March 23, 2016

expert reaction to study on the use of PET-CT scans to detect remaining cancer cells in neck and head cancer patients

The practice of neck dissection in the treatment of advanced head and neck cancer has been associated with complications for some patients. A randomised trial published in the New England Journal of Medicine reports that neck dissection is avoidable in 80% of cases and that the alternative application of PET-CT guided surveillance has similar survival rates and is more cost-effective.

Dr Mangesh Thorat, Research Fellow, Centre for Cancer Prevention, Queen Mary University of London, said:

“This randomised trial addresses a very important question in the management of nodal disease in advanced oropharyngeal cancers which are treated with chemo-radiotherapy as primary treatment modality. These very encouraging results of a prospective randomised trial show non-inferiority of the approach where neck dissection is performed only when PET-CT suggests a possibility of residual disease instead of routine neck dissection. This essentially helps avoid neck dissection in 4 out of 5 patients, particularly when it has a rather high complication rate in patients who have already received radiotherapy to the surgical field. Therefore, this is a major contribution to management of such patients and worthwhile even in absence of a notable long-term quality of life difference.

“Authors reported some difference in short-term quality of life, which was probably a result of absence of surgery and therefore avoidance of surgery-related worsening of quality of life. The major reason for absence of a notable long-term quality of life difference is likely to be due to the long-lasting impact of aggressive treatment like chemo-radiotherapy on quality of life as both groups of patients received this treatment. For example, Dysphagia inventory would largely be unaffected by nodal dissection but would be greatly impacted by radiotherapy which both groups of patients received, resulting in similar overall scores irrespective of the trial arms.

“Retrospective and prospective studies to assess likely impact of such or similar surveillance strategies exist, but this important patient management question could only be reliably addressed in a randomised trial. This is what this study achieves in a robust manner.

“There are a few other cancers, e.g. advanced cervical cancer, that are treated with chemo-radiotherapy as a primary treatment modality. However, management algorithms differ. Therefore, these results do not have direct implications for treatment of other cancers at the moment, but could prove useful for research.”

‘PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer’ by Mehanna et al. published in New England Journal of Medicine UK time on Wednesday 23rd March. 

Declared interests

Dr Mangesh Thorat: I was member of the Cancer Research UK (CRUK) Clinical Trials Advisory Awards Committee (CTAAC) which oversaw funding for the sample collection aspect of this trial. No other relevant conflicts. Note- As a surgical oncologist by training, I have had considerable experience in treating head and neck cancer patients, but I have now focussed myself on breast cancer as my primary specialty and no longer work in the field of head and neck cancer.