Background: More than 90% of head and neck cancer (HNC) survivors experience secondary head and neck lymphedema. Prompt identification and treatment are essential given the progressive nature of lymphedema and potential complications. Usual care includes complete decongestive therapy performed by a lymphedema therapist followed by lifelong home self-care. The ability to participate in lymphedema therapy (LT) is deleteriously impacted by numerous barriers. We are conducting a phase 3 multisite randomized trial involving HNC survivors with treatment-naïve lymphedema which compares usual lymphedema care to the use of an advanced pneumatic compression device (APCD). For patients treated on the usual care arm, data pertaining to LT delivery was collected prospectively. Herein we report the preliminary analysis from this dataset. Methods: Eligible patients were age ≥18 years, had pathologically confirmed HNC, completed curative intent cancer therapy with no evidence of active cancer, were diagnosed with internal or external head and neck lymphedema with at least one core lymphedema associated symptom and had not previously received treatment for lymphedema. Participants were randomized to either usual care with complete decongestive therapy directed by a lymphedema therapist followed by home self-care or daily self-directed use of APCD. Anatomic measurements and patient reported outcome measures were obtained at 2-, 4- and 6-month endpoints. The intervention phase lasted 6 months and therapy records were received for analysis. Key outcome measures included the time from referral to LT evaluation consultation, time from LT evaluation to treatment session and time from referral to treatment session. Results: At the time of this analysis, 87 participants randomized to usual care arm were eligible for inclusion in this assessment. Of the 87 patients, we were unable to document completion of LT consultation or therapy for 39 patients. Among the 48 participants who were referred for LT and received therapy, 72% were male and 28% were female, with 91% identifying as white, 7% as black, and 2% as other. The average age was 62. The mean time from referral by a health care provider to initial lymphedema consultation was 19.6 (σ 18.1) days. Of note, there was a wide-ranging timeframe from referral to LT treatment, varying from 0 to 93 days. The mean time from consultation to treatment was 1.7 days (σ 5.1) and referral to treatment was 21.3 (σ 17.8). Conclusions: A key finding of this study is the high rate (45%) of those referred for LT were not documented to complete a therapy consultation or to receive therapy. Of those patients who receive therapy, consultation and treatment were delay significantly in a high percentage of patients. These finding highlight the need for additional investigation into barriers to timely implementation of LT for head and neck cancer survivors. Guidelines and standards of care should be developed to guide practitioners. Clinical trial information: NCT04797390.