Patterns of referral and outcomes in oropharyngeal cancer management

Cancer care is increasingly centralized, with patients referred to specialized centers. While regionalization may improve outcomes, it can introduce barriers such as reduced access to specialized care. As surgery plays a growing role in oropharyngeal cancer treatment, understanding referral patterns and their impact on treatment modality and outcomes is essential.

We conducted a retrospective cohort study using the National Cancer Database to identify patients treated for oropharyngeal squamous cell carcinoma between 2010 and 2017. The primary outcome was referred care, defined as definitive treatment delivered at a facility different from the diagnosing institution. Multivariable logistic regression and Cox proportional hazards models were used to identify factors associated with referral and overall survival, respectively. All models adjusted for demographic, clinical, and facility-level variables and accounted for clustering effects.

Among 47,778 patients, 51.0 % were referred to another facility, with referral rates increasing from 48.5 % in 2010 to 52.2 % in 2017 (p < 0.01). Referral was more likely among patients residing farther from the diagnosing facility, diagnosed in later years, or with lingual tonsil primaries, and less likely among Black patients, those in a lower income quartile, Medicaid or lack of insurance, or those treated at non-academic centers. Referral increased the likelihood of receiving transoral robotic surgery at academic centers only. Referred care was independently associated with improved survival (adjusted HR 0.95; 95 % CI, 0.91-0.99; p < 0.02).

Referral patterns vary by sociodemographic and facility characteristics and are associated with improved survival, highlighting the importance of equitable access to specialized cancer care.