Economic analysis of FDG-PET-guided management of the neck after primary chemoradiotherapy for node-positive head and neck squamous cell carcinoma

FGD-PET/CT three months after (chemo)radiotherapy for head and neck squamous cell carcinoma spares considerable number of patients from a salvage neck dissection

PURPOSE

In the last decades FDG-PET/CT is increasingly used in combination with the standard diagnostic modalities (MRI + US-FNA) to identify residual neck disease (RND) after (chemo)radiotherapy for head-and-neck squamous cell carcinoma (HNSCC). The purpose of the current study is to identify the impact of increasing use of FDG-PET/CT on the accuracy of patient selection for salvage neck dissection (SND).

MATERIALS AND METHODS

Between 2008 and 2022, 908 consecutive patients with node-positive HNSCC were treated with (chemo)radiotherapy in our institution.

PRIMARY ENDPOINT

positive predictive value (PPV) of FDG-PET/CT for pathologic-confirmed RND (pRND) after SND, compared to the standard of care; MRI + US-FNA. Secondary endpoints: oncologic outcomes.

RESULTS

Of the entire group, 130 patients (14 %) received SND. Of them only 53 patients (41 %) had pRND at the SND-specimens. The PPV of FDG-PET/CT for the detection of pRND was considerably better, compared to MRI + US-FNA; 89 % and 65 %, respectively. If FDG-PET/CT showed metabolic CR, these patients did not undergo SND. The NPV was 97.5 %, as only 2.5 % of these patients developed delayed regional failure. FDG-PET/CT considerably improved the accuracy of patient selection for SND, as significantly more patients treated in the second period, compared to first period of the study (n = 454 each) still had vital tumor at SND-specimen (53 % and 31 %, p = 0.008). Regional recurrence free-survival, DFS, OS and HNSCC-death were significantly worse in patients with pRND (p < 0.05) CONCLUSIONS: Incorporating FDG-PET/CT into the diagnostic pathway for the response evaluation after (chemo)radiotherapy significantly improved the accuracy of patient selection for SND and spared considerable number of patients (>20 %) from unnecessary SND. For patients with metabolic CR, SND can safely be omitted while for patients with no metabolic CR, SND is strongly advocated.

Role of 18F-FDG PET/CT in Head and Neck Squamous Cell Carcinoma: Current Evidence and Innovative Applications

This article provides an overview of the use of 18F-FDG PET/CT in various clinical scenarios of head-neck squamous cell carcinoma, ranging from initial staging to treatment-response assessment, and post-therapy follow-up, with a focus on the current evidence, debated issues, and innovative applications. Methodological aspects and the most frequent pitfalls in head-neck imaging interpretation are described. In the initial work-up, 18F-FDG PET/CT is recommended in patients with metastatic cervical lymphadenectomy and occult primary tumor; moreover, it is a well-established imaging tool for detecting cervical nodal involvement, distant metastases, and synchronous primary tumors. Various 18F-FDG pre-treatment parameters show prognostic value in terms of disease progression and overall survival. In this scenario, an emerging role is played by radiomics and machine learning. For radiation-treatment planning, 18F-FDG PET/CT provides an accurate delineation of target volumes and treatment adaptation. Due to its high negative predictive value, 18F-FDG PET/CT, performed at least 12 weeks after the completion of chemoradiotherapy, can prevent unnecessary neck dissections. In addition to radiomics and machine learning, emerging applications include PET/MRI, which combines the high soft-tissue contrast of MRI with the metabolic information of PET, and the use of PET radiopharmaceuticals other than 18F-FDG, which can answer specific clinical needs.

Does Bulky Adenopathy in Human Papilloma Virus-Positive Oropharyngeal Squamous Cell Carcinoma Require a Planned Post-Treatment Neck Dissection for Occult Residual Disease?

PURPOSE

A planned neck dissection was traditionally considered for a large nodal disease after definitive chemoradiation, yet controversy exists for the human papilloma virus-positive oropharyngeal squamous cell carcinoma (HPV OPSCC). We aimed to measure the frequency of persistent occult neck disease in planned neck dissection for HPV OPSCC presenting with a large (≥3.0 cm) nodal burden.

METHODS

We designed a retrospective cohort study at a single tertiary referral institution. The study population was sampled from 2006 to 2018 and subjects with HPV OPSCC and adenopathy ≥3.0 cm. Inclusion criteria encompassed subjects who completed primary chemoradiation therapy (CRT) or primary radiation therapy (RT), and subsequently underwent a planned neck dissection. We excluded subjects who did not complete therapy or had less than 1-year follow-up. Our primary predictor variable was the size of cervical adenopathy on presentation (3.0-3.9 cm, 4.0-4.9 cm, 5.0-5.9 cm, and ≥6.0 cm). Our primary outcome of interest was the presence of disease based on the histopathology review. Other variables included the demographics, primary treatment with CRT or RT, and post-treatment clinical or radiographic evidence of disease. Chi-square testing was used to compare rates of persistent disease, with varying sizes of cervical adenopathy on presentation. The alpha level for statistical significance was set at 0.05.

RESULTS

A total of 86 subjects were analyzed, with forty-one females and forty-five males, ranging from 36 to 77 years (mean 54.6 years). From the total study sample, 35% showed persistent disease, and 67% of those subjects had occult disease at the time of planned neck dissection. Greater than 20% of subjects had persistent disease when the nodal burden was ≥3.0 cm at presentation. Furthermore, there was a statistically significant difference in the rates of persistent microscopic disease among subjects with nodal burden of different sizes based on chi-square testing (P = .01, χ2 = 10.66).

CONCLUSIONS

Our data suggest that subjects with HPV OPSCC presenting with a nodal burden ≥3.0 cm are likely to have 23% chance of persistent occult neck disease after primary CRT or RT. These findings may support the routine treatment of these subjects with a planned neck dissection after initial therapy to confirm or surgically complete disease eradication.

Adding MR Diffusion Imaging and T2 Signal Intensity to Neck Imaging Reporting and Data System Categories 2 and 3 in Primary Sites of Postsurgical Oral Cavity Carcinoma Provides Incremental Diagnostic Value

BACKGROUND AND PURPOSE

The NI-RADS lexicon doesn't use ADC parameters and T2 weighted signal for ascribing categories. We explored ADC, DWI, and T2WI to examine the diagnostic accuracy in primary sites of postsurgical oral cavity carcinoma in the Neck Imaging Reporting and Data System (NI-RADS) categories 2 and 3.

MATERIALS AND METHODS

We performed a retrospective analysis in clinically asymptomatic post-surgically treated patients with oral cavity squamous cell carcinoma who underwent contrast-enhanced MRI between January 2013 and January 2016. Histopathology and follow-up imaging were used to ascertain the presence or absence of malignancy in subjects with "new enhancing lesions," which were interpreted according to the NI-RADS lexicon by experienced readers, including NI-RADS 2 and 3 lesions in the primary site. NI-RADS that included T2WI and DWI (referred to as NI-RADS A) and ADC (using the best cutoff from receiver operating characteristic curve analysis, NI-RADS B) was documented in an Excel sheet to up- or downgrade existing classic American College of Radiology NI-RADS and calculate diagnostic accuracy.

RESULTS

Sixty-one malignant and 23 benign lesions included in the study were assigned American College of Radiology NI-RADS 2 (n = 33) and NI-RADS 3 (n = 51) categories. The recurrence rate was 90% (46/51) for NI-RADS three, 45% (15/33) for NI-RADS 2, and 73% (61/84) overall. T2WI signal morphology was intermediate in 45 subjects (53.5%) and restricted DWI in 54 (64.2%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the American College of Radiology NI-RADS were the following: NI-RADS (75.4%, 78.3%, 90.1%, 54.5%, and 76.1%); NI-RADS A (79.1%, 81.2%, 91.9%, 59.1%, and 79.6%); and NI-RADS B (88.9%, 72.7%, 91.4%, 66.7%, and 85.1%), respectively.

CONCLUSIONS

Adding MR imaging diagnostic characteristics like T2WI, DWI, and ADC to the American College of Radiology NI-RADS improved diagnostic accuracy and sensitivity.

Best Practices: Application of NI-RADS for Posttreatment Surveillance Imaging of Head and Neck Cancer

Imaging surveillance is an important component of posttreatment management of head and neck cancers. There is variability in the surveillance regimen used by various practitioners and institutions, with no official National Comprehensive Cancer Network guidelines for patients showing no symptoms beyond 6 months posttreatment. Moreover, imaging of the neck after treatment is a complex examination with significant interreader heterogeneity, particularly in terms of the manner in which degree of suspicion for disease recurrence is expressed. The Neck Imaging Reporting and Data System (NI-RADS) was introduced by the American College of Radiology (ACR) in 2018 as a practical guide for the interpreting radiologist. NI-RADS is a proposed interpretive framework that can be applied to any standardized or institutional surveillance imaging protocol. NI-RADS simplifies communication between radiologists and referring clinicians and provides management guidance linked to specific levels of suspicion. The ACR NI-RADS Committee also provided general best practice recommendations for imaging surveillance modality and timing in the 2018 white paper. This article will review existing literature regarding choice of modality and timeline for surveillance in treated cancer of the head and neck. NI-RADS will then be presented as an approach to imaging reporting, interpretation, and design of next steps in management.

PET-CT for Staging and Detection of Recurrence of Head and Neck Cancer

FDG PET-CT is one the main investigations for squamous cell (Sq) head and neck (H&N) cancer patients. FDG PET-CT has a key role for the staging of patients with T4 cancer of the hypopharynx and nasopharynx and patients with N3 nodal disease. It is effective in detecting recurrent disease accurately. In addition, it has an emerging role in the surveillance of Sq H&N cancer survivors. In patients with advanced neck nodal disease treated with chemoradiotherapy, there is compelling evidence that patients with no FDG uptake in the neck 12 weeks following completion of treatment do not require neck dissection. There is considerable interest in using FDG PET-CT for develop more effective clinical pathways for the surveillance of Sq H&N cancer. Currently, the detection rate of recurrence in patients who attend regular clinical follow-up is poor, less than 1% in asymptomatic patients. FDG PET-CT may enable survivors to be stratified into groups based on the likelihood of having recurrent disease. Optimal surveillance pathways can be developed, reserving most intense imaging regimes and most frequent follow-up for survivors at high risk of recurrence. FDG PET CT is sometimes considered for patients with non Sq H&N cancer. If used in this context, a baseline FDG PET-CT should be done to ensure that the tumour is avid. Most H&N malignant tumours are avid. However, salivary gland cancers, and tumours with muco-epidermoid, adenoid cystic and clear cell histology show paucity of FDG avidity, especially when they recur. In addition, peri-neural invasion cannot be detected reliably with FDG PET-CT.

The economic burden of oral squamous cell carcinoma in Australia

OBJECTIVES

The financial burden of treatment for oral squamous cell carcinoma in Australia has never been reported, and there is a paucity of international data. Here, we report the direct costs of treatment of surgically resectable oral cancer in a tertiary public hospital in Australia over a 15-year period.

MATERIALS AND METHODS

Pathology department records, records of hospital attendance and hospital finance department records were interrogated to determine the direct costs of inpatient and outpatient treatment. Costs were adjusted using the total health price index so that all costs were equivalent to costings for the 2016/2017 financial year.

RESULTS

A total of 113 cases were identified as suitable for inclusion. Complete inpatient and outpatient hospital attendance and costing data for treatment and subsequent 2-year follow-up was available for 29 cases. The average total cost over the 2-year period was $92 958AUD (median $102 722, range $11 662-$181 512). On average, 92.8% of costs were incurred in the first year post-diagnosis. Inpatient costs, outpatient costs and total costs increased with increasing pathological cancer stage. Both 1- and 2-year post-diagnosis overall cost for patients with Stage 4 oral cavity cancer were more than two times greater than for patients with Stage 1 oral cancer.

CONCLUSION

It is well documented that patients diagnosed at an earlier stage will have better survival outcomes, and it is assumed that the economic burden of their treatment will be less. We have shown that there is a direct correlation between cancer stage and cancer treatment cost. The findings provide clear economic support for oral cancer screening initiatives to detect earlier stage cancers, and the need to investigate novel techniques and technologies to detect oral squamous cell carcinoma early and reduce recurrence and mortality rates.

Activity-Based Costing and Time-Driven Activity-Based Costing for Assessing the Costs of Cancer Prevention, Diagnosis, and Treatment: A Systematic Review of the Literature

BACKGROUND

A review of the literature on economic analyses in cancer (prevention, diagnosis, and treatment) using activity-based costing (ABC) or time-driven activity-based costing (TDABC) for measuring costs and to examine how these approaches have been applied to assess and manage cancer costs.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a search for studies that used ABC or TDABC to calculate the cost of cancer in prevention, diagnosis, and treatment. Only English- and Portuguese-language articles were retrieved from Medline, Lilacs, ScieLO, and Embase (January 1990 to August 2016).

RESULTS

In total, 421 studies were evaluated. However, only 27 papers were included. The first publications were from the early 2000s, but most of the studies were published in 2016 (n = 10). Most of the studies were carried out in the United States (n = 6) and Belgium (n = 6). Cancer treatment was the major focus of all studies (n = 20), followed by screening programs evaluations (n = 4) and diagnosis (n = 3). Among treatment modalities, economic analysis of radiotherapy was the most common topic of study. Retrospective clinical data represented 57.6% of the studies. More than 50% of the studies presented unspecified economic analysis. The hospital perspective was the most prevalent perspective among the studies (46.1%).

CONCLUSIONS

ABC and TDABC economic analyses are a promising area of studies in oncology costs.

Cost-effectiveness analysis of PET-CT-guided management for locally advanced head and neck cancer

BACKGROUND

A recent large United Kingdom (UK) clinical trial demonstrated that positron-emission tomography-computed tomography (PET-CT)-guided administration of neck dissection (ND) in patients with advanced head and neck cancer after primary chemo-radiotherapy treatment produces similar survival outcomes to planned ND (standard care) and is cost-effective over a short-term horizon. Further assessment of long-term outcomes is required to inform a robust adoption decision. Here we present results of a lifetime cost-effectiveness analysis of PET-CT-guided management from a UK secondary care perspective.

METHODS

Initial 6-month cost and health outcomes were derived from trial data; subsequent incidence of recurrence and mortality was simulated using a de novo Markov model. Health benefit was measured in quality-adjusted life years (QALYs) and costs reported in 2015 British pounds. Model parameters were derived from trial data and published literature. Sensitivity analyses were conducted to assess the impact of uncertainty and broader National Health Service (NHS) and personal social services (PSS) costs on the results.

RESULTS

PET-CT management produced an average per-person lifetime cost saving of £1485 and an additional 0.13 QALYs. At a £20,000 willingness-to-pay per additional QALY threshold, there was a 75% probability that PET-CT was cost-effective, and the results remained cost-effective over the majority of sensitivity analyses. When adopting a broader NHS and PSS perspective, PET-CT management produced an average saving of £700 and had an 81% probability of being cost-effective.

CONCLUSIONS

This analysis indicates that PET-CT-guided management is cost-effective in the long-term and supports the case for wide-scale adoption.

PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography-computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck cancer

BACKGROUND

Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Thirty per cent of ND specimens show histological evidence of tumour. Consequently, a significant proportion of clinicians still practise planned ND. Fludeoxyglucose positron emission tomography (PET)-computerised tomography (CT) scanning demonstrated high negative predictive values for persistent nodal disease, providing a possible alternative paradigm to ND. Evidence is sparse and drawn mainly from retrospective single-institution studies, illustrating the need for a prospective randomised controlled trial.

OBJECTIVES

To determine the efficacy and cost-effectiveness of PET-CT-guided surveillance, compared with planned ND, in a multicentre, prospective, randomised setting.

DESIGN

A pragmatic randomised non-inferiority trial comparing PET-CT-guided watch-and-wait policy with the current planned ND policy in HNSCC patients with locally advanced nodal metastases and treated with radical CRT. Patients were randomised in a 1 : 1 ratio. Primary outcomes were overall survival (OS) and cost-effectiveness [incremental cost per incremental quality-adjusted life-year (QALY)]. Cost-effectiveness was assessed over the trial period using individual patient data, and over a lifetime horizon using a decision-analytic model. Secondary outcomes were recurrence in the neck, complication rates and quality of life. The recruitment of 560 patients was planned to detect non-inferior OS in the intervention arm with a 90% power and a type I error of 5%, with non-inferiority defined as having a hazard ratio (HR) of no higher than 1.50. An intention-to-treat analysis was performed by Cox's proportional hazards model.

SETTINGS

Thirty-seven head and neck cancer-treating centres (43 NHS hospitals) throughout the UK.

PARTICIPANTS

Patients with locally advanced nodal metastases of oropharynx, hypopharynx, larynx, oral or occult HNSCC receiving CRT and fit for ND were recruited.

INTERVENTION

Patients randomised to planned ND before or after CRT (control), or CRT followed by fludeoxyglucose PET-CT 10-12 weeks post CRT with ND only if PET-CT showed incomplete or equivocal response of nodal disease (intervention). Balanced by centre, planned ND timing, CRT schedule, disease site and the tumour, node, metastasis stage.

RESULTS

In total, 564 patients were recruited (ND arm, n = 282; and surveillance arm, n = 282; 17% N2a, 61% N2b, 18% N2c and 3% N3). Eighty-four per cent had oropharyngeal cancer. Seventy-five per cent of tested cases were p16 positive. The median time to follow-up was 36 months. The HR for OS was 0.92 [95% confidence interval (CI) 0.65 to 1.32], indicating non-inferiority. The upper limit of the non-inferiority HR margin of 1.50, which was informed by patient advisors to the project, lies at the 99.6 percentile of this estimate (p = 0.004). There were no differences in this result by p16 status. There were 54 NDs performed in the surveillance arm, with 22 surgical complications, and 221 NDs in the ND arm, with 85 complications. Quality-of-life scores were slightly better in the surveillance arm. Compared with planned ND, PET-CT surveillance produced an incremental net health benefit of 0.16 QALYs (95% CI 0.03 to 0.28 QALYs) over the trial period and 0.21 QALYs (95% CI -0.41 to 0.85 QALYs) over the modelled lifetime horizon.

LIMITATIONS

Pragmatic randomised controlled trial with a 36-month median follow-up.

CONCLUSIONS

PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.

FUTURE WORK

PET-CT surveillance is cost-effective in the short term, and long-term cost-effectiveness could be addressed in future work.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13735240.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 17. See the NIHR Journals Library website for further project information.

Dissecting Costs of CT Study: Application of TDABC (Time-driven Activity-based Costing) in a Tertiary Academic Center

RATIONALE AND OBJECTIVES

The lack of understanding of the real costs (not charge) of delivering healthcare services poses tremendous challenges in the containment of healthcare costs. In this study, we applied an established cost accounting method, the time-driven activity-based costing (TDABC), to assess the costs of performing an abdomen and pelvis computed tomography (AP CT) in an academic radiology department and identified opportunities for improved efficiency in the delivery of this service.

MATERIALS AND METHODS

The study was exempt from an institutional review board approval. TDABC utilizes process mapping tools from industrial engineering and activity-based costing. The process map outlines every step of discrete activity and duration of use of clinical resources, personnel, and equipment. By multiplying the cost per unit of capacity by the required task time for each step, and summing each component cost, the overall costs of AP CT is determined for patients in three settings, inpatient (IP), outpatient (OP), and emergency departments (ED).

RESULTS

The component costs to deliver an AP CT study were as follows: radiologist interpretation: 40.1%; other personnel (scheduler, technologist, nurse, pharmacist, and transporter): 39.6%; materials: 13.9%; and space and equipment: 6.4%. The cost of performing CT was 13% higher for ED patients and 31% higher for inpatients (IP), as compared to that for OP. The difference in cost was mostly due to non-radiologist personnel costs.

CONCLUSIONS

Approximately 80% of the direct costs of AP CT to the academic medical center are related to labor. Potential opportunities to reduce the costs include increasing the efficiency of utilization of CT, substituting lower cost resources when appropriate, and streamlining the ordering system to clarify medical necessity and clinical indications.

PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer

BACKGROUND

The role of image-guided surveillance as compared with planned neck dissection in the treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease (stage N2 or N3) and who have received chemoradiotherapy for primary treatment is a matter of debate.

METHODS

In this prospective, randomized, controlled trial, we assessed the noninferiority of positron-emission tomography-computed tomography (PET-CT)-guided surveillance (performed 12 weeks after the end of chemoradiotherapy, with neck dissection performed only if PET-CT showed an incomplete or equivocal response) to planned neck dissection in patients with stage N2 or N3 disease. The primary end point was overall survival.

RESULTS

From 2007 through 2012, we recruited 564 patients (282 patients in the planned-surgery group and 282 patients in the surveillance group) from 37 centers in the United Kingdom. Among these patients, 17% had nodal stage N2a disease and 61% had stage N2b disease. A total of 84% of the patients had oropharyngeal cancer, and 75% had tumor specimens that stained positive for the p16 protein, an indicator that human papillomavirus had a role in the causation of the cancer. The median follow-up was 36 months. PET-CT-guided surveillance resulted in fewer neck dissections than did planned dissection surgery (54 vs. 221); rates of surgical complications were similar in the two groups (42% and 38%, respectively). The 2-year overall survival rate was 84.9% (95% confidence interval [CI], 80.7 to 89.1) in the surveillance group and 81.5% (95% CI, 76.9 to 86.3) in the planned-surgery group. The hazard ratio for death slightly favored PET-CT-guided surveillance and indicated noninferiority (upper boundary of the 95% CI for the hazard ratio, <1.50; P=0.004). There was no significant difference between the groups with respect to p16 expression. Quality of life was similar in the two groups. PET-CT-guided surveillance, as compared with neck dissection, resulted in savings of £1,492 (approximately $2,190 in U.S. dollars) per person over the duration of the trial.

CONCLUSIONS

Survival was similar among patients who underwent PET-CT-guided surveillance and those who underwent planned neck dissection, but surveillance resulted in considerably fewer operations and it was more cost-effective. (Funded by the National Institute for Health Research Health Technology Assessment Programme and Cancer Research UK; PET-NECK Current Controlled Trials number, ISRCTN13735240.).

Lessons from a standardized program using PET-CT to avoid neck dissection after primary radiotherapy for N2 squamous cell carcinoma of the oropharynx

OBJECTIVES

To report the results of a standardized program using positron emission tomography (PET)-computed tomography (CT) approximately 12 weeks after primary radiotherapy to determine the need for a planned neck dissection in patients with radiographic N2 squamous cell carcinoma (SCC) of the oropharynx.

METHODS

Fifty consecutive patients with T1-4 and hemineck radiographic stage N2A-B SCC of the oropharynx for whom the only indication for planned neck dissection was a positive PET-CT performed ∼12 weeks after completing primary treatment with radiotherapy.

RESULTS

Results of PET-CT to identify residual neck disease were as follows: sensitivity and positive predictive value, 0%; specificity, 89%; negative predictive value, 91%; potential neck recurrence from using this 12-week PET-CT program, 2%. The time between negative PET-CT and detection of neck recurrence was 0.5, 0.6, 1.2, and 2.0 years. The rate of successful (>1 year) salvage of neck recurrence was 25% (1/4).

CONCLUSIONS

PET-CT approximately 12 weeks after radiotherapy for oropharyngeal cancer is an excellent way to identify patients who do not need neck dissection. Approximately half of neck recurrences present over 1 year after negative PET-CT and the chance of successful salvage is low.

Defining value-driven care in head and neck oncology

In the USA, increasing attention is being paid to adopting a value-based framework for measuring and ultimately improving health care delivery. Value is defined as the benefit achieved relative to costs. The numerator of the value equation includes quality of care and outcomes achieved. The denominator includes costs, both financial costs and harms of treatment. Herein, we describe these elements of value as they pertain to head and neck cancer. A particular focus is to identify areas of the value equation where physicians have some control. We examine quality in each of three dimensions: structure, process, and outcomes. We also adopt Porter's three-tiered hierarchy of outcomes model, with specific outcomes relevant to patients with head and neck and thyroid cancer. Finally, we review issues related to costs and harms. We believe these findings can serve as a framework for further efforts to drive value-based delivery of head and neck cancer care.

p16 status and interval neck dissection findings after a ‘clinically complete response’ to chemoradiotherapy in oropharyngeal squamous cell carcinoma

Objectives:

To evaluate the histopathological findings from post-treatment neck dissection of p16 positive and negative oropharyngeal carcinoma cases, after completion of chemoradiotherapy, and to question the role of neck dissection after a ‘clinically complete response’ to chemoradiotherapy.

Methods:

Data were collected retrospectively from a cohort of patients treated with curative intent using chemoradiotherapy and post-treatment neck dissection. Primary tumours underwent p16 immunohistochemistry. Neck dissection specimens were examined for viable cancer cells.

Results:

A total of 76 cases were assessed. Viable cancer cells were detected from neck dissection in 29 per cent of p16 negative cases. Locoregional recurrence occurred in 12.9 per cent of p16 negative cases. The association between p16 positivity in the primary tumour and histopathologically negative neck dissection was significant (p < 0.05).

Conclusion:

p16 status appeared to be an independent marker of disease control for the cohort in this study. The data raise questions about the role of post-treatment neck dissection in p16 positive cases with a ‘clinically complete response’ to chemoradiotherapy.

The economic burden of head and neck cancer: a systematic literature review

BACKGROUND

This systematic literature review aimed to evaluate and summarize the existing evidence on resource use and costs associated with the diagnosis and treatment of head and neck cancer (HNC) in adult patients, to better understand the currently available data. The costs associated with HNC are complex, as the disease involves multiple sites, and treatment may require a multidisciplinary medical team and different treatment modalities.

METHODS

Databases (MEDLINE and Embase) were searched to identify studies published in English between October 2003 and October 2013 analyzing the economics of HNC in adult patients. Additional relevant publications were identified through manual searches of abstracts from recent conference proceedings.

RESULTS

Of 606 studies initially identified, 77 met the inclusion criteria and were evaluated in the assessment. Most included studies were conducted in the USA. The vast majority of studies assessed direct costs of HNC, such as those associated with diagnosis and screening, radiotherapy, chemotherapy, surgery, side effects of treatment, and follow-up care. The costs of treatment far exceeded those for other aspects of care. There was considerable heterogeneity in the reporting of economic outcomes in the included studies; truly comparable cost data were sparse in the literature. Based on these limited data, in the US costs associated with systemic therapy were greater than costs for surgery or radiotherapy. However, this trend was not seen in Europe, where surgery incurred a higher cost than radiotherapy with or without chemotherapy.

CONCLUSIONS

Most studies investigating the direct healthcare costs of HNC have utilized US databases of claims to public and private payers. Data from these studies suggested that costs generally are higher for HNC patients with recurrent and/or metastatic disease, for patients undergoing surgery, and for those patients insured by private payers. Further work is needed, particularly in Europe and other regions outside the USA; prospective studies assessing the cost associated with HNC would allow for more systematic comparison of costs, and would provide valuable economic information to payers, providers, and patients.

Radiotherapy response in head and neck cancer - evaluation of the primary tumour site

CONCLUSION

PET-CT scans seem to be sufficient to rule out residual tumour at the primary site. Patients with positive or equivocal PET findings should be scheduled for endoscopy with biopsy or a second PET-CT scan.

OBJECTIVES

Assessment of remission at the primary site, in patients treated with organ preservation therapy with curative intent, is important to identify residual tumours requiring treatment with salvage surgery. The aim of this study was to evaluate the diagnostic accuracy of fluorodeoxyglucose positron emission tomography (FDG-PET) after radiotherapy with or without chemotherapy in assessing primary site response in patients with head and neck cancer.

METHODS

A total of 82 patients, with a positive baseline PET-CT scan before start of treatment, were evaluated with a PET-CT scan 6-7 weeks post-radiotherapy and with a clinical examination/endoscopy with or without biopsy 1-2 weeks later. The majority of patients had p16-positive oropharyngeal tumours.

RESULTS

Post-treatment, 77% of the patients had no visible hypermetabolism. If equivocal PET scans are regarded as positive, the sensitivity, specificity, negative (NPV) and positive predictive value (PPV) and accuracy were 100%, 78%, 100%, 6% and 78%, respectively. Eight patients suffered from relapses involving the primary site during the 9-month follow-up.

Reliability of post-chemoradiotherapy F-18-FDG PET/CT for prediction of locoregional failure in human papillomavirus-associated oropharyngeal cancer

OBJECTIVES

Although widely adopted, the accuracy of post-chemoradiotherapy (CRT) 18F-fluorodeoxygluocose positron emission tomography/computed tomography (PET/CT) for predicting locoregional failure (LRF) in human papillomavirus-related (HPV+) oropharyngeal cancer (OPC) remains poorly characterized. We assessed the predictive value of 3-month PET/CT response for LRF in this population.

MATERIALS AND METHODS

101 consecutive patients with stage III-IV HPV+ OPC who underwent definitive CRT with pre-treatment and 3-month post-CRT PET/CT at our institution from 3/2005-3/2011 were included. 3-month PET/CT response was re-classified as complete-response (CR), near-CR, or incomplete-response (

RESULTS

Among 98 patients with an evaluable primary tumor, LF occurred in 2/67 patients with CR, 0/20 with near-CR, and 1/11 with

CONCLUSIONS

In the largest study to-date of PET/CT response assessment in HPV+ OPC, 3-month PET/CT response demonstrated high NPV for LRF, though with disappointing sensitivity and PPV. Subsequent PET/CT surveillance showed potential utility for early detection of LRFs.

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Key Words

• Chemoradiotherapy
• Human papillomavirus
• Metabolic response
• PET surveillance
• PET/CT

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MESH Headings

• Adult
• Aged
• Female
• Fluorodeoxyglucose F18
• Humans
• Male
• Middle Aged
• Neoplasm Recurrence, Local/diagnostic imaging
• Oropharyngeal Neoplasms/diagnostic imaging
• Oropharyngeal Neoplasms/therapy
• Papillomaviridae
• Positron-Emission Tomography/methods
• Prognosis
• Prospective Studies
• Radiopharmaceuticals
• Sensitivity and Specificity
• Tomography, X-Ray Computed/methods

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Grants

• P30 CA046592 NCI NIH HHS
• P50 CA097248 NCI NIH HHS
• R01 DE019126 NIDCR NIH HHS

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Affiliation(s)

Jeffrey M Vainshtein Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States.
Matthew E Spector Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, United States
Matthew H Stenmark Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
Carol R Bradford Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, United States
Gregory T Wolf Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, United States
Francis P Worden Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
Douglas B Chepeha Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, United States
Jonathan B McHugh Department of Pathology, University of Michigan, Ann Arbor, MI, United States
Thomas Carey Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, United States
Ka Kit Wong Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, United States
Avraham Eisbruch Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States

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