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Original Investigation
August 8, 2019

Association of NCCN-Recommended Posttreatment Surveillance With Outcomes in Patients With HPV–Associated Oropharyngeal Squamous Cell Carcinoma

Author Affiliations
  • 1Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
  • 2San Francisco School of Medicine, University of California, San Francisco, San Francisco
  • 3Division of Research, Kaiser Permanente Northern California, Oakland, California
  • 4Graduate Medical Education, Kaiser Permanente Medical Center, Oakland, California
  • 5Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles
JAMA Otolaryngol Head Neck Surg. Published online August 8, 2019. doi:10.1001/jamaoto.2019.1934
Key Points

Question  Is National Comprehensive Cancer Network (NCCN)–recommended posttreatment clinical surveillance in patients with human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma (SCC) associated with improvements in recurrence detection and survival outcomes?

Findings  In this cohort study of 233 patients with HPV–associated oropharyngeal SCC, only 1 asymptomatic recurrence was detected of 3358 posttreatment clinical surveillance visits, and adherence to the recommended schedule did not seem to improve survival.

Meaning  The findings of this study suggest that reduction of the NCCN-recommended posttreatment clinical surveillance schedule for HPV–associated oropharyngeal SCC is warranted.


Importance  National Comprehensive Cancer Network (NCCN) guidelines recommend routine clinical follow-up as posttreatment surveillance for patients with head and neck cancer (HNC). Human papillomavirus–associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) is a unique subset of HNC, associated with fewer recurrences and improved survival. The utility of this guideline in this patient population is unknown.

Objective  To determine adherence to the NCCN clinical follow-up guideline, frequency of recurrence detection method, classified as symptom-directed, physician-detected, or imaging-detected, and survival benefit associated with adherence to the NCCN guideline.

Design, Setting, and Participants  Retrospective cohort study of patients with HPV-associated OPSCC diagnosed between January 1, 2011, and April 30, 2014, at a large integrated health care system. Multivariable analyses were conducted using the Cox proportional hazards regression model, with patient adherence to NCCN visit guidelines constructed as a time-dependent variable. All data analyses were complete on September 1, 2018.

Exposures  Posttreatment clinical and imaging surveillance.

Main Outcomes and Measures  Recurrence and overall survival. Secondary outcome was salvage therapy.

Results  Of the 233 study patients with HPV-associated OPSCC, the mean (SD) age at diagnosis was 60.5 (8.7) years; 201 (86.3%) were male, 189 (81.1%) were white, and 109 (46.8%) had a positive smoking history. Median follow-up time through recurrence or all-cause mortality was 4.5 years (interquartile range, 3.8-5.6). Patients demonstrated 83.0% (180 of 217) adherence to NCCN surveillance guidelines in year 1, 52.7% (106 of 201) in year 2, 73.4% (141 of 192) in year 3, 62.3% (96 of 154) in year 4, and 52.9% (45 of 85) in year 5. A total of 3358 clinical surveillance examinations were performed with 22 patients having recurrences. There were 10 symptom-directed, 1 physician-detected, and 11 imaging-detected recurrences. Of the symptom-directed recurrences, salvage therapy was attempted in 5; at the study end date, 1 was alive. Salvage neck dissection was attempted in the physician-detected recurrence; this patient subsequently died. All locoregional recurrences occurred within the first 2 years, and all salvageable recurrences within the first year. Adherence to NCCN guidelines was not protective against all-cause mortality in the multivariable Cox proportional hazards regression model (hazard ratio, 0.76; 95% CI, 0.28-2.05).

Conclusions and Relevance  Among patients with HPV-associated OPSCC, clinical surveillance is of limited utility. Nearly all clinically detected recurrences were elicited by patient symptoms that prompted earlier presentation to the clinician. Adherence to the current schedule does not appear to confer survival advantage, and locoregional recurrences are almost never detected beyond 2 years. These findings support reduction of posttreatment clinical surveillance in this population.