Should Surveillance Schedules Apply to HPV-Associated Oropharyngeal Squamous Cell Carcinomas?

A retrospective study of patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) found that most clinically detected recurrences of the disease were elicited by patient symptoms, according to a study published in JAMA Otolaryngology-Head & Neck Surgery. This indicates that National Comprehensive Cancer Center (NCCN)-directed follow-up may be of limited utility in this patient population.

The current NCCN guidelines for patients with head and neck cancer recommends surveillance every 1 to 3 months for the first year, every 2 to 6 months for the second year, every 4 to 8 months for years 3 to 5, and annually thereafter.

However, in a group of 233 patients with HPV-associated OPSCC diagnosed in the Kaiser Permanente health system between January 2011 and April 2014, only one asymptomatic recurrence was detected among 3,358 posttreatment clinical surveillance visits.

“For patients with HPV-associated OPSCC, the currently recommended clinical surveillance regimen almost never detects an asymptomatic recurrence,” researchers led by Farzad Masroor, MD, of Kaiser Permanente Oakland Medical Center, wrote in JAMA Otolaryngology-Head & Neck Surgery. “The findings of this study suggest that adherence to this schedule is not associated with improvements in survival, and locoregional recurrences were not detected beyond 2 years.”

The median follow-up though recurrence or all-cause mortality was 4.5 years. Adherence to NCCN recommended surveillance was greatest during the first year. During the first year, adherence was 83.0%; however, that decreased to 52.7% in year two, was 73.4% in year three, 62.3% in year four, and 52.9% in year five.

Of the 3,358 surveillance examinations that occurred, 22 patients had disease recurrence. Twenty-one of the 22 patients came in early for the visit at which the recurrence was detected. Almost half of these (10 of 22) were symptom directed. One recurrence was physician detected (the asymptomatic recurrence) and 11 were imaging-detected recurrences.

All locoregional recurrences occurred within the first 2 years of surveillance, and all salvageable recurrence occurred within the first year. Adherence to NCCN guidelines provided no protection from all-cause mortality (hazard ratio=0.76; 95% CI, 0.28–2.05).

“Researchers have recommended reducing posttreatment clinical surveillance schedules to three visits in the first year, two in the second year, and then annually for years three through five,” the researchers wrote. “Based on this study’s findings, results support the above recommended schedule for routine clinical surveillance.”

In addition, they wrote, “patients should be educated on warning signs for locoregional recurrence and have ready access to physicians when symptoms arise.”

In an editorial that accompanied the article, Warren C. Swegal, MD, and colleagues from Johns Hopkins School of Medicine in Baltimore, wrote that this study may identify a subgroup of patients with oropharyngeal squamous cell carcinoma that does not need as intense surveillance for oncologic outcomes as patients with other head and neck cancers.

However, they added that heterogeneity exists among HPV-associated cases, even among low-risk patients.

“Although decreased frequency of clinical visits may be attractive from the perspective of survivors, clinicians, and health care systems, there is presently insufficient data to support a change,” Swegal and colleagues wrote. “If reduced surveillance were espoused, accurate risk stratification would be needed to reliably determine which survivors are at higher or lower risk of recurrence.”