An expert panel has developed clinical practice guidelines for the management of head and neck cancer survivors.
Survivors of head and neck cancer (HNC) now comprise 3% of all cancer survivors in the United States, and their numbers—currently more than 400,000—are increasing, the American Cancer Society (ACS) reports.
Against this backdrop, a group of experts has developed a comprehensive clinical practice guideline focused on 5 key areas of survivorship for a population which the guideline authors note faces potentially significant physical, psychosocial, and practical effects from their cancer and its treatment.
The multidisciplinary workgroup was convened by The National Cancer Survivorship Resource Center, a collaboration between the American Cancer Society, The George Washington University Cancer Institute, and the Centers for Disease Control and Prevention.
The panel, which included experts in oncology, dentistry, nursing, speech pathology, and primary care, conducted a systematic literature review to develop these consensus-based management strategies for HNC survivors. Their search identified 2081 articles, of which 184 were ultimately included in the evidence base.
Surveillance for HNC Recurrence
The following are some of the key recommendations, published online in CA: A Cancer Journal for Clinicians:Primary care clinicians should individualize clinical follow-up care provided to HNC survivors based on age, specific diagnosis, and treatment protocol as recommended by the treating oncology team. They should conduct a detailed, cancer-related history and physical examination every 1 to 3 months for the first year after primary treatment, every 2 to 6 months in the second year, every 4 to 8 months in years 3 to 5, and annually after 5 years, as well as confirm continued follow-up with an otolaryngologist or HNC specialist for head and neck—focused examination.
Screening and Detection of Second Primary Cancers
Physical and Psychosocial Support
HNC survivors also need to be educated on signs of local recurrence and referred to an HNC specialist if symptoms of recurrence are observed.HNC survivors should be screened as they would be in the general population for early detection of primary cancers. However, the guideline notes that approximately 23% of HNC survivors will develop 1 or more second primary cancers, and HNC survivors should thus be screened as being at increased risk for lung, head and neck, and esophageal cancers, which together account for 89% of second primary cancers in this population.Long-term and late effects of HNC should be regularly assessed at each follow-up visit. Among the physical late effects that should be assessed in this population of survivors are spinal accessory nerve palsy; cervical dystonia/muscle spasms/neuropathies; shoulder dysfunction; trismus; dysphagia; gastroesophageal reflux disease; and lymphedema.
Additional recommendations include monitoring for fatigue, altered or loss of taste, hearing loss, vertigo, vestibular neuropathy, sleep apnea, speech disturbance, hypothyroidism, oral and dental caries, periodontitis, xerostomia, osteonecrosis, and oral infections.
If HNC survivors have body or self-image concerns, they should be referred to psychosocial care. Survivors should also be assessed regularly for distress or anxiety, and as needed be provided with in-office counseling, pharmacotherapy, and/or referral to appropriate psycho-oncology and mental health resources or social workers.
Care Coordination and Practice Implications
Recent research reported at the 2016 Multidisciplinary Head and Neck Cancer Symposium found that patients with locally advanced HNC are especially prone to such psychosocial concerns as feelings of isolation and financial hardship.These recommendations include educating HNC survivors on their treatment and its side effects, maintaining a healthy weight, encouraging physical activity, adequate nutrition, tobacco cessation, and the importance of personal and oral hygiene.Clinicians should obtain the survivor’s treatment summary and survivorship care plan from the oncology team, maintain a continued dialogue with the oncology team, and should include caregivers, spouses, or partners in the process of care and support.
Head and neck cancer will account for an estimated 61,760 new cancer cases in the United States in 2016, according to ACS, and tobacco use and alcohol consumption together account for an estimated 3 in 4 cases. HPV is also a risk factor, accounting for as many as 7 in 10 oropharyngeal cancers.
The new head and neck cancer guideline marks the fourth in the series of ACS cancer survivorship care guidelines. The series also includes guidelines for breast and prostate cancer survivors, as well as recommendations for optimum nutrition and physical activity in survivorship.
Cohen EE, LaMonte SJ, Erb NL, et al. American Cancer Society head and neck cancer survivorship care guidelines [published online March 22, 2016]. CA Cancer J Clin. doi:10.3322/caac.21343.