The American Cancer Society (ACS) recently issued new clinical practice guidelines for follow-up screening and care coordination for survivors of head and neck cancer.
The population of these patients is growing, and survivors of head and neck cancer are likely to experience physical, psychosocial and practical effects from cancer and its treatment.
Head and neck cancer will account for an estimated 61,760 new cancer cases in the United States in 2016, and there are currently 436,060 survivors (equivalent to 3 percent of U.S. cancer survivors), the ACS notes. Tobacco use and alcohol consumption together account for an estimated 3 in 4 cases, and HPV accounts for as many as 7 in 10 oropharyngeal cancers.
The head and neck cancer (HNC) survivorship care guideline, published online in CA: A Cancer Journal for Clinicians, was developed by a multidisciplinary workgroup representing a wide range of specialties, including oncology, dentistry, nursing, speech pathology and primary care. The group conducted a systematic literature review to develop consensus-based management strategies for HNC survivors focused on five main areas:
Surveillance for HNC Recurrence
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 one to three months for the first year after primary treatment, every two to six months in the second year, every four to eight months in years three through five, and annually after five years, as well as confirm continued follow-up with an otolaryngologist or HNC specialist for head and neck–focused examination.
HNC survivors also need to be educated on signs of local recurrence and referred to an HNC specialist if symptoms of recurrence are observed.
Screening and Detection of Second Primary Cancers
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 percent of HNC survivors will develop one 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 percent of second primary cancers in this population.
Physical and Psychosocial Support
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.
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.
Care Coordination and Practice Implications
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.
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. For more resources on implementing the practice guidelines, visit cancer.org/professionals.