Surveillance Sans Surgery Safe, Cost-Effective in Head and Neck Cancer

Undergoing surveillance with PET/CT resulted in similar survival to planned neck dissection in patients with squamous cell carcinoma of the head and neck with nodal disease who have completed chemoradiotherapy, according to the results of a study published in the New England Journal of Medicine. Undergoing the noninvasive surveillance also resulted in fewer operations and produced a significant cost savings.

“Our trial showed that PET/CT-guided surveillance was noninferior to planned neck dissection and was equally effective in both HPV-positive and HPV-negative patient groups,” wrote researcher Hisham Mehanna, PhD, from the Institute of Head and Neck Studies and Education at University of Birmingham, and colleagues.

“Patients in the surveillance group were not disadvantaged by undergoing delayed neck dissection; the global quality-of-life scores and rates of surgical complications were similar in this group and in the group of patients who underwent earlier planned neck dissection,” they wrote.

This non-inferiority study enrolled 564 patients from 2007 to 2012. The researchers compared PET/CT-guided surveillance performed 12 weeks after the end of chemoradiotherapy (n = 282) with planned neck dissection (n = 282) in patients with N2 or N3 disease. Patients in the PET/CT group had neck dissection performed only if the imaging showed incomplete or equivocal response. In the group, 84% of patients had oropharyngeal cancer and three-fourths of these patients stained positive for the p16 protein, indicating that HPV played a role in the cancer.

After a median of 3 years, there were fewer neck dissections among the group of patients who underwent surveillance with PET/CT (54 vs 221) compared with planned dissection, but when dissections did occur, the rate of surgical complications was similar between the two groups (42% vs 38%).

Patients undergoing PET/CT surveillance had a slight survival advantage compared with neck dissection, which met the prespecified boundary for non-inferiority. Two-year overall survival was 84.9% for the imaging surveillance compared with 81.5% for neck dissection.

The researchers compared quality of life in these two groups and found that at 6 months there was a small but significant difference in favor of the surveillance group; however, this difference narrowed and was not significant by 12 months, and was completely gone by 24 months.

The researchers found that undergoing PET/CT surveillance resulted in a saving of about £1,492 or about $2,190 per person during the duration of the trial.

“When extrapolating the data presented here to routine clinical practice, clinicians should note that few patients in our trial had low-prevalence, N3 (stage IVb) disease,” the researchers wrote. “Although five of the nine patients with stage N3 disease in the PET/CT surveillance group had complete responses, extrapolation of a PET/CT-guided surveillance policy to this higher-risk group of patients cannot currently be justified because of the small number of such patients in the trial.”