番茄社区

Guideline-recommended clinical follow-up appeared to offer no advantage for detecting disease recurrence in patients with human papillomavirus (HPV)-linked oropharyngeal squamous cell carcinoma (OPSCC), a study at a single health system in California found.

Among over 200 such patients, all-cause mortality was no different between those who followed National Comprehensive Cancer Network (NCCN) surveillance guidelines and those that did not (HR 0.76, 95% CI 0.28-2.05), reported Kevin Wang, MD, of Kaiser Permanente Oakland Medical Center in Oakland, California, and colleagues.

"For patients with HPV-associated OPSCC, the currently recommended clinical surveillance regimen almost never detects an asymptomatic recurrence," Wang and co-authors wrote in . "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."

At a median 4.5 years follow-up, 22 patients' disease recurred (23 total recurrences) following 3,358 clinical surveillance exams, of which only one was an asymptomatic recurrence (detected by the physician). Surveillance imaging picked up another 11 recurrences and presence of recurrence-related symptoms in 11 patients prompted early visits.

"A significant proportion of asymptomatic recurrences are detected by the first post-treatment PET/CT scan, and therefore may be more accurately characterized as radiotherapy failures rather than recurrence," the authors wrote.

Nineteen of the 22 patients (89.6%) had adhered to the NCCN guidelines, and a model that looked only at patients with recurrence also found no survival advantage with surveillance adherence (adjusted HR 0.62, 95% CI 0.17-2.30).

HPV-linked OPSCC comprises roughy two-thirds of new cases and is associated with improved prognosis for patients, but current NCCN guidelines do not take into account HPV status in their surveillance recommendations: every 1-3 months in year 1, every 2-6 months in year 2, and every 4-8 months in years 3-5, after which annual follow-up visits are recommended.

Wang's group backed a recently proposed : three visits in year 1, two visits in year 2, and then annual visits in years 3-5.

"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," wrote Carole Fakhry, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues in an . "If reduced surveillance were espoused, accurate risk stratification would be needed."

The editorialists suggested that perhaps HPV DNA on liquid biopsy or using could separate out those survivors at higher or lower risk of recurrence and who need more or less surveillance.

Patients with HPV-associated OPSCC are getting younger and living longer, they noted, and surveillance visits are not solely for oncologic outcomes but also for conditions that may occur in survivorship.

While the findings make a "compelling" case for changing the current recommendations, Fakhry's group sounded a note of caution.

"A change in the current surveillance recommendations may ultimately affect cost, psychological status, and both oncologic and non-oncologic outcomes," they wrote. "This change underscores the need for comprehensive evaluation of these issues before making significant changes to the current recommendations."

For their study, Wang and colleagues examined 233 patients with HPV-associated OPSCC in the Kaiser Permanente Northern California healthcare system from 2011 to 2014. Average patient age at diagnosis was 60.5 years, and the large majority were men (86.3%) and white (81.1%). About half were former smokers and nearly all had either stage I or II disease (92.3% combined).

In the first year, most patients adhered to the NCCN surveillance guidelines (83.0%), but this dropped off in subsequent years, ranging from 52.7% to 73.4% during years 2 to 5.

All recurrences occurred within the first 2 years of follow-up and all salvageable recurrences occurred within the first year. For the 11 patients who had symptoms of recurrence or relapse detected by a physician, six underwent salvage therapy and one was still alive at study end. By the end of follow-up, roughly three-fourths of patients with disease recurrence had died (16 of 22). Median survival was 2.6 years following disease recurrence.