious interventions for at-risk
patients.
measures at the individual and community levels will outper-
form a model with individual-level factors alone when pre-
dicting delays in PORT initiation.
Methods
This study received approval by the institutional review
board at the University of Kansas Medical Center (KUMC)
(#00001732), and all participants provided written informed
consent. Adult patients eligible for enrollment into the KUMC
Head and Neck Registry were those receiving primary evalu-
ation and treatment for HNSCC at KUMC, a tertiary care refer-
ral center. This registry has been described in detail in prior
work.26 Patients who completed radiation therapy between
September 2018 and June 2022 were included in the analy-
sis. These dates corresponded to the earliest registry enroll-
ment with available radiation records. Patients included in the
current study were those requiring primary surgical ablation
followed by PORT with or without chemotherapy. Patients
were enrolled at their initial consultation with a head and neck
oncologic surgeon. The decision to pursue PORT was deter-
mined by consensus recommendations of a multidisci-
plinary tumor board, which reflected the National Compre-
hensive Cancer Center (NCCN) guidelines for treatment of head
and neck mucosal squamous cell carcinomas. Surgery was per-
formed at the primary facility, and patients received adju-
vant radiation in or outside KUMC, depending on patient
preference. Data regarding PORT initiation were captured pro-
spectively from the electronic medical record or end of treat-
ment summaries. Eight patients were excluded because
radiation records were unavailable.
Individual-Level Measures
In the social-ecological framework, variables measured at the
individual level included clinical data such as tumor site and
stage, health literacy and education levels, race and ethnic-
ity, age, sex, insurance, Charlson Comorbidity Index (CCI) score,
and whether the patient required free flap reconstruction. The
CCI was coded as a categorical variable, excluding the index
tumor. A CCI score of 0 to 1 was considered low, a CCI score of
2 to 4 as intermediate, and a CCI score of 5 or greater as high.
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 Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy
The Brief Health Literacy Screening Tool (BRIEF) pro-
vides a short assessment of confidence in understanding
written and verbal health information.27 In this 4-item self-
reported survey, scores range from 4 to 20, with 4 to 12 being
considered limited health literacy, 13 to 16 being marginal
health literacy, and 17 to 20 being adequate health literacy.
Mean BRIEF scores in the delayed and nondelayed groups were
calculated and compared as continuous measures.
Community-Level Measures
In the social-ecological model, the Rural-Urban Continuum
Code (RUCC) and Area Deprivation Index (ADI) were consid-
ered community-level variables. The RUCC uses measures of
population density and urbanization to classify US counties.28
The latest classifications from 2013 were used to calculate the
RUCC. The ADI is a measure of socioeconomic disadvantage
of a neighborhood in relation to either the corresponding state
or US as a whole, and incorporates 17 measures of housing qual-
ity, education, income/employment, and poverty. The ADI uses
the census block group as the geographic unit of construc-
tion, which is a subdivision in a census tract and more closely
approximates the “neighborhood” of a given address than the
county or zip code reported in national databases.29 Patient
addresses were obtained at baseline and used to calculate the
ADI and RUCC. The ADI was calculated using the American
Community Survey from 2018. Current addresses were ex-
tracted from the electronic medical record and geocoded to lati-
tude and longitude coordinates using Geoapify,30 an online
geocoding tool, and then merged with the corresponding poly-
gon associated with their census block using ArcGIS Pro (Esri,
version 2.9). Only participants residing in Kansas or Missouri
were included. Eight (4.5%) participants provided only PO box
addresses, and for these ADI was manually mapped to the PO
box location. The ADI national percentile was scored on a con-
tinuous scale (1-99, with 1 the least disadvantaged, and 99 the
most disadvantaged).
Data Collection and Quantitative Analysis
Demographic information, insurance status, and BRIEF
survey were collected at baseline. Clinical data including
pathologic tumor stage, site, and radiation start date were
obtained from the electronic medical record. All data were
stored in a secure online database.31,32 Patients were divided
into 2 groups based on whether PORT was initiated within or
after 42 days.
Univariable logistic regression was performed to gener-
ate crude (unadjusted) odds ratios (ORs) based on patient
demographic information, clinical information, and survey
scores. To better outline specific aspects of the BRIEF screen
in relation to delays, individual question scores were com-
pared between cohorts. Multivariable logistic regression gen-
erated adjusted odds ratios (aORs) after controlling for other
variables in each model. With planned analysis of 8 variables
spanning the levels of the social-ecological model, an enroll-
ment target of 135 patients was set, provided an expected in-
cidence of delays of 60% based on historical experience at our
institution. This would provide the “rule of thumb” of at least
10 events per variable prior to analysis.33
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Original Investigation Research
Hypothesis Testing
To test the central hypothesis, we generated several multi-
variable models that built toward including measures from
multiple social-ecological levels of influence. In the first mul-
tivariable model, individual-level measures from the social-
ecological model were assessed, which included age, insur-
ance, overall stage, tumor site, and CCI score category (high,
intermediate, or low CCI scores). A second individual-level
model was generated, incorporating the “learning” score from
the BRIEF to evaluate its effect on the model’s strength, as the
effect of health literacy on PORT delay risk has not been di-
rectly evaluated in prior studies. A third model was gener-
ated incorporating the community-level measure ADI.
Finally, a fourth model incorporated both community-level
ADI and RUCC.
Multiple imputation was used to account for missing data
(0.96% of the total data set); most were missing BRIEF scores
(n = 11). A description of values imputed is provided in eTable 1
in Supplement 1. Multivariable imputation by chained equa-
tions was performed using the mice package in R. Twenty-
five data sets were generated, and sequential regression im-
putation calculated each missing value based on all other
variables in the regression equation. Residual variance was
added to the parameter estimates in the regression model using
the Bayesian method. A 2-sided α threshold of α = .05 was ap-
plied for all tests of statistical significance. All statistical analy-
sis was performed using R Studio (version 4.2.1; R Founda-
tion).
Results
A total of 171 patients who received primary surgery and ad-
juvant radiation therapy were included in the overall cohort.
Of these, 104 patients (60.8%) experienced a delay in initiat-
ing PORT. The mean (SD) age for the overall cohort was 61.0
(11.2) years. Overall, 161 patients were White (94.2%), and 105
were men (61.4%) (Table 1), which is representative of the popu-
lation of patients with head and neck cancer seen at KUMC.
This study categorized 14.97% of the US population as rural,
in agreement with published federal data.34 In 154 patients who
completed the BRIEF, overall health literacy score did not pre-
dict PORT delay on univariable analysis (Table 2). When ex-
amining individual subscores of the BRIEF, a lower self-
reported ability to learn written health information predicted
PORT delay (OR, 1.07; 95% CI, 1.00-1.16). In addition, a high
CCI score category predicted delay (OR, 1.29; 95% CI, 1.06-
1.58).
A series of multivariable logistic regression equations were
generated, sequentially adding measures from different lev-
els of influence in the social-ecological model. The first pre-
dictive model incorporating individual-level measures with-
out the BRIEF yielded a model with an area under the curve
(AUC) of 0.74 and R2 of 0.15 (eTable 2 in Supplement 1). A sec-
ond predictive model incorporating the BRIEF with other in-
dividual-level measures yielded an improved model (AUC, 0.77;
R2 = 0.17), and in which a low BRIEF learning score signifi-
cantly predicted delay (aOR, 1.45; 95% CI, 1.02-2.13) (eTable 3
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 Research Original Investigation Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy

Table 1. Demographics and Associations With Postoperative Radiation Therapy Delays

No. (%)
PORT delay
All Yes No
Characteristic (N = 171) (N = 104) (N = 67) Crude OR (95% CI)
Sex
Female 66 (38.6) 43 (41.3) 23 (34.3) 1.07 (0.92-1.25)
Male 105 (61.4) 61 (58.7) 44 (65.7) 1 [Reference]
White 161 (94.2) 63 (94.0) 98 (94.2) 1.01 (0.74-1.38)
RUCC, rurala 71 (41.8) 24 (36.4) 47 (45.2) 1.09 (0.94-1.27)
Age, mean (SD), y 61.0 (11.2) 62.3 (11.1) 59.0 (11.1) 1.01 (1.00-1.01)
Insurance
Employer-based 65 (38.5) 33 (32.4) 32 (47.8) 1 [Reference]
Public 75 (44.4) 50 (49.0) 25 (37.3) 1.17 (1.00-1.38)
Other 29 (17.2) 19 (18.6) 10 (14.9) 1.16 (0.94-1.43)
Employment
Full time 59 (35.3) 31 (30.7) 28 (42.4) 1 [Reference]
Part time 19 (11.4) 11 (10.9) 8 (12.1) 1.05 (0.82-1.36)
Unemployed 20 (12.0) 17 (16.8) 3 (4.5) 1.38 (1.08-1.77)
Retired 69 (41.3) 42 (41.6) 27 (40.9) 1.09 (0.92-1.29)
Education
High school 53 (31.9) 31 (31.3) 22 (32.8) 1 [Reference]
Some college 55 (33.1) 35 (35.4) 20 (29.9) 1.05 (0.87-1.27)
Completed college 35 (21.1) 21 (21.2) 14 (20.9) 1.02 (0.82-1.25)
Graduate education 23 (13.9) 12 (12.1) 11 (16.4) 0.94 (0.74-1.20)
Tumor site
Oral cavity 123 (71.9) 82 (78.8) 41 (61.2) 1 [Reference]
Oropharynx, HPV+ 23 (13.5) 9 (8.7) 14 (20.9) 0.76 (0.61-0.94)
Oropharynx, HPV− 4 (2.3) 1 (1.0) 3 (4.5) 0.66 (0.41-1.07)
Larynx 13 (7.6) 8 (7.7) 5 (7.5) 0.95 (0.72-1.25)
Other 8 (4.7) 4 (3.8) 4 (6.0) 0.85 (0.60-1.20)
AJCC clinical stage
1 19 (11.2) 7 (6.7) 12 (18.2) 1 [Reference]
Abbreviations: AJCC, American Joint
2 14 (8.2) 9 (8.7) 5 (7.6) 1.32 (0.94-1.84) Commission on Cancer; CCI, Charlson
3 29 (17.1) 18 (17.3) 11 (16.7) 1.29 (0.97-1.70) Comorbidity Index; HPV, human
4 108 (63.5) 70 (67.3) 38 (57.6) 1.32 (1.04-1.68) papilloma virus; PORT, postoperative
radiation therapy; RUCC, Rural Urban
Charlson Comorbidity Index (CCI) scoreb Continuum Codes.
Low (0-1) 34 (19.9) 17 (16.3) 17 (25.4) 1 [Reference] a
Urban corresponds to RUCC 1 to 2,
Intermediate (2-4) 75 (43.9) 40 (38.5) 35 (52.2) 1.03 (0.85-1.26) and rural corresponds to RUCC 3
to 9.
High (≥5) 62 (36.3) 47 (45.2) 15 (22.4) 1.29 (1.06-1.58)
b
Charlson Comorbidity Index was
Free flap reconstruction, yes 115 (67.3) 75 (72.1) 40 (59.7) 1.14 (0.98-1.34)
coded excluding the index cancer.

in Supplement 1). Including the community-level ADI yielded
a better-fitting model (AUC, 0.78; R2 = 0.18; eTable 4 in Supple-
ment 1). The strength of the model was largely unchanged with
the addition of RUCC (Table 3). Although mean ADI was higher
among delayed patients, this result was not significant on mul-
tivariable analysis (Table 2, Table 3). Controlling for all other
factors, a high CCI score category significantly predicted de-
lay (aOR, 4.21; 95% CI, 1.11–17.60) (Table 3).
In addition, HPV-positive oropharyngeal tumors were pro-
tective of delays on multivariable analysis (aOR, 0.10; 95% CI,
0.02-0.56) (Table 3). Compared with all other tumor sites in-
cluding HPV-negative oropharyngeal cancers, participants with
HPV-positive oropharyngeal tumors were less often women
(2 [9%] vs 64 [43%]; difference 34%; 95% CI, 18%-51%), less
often insured through a public payer (4 [17%] vs 71 [49%]; dif-
ference 32%; 95% CI, 11%-51%), less likely to present with stage
3 to 4 disease (3 [9%] vs 135 [92%]; difference 83%; 95% CI,
68%-98%), and had significantly lower ADI (50th vs 62nd per-
centile; difference 12 percentiles, 95% CI, 2nd percentile to 22nd
percentile). Age, race and ethnicity, education level, rural sta-
tus, and BRIEF scores were not significantly different in par-
ticipants with HPV-positive oropharyngeal tumors.
Further analysis was performed to assess the absolute dif-
ferences in median days to PORT initiation between groups for
each variable measured. Overall, median (IQR) days to PORT
initiation in the delayed group was 53.5 (16.5) days. Patients
with public insurance were significantly more delayed in me-
dian (IQR) days to PORT at 48.0 (18.5) days compared with 43.0

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 Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy Original Investigation Research

Table 2. Association of Area Deprivation Index and Health Literacy With Postoperative Radiation Therapy Delay Abbreviations: ADI, area deprivation
index; BRIEF, BRIEF Health Literacy
Mean (SD)
Screening Tool; NA, not applicable;
PORT delay OR, odds ratio; PORT, postoperative
Variable All Yes No Crude OR (95%CI) radiation therapy.
a
No. 171 104 67 NA National percentile ranges from 1
ADI, national percentile, mean (SD)a
60.7 (24.2) 63.2 (22.6) 56.8 (26.2) 1.00 (1.00-1.01) (least disadvantaged) to 99 (most
disadvantaged).
Health literacy Alle NA NA NA b
Scores range from 4 to 12 (limited
No. 154 96 58 NA health literacy), 13 to 16 (marginal
BRIEF score, mean (SD)b 15.8 (3.8) 15.6 (3.7) 16.0 (4.0) 1.01 (0.99-1.03) health literacy), 17 to 20 (adequate
How often do you have… health literacy).
c
Scores range from 1 (always [lower
Someone to help you read hospital 3.7 (1.4) 3.8 (1.4) 3.6 (1.5) 0.98 (0.93-1.03)
materials?c level of health literacy]) to 5 (never
[higher level of health literacy]).
Problems learning about your medical 4.1 (1.1) 4.0 (1.1) 4.3 (1.0) 1.07 (1.00-1.16)
d
condition because of difficulty Scores range from 1 (not at all [lower
understanding written information?c level of health literacy]) to 5
A problem understanding what is told to 4.1 (1.0) 4.1 (0.9) 4.2 (1.1) 1.01 (0.93-1.09) (extremely [higher level of health
you about your medical condition?c literacy]).
How confident are you filling out medical 3.8 (1.2) 3.7 (1.2) 3.9 (1.2) 1.03 (0.96-1.10) e
Imputation was not performed for
forms by yourself?d
univariable analysis.

(16.0) days among patients with private insurance (P = .04).

Table 3. Multivariable Logistic Regression Model
of Postoperative Radiation Therapy Delay Risk Subsequent analysis of patients at extremes of delay revealed
Based on Individual and Community Factorsa that 40 (30.5%) patients were delayed past 56 days. Notably,
a significant association was found between low levels on the
Patient characteristic aOR (95%CI)
BRIEF learning score and extreme PORT delay (OR, 1.09; 95%
Age, y 1.03 (0.98-1.08)
CI, 1.03-1.16) (eTable 5 in Supplement 1).
Insurance
Employer-based 1 [Reference]
Public 1.23 (0.47-3.22)
Other 2.33 (0.84-6.79)
Discussion
CCI The prevalence of PORT delay in the present study (104
Low 1 [Reference] [60.8%]) supports the finding from national database stud-
ies that most patients with HNSCC do not receive timely ini-
Intermediate 0.63 (0.19-2.03)
tiation of adjuvant radiation therapy.10 The University of
High 4.21 (1.11-17.6)
Wisconsin Population Health Institute has estimated social
AJCC clinical stage
determinants of health and physical environment traced
1 1 [Reference] to an individual’s zip code account for 50% of health
2 4.40 (0.77-21.80) outcomes. 35 When considering health behaviors such as
3 1.67 (0.29-9.70) tobacco and alcohol use, interactions with the health care
4 1.35 (0.25-7.12) environment are only estimated to be driving 20% of out-
Tumor site
comes. Likewise, PORT delays are multifactorial, contribut-
ing to the complexity of predicting and mitigating their risk.
Oral cavity 1 [Reference]
Although not explicitly applying the social-ecological frame-
Oropharynx, HPV+ 0.10 (0.02-0.56)
work, prior studies have considered individual-level factors
Oropharynx, HPV− 0.21 (0.01-2.37) and added a level to the framework, with organization-level
Larynx 0.66 (0.17-2.65) factors increasing risk of PORT delay. Specifically, authors
Other 0.26 (0.04-1.60) include payers, separate surgical and PORT facilities, postop-
BRIEF, learning 1.43 (1.00-2.08) erative length of stay, advanced stage at presentation, and
ADI, national percentile 1.01 (0.99-1.03) tumor site.11,17,36 Contrary to these prior investigations, the
current study assessed the individual- and community-level
RUCC, rural 1.21 (0.53-2.75)
influences on delays and found that a predictive model
Abbreviations: ADI, area deprivation index; AJCC, American Joint Commission
incorporating multiple levels of influence from the social-
on Cancer; aOR, adjusted odds ratios; AUC, area under the curve; BRIEF, BRIEF
Health Literacy Screening Tool; CCI, Charlson Comorbidity Index; HPV, human ecological framework outperformed a model based on
papilloma virus; PORT, postoperative radiation therapy; RUCC, Rural Urban individual-level factors alone.
Continuum Codes. In addition, incorporating health literacy strengthened the
a
Multiple imputation was used to fill missing data (0.96% of data set). Using predictive model in this study. Disparities in cancer care have
multivariable logistic regression with individual-level factors and
been associated with lower levels of health literacy.37 Though
community-level factors, a significant model was found with an area under the
curve (AUC), 0.78; R2 of 0.18. objective measures of health literacy have not been used to pre-
dict PORT delay, the BRIEF screen has previously been used

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 Research Original Investigation Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy
to predict self-directed behaviors in head and neck cancer, such
as active engagement, positive attitude and self-monitoring,
and skill acquisition.38 Lower scores have been associated with
decreased functional well-being, socio-emotional quality of
life, and disease-specific health-related quality of life.38,39
Among individual-level factors in the current study, a lower
score specifically on the learning component of the BRIEF as-
sessment was significantly associated with PORT delay and
even extreme delays (past 56 days). Given the overwhelming
information presented to patients with a new cancer diagno-
sis, the tools in place to assist with information retention may
not benefit individuals with lower written health literacy. For
example, these individuals may be less likely to reference or
understand information in after-visit summaries and online
medical record portals. Interventions targeting treatment de-
lays could benefit from improved communication methods via
illustrations, videos, and teach-back methodologies em-
ployed by care coordinators reiterating priorities and track-
ing progress through treatment. This is the first study to in-
corporate the BRIEF in a discussion of PORT delay risk, and
the strength of the predictive model emphasizes its applica-
tion in prospective risk stratification.
Rural residence, as measured by the RUCC classification,
was not associated with increased odds of PORT delay in the
current study. These findings are contrary to what Shew and
Levy et al found using data from the National Cancer Data-
base (NCDB).8,11 There are a number of potential explana-
tions for these discrepant findings. First, county-level classi-
fication may not have been sensitive enough to detect the true
influence of rurality in this cohort, where significant differ-
ences in population density and urbanization exist in 1 county
and where rurality may simply be a proxy for critical access
communities with limited health resources. Second, 71 (42%)
participants in the cohort resided in rural communities, which
is much higher than in prior studies.8,11 Unfortunately, no op-
timal measure has been developed to predict rural-urban health
disparities in all contexts.40
Although ADI alone did not significantly predict delay in
initiating PORT, its interaction with individual-level factors
strengthened the multivariable model. Factors potentially af-
fecting its significance include the homogenous cohort, influ-
ence from historical exposures to disadvantage, or societal-
level influences such as Medicaid expansion, which was not
assessable in the nonexpansion state examined in this study.
The ADI was used to estimate social vulnerability, as it is a more
precise measure than income quartiles from zip code infor-
mation available in the NCDB. Agreement exists in identify-
ing more significant delays and worse survival among indi-
viduals residing in lower-income areas.17,36,41 Furthermore,
prior work across other disciplines suggests an individual’s
address alone may predict risk without the need for individu-
ally reported household income information.42-44 Future mul-
ticenter prospective studies may provide more robust assess-
ments of community-level influence, but the current study
findings highlight the importance of environment on health
behavior.
Structure and process factors relating to care coordina-
tion and availability of consultation services have been shown
482 JAMA Otolaryngology–Head & Neck Surgery June 2023 Volume 149, Number 6 (Reprinted)
© 2023 American Medical Association. All rights reserved.
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to be independent factors affecting delays, but are also af-
fected by social determinants of health emphasized in this
work. For example, the decision to pursue PORT at an out-
side facility is likely influenced by distance from facility, so-
cial support, and access to transportation.17 Lower baseline so-
cial support, health literacy, and access to a main tertiary
hospital are later compounded by fragmented coordination be-
tween surgical and radiation facilities.45 Similarly, clinical fac-
tors previously associated with PORT delay in head and neck
cancer have included stage 4 disease and oral cavity site.11
Timely adjuvant therapy in patients with higher oncologic risk
is critical, and appropriate risk stratification may guide ear-
lier dental and radiation oncology referrals. In addition, pa-
tients with higher baseline comorbidity status were at signifi-
cantly higher risk of delay in this study, which may reflect an
effect on downstream postsurgical factors such as length of
stay or readmission not assessed in this study. By contrast, the
favorable individual social circumstances plus insurance and
income status in patients with HPV-mediated oropharyngeal
cancers in this study were likely the primary influencers con-
tributing to fewer delays, consistent with prior literature.46 Al-
though NCDB-based studies have been effective in outlining
the broad effect these factors have on delay risk, the present
study offers a more precise understanding of the interplay be-
tween clinical and social factors to guide precise interven-
tions in clinical practice.
Equity-Driven Interventions
Preliminary trials aimed at targeting risk factors for PORT
delay have focused on improving care coordination through
multidisciplinary referrals and tracking, clarifying patient
navigator roles, community-based travel support, and
patient education to emphasize goals.47,48 These interven-
tions have also targeted patients known to experience dis-
parities in access to care through intentional recruitment.
Pilot data from these interventions shows promising
improvements in timely PORT initiation, and larger studies
are under way to validate these findings.48 Though not spe-
cifically addressed in this study, the Medical Outcomes
Study—Social Support Inventory (MOS-SSS) is a measure of
social support evaluated in our prior work.45 Considered an
interpersonal-level factor in the social-ecological model,
social support has been shown to contribute to resilience
through cancer treatment, and has been associated with
increased follow-up, decreased travel burden, and improved
depressive symptoms and psychological distress associated
with physical symptoms.7,17,49-51 In our prior study consist-
ing of a smaller cohort from the same patient population, a
higher score on the MOS-SSS was indeed found to be a sig-
nificant predictor of PORT delay, even when controlling for
other baseline individual factors. In strengthening existing
nomograms of risk factors for PORT delay, studies may con-
sider including individual, interpersonal, and community
measures employed in this study and our prior work. Future
trials could adopt these measures to better stratify patient
risk factors for delays, and offer more precise interventions
that address both system care processes and negative social
determinant factors critical to timely therapy.
jamaotolaryngology.com
 Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy Original Investigation Research

Limitations evaluated this variable and found it to be significant on mul-

This is a single-institution study at a tertiary academic center
with a relatively homogenous patient cohort of White men,
thus limiting generalizability across patient populations. Al-
though the BRIEF has been validated for use in more repre-
sentative samples, the present results are subject to selection
bias and should be replicated in other patient populations.
Inherent social acceptability and voluntary enrollment bias also
exists in self-reported information obtained via in-person sur-
veys. We considered the potential for selection bias relating
to participant consent for enrollment and patient factors in-
fluencing the likelihood for consent. However, we offer en-
rollment to every new patient in our clinic, with a participa-
tion rate of no less than 90%, limiting this source of bias.
Estimates of rurality were made based on data from the 2013
edition of RUCC, which may not account for recent changes in
populations. Among the 8 participants with only PO box lo-
cations provided, we acknowledge the potential discrepancy
between ADI closer to their physical residence. However, be-
cause this was such a small proportion of participants, it did
not significantly influence our findings. In addition, resi-
dence, insurance, and employment status were captured at a
single time point and do not account for changes between the
initial consultation and initiation of PORT. As PORT facility rela-
tive to surgical facility has been shown to affect delays, we
tivariable analysis. However, because PORT facility is often not
known at baseline, we chose to include the RUCC and ADI
scores as community-level measures, which likely influence
the choice of PORT facility. Moreover, this study was not pow-
ered to assess additional variables that may affect baseline
PORT delay risk, such as BMI and smoking history. Future stud-
ies may evaluate the influence of these individual-level vari-
ables on a predictive model of risk.
Conclusions
Ample evidence exists to demonstrate the systemic inequi-
ties that predispose certain individuals to PORT delay. As shown
in iterative predictive models presented in this prospective co-
hort study, precise community-level measures of vulnerabil-
ity provide additional predictive value, and may be consid-
ered in multicenter studies examining the social determinants
of delays and outcomes. The current study presents patient-
centered precise measures of risk that aid in identifying those
at highest risk for delays. Future studies may also apply these
measures to develop resource-conscious interventions, with
the goal of reducing the effect of nonmodifiable risk factors
on PORT delay.

ARTICLE INFORMATION
Accepted for Publication: February 14, 2023.
Published Online: April 20, 2023.
doi:10.1001/jamaoto.2023.0308
Author Contributions: Dr Sykes had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Concept and design: Sawaf, Virgen, Renslo,
Farrokhian, Somani, Kakarala, Shnayder, Graboyes,
Sykes.
Acquisition, analysis, or interpretation of data:
Sawaf, Virgen, Renslo, Farrokhian, Yu, Bur, Gan,
Graboyes, Sykes.
Drafting of the manuscript: Sawaf, Virgen, Renslo,
Farrokhian, Somani.
Critical revision of the manuscript for important
intellectual content: Sawaf, Virgen, Renslo,
Farrokhian, Yu, Bur, Kakarala, Shnayder, Gan,
Graboyes, Sykes.
Statistical analysis: Sawaf, Renslo, Farrokhian,
Sykes.
Administrative, technical, or material support:
Sawaf, Virgen, Renslo, Farrokhian, Yu, Bur, Gan,
Sykes.
Supervision: Farrokhian, Bur, Kakarala, Shnayder,
Sykes.
Conflict of Interest Disclosures: Dr Bur reported
personal fees from Castle Biosciences outside the
submitted work. Dr Graboyes reported grants from
the National Cancer Institute (NCI) and grants from
Triological Society/American College of Surgeons
during the conduct of the study; grants from NCI,
personal fees from NCI, grants from Castle
Biosciences, and personal fees from Castle
Biosciences outside the submitted work; and
serving on the editorial board for
JAMA-Otolaryngology Head & Neck Surgery.
No other disclosures were reported.
Disclaimer: Dr Graboyes is on the JAMA
Otolaryngol Head–Neck Surgery Editorial Board; but
he was not involved in any of the decisions
regarding review of the manuscript or its
acceptance.
Data Sharing Statement: See Supplement 2. Due
to the sensitive nature of this data, we are unable to
make it publicly available. However, the senior
author is willing to provide deidentified data upon
request.
Additional Contributions: We thank Zack
Arambula, BA, and Joseph Penn, BS, at University
of Kansas Department of Otolaryngology–Head &
Neck Surgery, for their extensive contributions to
patient recruitment and data collection.
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