There has been significant progress in recent years in the treatment of head and neck cancer, and there are useful evidence-based guidelines to inform treatment choices. But less guidance is available when it comes to follow-up and surveillance of patients who have gone into remission.
Existing guidelines for advanced head and neck cancer follow-up are quite broad, with recommended follow-ups ranging from 11 to 27 visits in the 5 years following treatment and no consideration of subtypes.
“Once patients complete treatment for head and neck cancer in particular, they move into survivorship and surveillance phases, and then we are sort of just following patients based on expert opinion,” said Daniel Clayburgh, MD, PhD.
A new study, published online in JAMA Otolaryngology–Head & Neck Surgery, used a novel approach to group head and neck cancer subtypes and calculate optimal follow-up schedules for each.
“They found that in the low-risk types of cancers like HPV-related oropharynx cancers, you really don’t need to see patients all that often because they tend to do quite well, versus the patients that don’t do very well in the long run, such as hypopharyngeal cancers. Their model predicts that you need to see them much, much more often. When you compare that to our guidelines, it says that we’re probably seeing some patients too often, and then there are other patients who we may not be seeing often enough,” said Dr. Clayburgh, who was asked to comment on the study. He is an associate professor of otolaryngology head and neck surgery at Oregon Health and Science University, Portland, and chief of surgery at the Portland VA Healthcare System.
“I thought it was a clever approach to investigate this other aspect of cancer care that often is a little bit overlooked,” said Dr. Clayburgh. who coauthored an invited commentary published in conjunction with the study.
He said the study results are intriguing, but not quite ready for general clinical practice. The study did not include oral cavity cancers, which are a major subtype, and the results need to be validated in larger patient populations. He also pointed out that recurrence is only one reason to see patients after the treatment phase. “There are long term treatment effects. There are various mental health issues and other health issues that they can have aside from just cancer. So it can be helpful to see patients more often than just purely as dictated on how often they’re going to have a cancer recurrence. I don’t think we’re quite there to exactly what is the right number of visits or how often they need to come in, but I think (this paper is) an important step toward that, and it definitely provides fodder for modification of current guidelines,” Dr. Clayburgh said.
The study details
The researchers estimated event-free survival, defined as the time from end of treatment to any event, using a piecewise exponential model. Optimal follow-up timepoint was defined through the occurrence of a 5% event rate. The study included 673 patients with locally advanced head and neck cancer, with a median age of 58 years. A total of 82.5% were men. The researchers did not report race or ethnicity. Over a median follow-up of 57.8 months, frequency of events was 18.9% among 227 patients with nasopharyngeal cancer (NPC), 14.8% among 237 patients with human papillomavirus-positive oropharyngeal cancer (HPV+ OPC), 36.2% among 47 patients with HPV– OPC, 44.6% among 65 patients with hypopharyngeal cancer (HPC), and 30.9% among 97 patients with laryngeal cancer (LC).