Routine Imaging Not Necessary for HPV-Associated Oropharynx Cancer

Jessica Frakes, MD

Treatment and follow-up for HPV-associated oropharynx cancer should differ from the standard of care for non—HPV-associated disease, explains Jessica Frakes, MD, an assistant member in the Department of Radiation Oncology at Moffitt Cancer Center. However, she adds, the NCCN currently does not truly distinguish between the 2 subsets.

“If you look at the NCCN guidelines, it’s a one-size-fits-all approach. Whether a patient has an HPV-associated malignancy or an HPV-unassociated malignancy, the follow-up recommendations are the same. I think, in the future, we are going to start changing that,” Frakes says.

“Everyone recognizes that these HPV-associated cancers are very different than the non-HPV cancers, which are often due to smoking. There is really a trend now to separate these, based on deintensification of treatment, as well as what follow-up we should be doing for our patients.”

To better understand what changes are needed in the treatment and follow-up of HPV-associated cancers, Frakes and researchers at Moffit Cancer Center conducted a study looking at 246 patients with HPV- or p16-positive localized oropharyngeal cancers that were treated with definitive radiation therapy between 2006 and 2014.

The goal of the study was to determine time to recurrence, as well as mode of detection of recurrence to further help guide optimal follow-up for HPV-associated patients, says Frakes.

OncLive: What were the most significant findings?

In an interview with OncLive, Frakes explains the study’s findings and how they could impact clinical practice for the follow-up of patients with HPV-associated oropharynx cancer.Frakes: We looked at 3-year local control, and determined there was a control rate of 97%. That’s really good local control. We also looked at how many failures there were and how they were detected. There were a total of 6 failures, and 100% of them were noted by physical examination—either direct visualization or laryngoscopy.

Next, we looked at regional recurrences, and we found a 97% regional recurrence control rate. We found that the majority of those patients were detected by symptoms; the patient presented with a neck mass or the mass was detected on their 3-month imaging scan. Our protocol at our institution is that all patients get a 3-month PET/CT scan posttreatment. If that is negative, we just follow the patient clinically.

We also looked at distance failure, and again our distance control rate was 91%, also a really high control rate. Again, similarly to regional control we found that recurrence was detected based on symptoms or from the 3-month PET/CT scan.

What should community oncologists take away from these findings?

The majority of these local, regional, and distance recurrences happened in the first 6 months posttreatment. That is really when the follow-up is so important for these patients. From this study, we were able to determine some guidelines on what type of imaging, or lack of imaging, these HPV-positive patients should be receiving without compromising outcomes. We found that the first 6 months were important and, if the PET/CT scan was negative and the patient was asymptomatic, we didn’t need to do further imaging.We hope they will take away that routine imaging isn’t necessary. That really impacts the patient. It can decrease the stress and anxiety of waiting for a test result, and reduces the financial burden on the patient—not just due to the cost of the test, but also due to time away from work.

Are there next steps in this research?

With the rise of these patients—I believe the estimated number for next year is about 30,000 HPV-positive patients with oropharynx cancer—routine imaging is a huge burden for the healthcare system without a benefit to the patient.We hypothesized that less testing decreases the stress and financial burden, but we need more validation of that. Some people may say, “Knowledge is power and patients want to get that imaging test result to say, for sure, that they are cancer-free.”

How has the field of oropharynx cancer evolved in recent years?

However, we can empower our patients by showing them the data that a 3-month scan that is negative really means they are cancer-free and they will still be followed by physical examinations.Previously, most of the cases of oropharynx and head and neck cancer were smoking-related. Patients outcomes were a lot poorer; they didn’t do as well. They had more toxicity with treatment, more local failures, regional failures, and disease recurrence.

Now, we are starting to see younger patients who are relatively healthy with HPV-associated malignancies who do well. It is really important, in the future, to make sure we are not increasing toxicity. We have patients who are living a lot longer with no evidence of disease, and we need to make sure their quality of life is still high.

We did assess toxicity in our study and we looked at grade 3 or higher late-toxicity rates at 3 months. Initially, that was experienced by 9% of our patients. However, at the time of their last follow-up, only 2% of the patients actually had persistent late toxicities.

This means that we were very proactive with making sure that patients who had a feeding tube in place were able to meet with speech and swallow professionals as well as nutritionists. We made sure to control their pain, so they were still able to swallow during treatment, maintain the swallowing function, and use those muscles. There is a lot that really goes into helping to decrease toxicity for patients. That is really where the future is going.

Several ongoing national studies are looking at deintensification of treatment. That is really what is going on with these HPV-associated cancers. Patients do well, so it is really important that we do not reduce outcomes, but still maintain quality of life.

Frakes JM, Naghavi AO, Strom T, et al. Detection of recurrence in HPV associated oropharynx squamous cell carcinoma. Presented at: 2016 Multidisciplinary Head and Neck Cancer Symposium; February 18-20, 2016; Scottsdale, AZ. Abstract 6.