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PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer

Lookup NU author(s): Dr Max RobinsonORCiD

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Abstract

BACKGROUNDThe role of image-guided surveillance as compared with planned neck dissection in the treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease (stage N2 or N3) and who have received chemoradiotherapy for primary treatment is a matter of debate.METHODSIn this prospective, randomized, controlled trial, we assessed the noninferiority of positron-emission tomography-computed tomography (PET-CT)-guided surveillance (performed 12 weeks after the end of chemoradiotherapy, with neck dissection performed only if PET-CT showed an incomplete or equivocal response) to planned neck dissection in patients with stage N2 or N3 disease. The primary end point was overall survival.RESULTSFrom 2007 through 2012, we recruited 564 patients (282 patients in the planned-surgery group and 282 patients in the surveillance group) from 37 centers in the United Kingdom. Among these patients, 17% had nodal stage N2a disease and 61% had stage N2b disease. A total of 84% of the patients had oropharyngeal cancer, and 75% had tumor specimens that stained positive for the p16 protein, an indicator that human papillomavirus had a role in the causation of the cancer. The median follow-up was 36 months. PET-CT-guided surveillance resulted in fewer neck dissections than did planned dissection surgery (54 vs. 221); rates of surgical complications were similar in the two groups (42% and 38%, respectively). The 2-year overall survival rate was 84.9% (95% confidence interval [CI], 80.7 to 89.1) in the surveillance group and 81.5% (95% CI, 76.9 to 86.3) in the planned-surgery group. The hazard ratio for death slightly favored PET-CT-guided surveillance and indicated noninferiority (upper boundary of the 95% CI for the hazard ratio, <1.50; P = 0.004). There was no significant difference between the groups with respect to p16 expression. Quality of life was similar in the two groups. PET-CT-guided surveillance, as compared with neck dissection, resulted in savings of 1,492 pound (approximately $2,190 in U.S. dollars) per person over the duration of the trial.CONCLUSIONSSurvival was similar among patients who underwent PET-CT-guided surveillance and those who underwent planned neck dissection, but surveillance resulted in considerably fewer operations and it was more cost-effective.


Publication metadata

Author(s): Mehanna H, Wong WL, McConkey CC, Rahman JK, Robinson M, Hartley AGJ, Nutting C, Powell N, Al-Booz H, Robinson M, Junor E, Rizwanullah M, von Zeidler SV, Wieshmann H, Hulme C, Smith AF, Hall P, Dunn J, PET-NECK Trial Management Grp

Publication type: Article

Publication status: Published

Journal: New England Journal of Medicine

Year: 2016

Volume: 374

Issue: 15

Pages: 1444-1454

Print publication date: 14/04/2016

Online publication date: 23/03/2016

Acceptance date: 01/01/1900

ISSN (print): 0028-4793

ISSN (electronic): 1533-4406

Publisher: Massachusetts Medical Society

URL: http://dx.doi.org/10.1056/NEJMoa1514493

DOI: 10.1056/NEJMoa1514493


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Funding

Funder referenceFunder name
University Hospital Coventry
University of Warwick
University Hospital Warwickshire NHS Trust
06/302/129National Institute for Health Research Health Technology Assessment Programme
C19677/A9674Cancer Research UK

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