Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma.

BACKGROUND Delays in treatment of head and neck squamous cell carcinoma (HNSCC) are known to increase disease recurrence, generating the need for additional salvage treatment, often with immunotherapy. METHODS Three treatment metrics were identified: time from diagnosis to treatment initiation (TTI), time from surgery to postoperative radiotherapy (surg → PORT), and total treatment package time (TPT). Financial toxicity was calculated using hazard ratios, pembrolizumab cost, and dosing data for a Veterans Health Administration (VHA) institutional cohort (n = 338) and a standardized cohort (n = 100). RESULTS Estimated financial toxicity for the VHA cohort was $2 047 407, $316 545, and $1 114 101 for TTI, surg → PORT, and TPT, respectively. Estimated financial toxicity for the standardized patient cohort was $454 028, $544 576, and $1 879 628 for TTI, surg → PORT, and TPT, respectively. CONCLUSIONS Failure to meet established HNSCC treatment metrics generates significant, yet avoidable, institutional financial toxicity which is particularly relevant to integrated single-payer systems such as the VHA in the modern immunotherapy era.