Routine long-term follow-up in patients treated with curative intent for squamous cell carcinoma of the larynx, pharynx, and oral cavity. Does it make sense?

Metachronous second primary tumours in the aerodigestive tract in patients with early stage head and neck squamous cell carcinomas

Early-stage head and neck carcinomas can usually be controlled with the appropriate treatment. In these patients, the long-term prognosis mainly depends on second metachronous malignancies, frequently in the aerodigestive tract. Our study aims to identify risk factors for the appearance of second tumours in this group of patients with early head and neck cancer. Of 949 patients included in the study, 189 (20%) developed a metachronous second primary malignancy, most frequently in the aerodigestive tract. Independent risk factors associated with second tumours were heavy alcohol use and the location of the index tumour in the oropharynx. Compared to non-drinkers, heavy drinkers (>80 g/day) presented a 1.8-times higher risk of a second tumour (CI 95%: 1.01-3.50). Patients with oropharyngeal tumours had a 2.15-higher risk than patients with oral cavity tumours (CI 95%: 1.03-4.47). Recursive partitioning analysis was used to characterise two risk groups for second tumours. The low-risk group included patients over 75 years and patients with low levels of carcinogen use. It comprised 171 patients (18%) with a 5.3% frequency of second tumours. The high-risk group accounted for 80% of the patients (n = 778), and the rate of second neoplasms was 16.3%. Classification of the patients according to the mentioned variables allows us to focus follow-up and prevention efforts on high-risk patients.

A new assay to screen for head and neck squamous cell carcinoma using the tumor marker metallopanstimulin

OBJECTIVE

To date, no serologic marker has proven effective as a diagnostic test for head and neck squamous cell carcinoma (HNSCC). Levels of metallopanstimulin (MPS), as measured by a difficult to reproduce radioimmunoassay, are significantly elevated in untreated HNSCC patients. Our objective was to develop a simpler MPS assay.

METHODS

Serum was obtained from HNSCC patients through Institutional Review Board approved protocols at the Penn State University College of Medicine and healthy volunteers donating blood at the hospital blood bank from 2000 to present. Serum MPS was immunoprecipitated, slot blotted, and Western blotted. MPS levels were quantified by densitometry.

RESULTS

Forty-eight blood donors and 45 known HNSCC patients were studied. The MPS level was 14 ng/mL +/- 1 (SEM) for blood donors and 36 ng/mL +/- 3 (SEM) for known HNSCC patients. The difference was statistically significant (P < 0.0001).

CONCLUSION

Slot blot analysis of MPS is a safe, effective, and reproducible assay that may be used to screen for HNSCC in high-risk populations.

Value of routine follow-up for patients cured of laryngeal carcinoma

BACKGROUND

Routine follow-up offered to patients with laryngeal carcinoma in The Netherlands consisted of 22 routine visits over a time period of 10 years after treatment. The primary aims of the follow-up were to detect cancer recurrence in asymptomatic patients and to achieve better survival outcome by reducing cancer-specific mortality rates.

METHODS

A longitudinal cohort study was performed to evaluate the effect of this follow-up schedule. Between January 1990 and January 1995, the authors studied all patients with primary laryngeal squamous cell carcinoma who were treated with intention to cure. For patients who developed cancer recurrence, all routine and extra visits were documented. Reported symptoms and physical evidence of tumor were mapped.

RESULTS

The patients complied with the follow-up protocol closely. In only 2% of all routine visits an asymptomatic cancer recurrence was found. There was no difference in survival and tumor mortality rates for patients with and without symptoms, despite the difference in whether the therapy applied had the intention to cure. It seemed that patients who developed tumor recurrence after therapy for laryngeal carcinoma received no benefit from screening for cancer recurrence detection. The lack of benefit for cancer detection screening among asymptomatic patients might be explained by unfavorable tumor biology parameters.

CONCLUSIONS

The routine follow-up program after treatment for laryngeal carcinoma did not lead to survival benefit for asymptomatic patients with tumor recurrence.

On completion of curative treatment of head and neck cancer: why follow up?

PURPOSE OF REVIEW

To review the rationale and evidence for maintaining clinical contact with patients who have received curative treatment for head and neck cancer.

RECENT FINDINGS

Very little work has been published in the scientific literature on this subject. Most information regarding follow-up care has focused on survival outcomes rather than the rationale for, or cost-effectiveness of, routine surveillance of head and neck cancer patients. Perhaps this is because there seems to be very little controversy. A large survey of surgeons has revealed a diminishing frequency of follow-up with time after treatment, although with variance in respect of specific investigations such as bone scans. Notwithstanding the current paper identifies areas that need to be considered when decisions are made regarding the scheduling of follow-up appointments

SUMMARY

Regular post-treatment surveillance is important for patients' general well-being and for the management of late complications of treatment in long-term survivors. It is unclear whether surveillance provides any survival advantage; this information requires the sort of clinical trial that has been conducted for tumors at other sites, such as colorectal cancer and breast cancer, but not head and neck cancers.

Post-treatment imaging of head and neck cancer

The expected changes on CT or MRI after treatment of a head and neck cancer are described; it is important not to confuse such expected changes with persisting or recurrent tumour, or a treatment complication. Post-treatment CT or MRI is of value when a recurrent tumour is suspected, to confirm the presence of such a lesion and to determine its extent; this is important information for determining the possibility of salvage therapy. More rarely, imaging may be of use in the differentiation between tumour recurrence and a treatment complication. In patients with a high-risk profile for tumour recurrence after treatment, imaging is of value for surveillance of the patient, as an adjunct to clinical follow-up. The baseline study should be obtained about 3 to 4 months after the end of therapy. There is evidence that tumour recurrences can be detect earlier by systematic follow-up imaging.

Postradiotherapy surveillance practice for head and neck squamous cell carcinoma?too much for too little?

INTRODUCTION

Limited information is available regarding surveillance patterns after head and neck cancer radiotherapy. We cataloged follow-up for a specified patient cohort treated at three neighboring university, community, and Veterans Administration institutions.

METHODS

One hundred fifteen patients were treated with curative intent between 1994-1998 with definitive or postoperative radiotherapy for newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx. One hundred patients had continuous follow-up at their treating institution and were included for analysis. Median follow-up until disease recurrence or censorship was 28.5 months.

RESULTS

Median follow-up frequency was 5.7 visits/year and was highly variable. Although visit frequency correlated with disease stage and the presence of high-risk disease features, this association was lost when patients with early recurrences were removed from analysis. Procedure and test utilization closely mirrored visit frequency, resulting in a wide range of estimated yearly charges (0-15,668 dollars/year; median, 1,772 dollars/year). Actuarial 3-year overall survival for the study group was 71%. Eighty-six percent (19 of 22) of potentially salvageable locoregional failures were discovered secondary to symptomatic complaint rather than by test results. Disease failure, whether detected by symptom or testing, predicted for poor survival (22% at 24 months after recurrence).

CONCLUSIONS

Postradiotherapy surveillance for head and neck cancer is inconsistently pursued. A proven correlation between intensive follow-up and improved patient survival is lacking. Surveillance directed by patient symptoms should be investigated as an alternative approach.

Videofiberoptic examination of the pharyngoesophageal segment and esophagus in patients after total laryngectomy

BACKGROUND

Posttreatment follow-up in patients with squamous cell carcinoma of the head and neck is critical because of the high risk of recurrence or a new primary tumor. However, in patients who have undergone total laryngectomy, evaluation of the pharyngoesophageal segment (PES) and esophagus is difficult.

METHODS

Sixty patients who had undergone total laryngectomy received a videofiberoptic examination of the PES and esophagus at the OPD office during follow-up.

RESULTS

Satisfactory examination was achieved in 56 (93%) of the patients. Each procedure was completed within 15 minutes. Although only 11 (18%) of the patients were symptomatic at follow-up, 19 patients (34%) had significant findings, including one local recurrence and two secondary esophageal cancers. Patients were asymptomatic in all three cases.

CONCLUSIONS

Videofiberoptic examination is a simple, effective, and relatively noninvasive method that can be performed in the OPD office to evaluate the PES and esophagus in patients after total laryngectomy.

Evolution of patients with squamous cell carcinoma of upper aerodigestive tract

CONTEXT

Local and regional recurrences are frequent in patients with squamous cell carcinoma of the upper aerodigestive tract and early diagnosis is important for salvage treatment.

OBJECTIVE

To identify the period of highest risk for the development of recurrences after surgical treatment of squamous cell carcinoma of the upper aerodigestive tract, in spite of radical therapy, in order to plan the follow-up for these patients.

TYPE OF STUDY

Cross-sectional, descriptive.

SETTING

Department of Head and Neck Surgery/Otorhinolaryngology, Heliópolis Hospital (Hosphel), São Paulo, Brazil.

PARTICIPANTS

A review was made of the hospital records of 889 patients with squamous cell carcinoma of the upper aerodigestive tract surgically treated between October 1977 and December 1996: 364 had oral cavity tumors, 107 had tumors of the oropharynx, 152 of the hypopharynx and 266, larynx tumors. The disease was stage I in 14 patients, stage II in 117, stage III in 352, stage IV in 397 and 9 patients were not staged.

MAIN MEASUREMENTS

The interval between treatment and recurrence of disease was evaluated. The results were expressed as medians, quartiles (25% to 75%) and percentiles (10% to 90%). The annual incidence of recurrences and second tumors was calculated.

RESULTS

Seventy-four percent of the recurrences were diagnosed within 18 months post-treatment. The local and regional recurrences and distant metastases showed medians of 270, 210 and 435 postoperative days respectively. The incidence of a second primary tumor varied from 2 to 3.1% a year.

CONCLUSION

The majority of recurrences occurred within 18 months after the initial surgical treatment. The incidence of a second tumor remained stable after the first post-treatment year.

Follow-up of head and neck cancer patients post-radiotherapy

Diverging opinions exist regarding follow-up studies post-radiotherapy for head and neck cancer. This report describes the efficacy of follow-up physical examinations, thyroid function tests and screening chest X-rays in post-radiotherapy patients in a practice analysis schema. This analysis suggests that physical examination and thyroid function testing remain valid parts of routine follow-up for head and neck cancer patients; chest X-rays appear less vital unless the patient's clinical situation warrants aggressive therapy of a second primary lung cancer.

Screening for second primary lung cancer after treatment of laryngeal cancer

OBJECTIVES/HYPOTHESIS

As a result of smoking, patients who have received curative treatment for laryngeal cancer run a high risk of developing lung cancer. Therefore, these patients enter a screening program that aims to detect lung cancer at an asymptomatic stage. The study evaluated whether screening for lung cancer by means of regular chest x-ray examinations contributed to prolonging survival.

STUDY DESIGN

A longitudinal follow-up study was performed to analyze the survival of patients who had received curative treatment for squamous cell laryngeal cancer and developed lung cancer during the follow-up period.

METHODS

Patients with lung cancer were divided into two groups: 1) patients with asymptomatic screen-detected lung cancer and 2) patients with complaints indicating lung cancer, whose tumor was detected in the interval between screening examinations by chest x-ray films.

RESULTS

In the complete group of patients with laryngeal cancer, no prognostic factors could be identified for developing lung cancer. There was no prolongation of survival in the screen-detected asymptomatic lung cancer patients. The median survival of both groups was 56 months (P =.57). The date of detection of the lung cancer was clearly brought forward by screening; a difference of 8 months was found between the median detection date of the two groups (P <.001). There was no difference in tumor-specific mortality between the two groups.

CONCLUSION

Screening by chest x-ray examination to detect lung cancer in an asymptomatic stage after curative treatment for squamous cell laryngeal cancer does not improve survival for patients who develop lung cancer.

Recurrent cervical cancer: detection and prognosis

BACKGROUND

Only a small proportion of cervical cancer recurrences is detected during routine follow-up. We investigated which percentage of recurrences is detected during follow-up, which diagnostic tools are helpful to detect recurrent disease and which factors are of prognostic significance once recurrent disease has been established in patients treated for cervical cancer stage IB-IVA.

METHODS

Characteristics of the primary tumor, characteristics of recurrent disease and follow-up were collected retrospectively from clinical records of 277 patients who achieved a complete remission of at least 3 months after primary treatment for cervical cancer in 1992, 1993 and 1994 in three university hospitals in the Netherlands.

RESULTS

Of 277 patients, 47 (17%) developed recurrent disease; this was most often detected after self-referral (45%), and in 32% during routine follow-up. Survival did not differ significantly between these two groups. The presence of symptoms (87%) was the most important first abnormal test result leading to diagnosis of recurrence. In univariate analysis, disease-free interval (DFI) and treatment modality were significant prognostic factors for crude survival of recurrence. However, treatment modality varied considerably and the subgroups were small. Therefore, multivariate analysis was not feasible and clinically valid conclusions could not be drawn.

CONCLUSIONS

In only 32% of all cases, recurrence was detected during a scheduled follow-up visit. In the majority of patients, recurrent cervical cancer was detected by symptoms (87%). In recurrent disease, DFI was a prognostic factor for survival.

Risk of second primary cancer following treatment of squamous cell carcinoma of the lower lip

The risk of second primary cancers (excluding skin cancers) was evaluated among 56 patients who underwent treatment for a squamous cell carcinoma of the lower lip. The mean follow-up was 5.5 years. Ten patients (17.8%) developed at least one new primary cancer. The prevalence of second primary cancers within the respiratory and upper digestive tract, and elsewhere in the body, was 19.4 and 12.9 per 1000 person-years of follow-up, respectively. Patients were at risk for a second primary cancer at a steady rate of 2.7% per year during at least 5 years.

Current followup strategies after radical prostatectomy: a survey of American Urological Association urologists

PURPOSE

Followup care of men who have undergone potentially curative surgical treatment for prostate cancer varies widely among clinicians. To determine current practice patterns we mailed a custom designed questionnaire to American and nonAmerican urologists who were American Urological Association (AUA) members.

MATERIALS AND METHODS

Surveys were mailed to a random sample of the approximately 12,000 AUA members, comprising 3,205 Americans and 1,262 nonAmericans. Evaluable surveys were returned by 760 American (24%) and 290 nonAmerican (23%) urologists. Our analysis is based on these 1,050 responses.

RESULTS

In generally healthy patients after radical prostatectomy for stages T1 to 2NOMO and T3a to cNOMO prostate cancer the most frequently recommended followup diagnostic tests included office visit with digital rectal examination, serum prostate specific antigen (PSA) and urinalysis. Although there is appreciable variation in the frequency of use of these methods, respondents generally recommended office visit with digital rectal examination, serum PSA and urinalysis every 3 months in year 1, every 6 months in years 2 to 5 and annually thereafter. Other tests, such as serum prostatic acid phosphatase, bone scan, and abdominal and pelvic computerized tomography and magnetic resonance imaging, are rarely recommended.

CONCLUSIONS

Our survey provides information regarding current followup strategies recommended by AUA urologists after radical prostatectomy for stages T1 to 2NOMO and T3a to cNOMO disease. Office visits and digital rectal examination, urinalysis and PSA measurement are the main tools that urologists currently use. Although optimal strategy remains unknown, these data permit the rational design of clinical trials of alternate followup strategies based on actual current practice to answer this important question.

How tumor stage affects surgeons' surveillance strategies after surgery for carcinoma of the upper aerodigestive tract

BACKGROUND

The factors that influence decision-making among surgeons are not well understood. The authors evaluated how tumor stage in otherwise healthy patients subjected to potentially curative surgery for upper aerodigestive tract (UADT) epidermoid carcinoma affects the self-reported follow-up strategies employed by practicing surgeons.

METHODS

Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to the 824 members of the Society of Head and Neck Surgeons (SHNS) and the 522 members of the American Society for Head and Neck Surgery who were not members of SHNS. The effect of TNM stage on the surveillance strategies chosen by the respondents was analyzed.

RESULTS

Ten of the 14 most commonly employed surveillance modalities were ordered significantly more frequently with increasing TNM stage. This effect persisted through 5 years of follow-up, but the differences across stages were small. Only 30% of respondents modified their strategies according to the patient's TNM stage.

CONCLUSIONS

Most surgeons performing surveillance after potentially curative surgery in otherwise healthy patients with UADT carcinoma use the same follow-up strategy irrespective of TNM stage. These data permit rational design of a randomized clinical trial of two alternate follow-up plans.