see also: Head and Neck Cancer Survivorship - General Principles

connect to:  SPOHNC "Support for People with Oral and Head and Neck Cancer"

see also: Ultrasound Screenings for Carotid Artery Stenosis in Patients with Neck Irradiation (External Beam Radiation; Radiotherapy); Followup SCC Case Example; Management of Xerostomia (Dry Mouth)

Medical Care of the Irradiated Patient

Updated 2-4-2024 (Rahul Gulati MD - Iowa Head and Neck Fellow and Kara Pasker PA-C)

Head and Neck Cancer Follow-Up and Survivorship Clinic

• The goals of surveillance for head and neck cancer (HNC) patients include early detection of locoregional recurrence, distant metastasis, or second primary malignancies, and identification and management of treatment related complications. 
• Currently, no standard consensus exists on the frequency and extent of surveillance in HNC patients.
• Evidence demonstrating a clear survival benefit in HNC patients with ongoing surveillance is controversial, although some patients may benefit from early diagnosis of recurrent cancer.  
• Early stage patients may show greater benefits from surveillance compared to later stage patients following definitive treatment.

History and Physical Exam (including flexible transnasal laryngoscopy)

• “No consensus in the literature on the optimum frequency of follow-up visits after treatment with curative intent” (Manikantan K et al 2009).
• Frequency of follow up can be modified for each patient depending on multiple factors including – co-morbidities (breathing, swallowing, communication concerns), risk of recurrence, distances traveled, desires of informed patient.

Diagnostic Imaging

• Consider repeating pre-treatment baseline imaging of primary (and neck, if treated) within 3-6 months of treatment
• There are no universally accepted recommendations for surveillance imaging in asymptomatic patients more than 6 months after completing treatment.

University of Iowa advanced imaging broad considerations

            Advanced Stage (III or IV) or high risk for recurrence

• PET/CT 3-6 months after competing treatment
• Depending on stage and location of tumor possible post-treatment scanning w CT or MRI, if clinically indicated
• Routine annual imaging (repeat use of pretreatment imaging modality) may be indicated in areas difficult to visualize on exam. May consider imaging studies earlier than 3 months if suspect persistent or progressive malignancy.
• Consider Chest CT with or without contrast as clinically indicated for patients with smoking historyNCCN Guidelines for Lung Cancer Screening (Version 2.2247, Jan 2024)
• Consider low dose chest CT or non-contrast chest CT annually until patient is no longer candidate for definitive treatment

            High-risk:

• Age (≥50 y) and at least 20 pack-year history of smoking cigarettes. Shared patient / physician decision making is recommended, including a discussion of benefits and risks.
• Further imaging as indicated based on worrisome or equivocal signs/symptoms, smoking history, and areas inaccessible to clinical examination.

Ultrasound screenings for carotid artery stenosis in patients with neck radiation 

• The use of ultrasound for patients with asymptomatic carotid artery stenosis is not routinely used. The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. USPSTF concludes with moderate certainty that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits (USPSTF, 2021).

• Studies show that prior neck radiation contributes to accelerated atherosclerosis and significantly greater risk for carotid artery stenosis and cerebrovascular disease (Carpenter 2018). The NCCN Survivorship Guidelines note that carotid stenosis as a well-known late effect of radiation, but stop short of making specific screening recommendations (Randolph 2022).

• A literature review by Randolph 2022, recommend ultrasound screenings for carotid artery stenosis in patients with neck radiation prior to treatment and at 1 year post treatment to optimize medical management.

• A study by Carpenter et al 2023, suggest initially screening for CAS <2 years following radiation therapy completion, then every 3 years thereafter.

Labs

Recommend checking thyroid-stimulating hormone (TSH) every 6-12 months if neck irradiated

Annual screening for panhypopituitarism following radiation to the skull base.

Recommend thyroglobulin with thyroglobulin antibodies for well differentiated thyroid cancer every 6 to 12 months

Molecular Biomarkers

• HPV ctDNA
  • Circulating, cell free tumor tissue modified viral (TTMV)-HPV DNA is produced during the fragmentation of integrated and/or episomal HPV DNA of malignant epithelial cells during the degradation of HPV-driven tumors.
  • ctDNA in patients with HPV+ oropharyngeal squamous cell carcinoma has emerged as a diagnostic tool to detect the presence of recurrent cancer
  • A large retrospective study published in 2022 (Berger 2022) demonstrated 95% positive and negative predicted values for recurrent cancer when evaluating circulating TTMV-HPV DNA at least 3 months after definitive treatment.
  • Prospective studies are under way to help clarify how to incorporate HPV ctDNA testing during surveillance  
• EBV DNA
  • Incorporated into monitoring of patients after definitive treatment for nasopharyngeal cancer.
• The significance of non-viral ctDNA, ctDNA gene methylation, and exosomes are areas of on-going investigation.

Dental

• Recommend dental evaluation for oral cavity and sites exposed to significant intraoral radiation treatment every 6 to 12 months. Some patients may prefer dental evaluations and cleanings more frequently.
• See NCCN dental evaluation/management guidelines (Version 2.2024)

Supportive Care & Rehabilitation

• Consider speech/hearing evaluation and rehabilitation as clinically indicated
• Consider audiograms before and after initiation of ototoxic chemotherapy (i.e. Cisplatin)
• Refer to otologist and/or hearing aid center if clinically indicated
• Consider swallowing evaluation and rehabilitation as clinically indicated
• Prolonged NPO status is directly correlated with worse swallowing outcomes and increase risk for dysphagia (Shune, SE, et al 2012).
• May be beneficial to obtain baseline measures of swallowing function and to integrate swallowing therapy by referring patients to speech pathologist prior to initiation of cancer treatment.
• Dysphagia can be a long term problem for head and neck cancer patients. Monitor patients for swallowing related problems during each follow up visit and provide referrals
• Consider nutritional evaluation and rehabilitation as clinically indicated until nutritional status stabilized
  • Significant weight loss (5% in 1 month, 10% in 6 months)
  • Clinically significant odynophagia
• Refer patients requiring PEG tube feedings to nutritionist/dietician every 1-2 years to ensure beneficial nutritional status
• Refer patients to nutritionist/dietician with or without PEG tube to provide individualized dietary counseling and advice

Consider ongoing surveillance for depression

• Recommend distress screening (NCCN Guidelines Distress Management Version 1.2024).
• Screen patients for distress at every medical visit or at minimum, patients should be screened for distress at their initial visit, at appropriate intervals, and as clinically indicated, especially with changes in disease status.
• Distress should be assessed and managed according to clinical practice guidelines.

References

Manikantan K, Khode S, Dwivedi RC, Palav R, Nutting CM, Rhys-Evans P, Harrington KJ, Kazi R. Making sense of post-treatment surveillance in head and neck cancer: when and what of follow-up. Cancer Treat Rev. 2009 Dec;35(8):744-53. doi: 10.1016/j.ctrv.2009.08.007. Epub 2009 Sep 9. PMID: 19744793.

Shune SE, Karnell LH, Karnell MP, Van Daele DJ, Funk GF. Association between severity of dysphagia and survival in patients with head and neck cancer. Head Neck. 2012 Jun;34(6):776-84. doi: 10.1002/hed.21819. Epub 2011 Aug 30. PMID: 22127835; PMCID: PMC4304637.

Hanna GJ, Patel N, Tedla SG, Baugnon KL, Aiken A, Agrawal N. Personalizing Surveillance in Head and Neck Cancer. Am Soc Clin Oncol Educ Book. 2023;43:e389718. doi:10.1200/EDBK_389718

Berger BM, Hanna GJ, Posner MR, et al. Detection of Occult Recurrence Using Circulating Tumor Tissue Modified Viral HPV DNA among Patients Treated for HPV-Driven Oropharyngeal Carcinoma. Clin Cancer Res. 2022;28(19):4292-4301. doi:10.1158/1078-0432.CCR-22-0562

Carpenter DJ, Mowery YM, et al. The risk of carotid stenosis in head and neck cancer patients after radiation therapy. Oral Oncol. 2018 May;80:9-15. doi:10.1016/j.oraloncology.2018.02.021

Carpenter DJ, Patel P, et al. Long-term risk of carotid stenosis and cerebrovascular disease after radiation therapy for head and neck cancer. Cancer. 2023 Oct: https://doi.org/10.1002/cncr.35089

Randolph, W, & Dains, JE. Ultrasound Evaluation of carotid Artery Intima-media Thickness: Effective early marker of Carotid Artery Disease in Adult Head and Neck Cancer patients After neck Radiation? J Adv Pract Oncol. 2022 Sept; 13(7): 683-694. doi: 10.6004/jadpro.2022.13.7.4

U.S. Preventive Services Task Force. Final Recommendation Statement. Asymptomatic Carotid Artery Stenosis: Screening. February 2021.