Follow-Up of Head and Neck Cancer Survivors: Tipping the Balance of Intensity

Abstract

The traditional concept of post-treatment surveillance in head and neck cancer patients relies on examinations directed at early detection of disease recurrence and/or second primary tumors. They are usually provided by ear, nose and throat specialists with complementary input from radiation oncologists and medical oncologists. Emerging evidence underscores the importance of monitoring and effective management of late adverse events. One of the major drawbacks is a lack of prospective controlled data. As a result, local institutional policies differ, and practice recommendations are subject to continuing debate. Due to the economic burden and impact on emotional comfort of patients, intensity and content of follow-up visits are a particularly conflicting topic. According to the current evidence-based medicine, follow-up of head and neck cancer patients does not prolong survival but can improve quality of life. Therefore, an approach giving priority to a multidisciplinary care involving a speech and swallowing expert, dietician, dentist, and psychologist may indeed be more relevant. Moreover, on a case-by-case basis, some patients need more frequent consultations supplemented by imaging modalities. Human papillomavirus positive oropharyngeal cancer tends to develop late failures at distant sites, and asymptomatic oligometastatic disease, especially in the lungs, can be successfully salvaged by local ablation, either surgically or by radiation. The deep structures of the skull base related to the nasopharynx are inaccessible to routine clinical examination, advocating periodic imaging supplemented by nasofibroscopy as indicated. Anamnesis of heavy smoking justifies annual low-dose computed tomography screening of the thorax and intensive smoking cessation counseling. Finally, some cancer survivors feel more comfortable with regular imaging, and their voice should be taken into consideration. Future development of surveillance strategies will depend on several variables including identification of reliable predictive factors to select those who could derive the most benefit from follow-up visits, the availability of long-term follow-up data, the results of the first randomized trials, resource allocation patterns, infrastructure density, and the therapeutic landscape of locally advanced and recurrent and/or metastatic disease, which is rapidly changing with the advent of immune checkpoint inhibitors and better utilization of local approaches.

Identification and management of late dysfunction in survivors of head and neck cancer: Implementation and outcomes of an interdisciplinary quality of life (IQOL) clinic

“…In fact, there are no published reports detailing implementation methods of HNC survivorship clinic models and none reporting efficacy or effectiveness data. The absence of such data limits progress in determining, implementing, and sustaining optimal survivorship care 14,24‐26 …”

“…Furthermore, effective functional screening requires expertise not typically possessed by physicians/oncologists/APPs 19,24 . Expertise facilitates early identification of dysfunction (i.e., subclinical, mild in severity, or asymptomatic), an important factor in rehabilitative success 26,37 …”

Oligometastatic Disease Management: Finding the Sweet Spot

“…In a prospective trial of 233 patients, the addition of FDG-PET to a conventional work-up (physical examination, head and neck CT or magnetic resonance [MR], and thoracic CT) changed the M-stage in 8.6% of the study cohort (11). On the other hand, its role in follow-up of head and neck cancer survivors has been proved only for an early evaluation of regional control after definitive chemoradiotherapy but still needs to be defined for metastatic disease (12)(13)(14). One of the new, promising techniques that could find its place especially in surveillance protocols is liquid biopsy.…”

“…According to an arbitrary definition, metachronous metastases occur after 3 months from the initial diagnosis, which typically means that at least one radiological survey had been carried out. In this respect, it should be noted that in the majority of head and neck cancer patients treated with curative intent, no radiological surveillance is recommended as it had not consistently demonstrated survival benefit, although this does not perhaps hold true for some patient subgroups, such as with HPV-positive oropharyngeal cancer, in whom periodic imaging might be warranted ( 14 ).…”

“…Despite the advantages of local ablation across different tumor types, the applicability in head and neck cancer remains to be established. Its role in the management of synchronous metastases still cannot be generalized, and radiological post-treatment follow-up in the primary disease setting in search for metachronous metastases has not been uniformly recommended in clinical practice because of its controversial impact on patient survival and the resulting low cost-effectiveness ( 14 ). However, oligometastatic disease amenable to local treatment tends to be asymptomatic due to its typical localization in the lungs, a paucity of nodules by definition, and their limited size and appears preferably late after the initial diagnosis.…”