Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Circulating tumor DNA (ctDNA) is revolutionizing early detection of minimal residual disease, metastasis, and recurrence among patients with human papillomavirus-mediated oropharyngeal squamous cell carcinoma (HPV+OPSCC). CtDNA holds the potential to change surveillance guidelines for this group due to their amenability to treatment when detected early and improved survival with treatment. Current National Comprehensive Cancer Network guidelines provide the same surveillance guidelines for all head and neck cancer patients. Although disease-free survival and overall survival are well-studied, there is a paucity of data on how recurrences were initially detected among HPV+OPSCC prior to the advent of ctDNA testing. This data is important to justify proposed changes in routine surveillance for HPV+OPSCC, specifically guidance regarding the utility of in-office head and neck exams.
Methods: The Kentucky Cancer Registry, part of the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program, was queried for patients who underwent treatment for HPV+OPSCC in Kentucky between 6/2021 and 10/2024 and were found to have a recurrence. Chart review was performed for additional information regarding patient signs and symptoms at follow-up appointments, exam findings, and imaging to determine the initial trigger for recurrence work-up. The primary outcome was triggering event (patient-reported symptom, routine imaging, or physical exam finding).
Results: This study included 273 HPV+OPSCC patients, of which 13 were found to have local or distant recurrences (5%). Two were detected with routine ctDNA testing and excluded from analysis. Of the HPV+ patients who recurred, 10 were male and 1 was female. The median age of primary diagnosis was 64 (IQR 59-80), and the median time to recurrence was 16 months (IQR 7-21). Most (72.7%) patients who recurred had early-stage primaries (T0-T2) and 5 (45.5%) were treated with chemoradiation, while 3 (27.3%) were treated with surgery and chemoradiation. 63.6% of patients had a history of smoking. Most recurrences were distant (63.6%), with 5 in the lung, 1 in the spinal column, and 1 in the contralateral lymph nodes. Three were local and one locoregional. Recurrence work-up was most often triggered by a finding on routine surveillance imaging (81.8%). Patient-reported symptoms including bone pain and ear pain triggered workup for two patients (18%). Routine in-office exams were the triggering event for 0 recurrences. Of the patients who had recurrence workup triggered by imaging results, 33.3% had no history of smoking and 66.6% of the non-smokers whose recurrence work up occurred due to imaging demonstrated distant metastases.
Conclusion: Recurrence workup of HPV+OPSCC in our cohort was most often triggered by routine surveillance imaging, followed by patient-reported symptoms. No recurrences were initially on in-office exam. As the utility of ctDNA in HPV+OPSCC surveillance continues to undergo investigation as a mechanism for altered surveillance regimens, our findings support de-escalating surveillance by reducing reliance on routine in-office exams, given their limited utility for the detection of recurrence and metastasis of HPV+OPSCC. This corroborates the findings of the very few other reported studies on this question. Our findings also support routine surveillance chest CT scans regardless of the smoking status.