Top Takeaways from ASCO: Neck dissection in head and neck cancer
Approaches to neck dissection include elective and guided, active surveillance.
CHICAGO – The decision-making process used by physicians to determine whether a neck dissection is appropriate in patients with head and neck cancer may change as a result of two studies presented at the ASCO 2015 Annual Meeting.
David Adelstein, MD, staff physician in the department of hematology and medical oncology at the Taussig Cancer Institute, Cleveland Clinic, and professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and Barbara Ann Burtness, MD, professor of medicine (medical oncology), clinical research program leader, Head and Neck Cancers Program, and co-director, Developmental Therapeutics Research Program, Yale University, discussed the impact of these findings with Healio.com.
Elective vs. therapeutic neck dissection
A phase 3 study conducted by Anil D’Cruz, MD, a surgical oncologist in the Head and Neck Services Disease Management Group at Tata Memorial Hospital in Mumbai, India, and colleagues demonstrated improvements in OS and DFS among patients with early oral squamous cell carcinoma undergoing elective compared with therapeutic neck dissection.
The researchers “asked a question that we’ve been debating for a long, long time – whether or not a patient with an early-stage, clinically node-negative, oral cavity cancer needs a neck dissection in addition to removal of the primary tumor,” Adelstein said. “The approach for early-stage oral cavity cancer is single-modality surgery. Radiation and chemotherapy are generally not used. An ongoing concern, however, has been risk of occult nodal metastases in the clinically node-negative neck at the time of disease presentation and the need for and benefit of an elective neck dissection at that time. The alternative of close clinical follow up with therapeutic neck dissection if nodal disease develops can allow many patients to avoid neck surgery, at the expense of finding more extensive disease, and requiring more adjuvant treatment in those experiencing regional failure.”
D’Cruz and colleagues evaluated 500 patients with tongue, buccal mucosa and floor-of-mouth tumors. Participants were randomized to either watchful waiting after primary site surgery, with a therapeutic neck dissection for regional failure (n = 255) or an elective neck dissection at the time of initial treatment (n = 245).
At a median follow-up point of 39 months, there were 146 recurrences in the therapeutic neck dissection arm and 81 in the elective neck dissection arm. Three-year OS rates were higher in the elective arm compared with the therapeutic arm (80% vs. 67.5%; HR = 0.63; 95% CI, 0.44-0.89), as were rates of DFS (68.5% vs. 45.9%; HR = 0.44; 95% CI, 0.34-0.58).
“The results are pretty striking and very clear,” Adelstein told Healio.com. “An elective neck dissection at the time of primary site surgery improves survival. While there has been considerable suggestion in the literature that patients with very thin tumors at the time of presentation have a very low chance of developing neck node metastases, the standard of care, particularly when close patient follow up may be difficult, is an elective neck dissection.”
PET-NECK: Guided active surveillance vs. planned neck dissection after chemoradiation
Guided active surveillance using PET-computed tomography resulted in fewer neck dissections and complications among head and neck cancer patients with locally advanced nodal metastases, according to study results from Hisham Mohamed Mehanna, PhD, BMedSc, MBChB, FRCS, FRCS (ORL-HNS), chair of head and neck surgery and director of the Institute of Head and Neck Studies and Education, School of Cancer Sciences, University of Birmingham, United Kingdom, and fellow researchers.
The study was conducted “to look at the question of whether routinely doing a neck dissection in patients who’ve completed chemoradiation for locally advanced head and neck cancer is necessary – or whether it’s okay to wait until a PET scan at 12 weeks and make the decision about neck dissection based on the PET scan,” Burtness told Healio.com.
Barbara Ann Burtness
Mehanna and colleagues followed 564 patients, with 282 randomized to the planned neck dissection arm and 282 randomized to the active surveillance arm. Median follow-up was 36 months.
Fifty-four neck dissections were performed in the surveillance arm, results from the meeting demonstrate, compared with 221 neck dissections were performed in the planned neck dissection arm. Surgical complications occurred in 22 neck dissections in the surveillance arm and 85 neck dissections in the planned neck dissection arm. The authors concluded that guided active surveillance with PET computed tomography showed similar survival outcomes to the planned neck dissection arm, but resulted in considerably fewer neck dissections and complications, “supporting its use in routine practice.”
“For all cancer-related endpoints, there was not a significant difference between the two groups, although, if anything, there was perhaps a hint that patients who did not routinely have neck dissections may have had a slightly better outcome, a slightly lower number of non-cancer-related deaths and less toxicity,” Burtness told Healio.com. “Quality of life was also perhaps a little bit better for the patients who had PET-guided neck dissection. Quality-adjusted life years were about $2,000 more cost-effective for the use of PET.”
Implications for clinical practice
Findings from both studies will affect physicians considering neck dissection for patients with head and neck cancer, Adelstein and Burtness told Healio.com.
Results from the PET-NECK study could be “very useful” in clinical practice, Burtness said.
“For patients with locally advanced disease who do well with chemoradiation and who don’t have a clinical indication of progressive or persistent disease, it is preferable – not only okay but actually preferable – to wait for a PET scan at the 12-week mark.”
Adelstein commented on the “take-home message” from D’Cruz and colleagues.
“In patients with an early oral cavity cancer, an elective dissection is a reasonable standard-of-care approach,” Adelstein said. “There’s now very good evidence to support that.” – by Julia Ernst, MS
D’Cruz A, et al. Abstract LBA3.
Mehanna HM, et al. Abstract 6009.
Presented at: ASCO Annual Meeting; May 29-June 2, 2015; Chicago.
Disclosure: Adelstein and Burtness report no relevant financial disclosures.