Follow-up program in head and neck cancer
Introduction
Head and neck cancer (HNC) is a relatively common cancer worldwide, resulting in approximately estimated 490,000 new cases and 200,000 deaths annually (Torre et al., 2015). Although this disease may be considered as unique, it is notable that incidence varies in relation to primary site onset, as well as geographic and ethnic populations. Over the past decades, independently of primary tumor, conservative treatments with curative intent have increased significantly in the management of HNC, both in early and advanced stage disease (National Comprehensive Cancer Network, 2015). However, the overall risk of loco-regional recurrence and distant metastasis remains high, varying from less than 10% to more than 50%, based on primary site, stage and histological classification (De Felice et al., 2015a).
Therefore, a well-delineated post-treatment surveillance is paramount, but controversies remain regarding the selection of optimal follow-up strategies, especially for asymptomatic patients. The aim of a reasonable follow-up schedule after potentially curative management is mainly to evaluate therapeutic efficacy, manage late complications and offer a psychological support to the patient (Hambek, 2012). There is little evidence to suggest that early detection of recurrences adds significantly benefit to survival outcomes (Lester and Wight, 2009, Barker et al., 2001). The absence of an overall survival difference between early detection of loco-regional recurrence compared with self-referral new tumor manifestations only contrasts with the findings of a retrospective study in patients treated with curative intent for carcinoma of larynx, pharynx, and oral cavity that showed a survival benefit in early detection in asymptomatic patients (58 versus 32 months, p < 0.05) (de Visscher and Manni, 1994). Considering that the vast majority of failures appears within 24 months, a closely follow-up is almost more important during the first 2 years to guarantee the better chance of cure, especially in term of curative salvage treatment (Haas et al., 2016). There are several general features of an appropriate surveillance program – including systematic follow-up visits with a complete physical examination, and baseline post-treatment radiologic investigations – but timing protocols as well as modalities used vary considerably among countries, due to diagnostic exams cost ineffectiveness (Barker et al., 2001).
The primary objective of this practice guideline is to provide an optimal follow-up program in HNC patients after curative treatment. We focused on the value of clinical and imaging follow-up in asymptomatic patients. We delineated how often the clinical examination and what kind of diagnostic investigations should be performed by the clinicians per year.
Section snippets
Methods
Head and Neck Unit of Policlinico Umberto I, Sapienza University of Rome conducted several group meetings in order to delineate the most appropriate follow-up strategy for patients with HNC. The combination information collected from cross-sectional imaging with clinical examination allows for the most accurate surveillance. Computed tomography (CT) and diffusion-weighted magnetic resonance imaging (DW-MRI) are part of the routine follow-up.
The consensus process was based on the available
Results
Although HNC shares many characteristics, yet also has unique features that are attributable to primary site. We presented follow-up program respective to HNC primary location.
Overview
In order to offer a more practical tool, we formulated a final consensus for the following two clinical condition: clinically evaluable primary tumor and no clinically evaluable primary tumor. A schematic overview is shown in Table 1.
In all cases, annually chest imaging is recommended in case of very advanced disease and smoking habit; in those cases, such as after definitive CRT, in which MRI or CT imaging is dubious about nodal relapse, ultrasound (US) and/or PET-CT are performed (Nishimura
Discussion
The aim of these consensus guidelines is to illustrate and standardize the follow-up program of HNC, of which, despite its variegated management scenario, clinicians treating oncologic disease should be aware. We attempt to provide a reasonable follow-up program for clinical and subclinical conditions that is still not described in literature.
In post treatment setting of HNC patients, the involvement of qualified head and neck specialists are highly desirable for optimal interpretation of
Conclusion
This document is a detailed subsite follow-up guidelines in HNC. It could be useful to assist both clinicians and patients to delineate the best follow-up strategy.
Authors’ contributions
Conception and design: Francesca De Felice, Vincenzo Tombolini.
Collection and assembly of data: Francesca De Felice, Marco de Vincentiis, Valentino Valentini, Daniela Musio, Silvia Mezi, Luigi Lo Mele, Valentina Terenzi, Umberto Romeo, Vincenzo Tombolini.
Data analysis and interpretation: All authors.
Manuscript writing: All authors.
Final approval of manuscript: All authors.
Conflict of interest statement
The authors declare that they have no competing interests.
Acknowledgement
None.
Francesca De Felice was born in Rome in 1983. She graduated from the Faculty of Medicine of the University of Rome “Sapienza” in 2007. She obtained the license to practice medicine in Italy in 2008. She was specialized in Radiation Oncology at the University of Rome “Sapienza” in 2012. In 2013 she was a medical attendant at the Département de Radiothérapie, Institut de Cancérologie Gustave Roussy, Villejuif-Parigi and in 2014 she was a medical attendant at the Division of Clinical Oncology,
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Francesca De Felice was born in Rome in 1983. She graduated from the Faculty of Medicine of the University of Rome “Sapienza” in 2007. She obtained the license to practice medicine in Italy in 2008. She was specialized in Radiation Oncology at the University of Rome “Sapienza” in 2012. In 2013 she was a medical attendant at the Département de Radiothérapie, Institut de Cancérologie Gustave Roussy, Villejuif-Parigi and in 2014 she was a medical attendant at the Division of Clinical Oncology, Guy’s and st. Thomas’ Hospital, King’s College, London, UK. From 2012 onwards she is a PhD student at the Department of Radiological Sciences, Oncology, and Pathology, University of Rome “Sapienza”. She is author of several indexed papers, all in the field of clinical and experimental oncology.