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Edwards DM, Gharzai LA, Wang W, Mayo C, Suresh K, Schipper M, Evans JR, Malloy K, Chinn SB, Prince M, Spector M, Shuman A, Stucken C, Swiecicki PL, Worden F, Jarema J, Henderson C, Kovach A, Brenner C, Shah JL, Mierzwa ML, Casper K. Follow-up for human papillomavirus-related oropharynx cancer concentrated on unequal symptom change (FOCUS): Prospective patient-reported outcome collection. Head Neck 2024. [PMID: 38680087 DOI: 10.1002/hed.27778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/12/2024] [Accepted: 04/09/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Post-treatment surveillance recommendations for oropharyngeal cancer do not vary with p16 status despite the differences in outcomes. The optimal algorithm personalizing follow-up for these patients remains undefined. Here, we evaluate the feasibility and utility of incorporating electronic patient-reported outcomes (ePROs) and circulating tumor DNA (ctDNA) into routine surveillance for patients treated for p16+ oropharynx cancer. METHODS A prospective registry was developed in which ePROs and ctDNA were incorporated into routine surveillance among patients with oropharynx cancer. ePROs were emailed monthly for 1 year and blood HPV ctDNA testing was performed every 3-6 months. The primary objective was to assess patient compliance with ePRO-based surveillance with adequate compliance defined as ≥85% of patients completing monthly ePROs. Sensitivity, specificity, and positive/negative predictive values to detect recurrence were calculated for ePROs, HPV ctDNA, or the combination. RESULTS Of 122 patients who initially expressed interest, 76 completed the electronic consent process and 44/76 (58%) were compliant with monthly surveys over 1 year; thus adequate compliance was not achieved. Technical difficulties associated with ePRO receipt through email largely limited participation. Provider feedback was significantly associated with heightened ePRO compliance. One hundred and six patients had ctDNA testing with a mean number of three tests per patient. Sensitivity to detect recurrence was 75% for the combination of ePROs and ctDNA. CONCLUSION Despite lower than anticipated compliance with ePROs, our findings show promise for incorporation of HPV ctDNA into surveillance paradigms for HPV-related oropharynx cancer with suggestions of methods to optimize ePRO formats for personalized surveillance.
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Affiliation(s)
- Donna M Edwards
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Radiation Oncology, Northwestern University, Chicago, Illinois, USA
| | - Weilin Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Krithika Suresh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph R Evans
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelly Malloy
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven B Chinn
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark Prince
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew Spector
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Shuman
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chaz Stucken
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul L Swiecicki
- Department of Medicine, Hematology-Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francis Worden
- Department of Medicine, Hematology-Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Jarema
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caitlin Henderson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Amanda Kovach
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad Brenner
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer L Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith Casper
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
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2
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Lin ME, Castellanos CX, Acevedo JR, Yu JC, Kokot NC. Cost-Effectiveness Analysis of PET-CT Surveillance After Treatment of Human Papillomavirus-Positive Oropharyngeal Cancer. Otolaryngol Head Neck Surg 2024; 170:122-131. [PMID: 37622527 DOI: 10.1002/ohn.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness of surveillance imaging with PET/CT scan among patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma. STUDY DESIGN Cost-effectiveness analysis. SETTING Oncologic care centers in the United States with head and neck oncologic surgeons and physicians. METHODS We compared the cost-effectiveness of 2 posttreatment surveillance strategies: clinical surveillance with the addition of PET/CT scan versus clinical surveillance alone in human papillomavirus-positive oropharyngeal squamous cell carcinoma patients. We constructed a Markov decision model which was analyzed from a third-party payer's perspective using 1-year Markov cycles and a 30-year time horizon. Values for transition probabilities, costs, health care utilities, and their studied ranges were derived from the literature. RESULTS The incremental cost-effectiveness ratio for PET/CT with clinical surveillance versus clinical surveillance alone was $89,850 per quality-adjusted life year gained. Flexible fiberoptic scope exams during clinical surveillance would have to be over 51% sensitive or PET/CT scan cost would have to exceed $1678 for clinical surveillance alone to be more cost-effective. The willingness-to-pay threshold at which imaging surveillance was equally cost-effective to clinical surveillance was approximately $80,000/QALY. CONCLUSION Despite lower recurrence rates of human papillomavirus-positive oropharyngeal cancer, a single PET/CT scan within 6 months after primary treatment remains a cost-effective tool for routine surveillance when its cost does not exceed $1678. The cost-effectiveness of this strategy is also dependent on the clinical surveillance sensitivity (flexible fiberoptic pharyngoscopy), and willingness-to-pay thresholds which vary by country.
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Affiliation(s)
- Matthew E Lin
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Carlos X Castellanos
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Joseph R Acevedo
- Department of Otolaryngology-Head & Neck Surgery, Kaiser Permanente Medical Center, Panorama City, California, USA
| | - Jeffrey C Yu
- School of Pharmacy, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
| | - Niels C Kokot
- Caruso Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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3
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Lang Kuhs KA, Brenner JC, Holsinger FC, Rettig EM. Circulating Tumor HPV DNA for Surveillance of HPV-Positive Oropharyngeal Squamous Cell Carcinoma: A Narrative Review. JAMA Oncol 2023; 9:1716-1724. [PMID: 37824111 DOI: 10.1001/jamaoncol.2023.4042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Importance Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma has an overall favorable prognosis, yet a subset of patients will experience devastating disease recurrence. Current surveillance standards for detection of recurrent disease are imperfect. There is growing interest in improving detection of recurrent disease through the use of plasma-based assays able to detect circulating tumor HPV DNA. Observations Although most circulating tumor HPV DNA assays remain in the research domain, the circulating tumor tissue-modified viral HPV DNA assay became commercially available in the United States in early 2020 and has been increasingly used in the clinical setting. With the rapidly increasing incidence of HPV-positive oropharyngeal squamous cell carcinoma and concomitant expansion of biomarker capabilities for this disease, it is critical to reexamine current posttreatment surveillance practices and to determine whether emerging technologies may be used to improve outcomes for a growing survivor population. However, caution is advised; it is not yet known whether biomarker-based surveillance is truly beneficial, and as is true with any intervention, it has the capacity to cause harm. Conclusions and Relevance Using Margaret Pepe's classic 5 phases of biomarker development for early detection of cancer as a framework, this article reviews the current state of knowledge, highlights existing knowledge gaps, and suggests research that should be prioritized to understand the association between biomarker-based surveillance and patient outcomes. Specific attention is paid to the commercially available tumor tissue-modified viral HPV DNA assay, given its increasing clinical use. This review may serve as a road map for future research and a guide for clinicians considering its adoption in practice. Enrollment of patients into clinical trials incorporating biomarker-based surveillance should be prioritized.
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Affiliation(s)
- Krystle A Lang Kuhs
- Department of Epidemiology and Environmental Health, College of Public Health, University of Kentucky, Lexington
- Markey Cancer Center, University of Kentucky, Lexington
| | - J Chad Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
- Rogel Cancer Center, University of Michigan, Ann Arbor
- Department of Pharmacology, University of Michigan, Ann Arbor
| | - F Chris Holsinger
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, California
| | - Eleni M Rettig
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- The Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Head and Neck Oncology Center, Dana-Farber Cancer Institute, Boston, Massachusetts
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Alexander GS, Pollock AE, Arons D, Ferris MJ, Molitoris JK, Regine WF, Witek ME. Post-treatment PET/CT for p16-positive oropharynx cancer treated with definitive proton therapy. J Clin Imaging Sci 2023; 13:31. [PMID: 37810180 PMCID: PMC10559439 DOI: 10.25259/jcis_74_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives Given emerging data suggesting that uncertainty in the relative biologic effectiveness at the distal end of the Bragg peak results in increased mucosal injury in patients with oropharynx cancer receiving adjuvant proton therapy, we evaluated the results of post-treatment positron emission tomography-computed tomography (PET/CT) in patients with p16-positive oropharynx cancer (p16+OPC) treated with definitive intensity-modulated proton therapy (IMPT). Material and Methods A retrospective cohort study of patients with p16+OPC treated with definitive IMPT between 2016 and 2022 was performed at a single institution. Patients with PET/CT scans within 6 months following completion of IMPT were included in the study. Positive post-treatment scans were defined by a maximum standard uptake values (SUVmax) >4.0 or a <65% reduction in SUVmax in either the primary tumor or lymph node. The Fisher's exact test was used to evaluate factors associated with positive post-treatment PET/ CT values. Results Sixty-two patients were included for analysis. Median follow-up was 21 months (range: 3-71 months) with a median time to post-treatment PET/CT of 3 months (range: 2-6 months). Median post-treatment SUVmax of the primary disease and nodal disease was 0 (mean: 0.8, range: 0-7.7) and 0 (mean: 0.7, range: 0-9.5), respectively. Median post-treatment percent reduction in SUVmax for the primary site and lymph node was 100% (mean: 94%, range: 31.3-100%) and 100% (mean: 89%, range: 23-100%), respectively. Eleven patients had a positive post-treatment PET/CT with one biopsy-proven recurrence. Negative and positive predictive values (NPV and PPV) were 98% and 9.1%, respectively. There were no factors associated with positive post-treatment PET/CT. Conclusion Similar to patients treated with photon-based radiation therapy, post-treatment PET/CT has a high NPV for patients with p16+OPC treated with definitive proton therapy and should be used to guide patient management. Additional patients and more events are needed to confirm the PPV of a post-treatment PET/CT in this favorable patient cohort.
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Affiliation(s)
- Gregory S. Alexander
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Ariel Eve Pollock
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Danielle Arons
- School of Medicine, University of Maryland, Baltimore, United States
| | - Matthew J. Ferris
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Jason K. Molitoris
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Matthew E. Witek
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, United States
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5
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Tran NA, Gorolay VV, Wu X. Differentiating Post-treatment Changes from Tumor Recurrence in the Oral Cavity and Oropharynx. Semin Roentgenol 2023; 58:272-289. [PMID: 37507169 DOI: 10.1053/j.ro.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/17/2023] [Accepted: 04/02/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Ngoc-Anh Tran
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Vineet V Gorolay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Xin Wu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA.
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6
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Iyizoba-Ebozue Z, Billingsley S, Frood R, Vaidyanathan S, Scarsbrook A, Prestwich RJD. Accuracy of Response Assessment FDG PET-CT Post (Chemo)Radiotherapy in HPV Negative Oropharynx Squamous Cell Carcinoma. Cancers (Basel) 2022; 14:4680. [PMID: 36230604 PMCID: PMC9563399 DOI: 10.3390/cancers14194680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Data on the accuracy of response assessment 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) following (chemo)radiotherapy in patients with oropharynx squamous cell carcinoma (OPSCC) is predominantly based on HPV-positive disease. There is a paucity of data for HPV-negative disease, which has a less favourable prognosis. Methods: 96 patients treated with (chemo)radiotherapy for HPV-negative OPSCC with baseline and response assessment FDG PET-CT between 2013−2020, were analysed. PET-CT response was classified as negative, equivocal, or positive based on qualitative reporting. PET-CT response categories were analysed with reference to clinicopathological outcomes. Test characteristics were evaluated, comparing negative results to equivocal and positive results together. Post-test probabilities were calculated separately for positive and equivocal or negative results. Results: Median follow-up was 26 months. The negative predictive value of a negative scan was 93.7 and 93.2%, respectively, for primary tumour and nodal disease. For a negative scan, the post-test probability was 0.06 for primary and 0.07 for nodal disease. The post-test probability of an equivocal scan was 0.51 and 0.72 for primary and lymph node, respectively. The post-test probability of a positive scan approached 1. For patients with/without a negative scan, two-year overall survival and progression-free survival were 83% versus 30% and 79% versus 17% (p < 0.001), respectively. Conclusion: The NPV of a negative response assessment PET-CT in HPV-negative OPSCC is high, supporting a strategy of clinical monitoring. Contrasting with the published literature for HPV-positive OPSCC, an equivocal response scan was associated with a moderate rate of residual disease.
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Affiliation(s)
| | | | - Russell Frood
- Department of Radiology, Leeds Cancer Centre, Leeds LS9 7TF, UK
| | | | - Andrew Scarsbrook
- Department of Radiology, Leeds Cancer Centre, Leeds LS9 7TF, UK
- Leeds Institute of Health Research, University of Leeds, Leeds LS2 9NL, UK
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7
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Oldan JD, Beaty BM, Jewells VL, Muhleman MA, Benefield T, Chera B. Qualitative and quantitative methods in post-chemoradiation PET for head and neck cancer. Nucl Med Commun 2022; 43:710-716. [PMID: 35414636 DOI: 10.1097/mnm.0000000000001558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether quantitative methods could aid in the evaluation of post-treatment head and neck scans, particularly taking human papillomavirus status into account. METHODS Clinical readings of positron emission tomography/computed tomography scans as well as standardized uptake value (SUV)max (and other metrics) of nodes visible on PET conducted on a total of 172 patients with head and neck squamous cell cancer were examined. Locoregional recurrence at 2 years was assessed. In total 88 of these patients had close enough follow-up to determine whether individual nodes were positive or negative, and 233 nodes on these patients were compared to surgical pathology notes or follow-up (if no path was available). RESULTS General negative predictive value (NPV) of complete response was 93% and an equivocal response was 89%; focusing on nodal recurrence, NPV was found to be 97% and positive predictive value (PPV) 46% if equivocal reads were treated as negative and NPV 98% and PPV 16% if equivocal reads were treated as positive. Using SUVmax of the hottest node with a cutoff of 3.4 gave NPV 97% and PPV 26%; a direct re-read (using 2 observers) gave NPV 98% and PPV 32% if equivocal reads were treated as negative, and NPV 99% and PPV 18% if equivocal reads were treated as positive. Using other first-order radiomics data such as SD and skewness did not improve this. CONCLUSIONS Quantitative data such as SUVmax does not show additional value over qualitative evaluation of response to chemoradiation in head and neck tumors.
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Affiliation(s)
| | - Brian M Beaty
- Department of Radiation Oncology, University of North Carolina-Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | | | | | | | - Bhishamjit Chera
- Department of Radiation Oncology, University of North Carolina-Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
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8
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Salzillo TC, Taku N, Wahid KA, McDonald BA, Wang J, van Dijk LV, Rigert JM, Mohamed ASR, Wang J, Lai SY, Fuller CD. Advances in Imaging for HPV-Related Oropharyngeal Cancer: Applications to Radiation Oncology. Semin Radiat Oncol 2021; 31:371-388. [PMID: 34455992 DOI: 10.1016/j.semradonc.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
While there has been an overall decline of tobacco and alcohol-related head and neck cancer in recent decades, there has been an increased incidence of HPV-associated oropharyngeal cancer (OPC). Recent research studies and clinical trials have revealed that the cancer biology and clinical progression of HPV-positive OPC is unique relative to its HPV-negative counterparts. HPV-positive OPC is associated with higher rates of disease control following definitive treatment when compared to HPV-negative OPC. Thus, these conditions should be considered unique diseases with regards to treatment strategies and survival. In order to sufficiently characterize HPV-positive OPC and guide treatment strategies, there has been a considerable effort to diagnose, prognose, and track the treatment response of HPV-associated OPC through advanced imaging research. Furthermore, HPV-positive OPC patients are prime candidates for radiation de-escalation protocols, which will ideally reduce toxicities associated with radiation therapy and has prompted additional imaging research to detect radiation-induced changes in organs at risk. This manuscript reviews the various imaging modalities and current strategies for tackling these challenges as well as provides commentary on the potential successes and suggested improvements for the optimal treatment of these tumors.
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Affiliation(s)
- Travis C Salzillo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Nicolette Taku
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Kareem A Wahid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Brigid A McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jarey Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Lisanne V van Dijk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jillian M Rigert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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9
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Mathews F, Irizarry R, Rosenfeld R, Sundaram K. Systematic Review and Meta-Analysis of Post-Treatment PET/CT in HPV-Associated Oropharyngeal Cancer. Ann Otol Rhinol Laryngol 2021; 131:595-603. [PMID: 34353135 DOI: 10.1177/00034894211036842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To perform a systematic review with meta-analysis to investigate the utility of post-treatment PET/CT specifically in HPV-associated oropharyngeal squamous cell carcinoma following curative intent treatment. METHODS Random-effects meta-analysis was used to pool data from 7 observational studies (2013-2019) obtained from a database search of PubMed, Web of Science, and EMBASE using an a priori protocol with dual independent evaluation for inclusion, risk of bias assessment for acceptable methodology, and extraction of data for analysis. PET/CT results, treatment failure, imaging and interventions subsequent to PET/CT findings, and efficacy of salvage therapy were extracted. RESULTS Of the 907 post-treatment scans, PET/CT results were largely negative (76.2%; 95% CI, 63.4-85.6) and least often positive (11.3%; 95% CI, 8.8-14.4). PET/CT results were equivocal for 22.5% (95% CI, 12.5-36.9) and equivocal/positive for 34.2% of patients (95% CI, 25.1-44.5). Patients with an initial positive scan had the highest treatment failure rates (43.1%; 95% CI, 21.4-67.7) and those with an initial negative scan had the lowest rates (7.4%; 95% CI, 5.7-9.7). The equivocal and equivocal/positive scans had intermediate prevalence of 16.5% (95% CI, 9.4-27.6) and 16.7% (95% CI, 9.1-28.7), respectively. CONCLUSION The low treatment failure rate following a negative PET/CT scan is reassuring, but the data are consistent with treatment failure rates up to 9.7% suggesting follow-up of these patients is prudent. Additionally, the low positive predictive value for treatment failure observed alludes to use of post-treatment PET/CT in HPV-associated disease frequently leading to unnecessary subsequent imaging and intervention.
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Affiliation(s)
- Fasil Mathews
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Rachel Irizarry
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Richard Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Krishnamurthi Sundaram
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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10
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Gharzai LA, Burger N, Li P, Jaworski EM, Henderson C, Spector M, Rosko A, Chen MM, Prince ME, Bradford CR, Malloy KM, Stucken CL, Swiecicki P, Worden F, Schipper MJ, Schonewolf CA, Shah J, Jagsi R, Chinn S, Shuman A, Casper K, Mierzwa ML. Patient Burden with Current Surveillance Paradigm and Factors Associated with Interest in Altered Surveillance for Early Stage HPV-Related Oropharyngeal Cancer. Oncologist 2021; 26:676-684. [PMID: 33823077 DOI: 10.1002/onco.13784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/26/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Optimal surveillance paradigms for survivors of early stage human papillomavirus (HPV)-related oropharyngeal cancer are not well defined. This study aimed to characterize patient interest in and factors associated with an altered surveillance paradigm. MATERIALS AND METHODS We surveyed patients with Stage I or II HPV-related oropharyngeal cancer treated at a tertiary care institution from 2016 to 2019. Primary outcomes were descriptive assessment of patient knowledge, interest in altered surveillance, burdens of in-person appointments, and priorities for surveillance visits. Ordinal regression was used to identify correlates of interest in altered surveillance. RESULTS Sixty-seven patients completed surveys from February to April 2020 at a median of 21 months since completing definitive treatment. A majority (61%) of patients were interested in a surveillance approach that decreased in-person clinic visits. Patients who self-identified as medical maximizers, had higher worry of cancer recurrence, or were in long-term relationships were less likely to be interested. Patients reported significant burdens associated with surveillance visits, including driving distance, time off work, and nonmedical costs. Patients were most concerned with discussing cancer recurrence (76%), physical quality of life (70%), mortality (61%), and mental quality of life (52%) with their providers at follow-up visits. CONCLUSION Patients with early stage HPV-related oropharyngeal cancers are interested in altered surveillance approaches, experience significant burdens related to surveillance visits, and have concerns that are not well addressed with current surveillance approaches, including physical and mental quality of life. Optimized surveillance approaches should incorporate patient priorities and minimize associated burdens. IMPLICATIONS FOR PRACTICE The number of patients with HPV-related oropharyngeal cancers is increasing, and numerous clinical trials are investigating novel approaches to treating these good-prognosis patients. There has been limited work assessing optimal surveillance paradigms in these patients. Patients experience significant appointment-related burdens and have concerns such as physical and mental quality of life. Additionally, patients with early stage HPV-related oropharyngeal cancers express interest in altered surveillance approaches that decrease in-person clinic visits. Optimization of surveillance paradigms to promote broader survivorship care in clinical practice is needed.
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Affiliation(s)
- Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas Burger
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pin Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth M Jaworski
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caitlin Henderson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew Spector
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andy Rosko
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle M Chen
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark E Prince
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Carol R Bradford
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelly M Malloy
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chaz L Stucken
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Swiecicki
- Department of Medical Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francis Worden
- Department of Medical Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew J Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Caitlin A Schonewolf
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Steve Chinn
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Shuman
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith Casper
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
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11
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Radiation Therapy Alone for Human Papillomavirus-Related Squamous Cell Carcinoma of the Oropharynx: A Single-Arm, Phase 2 Study. Int J Radiat Oncol Biol Phys 2020; 110:403-411. [PMID: 33373656 DOI: 10.1016/j.ijrobp.2020.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/01/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Human papillomavirus (HPV)-related squamous cell carcinoma of the oropharynx (OPSCC) is extremely radiosensitive. Radiation therapy plus high-dose cisplatin remains the standard of care but causes long-term toxicity. Treatment deintensification approaches that reduce toxicity while maintaining survival are desirable for HPV-related OPSCC. METHODS AND MATERIALS We conducted a single-arm, multicenter, phase 2 trial. Patients with newly diagnosed, biopsy-proven, American Joint Committee on Cancer (seventh edition) stage III or IV OPSCC positive for both p16 and HPV DNA were eligible. Patients with T4, N3, or T1N1 disease were excluded. Smoking history was not included in eligibility criteria. Patients received intensity modulated radiation therapy (IMRT) of 70 Gy in 35 fractions or 70.4 Gy in 32 fractions without chemotherapy. The primary endpoint was complete response or complete metabolic response 10 weeks after IMRT completion. RESULTS Between September 13, 2013, and November 15, 2016, 39 patients were enrolled according to a 2-stage Simon design. Twenty-three patients (59%) had smoked for more than10 pack-years. Thirty-six patients (92%) had tumors genotyped as HPV16. Thirty-seven patients (95%) received full-dose radiation therapy and 35 (90%) had complete response or complete metabolic response. Median follow-up was 51 months (interquartile range, 41-63 months). One patient (3%) had regional recurrence and 3 (8%) had distant metastasis. One patient died of disease. The 2-year progression-free survival rate was 94% (95% CI, 81%-99%), and the 2-year overall survival rate was 100%. Common grade 3 adverse events during IMRT included mucositis in 10 patients (26%) and dysphagia in 7 patients (18%). No patients were dependent on a feeding tube at 1 month after IMRT completion. No grade 3 or 4 late adverse events were observed. CONCLUSIONS IMRT alone is associated with excellent response as well as reduced toxicity and could be a treatment option for carefully selected patients with locally advanced "true" HPV-related OPSCC. Further studies are warranted.
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12
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McDowell L, Ng SP, Corry J. COVID-19—An Opportunity for Optimizing Surveillance Protocols During and Beyond the Pandemic: HPV-Associated Oropharyngeal Cancer as an Example of Response-Based Local Surveillance. Int J Radiat Oncol Biol Phys 2020; 108:400-403. [PMID: 32890520 PMCID: PMC7462789 DOI: 10.1016/j.ijrobp.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Lachlan McDowell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Victoria, Australia.
| | - Sweet Ping Ng
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - June Corry
- GenesisCare Radiation Oncology, Division Radiation Oncology, St. Vincent's Hospital, Melbourne, Victoria, Australia; Department of Medicine, St Vincent's Hospital, University of Melbourne, Victoria, Australia
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13
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Ng SP, Ajayi T, Schaefer A, Pollard C, Bahig H, Garden AS, Rosenthal DI, Gunn GB, Frank SJ, Phan J, Morrison WH, Johnson JM, Mohamed A, Sturgis EM, Fuller CD. Surveillance imaging for patients with head and neck cancer treated with definitive radiotherapy: A partially observed Markov decision process model. Cancer 2020; 126:749-756. [PMID: 31725906 PMCID: PMC8439665 DOI: 10.1002/cncr.32597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/04/2019] [Accepted: 09/24/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND A possible surveillance model for patients with head and neck cancer (HNC) who received definitive radiotherapy was created using a partially observed Markov decision process. The goal of this model is to guide surveillance imaging policies after definitive radiotherapy. METHODS The partially observed Markov decision process model was formulated to determine the optimal times to scan patients. Transition probabilities were computed using a data set of 1508 patients with HNC who received definitive radiotherapy between the years 2000 and 2010. Kernel density estimation was used to smooth the sample distributions. The reward function was derived using cost estimates from the literature. Additional model parameters were estimated using either data from the literature or clinical expertise. RESULTS When considering all forms of relapse, the model showed that the optimal time between scans was longer than the time intervals used in the institutional guidelines. The optimal policy dictates that there should be less time between surveillance scans immediately after treatment compared with years after treatment. Comparable results also held when only locoregional relapses were considered as relapse events in the model. Simulation results for the inclusive relapse cases showed that <15% of patients experienced a relapse over a simulated 36-month surveillance program. CONCLUSIONS This model suggests that less frequent surveillance scan policies can maintain adequate information on relapse status for patients with HNC treated with radiotherapy. This model could potentially translate into a more cost-effective surveillance program for this group of patients.
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Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Temitayo Ajayi
- Department of Computational and Applied Mathematics, Rice University, Houston, Texas, USA
| | - Andrew Schaefer
- Department of Computational and Applied Mathematics, Rice University, Houston, Texas, USA
| | - Courtney Pollard
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Houda Bahig
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
- Department of Radiation Oncology, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - Adam S Garden
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - David I Rosenthal
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - G Brandon Gunn
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Steven J Frank
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Jack Phan
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - William H. Morrison
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Jason M Johnson
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Abdallah Mohamed
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
| | - Clifton D Fuller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
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14
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Koyfman SA, Ismaila N, Holsinger FC. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline Summary. J Oncol Pract 2019. [DOI: 10.1200/jop.18.00727] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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15
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Arunsingh M, Vaidyanathan S, Dyker K, Sen M, Scarsbrook A, Prestwich R. Accuracy of Response Assessment Positron Emission Tomography-Computed Tomography Following Definitive Radiotherapy Without Chemotherapy for Head and Neck Squamous Cell Carcinoma. Clin Oncol (R Coll Radiol) 2019; 31:212-218. [DOI: 10.1016/j.clon.2018.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/07/2018] [Accepted: 11/11/2018] [Indexed: 12/26/2022]
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16
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Koyfman SA, Ismaila N, Crook D, D'Cruz A, Rodriguez CP, Sher DJ, Silbermins D, Sturgis EM, Tsue TT, Weiss J, Yom SS, Holsinger FC. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:1753-1774. [PMID: 30811281 DOI: 10.1200/jco.18.01921] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx. METHODS ASCO convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2018. Outcomes of interest included survival, regional disease control, neck recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical scenarios were devised; three for oral cavity cancer and three for oropharynx cancer, and recommendations were generated for each one. RECOMMENDATIONS For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended. Consensus was reached and recommendations were made for all six clinical scenarios. Additional information is available at www.asco.org/head-neck-cancer-guidelines .
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Affiliation(s)
| | | | - Doug Crook
- 3 Patient representative, Indianapolis, IN
| | | | | | | | | | | | | | - Jared Weiss
- 10 University of North Carolina, Chapel Hill, NC
| | - Sue S Yom
- 11 University of California, San Francisco, San Francisco, CA
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17
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de Ridder M, Gouw ZAR, Navran A, Hamming-Vrieze O, Jasperse B, van den Brekel MWM, Vogel WV, Al-Mamgani A. FDG-PET/CT improves detection of residual disease and reduces the need for examination under anaesthesia in oropharyngeal cancer patients treated with (chemo-)radiation. Eur Arch Otorhinolaryngol 2019; 276:1447-1455. [PMID: 30758660 DOI: 10.1007/s00405-019-05340-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/08/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Early detection of residual disease (RD) after (chemo)radiation for oropharyngeal (OPC) is crucial. Surveillance of neck nodes with FDG-PET/CT has been studied extensively, whereas its value for local RD remains less clear. We aim to evaluate the diagnostic value of post-treatment FDG-PET/CT in detecting local RD and the outcome of patients with local RD. METHODS A cohort (n = 352) of consecutively treated OPC patients at our institute between 2010 and 2017 was evaluated. Patients that underwent FDG-PET/CT at 3 months post-treatment (n = 94) were classified as having complete (CMR) or partial metabolic response (PMR). PMR was defined as visually detectable metabolic activity above the background of surrounding normal tissues. Primary endpoint was diagnostic accuracy in detecting local RD. RESULTS Local RD was seen in 19/352 patients (5%), all of them were HPV negative. The FDG-PET/CT had a sensitivity of 100% (8/8), specificity 85% (73/86), PPV 38% (8/21), NPV 100% (73/73), and accuracy 86%. Patients with local RD had significantly worse OS at 2 years, compared to those without (10 versus 88%, P < 0.001). In multivariable analysis, local RD remained a significant predictive factor for death with a hazard ratio of 11.9 (95% CI 5.8-24.3). The number of patients that underwent PET/CT increased over time (P < 0.001), whereas the number of patients that underwent EUA declined (P = 0.072). CONCLUSION FDG-PET/CT has excellent performance for the detection of RD, with the sensitivity and negative predictive value approaching 100%. Due to these excellent results is examination under anaesthesia today in the vast majority of the PET-negative cases not necessary anymore.
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Affiliation(s)
- Mischa de Ridder
- Department of Radiation Oncology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department of Radiation Oncology, Verbeeten Instituut, Tilburg, The Netherlands
| | - Zeno A R Gouw
- Department of Radiation Oncology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Arash Navran
- Department of Radiation Oncology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Bas Jasperse
- Department of Radiology, Antoni van Leeuwenhoek/Netherlands Cancer Institute Amsterdam, Amsterdam, The Netherlands
| | - Michiel W M van den Brekel
- Department of Head and Neck Surgery, Antoni van Leeuwenhoek/Netherlands Cancer Institute Amsterdam, Amsterdam, The Netherlands.,Amsterdam UMC, Department of Maxillo-facial Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Department of Radiation Oncology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department of Nuclear Medicine, Antoni van Leeuwenhoek/Netherlands Cancer Institute Amsterdam, Amsterdam, The Netherlands
| | - A Al-Mamgani
- Department of Radiation Oncology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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18
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Kotowski U, Brkic FF, Koperek O, Nemec SF, Perisanidis C, Altorjai G, Grasl MC, Erovic BM. Accuracy of fine‐needle aspiration cytology in suspicious neck nodes after radiotherapy: Retrospective analysis of 100 patients. Clin Otolaryngol 2019; 44:384-388. [DOI: 10.1111/coa.13271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 10/29/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Ulana Kotowski
- Department of Otolaryngology, Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Faris F. Brkic
- Department of Otolaryngology, Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Oskar Koperek
- Department of Clinical Pathology Medical University of Vienna Vienna Austria
| | - Stefan F. Nemec
- Department of Biomedical Imaging and Image‐guided therapy Medical University of Vienna Vienna Austria
| | - Christos Perisanidis
- Department of Maxillofacial Surgery and Medical University of Vienna Vienna Austria
| | - Gabriela Altorjai
- Department of Radiation Oncology Medical University of Vienna Vienna Austria
| | - Matthaeus Ch. Grasl
- Department of Otolaryngology, Head and Neck Surgery Medical University of Vienna Vienna Austria
| | - Boban M. Erovic
- Institute of Head and Neck Diseases Evangelical Hospital Vienna Vienna Austria
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19
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Bahig H, Yuan Y, Mohamed AS, Brock KK, Ng SP, Wang J, Ding Y, Hutcheson K, McCulloch M, Balter PA, Lai SY, Al-Mamgani A, Sonke JJ, van der Heide UA, Nutting C, Li XA, Robbins J, Awan M, Karam I, Newbold K, Harrington K, Oelfke U, Bhide S, Philippens ME, Terhaard CH, McPartlin AJ, Blanchard P, Garden AS, Rosenthal DI, Gunn GB, Phan J, Cazoulat G, Aristophanous M, McSpadden KK, Garcia JA, van den Berg CA, Raaijmakers CP, Kerkmeijer L, Doornaert P, Blinde S, Frank SJ, Fuller CD. Magnetic Resonance-based Response Assessment and Dose Adaptation in Human Papilloma Virus Positive Tumors of the Oropharynx treated with Radiotherapy (MR-ADAPTOR): An R-IDEAL stage 2a-2b/Bayesian phase II trial. Clin Transl Radiat Oncol 2018; 13:19-23. [PMID: 30386824 PMCID: PMC6204434 DOI: 10.1016/j.ctro.2018.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/09/2018] [Accepted: 08/22/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Current standard radiotherapy for oropharynx cancer (OPC) is associated with high rates of severe toxicities, shown to adversely impact patients' quality of life. Given excellent outcomes of human papilloma virus (HPV)-associated OPC and long-term survival of these typically young patients, treatment de-intensification aimed at improving survivorship while maintaining excellent disease control is now a central concern. The recent implementation of magnetic resonance image - guided radiotherapy (MRgRT) systems allows for individual tumor response assessment during treatment and offers possibility of personalized dose-reduction. In this 2-stage Bayesian phase II study, we propose to examine weekly radiotherapy dose-adaptation based on magnetic resonance imaging (MRI) evaluated tumor response. Individual patient's plan will be designed to optimize dose reduction to organs at risk and minimize locoregional failure probability based on serial MRI during RT. Our primary aim is to assess the non-inferiority of MRgRT dose adaptation for patients with low risk HPV-associated OPC compared to historical control, as measured by Bayesian posterior probability of locoregional control (LRC). METHODS Patients with T1-2 N0-2b (as per AJCC 7th Edition) HPV-positive OPC, with lymph node <3 cm and <10 pack-year smoking history planned for curative radiotherapy alone to a dose of 70 Gy in 33 fractions will be eligible. All patients will undergo pre-treatment MRI and at least weekly intra-treatment MRI. Patients undergoing MRgRT will have weekly adaptation of high dose planning target volume based on gross tumor volume response. The stage 1 of this study will enroll 15 patients to MRgRT dose adaptation. If LRC at 6 months with MRgRT dose adaptation is found sufficiently safe as per the Bayesian model, stage 2 of the protocol will expand enrollment to an additional 60 patients, randomized to either MRgRT or standard IMRT. DISCUSSION Multiple methods for safe treatment de-escalation in patients with HPV-positive OPC are currently being studied. By leveraging the ability of advanced MRI techniques to visualize tumor and soft tissues through the course of treatment, this protocol proposes a workflow for safe personalized radiation dose-reduction in good responders with radiosensitive tumors, while ensuring tumoricidal dose to more radioresistant tumors. MRgRT dose adaptation could translate in reduced long term radiation toxicities and improved survivorship while maintaining excellent LRC outcomes in favorable OPC. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03224000; Registration date: 07/21/2017.
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Affiliation(s)
- Houda Bahig
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Ying Yuan
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Kristy K. Brock
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sweet Ping Ng
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jihong Wang
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yao Ding
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate Hutcheson
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Molly McCulloch
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter A. Balter
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen Y. Lai
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | - X. Allen Li
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Irene Karam
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | - Uwe Oelfke
- Institute of Cancer Research, London, UK
| | | | | | | | | | | | - Adam S. Garden
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Gary B. Gunn
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | - John A. Garcia
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | - Sanne Blinde
- Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Steven J. Frank
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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