Timely Adjuvant Therapy in Head and Neck Cancer: Barriers and Facilitators in Rural Care

Abstract

Importance:

Timely initiation of postoperative radiotherapy (PORT) within six
weeks of surgery improves survival for patients with head and neck squamous
cell carcinoma. Rural populations experience disproportionate delays, yet
contextual drivers remain poorly understood.

Objective:

To identify barriers, facilitators, and themes influencing the
receipt of timely PORT in rural settings to inform a future multilevel
intervention.

Design, Setting, and Participants:

This qualitative study used a phased, patient-and-caregiver involved
design at two rural northern New England cancer center clinics. Phase 1
included two facilitated dialogues with patients, caregivers, and staff
followed by participant-led coding. Phase 2 included three facilitated
dialogues focused on refining barriers, facilitators and solutions-focused
themes (two with patients/caregivers and one with staff). Phase 3 included
reviewing preliminary insights at a clinic staff retreat for feedback. The
analysts used an inductive–deductive approach guided by Intervention
Mapping and the Consolidated Framework for Implementation Research (CFIR)
2.0.

Main Outcomes and Measures:

Barriers, facilitators, and themes related to timely PORT
initiation.

Results:

Eleven individuals participated in the Partnership Academies and 18
in the Community Engagement Studios. We identified five
barriers – communication, care coordination,
access to dental care, transportation, and confronting negative
emotions – and four facilitators:
key staff as central contacts, caregivers as advocates, rural
culture, and leveraging pre-existing resources. Four
themes emerged: (1) Leveraging strengths; (2) Managing
the steep learning curve after cancer diagnosis; (3) The value of peer
support; and (4) The desire for information support was
far-reaching.

Conclusions and Relevance:

This study uniquely examines PORT delays in a rural context with
patient, caregiver, and staff voices. Findings highlight the importance of
community resources, effective communication, and peer support to inform
multilevel strategies aimed at reducing delays and improving equity in
cancer care.

Keywords: Head and Neck Cancer, Postoperative Radiotherapy (PORT), Rural Health, Community-Engaged Research, Implementation Science, Cancer Care Delivery

Introduction

The timely initiation of adjuvant radiotherapy after surgery, also known as
surgery to postoperative radiotherapy time (PORT), is a nationally endorsed quality
metric in the treatment of head and neck squamous cell carcinoma (HNSCC).1,2 Starting radiotherapy within six weeks of surgery has been shown
to significantly improve tumor control and overall survival.3–5 Yet, nationally, 50–60% of patients do not receive timely
PORT.6–8 Delays are linked to rural
residence,9 race,6,10,11
comorbidities,12 insurance
status,13 delayed wound
healing,14 higher stage
tumors,15 patient
information overload,16,17 obtaining dental clearance,16,18,19 and fragmented
care.6,10 A recent large randomized controlled trial
that enrolled patients both within the US and internationally affirmed that fewer
than half of the enrolled patients achieved timely PORT,20 underscoring the persistence of this
problem.

Existing studies investigating strategies to positively impact PORT
timeliness in the United States (US) fall into two groups: pre-implementation
studies identifying causal barriers,16,21–25 and interventional studies addressing those
barriers (see eTable1).17–19,26–29 Both
typically emphasize the importance of addressing clinical processes connected to the
initiation of PORT, including dental evaluations, care-team referrals, and
communication among staff and between staff and patients.16–19,21–29 Other reported contributors to delayed PORT
start include postoperative complications,18,19,27 insufficient awareness of the PORT
guideline,16,17,22,28,29 transportation difficulties16,17,22,28,29, and limited
social support.16 While some
studies have incorporated patient perspectives, none included caregivers; all were
single-site, urban, and none were conducted in the Northeast US.

To address this gap, we identified barriers and facilitators to timely PORT
in two rural-serving oncology clinics in the Northeast US using
patient-and-caregiver involved research methods that were guided by implementation
science principles. Our findings will inform the development of a multilevel
intervention to reduce PORT delays in rural settings and address survival
disparities for rural patients with HNSCC.30,31

Methods

Overview

We applied community-engaged research principles
(classified as patient and caregiver involved research) in three sequential
phases: (1) facilitated dialogues that included patients, caregivers, and staff
perspectives (Partnership Academies)32,33; (2) facilitated dialogues with larger numbers of
representative participants (Community Engagement
Studios)34;
and (3) feedback on interim results during a staff research retreat (member
checking) (Table 1). Italicized
methodologic and analytic terms at first mention in the methods are defined in eSupplement 2, a plain-language
reference for terms used in this study. The project was reviewed by the IRB and
designated as Quality Improvement, and the CE studios had a separate IRB
approval. We provide detailed COREQ guideline reporting, a tool used for
qualitative methods, in eTable3.35

Table 1.

Partnership Academies
Community Engagement Studios
Member Checking

Goal
Identify barriers and facilitators to
timely PORT.
Enhance insight into barriers and
facilitators with local context.
Refine insights with staff feedback from
those directly involved.

Sampling Process
Purposive sampling to engage diverse and
involved stakeholders
Patients and caregivers with HNSCC treated
at Lebanon, NH, and St. Johnsbury, VT.
Staff at both
locations.
Staff at an institutional HNSCC retreat. In
addition, the study team includes patient and caregiver advocates.

Sampled Participant
Roles
• Patient
•
Caregiver
• Nurse navigator
• Hospital
administrator
• Social worker
•
Dentist
• Dental assistant and Public Health
Student
• Medical oncologist
Radiation
oncologist
• Patients (9)
•
Caregivers (3)
• Pathology Administrator
•
Pathology Technician
• Dietician
•
Scheduler
• Medical Oncologist
• Radiation
Oncologist
• Surgeons
•
Pathologists
• Dietician
•
Radiologist
• Nurse Practitioners
•
Physician Assistant
• Medical Oncologist
•
Radiation Oncologist
• Nurse Navigator
•
Speech Language Pathologist
Social Worker
•
Resident Physicians

Data Collection
Transcribed verbatim dialogue
Summarized dialogue
Written and verbal comments

Analysis
Open coding by eight participants over
several sessions
Axial coding (all data) by two
analysts.
The study team reviewed barriers,
facilitators and themes.

Setting

The two outpatient oncology clinics included in this study are part of
the Dartmouth Cancer Center, an NCI-designated comprehensive cancer center. One
clinic is located at the main academic medical center in Lebanon, New Hampshire,
and the other is a satellite clinic located approximately 70 miles north in St.
Johnsbury, Vermont. Both clinics serve rural populations and include medical
oncology and radiation oncology services; surgical oncology services are
available only at the Lebanon, New Hampshire site.

Sampling

Participants in the Partnership Academies, the first phase of
facilitated dialogues, were adults (≥18 years) recruited by purposive
sampling for predetermined roles (e.g., patient, caregiver, hospital
administrator). Participants from the first session also recommended additional
participants for the second session (e.g., dentistry, social work, specific
health system leaders).

Two sampling strategies were used for the Community Engagement Studios
(CE Studios), the second phase of facilitated dialogues. For the two
patient/caregiver CE Studios, participants were eligible if they were ≥18
years, had completed definitive HNSCC treatment (surgery followed by radiation
or radiation alone) 6 months–3 years prior or were a caregiver of such a
patient, spoke English, had internet-enabled video access, and had completed a
REDCap interest form. Each received a $100 stipend. Participants were scheduled
into CE Studios according to where they received most of their adjuvant care
(St. Johnsbury, VT vs Lebanon, NH). Clinical staff were invited by email or
in-person if they were stakeholders in the surgery-to-PORT care pathway and had
completed a REDCap form.

Decisions to conclude each data-collection phase (Partnership Academies,
CE Studios, member checking) were made by team consensus.
Recruitment ceased once the team judged that sufficient content depth and
participant diversity were present for the purposes of informing CE Studio
design and subsequent analyses.

Data Collection

Each Partnership Academy was facilitated by one researcher trained in
this facilitation method (KLF) and co-led by the two principal investigators
(GTW, PES). After orienting participants to the format, the session started with
a patient vignette and open-ended questions on what participants thought may be
causing treatment delays or potential solutions. Sessions were 60 minutes, held
virtually, and audio recorded with transcription.

For the CE Studios, an institutional team trained in the CE Studio model
led the sessions. Discrete categories of barriers were drafted by the study team
(derived from Partnership Academies), which served as a basis for the first half
of the session dialogue (review of previously identified barriers). The second
half of the session focused on potential solutions to these barriers. The two
patient/caregiver CE Studios lasted 120 minutes each; the health system
stakeholder CE Studio lasted 75 minutes. These sessions were held virtually, and
not recorded; a facilitator took notes and distributed detailed summaries to the
study team.

For the off-site staff retreat (member checking), the study team
presented the preliminary thematic analysis, and during an
interactive, 60-minute session, solicited verbal and written comments from all
attendees. One team member took notes and collated all written comments after
the session.

Analysis and Interpretation

We used the Consolidated Framework for Implementation
Research (CFIR 2.0)37 to organize participant-identified barriers and
facilitators across multiple levels; the goal was not one-to-one mapping of each
barrier to a specific CFIR domain, but rather to apply the main ideas within a
framework used across many implementation studies. We also used principles from
Intervention Mapping (IM), a six-step process to design
interventions,38
during interpretation to organize determinants (factors, conditions, or drivers
of delayed PORT) into solution-oriented themes intended to inform future
intervention design; formal, stepwise IM was outside the scope of this
manuscript. We identified barriers and facilitators as analytic categories
intended to summarize determinants of timely PORT, while reserving thematic
analysis for solution-oriented interpretation focused on how participants wished
these determinants to be addressed.

We employed an inductive-deductive approach to analyze our
participants’ responses during all sessions.39 The specific coding method varied
between the Partnership Academy and the CE Studies since the Partnership Academy
instructs participants to use a collaborative consensus method that assigns
meaning (code) to transcribed quotes. This approach is called the Rapid
and Rigorous Qualitative Data Analysis (RADaR) method, and is
described in more depth elsewhere.36 Findings from this analysis informed facilitation plans for
the CE Studios (Table 1). After the
completion of the three CE studios, two analysts (GTW, KS) independently
examined all dialogues. Microsoft Excel (Microsoft 365) was used to manage codes
across both phases. Findings were iteratively reviewed with the
interdisciplinary team during weekly project meetings and further refined at a
staff retreat that served as member checking. The decision not to conduct
further dialogues was made as a consensus decision among team members after
reviewing the derived themes and judged that we achieved sufficient depth. This
decision was guided by the concept of information
power,40
which emphasizes that focused aims, theoretical framing, and rich dialogue
support the use of smaller samples.

Results

Participants

Across the two Partnership Academies, 11 individuals participated.
Across the three CE Studios, nine patients, three caregivers, and six staff
participated; 16 staff contributed during member checking. Participant roles are
described in Table 1.

Barriers

We found five barriers to achieving timely PORT: communication, care
coordination, access to dental care, confronting negative emotions, and
transportation (Figure 1). These are
presented as determinant categories rather than fully developed themes. Their
ordering is not hierarchical (does not convey importance), and each determinant
category was subdivided into subdomains to enhance clarity.

Figure 1.

Fishbone Diagram on Barriers and Facilitators to Timely PORT.

Communication.

Participants cited both staff-patient and staff-staff communication
barriers. In staff-patient exchanges, all groups noted high information
burden, complexity, and difficulty tailoring the message. Patients and
caregivers received extensive new medical information (e.g., feeding tube
use, postoperative pain management) that had to be acted on quickly, often
without clear instructions. Difficulties in staff-patient communication were
not restricted to clinic or hospital encounters. For example, one patient
described confusion after seeing unfamiliar appointments in the health
portal. A key downstream effect of poor communication was the widespread
lack of awareness about the six-week PORT initiation guideline, despite
efforts by some to emphasize it in their clinic visits. Staff references to
“non-compliant patients” (e.g., declining or delaying visits)
likely also reflected underlying communication failures. In many cases, this
“non-compliance” may have been the downstream consequence of
insufficient education about the purpose of a visit or not fully addressing
the root cause of the patient’s reluctance.

Staff–staff communication challenges included limited
awareness of timelines outside one’s role (e.g., surgical teams
unaware that simulation-to-treatment averaged almost two weeks, not one).
Missed meetings and fragmented communication across specialties or external
institutions also contributed.

Care coordination.

All groups described internal (within the health system) and
external (outside the health system) coordination difficulties. Internal
barriers included care transitions (e.g., discharge, rehospitalization) and
patients meeting multiple teams (surgery, radiation oncology, medical
oncology, oral surgery). Tracking patients from diagnosis to adjuvant
therapy was labor-intensive, and electronic health record tools to assist in
the labor (e.g., task handoffs, live updates) were limited. In contrast, the
Radiation Oncology department relied upon software to manage handoffs on a
timeline that was well liked by its users. This system, however, was
unavailable to users outside the department. Externally, staff relied on
community dentists for clearance since the health system lacked general
dentists; referral processes were cumbersome and network knowledge was
inconsistent (e.g., which dentists could see patients within 1–2
weeks).

A related subdomain, inflexibility to changing
circumstances, involved unanticipated events (e.g., infection,
hospitalization, bereavement) that disrupted the multi-week outpatient
sequence. Causes spanned clinician scheduling (different clinic days),
system constraints (services unavailable), and broader factors (insurance or
geographic barriers).

Access to dental care.

Barriers included limited availability (e.g., few dentists in their
rural area, long waits, dependence on community providers), financial
strain, or no pre-existing dental relationships.

Transportation.

Participants highlighted transportation as a major concern, given
that adjuvant radiation often requires daily weekday visits over six weeks.
Winter weather compounded the challenge, and public transportation was
rarely feasible due to limited routes and misaligned schedules in rural
areas.

Confronting negative emotional and physical hardship.

Patients and caregivers described emotional strain (fear, isolation,
loss) and physical challenges (symptoms, time-intensive care) persisting for
months or years after treatment. Though the severity often waned
post-treatment, the nature of the distress evolved – from fear of
therapy to managing ongoing uncertainty and adaptation to a “new
normal.”

Facilitators

We identified four facilitators to timely PORT: key staff serving as
central contacts, caregivers as advocates and knowledge brokers, rural culture,
and leveraging pre-existing resources (Figure
1). As with barriers, each included subdomain reflects distinct
aspects of the facilitator.

Key staff serving as central contacts.

Patients and caregivers consistently valued clinic staff who
functioned as reliable points of contact—often nurses, navigators, or
administrative personnel. These staff were described as knowledgeable,
engaged, and approachable, providing both information and reassurance. Their
presence simplified communication pathways, clarified next steps, and
strengthened therapeutic relationships. Participants noted that
non-physician staff were particularly effective for routine coordination,
allowing physicians to focus on clinical decision-making.

Caregivers as advocates and knowledge brokers.

Caregivers were portrayed as indispensable in navigating complex
systems. They actively sought information, coordinated appointments, and
managed logistics related to scheduling, transportation, and finances. Their
advocacy often compensated for system-level coordination and service gaps.
However, participants recognized the emotional labor this required,
emphasizing the need to better support caregivers in this role.

Rural culture of resiliency and helping one’s neighbor.

Participants described a strong sense of social cohesion and mutual
support as integral to rural life. Many cited community members’
willingness to “step in” for others, especially during
treatment. Several noted that messages delivered by individuals perceived as
similar to themselves (e.g., community members or cancer survivors) were
desirable. This cultural orientation facilitated perseverance but could also
foster reluctance to seek help—underscoring its dual potential as
strength and barrier

Leveraging pre-existing resources.

Participants highlighted the importance of building on existing
assets, including both the health system and community-based organizations.
Staff emphasized health system strengths including established dental
referral networks, social resource programs, and philanthropic funds that
could offset costs. Patients and caregivers emphasized community-based
organizations as potential partners to provide transportation, financial
support, and psychosocial assistance. All groups valued the current
recurring, structured clinic encounters, such as weekly dietitian visits,
since they fostered trust and continuity. Together, these examples
illustrated how existing infrastructure could be mobilized to support timely
PORT.

Consolidated Framework for Implementation Research (CFIR) 2.0

Figure 2 uses CFIR 2.0 as an
organizing framework to locate participant-identified determinants of timely
PORT within two settings, an “outer setting” related to factors
outside of the health system, and an “inner setting” related to
factors within the health system. Determinants shown may function as barriers,
facilitators, or context-dependent influences; of note, these determinants are
not intended to map 1:1 to the list of barriers and facilitators in Figure 1. Consistent with the CFIR 2.0
framework, the “Individuals” domain represents stakeholders
involved in the PORT care pathway whose roles and interactions shape
implementation. This multilevel mapping highlights how organizational,
interpersonal, societal, and contextual influences intersect to shape PORT
timeliness and inform the themes described in the following section.

Figure 2. CFIR 2.0–based analytic organization of determinants influencing
timely postoperative radiotherapy (PORT).

This figure uses the CFIR 2.0 framework as an organizing lens to situate
participant-identified determinants across multiple levels of the implementation
context. Determinants shown may function as barriers, facilitators, or
context-dependent influences and are not intended to map one-to-one to the list
of barriers and facilitators presented elsewhere. Consistent with CFIR 2.0
conventions, the “Individuals” domain reflects characteristics and
roles of actors involved in the PORT care pathway rather than discrete
implementation determinants

Themes on achieving timely PORT

Participants articulated four themes describing what they sought from a
multilevel intervention to improve timely PORT. Table 2 summarizes themes, subthemes, and illustrative quotes.

Table 2.

Themes on barriers and facilitators to timely PORT

Themes
Subthemes
Illustrative quotes

1. Leveraging strengths
Leveraging existing dentistry and health
system networks

Emulating approaches used in
other clinics or professional networks

Patient
and caregivers like resources based in the
community

Community health worker to assess and
address social needs

“I think the biggest thing
that we’ve seen where we’ve kind of tried to help,
especially with the transplant team, because our office works pretty
close to the transplant team, too, is just making sure the patients
are getting their full [dental] evaluations before being picked for
a
transplant.”
Dentist

“Our
community health worker tries to outreach as much as she can to a
lot of our patients who identify in the social determinants of
health and need for
transportation.”
Cancer Center
Administrator

2. Managing the steep learning curve after
cancer diagnosis
Among all stakeholders, there was variable
awareness of the 6-week PORT goal

Patients noted unclear
role delineation among clinicians

Written materials that
provide simplified short-term and long-term goals

Skill
among patients in navigating the patient portal is variable

“Needs to be brought to
everyone’s attention about the goal of [PORT] in six
weeks.”
Patient

“The
biggest issue was navigating the system. Do I go to primary care,
dermatology, or
oncology?”
Patient

3. The value of peer support
Lay health
navigator

Learning from someone with personal
experience

Value of developing an
“advocate”. Learning all that has to
happen

Better from the community than from the health
system

“It was very helpful to hear
from people who have been through what I went through. I
don’t feel so alone
now.”
Patient

“I
did a lot on Facebook like I found a lot of supports on Facebook.
but I think I understand where [he] is coming from is that it
can’t just be a Dartmouth thing. It needs to be more of a
community-like
outreach.”
Caregiver

4. The desire for information support was
far-reaching
Patients desire information related to
living life to its fullest following cancer
treatment

Adapting to the new normal immediately
after surgery

Complexities and challenges in
treatment selection

“[I desire] info on the
aspects of care after surgery, including speech therapy, lymphedema,
thyroid concerns, and stretching the
neck.”
Patient

“As
a patient ‘scared out of my wits’ [I] needed more
up-front conversation with doctors who just didn’t tell
enough. Could have been more
transparent.”
Patient

Theme 1 – Leveraging strengths.

Patients and caregivers identified community-based organizations
addressing needs such as transportation and fuel assistance as ideal
partners. Staff and leaders cited preexisting health system programs as
models to replicate (e.g., existing dental-referral processes used in
transplant clinics) or resources to access (e.g., social work, patient
support services). Staff widely supported assuming responsibility for
connecting patients with needed services; in contrast, some patients
emphasized self-reliance and community support.

Theme 2 – Managing the steep learning curve after cancer
diagnosis.

Participants described patients and caregivers facing an
overwhelming volume of information to integrate within short timeframes
(e.g., hour-long visits). The task was further compounded by short timelines
(i.e., days to a few weeks) to see the necessary specialists or complete
medical procedures or imaging. Awareness of the six-week PORT guideline was
often lost, even among staff. Consequences included information overload,
difficulty prioritizing, and missed coordination opportunities.

Theme 3 – The value of peer support.

Patients and caregivers desired connections with others who had
undergone head and neck cancer treatment. Peer support offered instrumental
benefits (practical strategies for navigating care) and emotional benefits
(feeling understood, less isolated).

Theme 4 – The desire for information support was far-reaching.

Information needs extended beyond the peri-operative period to
long-term recovery and survivorship. Desired topics ranged from surgical
recovery to late swallowing outcomes. Participants emphasized the need for
tailored, phased information delivery—too much too soon could
exacerbate overload, while adaptive, just-in-time access was preferred.

Discussion

The work performed in our study is significant for two main reasons. First,
we identified barriers, facilitators, and solutions-focused themes related to timely
PORT in a rural context, whereas prior studies performed in the US were conducted at
urban centers. Second, we describe the application of two distinct
community-engagement methods to obtain knowledge in a rigorous, time-sensitive, and
inclusive manner. Of note, the inclusion of the caregiver perspective as it relates
to the context of timely PORT is novel. Soliciting the perspective of a diverse
group of participants (i.e., patients, caregivers, multidisciplinary staff) provided
unique insights into the needs of our community that would not have emerged if we
had interviewed only clinical staff. Specifically, the desires for peer support,
information support throughout the continuum of cancer survivorship, and a
preference for material support from community-based organizations were sourced from
the patient and caregiver participants. As the tenets of the co-production suggest,
incorporating the lived experiences of patients, their caregivers, and staff
together can lead to the design of more effective interventions.41,42

The barriers and facilitators for timely PORT that we identified are
well-supported by existing evidence. There is broad support that clinical care
factors like communication barriers, care coordination difficulties, and timely
dental care impact the receipt of timely PORT.16–19,21–29 Similarly, transportation difficulties as a barrier to timely
PORT were identified in multiple studies across different geographic
regions,16,17,22,29 and were the most frequently cited
barrier in a national survey of US healthcare organizations that treat
HNSCC.21 When examining
barriers such as communication more granularly, we found incomplete awareness of the
PORT metric among staff and patients, consistent with prior research.16,21,22 Similarly, our
participants – like others – cited pathology result turnaround
time,23,28 timing of dental evaluations,16–19,22,23,26–29 and timing
of radiation oncology visits16–19,22,23,26–29 as key drivers for delays.

What set our PORT-focused study apart was its attention to emotional
challenges, peer support, caregiver roles, rural culture, and preferences for
community-based organizations. There is published evidence supporting these
findings, both from timely PORT-focused studies and from the broader cancer care
delivery literature. For instance, two separate PORT-focused studies performed at
the same cancer center affirm the importance of emotional and peer support: the
first interviewed 26 people living with HNSCC and identified the importance of
emotional support,16 and the
second used validated survey measures of social support that assessed four
subdomains (positive social interaction, affectionate support, tangible support, and
emotional/informational support) and each were associated with PORT
delays.43 The interview
study previously mentioned also identifies the role of the caregiver as an advocate,
and when caregiver strain becomes significant, then that strain acts as a barrier to
timely PORT.16 The role of rural
culture as a mediator of whether individuals seek or accept support appears unique
within the PORT-focused literature, likely because prior work has largely been
conducted in urban settings. Interview studies with survivors of HNSCC and other
cancers similarly highlight how “rural culture” shapes the willingness
to engage with psychosocial support.44,45 In parallel,
although there is no direct evidence in the PORT-focused literature regarding the
preference for “community-based organizations” over health
system-delivered resources, a recent review found that people “strongly
preferred a community outreach approach” for cancer screening and
navigational services.46
Altogether, these findings deepen understanding of the multilevel factors
influencing timely PORT.

While our study had several important strengths that include sampling a
variety of perspectives, using established implementation science frameworks to add
rigor to the analysis, and conducting the work at two rural-serving cancer clinics,
there are also limitations. The study focus on two clinics in rural Northern New
England limits generalizability to other geographic areas and cultural contexts. We
did not collect demographic data beyond participant role (i.e., patient, caregiver,
staff job role) on account of regulatory constraints (i.e., QI designation,
specifics of the CE Studio IRB). There is also the possibility of selection bias, as
participation in the facilitated dialogues was by invitation and required a
substantial time commitment; perspectives of individuals who lacked the time,
interest, or ability to participate may therefore be underrepresented. Decisions to
conclude data collection were based on team judgments of sufficient content depth
and participant diversity, while also considering pragmatic factors such as project
timelines and the resources required to reach additional participants. Although
further dialogues might have yielded additional insights, qualitative methodologists
note that such trade-offs between depth and scope are inherent to qualitative
inquiry.47 This limitation
is most notable for caregiver participants, whose numbers were fewer than patients
and staff sampled. We did not ask our participants to rank the importance of the
identified barriers or facilitators, as we plan to use alternate means (e.g.,
electronic health record data, design dialogues, small tests of change) to
prioritize intervention targets. Despite these limitations, our findings provide
actionable insights into barriers and facilitators to timely PORT in rural settings
and highlight opportunities for intervention development.

By including the perspectives of patients, caregivers, and staff in rural
oncology clinics, this study provides new insights into barriers and facilitators
that contribute to delays in PORT. Our findings underscore the importance of care
coordination, communication, and emotional support, while also highlighting the role
of rural culture and community resources as both challenges and opportunities. These
results will inform the development of multilevel, contextually-grounded
interventions aimed at improving the timeliness of PORT and reducing survival
disparities in rural head and neck cancer care.

Supplementary Material

eTable 1: PORT focused studies

eSupplement2: Analytic and Methodologic terms

eTable3: COREQ checklist

Key Points.

Question

What barriers, facilitators, and themes influence timely postoperative
radiotherapy (PORT) for head and neck squamous cell carcinoma in rural cancer
clinics?

Findings

In this qualitative, implementation science-informed study at two rural
cancer clinics, participants identified five barriers—communication, care
coordination, access to dental care, transportation, and confronting negative
emotions—and four facilitators: key staff as central contacts, caregivers
as advocates, rural culture, and leveraging pre-existing resources. Four themes
emerged: (1) Leveraging strengths; (2) Managing the steep learning curve after
cancer diagnosis; (3) The value of peer support; and (4) The desire for
information support was far-reaching.

Meaning

These findings highlight multilevel factors shaping timely PORT in rural
settings and point to specific opportunities for designing
interventions that reduce delays and improve equity
in HNSCC care.

FUNDING/SUPPORT:

Research reported in this publication was supported by grant
5P30HS029771–02 (fed ID P30HS029771) funded by the Agency of Healthcare
Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute
(PCORI®) through a research collaboration. The statements
presented in this publication are solely the responsibility of the author(s) and do
not necessarily represent the views of AHRQ, the U.S. Department of Health and Human
Services, or PCORI®. One author (GTW) was supported by a K08 from
the National Cancer Institute [1K08CA286746]. Another author (PES) had salary
support from the cancer center core grant from the National Cancer Institute [Grant
P30CA023108].

ROLE OF FUNDER/SPONSOR STATEMENT:

The funding organizations had no influence on the design and conduct of
the study; collection, management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; and decision to submit the
manuscript for publication.

Footnotes

Conflicts of Interest Disclosure: The authors have no
financial conflicts of interest to report.

Prior Presentations: This work was presented as a poster
presentation at the 2025 ASCO Quality Care Symposium, Chicago, IL on October 11,
2025.

Access to Data and Data Analysis:

GTW had full access to the data and takes responsibility for the integrity
of the data and the accuracy of the data analysis.

Data Sharing Statement:

The data in this study, participants transcripts and facilitation notes,
will not be made available as the statements in them could potentially identify
individuals and violate expectations of confidentiality.

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