Download - Surveillance Head and Neck Cancer
Post Treatment SurveillanceIFHNOS New York 2014
Michiel van den Brekel• Head and Neck Service• Netherlands Cancer Institute,
Amsterdam
William Carroll• George W Barber, Jr. Professor of
Surgery• Section Head and Neck Oncology,
University Alabama Birmingham
Surveillance
• Different Perspectives– Patient– Doctor– Society– Oncologic
• Current Protocols, future perspectives
Patient perspective• Attention, security / being taken care
– Feels safer (oncologic perspective)• Rehabilitation
– Physical Condition– Functional Sequellae
• WHO core set disability– Psychological distress / acceptance
• Builds personal relationship with doctor
HN Rehabilitation Program of the Netherlands Cancer Institute
Goal• The curatively treated HN cancer patient regains his/her
place in society, using his/her own abilities• Prevention and treatment of treatment sequels
A multidisciplinary team approach with clear goals for each patient
• HN Surgeon and Radiotherapist• Specialist in physical medicine and rehabilitation• SLP• Physiotherapist• Dietician• Social worker• Etc.
Stepped Care Model Targeting Anxiety and Depression
Step 1: Step 2: Step 3: Step 4: Watchful waiting Self-help Counselling Psychologist/
Internet / book nurse antidepressants
Example of numberof patients in: 100 70 35
15 (recovered) out: 30 35
20
Week 0 2 7 12
Krebber et al. BMC Cancer 2012;12:173
Doctor perspective• Care of patient
– Early detection of recurrence / 2nd primaries– Rehabilitation– Smoking / Alcohol Cessation !– Thyroid function (every 6 months)*
• Scientific reasons– outcome, toxicity
• Quality control– Audit, complications, QOL, feedback learning
• Financial incentives versus workload
Society Perspective• Cost – benefit
– chances to increase survival– influence on QALY ?– Rehabilitation has impact on return to society ?
• How long• Who should do it ?
– NP/PA/residents– treating physician– general practitionar
Oncologic Perspective
• Chance to develop a recurrence• Chance to find recurrence before symptoms• Curability when detected• Screening second primaries
– 33% of deaths due to alcohol and tobacco related 2nd primaries
– Incidentalomas found…• Curability versus morbidity
– Prognostic significance of screening• US National Lung Screening Trial• Dutch-Belgian lung cancer screening trial (NELSON):
Time Window Surveillance
Undetectable tumor detectable Symptoms
ResidualTumor
death
Surveillance
Incurable• How often, for how long• Find before symptoms occur
• Fast growing recurrences: more symptoms, less curability• Slow growing recurrences: less symptoms, early detection less
important• Imaging: when, which modality• Future
• blood tests, sputum, brush, breath analysis (e-nose)
Ritoe, Cancer 2004402 patients with laryngeal cancer
• 4639 routine visits• in 2% of visits an asymptomatic recurrence was found• 224 events
• 83 local recurrence• 37 regional recurrences• 55 lung metastases / 2nd primaries (50% of DM are in fact 2nd primaries: Geurts et
al)• 27 HNSCC 2nd primaries
• In case of recurrences: still 35% survival !!
How Recurrences are Detected
No Difference in Survival
How Long ?• Ritoe (Larynx): 78% recurrences / 2nd primaries in first 3 years• Boysen (all sites): 76% of recurrences in first 2 years• De Visscher (all sites): 76% of recurrences and 2nd primaries in first 3 years• Lester: 95% of all evens in first
• 2.7 years for oropharynx• 2.3 years for hypopharynx• 4.7 years for larynx
Second Primaries in Netherlands
• 1989-2008: 16.937 oral + oropharyngeal cancers– 3177 2nd primaries (19%)
• 837(26 %) synchronous (< 6 months)– 397 (47%) HNSCC– 79 (9%) esophagus– 197 (24%) lung
• 2340 (74%) metachronous– 708 (30%) HNSCC– 205 (9%) esophagus– 656 (28%) lung
– 1/3 of mortality is because of 2nd primaries– Smoking and drinking is major cause of death (also
cardiovascular)
How Often
Undetectable tumor detectable Symptoms
ResidualTumor
death
Lead timeMostly 3-6 weeks
Per
cent
age
dete
ctio
n as
ympt
omat
ic
month
(months)
Ritoe, Cancer 2007: Markov Model Comparing
prognosis with different schemesAge 50 Age 70
Life expectancy (general population) 27.7 11.6Current follow-up 22.2 10.5No follow-up 21,4 10.2Perfect follow-up 24.7 11.0
Disease Specific Mortality for men (%)Current follow-up 33.6 14.7No follow-up 38.5 17.5Perfect follow-up 18.4 7.3
Published Guidelines
BAHNO NCCN ASHNS SHNS DHNS
Year 1 4–6 w 1–3 m 1–3 m 1–3 m 2 m
Year 2 4–6 w 2–4 m 2–4 m 2–4 m 3 m
Year 3 3 m 4–6 m 3–6 m 3–6 m 4 m
Year 4 6 m 4–6 m 4–6 m 4–6 m 6 m
Year 5 6 m 4–6 m 4–6 m 4–6 m 6 m
>Year 6 1 yr 6–12 m 1 yr 1 yr None
By courtesy of Prof. Remco de Bree
By courtesy of Prof. Remco de Bree
2004
By courtesy of Prof. Remco de Bree
By courtesy of Prof. Remco de Bree
NCCH Guidelines 2014
NCCH Guidelines 2014
2nd Primary Lung Cancer Screening
• 5-10% of surviving HNSCC develop pulmonary cancer
• US National Lung Screening Trial (NLST): 20% reduction in lung cancer mortality in high-risk cohort
• Dutch-Belgian lung cancer screening trial (NELSON):
– 7582 participants: 3 CT scans in 5.5 years » 458 (6%) positive screen results» 200 (2.6%) were diagnosed with lung cancer. » Positive screenings had a predictive value of 40.6%
(1.2% false-positive)» Survival benefit awaiting
Individualizing Surveillance• Length and intensity
– Between 3-5 year is optimal for HNSCC– Shorter than 3 months interval is not effective– Risk of locoregional recurrences versus
chances to effectively treat them• Smoking / alcohol / HPV• Tumor and treatment dependent
• In case effective options available and high risk recurrence: more frequent and vice versa.
Conclusions• Little evidence, possibly some survival advantage • Interval: less than 3 months very inefficient
– How long: 3-5 years– Modality: dependent on salvage/treatment
possibilities / consequences• Lung 2nd primaries: annual CT defendable
– Who: trained physician / NP / PA• More emphasis on:
– Train symptom awareness of patient !!– Stop smoking / alcohol– Rehabilitation
Surveillance of the N0 Neck
Options for the N0 Neck• Observation
– Based on an estimated low risk of occult metastases: T1 larynx
• Staging– CT / MRI / PET– Ultrasound (guided FNAC)– Sentinel node biopsy
• Treatment– Elective ND– Elective Radiotherapy
The N0 Neck – Considerations
• Risk of occult disease• Modality of treatment for
primary• Will the neck be entered?• Prognostic impact of W&S
policy– Follow-Up reliability
• Morbidity of neck treatment• Patient and doctor
preferences
Benefits of Elective ND
• Provides pathological information• Facilitates microvascular surgery• Early treatment
– Avoids delayed presentation– may improve overall outcome ? – Helps avoid radiotherapy
• In about 10% patient ? • Limited morbidity if unilateral
Disadvantages Elective Neck Treatment
• Overtreatment for 50-70%– costs, OR time
• morbidity• Change in patterns of
metastasis – recurrences– second primaries in 30%
Regional recurrence after (s)elective neck dissection cN0 neck
Author Year Primary RTx Neck recurrence
Percentagefailure
McGuirt 1995 FOM None 1/26 3.8%
Spiro 1996 Oral cavity None 6/152 5%
Hosal 2000 All None 6/127 4%
Chow 1989 Oral cavity None 5/63 8%
Carvalho 2000 Oral/Oropharynx 44% 7/154 4.5 %
Yuen 1997 Tongue Some 3/33 9%
BHNCSG 1998 Oral cavity Some 6/72 8%
D’Cruz 2008 Tongue 35% 9/159 5.7%
Sensitivity US-FNAC N0 Neck
Author Tumor N0 Neck Sides Sens SpecvdBrekel (1993)
HNSCC 43 73 100
Righi (1997) HNSCC 33 50 100Takes (1998) HNSCC 64 48 100Nieuwenhuis (2002)
Oral SCC (T3-4) 23 71 100
Nieuwenhuis (2002)
Oral SCC (T1-2) 37 25 100
Hodder (2000) Oral SCC (T1-4) 33 58 100Borgemeester (2009)
Oral SCC (T1-2) 37 18 100
Borgemeester (2009)
HNSCC (T3-4) 128 39 100
US-FNAC vs conventional imaging meta-analysis
De Bondt et al. Eur. J. Radiol. 2007
Sensitivity versus radiologist
Radiologist
Neck sides examined HP positive Sensitivity (%)
1 39 11 9
2 29 14 29
3 31 11 45
4 43 17 53
Prognostic Impact Wait & See
• Depends on salvage rate of neck metastases– treatment delay– metastatic rate of the lymph node
metastases
• Study: decrease treatment delay by regular USFNAC follow-up after transoral excision
Wait & See and Prognosis
Kligerman 33 33% 27%Ho 28 36% 30%Fakih 40 57% 30%Cunningham 43 42% 50%McGuirt 103 36% 59%Vandenbrouck
36 47% 82%
TOTAL 283 41% 50%
van den Brekel 77 18% 71%Nieuwenhuis 161 21% 79%
Pts N+ salvagedPalpation
USFNAC
Survival NKI• 5-year survival in W&S oral cavity (T1-2) is 79%. • 5-year survival in END oral cavity(T2) is 75%.
years from diagnosis
Surv
ival
Pro
babi
lity
0 1 2 3 4 5 6 7
0.0
0.2
0.4
0.6
0.8
1.0
36 34 29 24 19 14 8 5 Mondholte W&S40 31 23 15 14 10 7 4 Mondholte electief ND
Mondholte W&S
Mondholte electief ND
Survival
p = 0.48356 (logrank, two-sided)
Follow-up in months6050403020100
Dis
ease
Spe
cific
Sur
viva
l1,0
0,8
0,6
0,4
0,2
0,0
W&S delayed-censoredEND N+-censoredEND N0-censoredW&S N0-censoredW&S delayedEND N+END N0W&S N0
5-year DSS
Wait and scan
Flach et al. Oral Oncol 2013;49:165-168
• 1990-2004 VUmc• 234 patients• T1 / T2 oral SCC
Conclusions• No difference in survival between W&S and END if follow-up
is very strict
• The incidence of occult LNM is very high in oral cancer, even T1
• US-FNAC to select for a W&S policy remains disputable…..– ND spared in 70%– 90% of eventual ND patients needed Radiotherapy
• SN biopsy might be more accurate than imaging but less than END, role unclear