Head & Neck/Thyroid Cancers

BOSTON – Normalizing the serum thyroglobulin level by thyroid nodule size in patients surgically treated for a thyroid nodule produced a strongly significant link between the level of this marker and nodule malignancy in a review of nearly 200 patients treated at any of three Montreal centers.

After normalization, the serum thyroglobulin of patients with a malignant nodule averaged 51 mcg/L*cm, more than double the average 23 mcg/L*cm among patients with benign nodules, Neil Verma, MD, said at the World Congress on Thyroid Cancer.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BOSTON – Normalizing the serum thyroglobulin level by thyroid nodule size in patients surgically treated for a thyroid nodule produced a strongly significant link between the level of this marker and nodule malignancy in a review of nearly 200 patients treated at any of three Montreal centers.

After normalization, the serum thyroglobulin of patients with a malignant nodule averaged 51 mcg/L*cm, more than double the average 23 mcg/L*cm among patients with benign nodules, Neil Verma, MD, said at the World Congress on Thyroid Cancer.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BOSTON – Normalizing the serum thyroglobulin level by thyroid nodule size in patients surgically treated for a thyroid nodule produced a strongly significant link between the level of this marker and nodule malignancy in a review of nearly 200 patients treated at any of three Montreal centers.

After normalization, the serum thyroglobulin of patients with a malignant nodule averaged 51 mcg/L*cm, more than double the average 23 mcg/L*cm among patients with benign nodules, Neil Verma, MD, said at the World Congress on Thyroid Cancer.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BOSTON – Many selected patients with low- or intermediate-risk differentiated thyroid cancer who have had excellent or good responses to their treatment may be able to safely transition to follow-up monitoring at longer intervals, Bryan R. Haugen, MD, suggested in a keynote lecture during the World Congress on Thyroid Cancer.

Traditionally, thyroid cancer specialists have monitored these patients for persistent or recurrent disease as often as every 6 or 12 months. “But what we’ve realized with recent assessments of response to treatment is that some patients do well without a recurrence over many years; so, the concept of doing less monitoring and less imaging, especially in patients with an excellent response [to their initial treatment], is being studied,” Dr. Haugen said in a video interview following his talk.

He estimated that perhaps two-thirds or as many as three-quarters of patients with differentiated thyroid cancer fall into the category of having low- or intermediate-risk disease with an excellent or good response to treatment, and hence they are potential candidates for eventually transitioning to less frequent follow-up.

During his talk, Dr. Haugen suggested that after several years with no sign of disease recurrence, lower-risk patients with an excellent treatment response may be able to stop undergoing regular monitoring, and those with a good treatment response may be able to safely have their monitoring intervals extended.

According to the most recent (2015) guidelines for differentiated thyroid cancer management from the American Thyroid Association, lower-risk patients with an excellent treatment response should have their serum thyroglobulin measured every 12-24 months and undergo an ultrasound examination every 3-5 years, while patients with a good response are targeted for serum thyroglobulin measurement annually with an ultrasound every 1-3 years (Thyroid. 2016 Jan;26[1]:1-133). Dr. Haugen chaired the expert panel that wrote these guidelines.

In another provocative suggestion, Dr. Haugen proposed that once well-responsive, lower-risk patients have remained disease free for several years, their less frequent follow-up monitoring could be continued by a primary care physician or another less specialized clinician.

At some time in the future, “a patient’s primary care physician could follow a simple tumor marker, thyroglobulin, maybe once every 5 years,” said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. “At the University of Colorado, we use advanced-practice providers to do long-term follow-up” for lower-risk, treatment-responsive patients, he said.

BOSTON – Many selected patients with low- or intermediate-risk differentiated thyroid cancer who have had excellent or good responses to their treatment may be able to safely transition to follow-up monitoring at longer intervals, Bryan R. Haugen, MD, suggested in a keynote lecture during the World Congress on Thyroid Cancer.

Traditionally, thyroid cancer specialists have monitored these patients for persistent or recurrent disease as often as every 6 or 12 months. “But what we’ve realized with recent assessments of response to treatment is that some patients do well without a recurrence over many years; so, the concept of doing less monitoring and less imaging, especially in patients with an excellent response [to their initial treatment], is being studied,” Dr. Haugen said in a video interview following his talk.

He estimated that perhaps two-thirds or as many as three-quarters of patients with differentiated thyroid cancer fall into the category of having low- or intermediate-risk disease with an excellent or good response to treatment, and hence they are potential candidates for eventually transitioning to less frequent follow-up.

During his talk, Dr. Haugen suggested that after several years with no sign of disease recurrence, lower-risk patients with an excellent treatment response may be able to stop undergoing regular monitoring, and those with a good treatment response may be able to safely have their monitoring intervals extended.

According to the most recent (2015) guidelines for differentiated thyroid cancer management from the American Thyroid Association, lower-risk patients with an excellent treatment response should have their serum thyroglobulin measured every 12-24 months and undergo an ultrasound examination every 3-5 years, while patients with a good response are targeted for serum thyroglobulin measurement annually with an ultrasound every 1-3 years (Thyroid. 2016 Jan;26[1]:1-133). Dr. Haugen chaired the expert panel that wrote these guidelines.

In another provocative suggestion, Dr. Haugen proposed that once well-responsive, lower-risk patients have remained disease free for several years, their less frequent follow-up monitoring could be continued by a primary care physician or another less specialized clinician.

At some time in the future, “a patient’s primary care physician could follow a simple tumor marker, thyroglobulin, maybe once every 5 years,” said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. “At the University of Colorado, we use advanced-practice providers to do long-term follow-up” for lower-risk, treatment-responsive patients, he said.

BOSTON – Many selected patients with low- or intermediate-risk differentiated thyroid cancer who have had excellent or good responses to their treatment may be able to safely transition to follow-up monitoring at longer intervals, Bryan R. Haugen, MD, suggested in a keynote lecture during the World Congress on Thyroid Cancer.

Traditionally, thyroid cancer specialists have monitored these patients for persistent or recurrent disease as often as every 6 or 12 months. “But what we’ve realized with recent assessments of response to treatment is that some patients do well without a recurrence over many years; so, the concept of doing less monitoring and less imaging, especially in patients with an excellent response [to their initial treatment], is being studied,” Dr. Haugen said in a video interview following his talk.

He estimated that perhaps two-thirds or as many as three-quarters of patients with differentiated thyroid cancer fall into the category of having low- or intermediate-risk disease with an excellent or good response to treatment, and hence they are potential candidates for eventually transitioning to less frequent follow-up.

During his talk, Dr. Haugen suggested that after several years with no sign of disease recurrence, lower-risk patients with an excellent treatment response may be able to stop undergoing regular monitoring, and those with a good treatment response may be able to safely have their monitoring intervals extended.

According to the most recent (2015) guidelines for differentiated thyroid cancer management from the American Thyroid Association, lower-risk patients with an excellent treatment response should have their serum thyroglobulin measured every 12-24 months and undergo an ultrasound examination every 3-5 years, while patients with a good response are targeted for serum thyroglobulin measurement annually with an ultrasound every 1-3 years (Thyroid. 2016 Jan;26[1]:1-133). Dr. Haugen chaired the expert panel that wrote these guidelines.

In another provocative suggestion, Dr. Haugen proposed that once well-responsive, lower-risk patients have remained disease free for several years, their less frequent follow-up monitoring could be continued by a primary care physician or another less specialized clinician.

At some time in the future, “a patient’s primary care physician could follow a simple tumor marker, thyroglobulin, maybe once every 5 years,” said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. “At the University of Colorado, we use advanced-practice providers to do long-term follow-up” for lower-risk, treatment-responsive patients, he said.

Lymphedema is the swelling of tissue caused by the accumulation of interstitial fluid in any area of the body where lymphatic flow has been compromised.¹ Secondary lymphedema is an acquired abnormality in lymph drainage^1,2 and is the type commonly seen in cancer patients. Secondary lymphedema can be described as external or internal. Internal lymphedema, swelling of deep structures and tissues, is very difficult to quantify.

Lymphedema in patients with head and neck cancers
Lymphedema is a complicating morbidity frequently seen in head and neck cancer patients who have undergone treatment with surgery, radiation, and chemotherapy. However, although it is one of the most prevalent side effects of treatment, it is both under-recognized and under-treated.³

In head and neck cancer patients, internal swelling may develop in the soft tissues of the upper aero-digestive tract,⁴ affecting articulation and swallowing. Currently, there does not seem to be an effective practical and reliable tool with which to measure internal lymphedema. In addition, it is generally accepted that there is no effective way to treat internal lymphedema. By contrast, external lymphedema is more readily observed, but both subjective and objective assessments are difficult. External swelling may occur in the face, jaw, and neck. However, the subjective scales currently available are insufficient to capture very important characteristics of external lymphedema.⁵ The Edge Task Force on Head and Neck Cancer in 2015 was not able to recommend any outcome measures for objectively quantifying external edema.⁶ Furthermore, objective measurements of head and neck lymphedema can be expensive and time consuming.

Extent and risk

A combination of both internal and external swelling is seen in more than 50% of patients.⁷ Risk factors include “throat” tumors, multicancer treatment approaches, higher total radiation dose, a greater number of radiation procedures, and radiation at the surgical site.⁵ More than 500,000 survivors of head and neck cancer in the United States are at risk of lymphedema.⁵ Although recent advances in treatment have reduced the incidence of other morbidities, 50% of patients who are treated for head and neck cancer may still develop lymphedema.^1,8 The reported incidence in some centers may be much higher, with up to 75% of patients developing lymphedema following treatment.⁹

Measurement modalities for clinical evaluation

There is little current research into lymphedema of the head and neck, despite the high prevalence of the condition.⁸ According to Deng and colleagues, measurement of head and neck lymphedema is a challenge, which has an impact on clinical assessment, diagnosis, and treatment of this under-recognized, under-reported and under-addressed problem in head and neck cancer patients.¹⁰ In a review of the literature, Deng and colleagues identified three measurement modalities available for clinical evaluation: patient-reported outcomes, clinician-reported outcomes, and technology.¹⁰ One major factor, though, in detecting lymphedema, is physician awareness: physicians, health care professionals, and even some lymphedema therapists are not well educated about this problem.⁸

Treatment

The effectiveness of traditional lymphedema treatment is not well defined.⁸ Currently, complete decongestive therapy (CDT), is considered the standard of care for lymphedema. The National Lymphedema Network has stated that modifications of CDT, especially manual lymphatic drainage and modified compressive garments for external lymphedema, have been shown to be beneficial for the treatment of lymphedema in head and neck cancer patients.¹¹ Most findings in lymphedema research, mainly in breast cancer patients, have shown that early intervention is the best management and yields the best outcomes. As with other chronic conditions, early identification and timely, appropriate treatment of lymphedema is critical to improve clinical outcomes, to decrease symptom burden and functional impairment, and to improve overall quality of life in head and neck cancer patients.¹⁰

Improving recognition and treatment

Head and neck oncologic treatment is increasingly offered outside the network of specialist academic hospitals, at hospitals serving more localized communities where the neediest, sickest patient groups may be receiving less than optimal care.³ This challenges community hospitals to provide optimal treatment, similar to that being offered at nationally recognized institutions. In January 2012, we implemented a prehabilitation program in our community hospital cancer center to provide early intervention for our patients based on the understanding that proper and prompt treatment for patients with early signs of lymphedema should be a priority.¹² In this article, we outline how we implemented the program and the describe improvements we observed before and after the implementation of the program.

The prehabilitation program

The role of the nurse navigator

Before the introduction of the prehabilitation program, our pattern of practice was to refer patients to oncology rehabilitation for lymphedema management after they had completed their medical treatment with surgery, radiation, and chemotherapy. In 2012, that was changed to a prehabilitation model of care that was overseen by a head and neck nurse navigator. This focus on prehabilitation begins with patients being referred to oncology rehabilitation at the time of cancer diagnosis for baseline assessment of head and neck swelling. In addition, there is assessment of the many possible other side effects associated with head and neck cancer and its treatment, namely loss of range of motion of the neck, jaw (trismus), and/or shoulders, postural deficits, functional loss, pain, balance dysfunction with fall risk, weakness, and fatigue. Therapeutic interventions are initiated as needed and appropriate. This process also raises awareness of a condition that has been described as under-recognized and under-treated.³

The nurse navigator sits in on each radiation oncology consultation and aids in “navigating” patients through their treatment. The nurse ensures that each patient is referred to different ancillary services from the outset, such as seeing a dietician, social worker, physical/occupational therapist and certified lymphedema therapist, speech pathologist, and financial assistance advisor, if necessary (Table 1).

Assessment of lymphedema

Measurement of head and neck lymphedema is a challenge.¹⁰ In our program, the physical therapy assessment also includes the evaluation of several other morbidities associated with head and neck cancer and its treatment, such as range of motion, weakness, fatigue, radiation fibrosis, balance dysfunction, and risk of falling (Table 2).

Although objective criteria for external lymphedema have not been established, simple measurements such as using a tape measure to record neck circumference, allow a useful longitudinal assessment. Digital photography may be effective in the documentation and subjective evaluation of changes of external lymphedema.^10,17 However, there are some limitations with photography because although external photographs (including digital photography and three-dimensional imaging) can capture some features, such as changes in contours, symmetry, and changes in skin quality and color, they do not detect changes in skin and soft tissue texture and compliance (Table 3).¹⁰

Impact on clinical outcomes

We retrospectively reviewed the medical records of 230 head and neck cancer patients who had been treated at our center between June 2008 and June 2015. Complete clinical data were available for 190 patients. The following information was extracted from each patient’s chart: whether they developed lymphedema, tumor stage, had surgery, radiation dose, type of chemotherapy given, their smoking history, if they had had a neck dissection and the primary site of the tumor (Table 3).

Incidence in different time periods. Of the 190 patients with complete records 78 (41%) were found to have lymphedema. These were all patients undergoing treatment for head and neck cancer during June 2008-June 2015. The prehabilitation program was initiated with the hiring of a nurse navigator for head and neck cancer, starting in January 2012. It is interesting to note that the incidence of lymphedema was 27% before the program was started, but after nurse navigator joined the team, the incidence increased significantly to 48% (P = .0002), in line with published expectations. This increase in recorded incidence may be attributable to the greater awareness of lymphedema intentionally fostered by the prehabilitation program.

Smoking history. Patients’ lifetime smoking history was retrieved from their medical records, based on their verbal admission of tobacco use. Most of the patients (n = 110) self-reported a history of smoking. Of those with a history of smoking, 36 (33%) developed external lymphedema after treatment for head and neck cancer, and 74 (67%) did not. However, this difference was not statistically significant. Hence, although smoking is a risk factor for head and neck cancer, it was not associated with the development of external lymphedema in our cohort of patients.

Type of tumor

Most of the patients (n = 156, 82%) had squamous cell carcinomas (SCC). Of those, 45% developed external lymphedema and 55% did not. Therefore, having SCC did not predispose to lymphedema. The other cancers were mixed type, mainly adenocaricoma, but their numbers were too small to draw statistical conclusions.

Stage of the tumor

About two thirds of the patients (n = 121, 64%) had stage 3 or 4 cancer. However, treatment of more advanced cancers was not associated with lymphedema development.

Site of the tumor

The literature suggests that patients with a primary tumor in the throat are at increased risk for lymphedema.⁵ The American Cancer Society has defined cancers of the oropharynx (throat) as including the base of the tongue (back third of the tongue), the soft palate, the tonsils, and the side and back walls of the throat.¹⁸ In our head and neck cancer cohort, patients with primary tumors of the oropharnyx were, perhaps, more susceptible to lymphedema (P = .044, Table 3). By contrast, in our cohort of patients, those with nasopharyngeal, hypopharyngeal, and parotid gland tumors were significantly less likely to develop lymphedema (Ps = .017, .04, .012, respectively).

No surgery

Half of our patients (n = 95) were not treated with surgery. In the patients who did not have surgery, 25 (26%) developed lymphedema, whereas 70 (74%) did not. Hence, although the incidence of lymphedema was significantly lower in patients who did not have surgery (P = .015), lymphedema did develop in patients who did not have a surgical procedure.

Resection of primary tumor without neck dissection

Of the 64 patients who had surgery, but without neck dissection, 35 (55%) developed external lymphedema. Compared with the no-surgery patients, the doubling of the incidence (from 26% to 55%) was highly significant (P = .0004). These findings are compatible with the literature reports that surgery increases the incidence of lymphedema, which is not surprising because surgery and subsequent scarring is known to compromise the lymphatic system.

Resection of primary tumor with neck dissection

The incidence of external lymphedema was increased to 69% when patients were subjected to both surgery and neck dissection. Compared with the June 2008-June 2015 cohort, there was a significant increase in the incidence of lymphedema in the neck dissection group (P = .007). Neck dissection involves the removal of lymph nodes and disruption of the lymphatic vessels, so it is not surprising that there is a higher incidence of external lymphedema. In our practice, neck dissections increased in frequency every year from June 2008 until December 2011, when 8 patients underwent neck dissections, 6 (75%) of whom developed lymphedema. Since January 2012, when the prehabilitation program was implemented, the number of neck dissections have declined, with more patients receiving chemoradiation and surgery being reserved for surgery. Hamoir and colleagues have reported that neck dissection is no longer justified unless there is clinically residual disease in the neck.¹⁹

Radiation

Lymphedema occurred in patients regardless of the dose of radiation received. Although the incidence of lymphedema seemed to be higher in patients who received more than 60 cGy, that difference was not statistically significant (Table 3). We had expected a relationship between radiation damage and greater lymphedema, but that was not evident in our patients.

Chemotherapy

The majority of patients (n = 131, 69%) received chemotherapy. The exposure to chemotherapy was not correlated with the risk of external lymphedema in our cohort of patients, with 58 of the 131 treated patients (44%) developing lymphedema, compared with 73 (56%) of treated patients who did not (Table 3).

Complete decongestive therapy

All patients with documented lymphedema were evaluated for complete decongestive therapy (CDT). Contraindications to CDT included congestive heart failure, renal failure, acute infection, peripheral artery disease, upper-quadrant deep vein thrombosis, and carotid artery stenosis. Eligible patients were referred to a certified lymphedema therapist for CDT. As the program evolved, patients at risk for lymphedema were referred for CDT early on, usually at the time of diagnosis, to improve early identification and surveillance of lymphedema.

CDT included manual lymph drainage, compression bandaging (Figure), decongestive exercises, skin care, and education in swelling self-management. Manual lymph drainage is a specialized light pressure hands-on technique that reduces swelling by enhancing lymphatic reabsorption and flow. Compressive bandaging/garments increase venous and lymphatic drainage and soften fibrotic tissue. Continued use of compression depends on progress. In head and neck cancer patients, the need for lifelong compression is not evident when they are treated early and there is good patient compliance.⁸ Therapeutic exercise enhances lymphatic and venous circulation, and good skin care reduces the risk of infection.

Communication and education

The head and neck cancer nurse navigator attends the cancer center’s multidisciplinary head and neck tumor board, which has representation from otolaryngology, diagnostic radiology, pathology, radiation oncology, medical oncology, reconstructive surgery, oncology rehabilitation (physical/occupational therapist), dietary services, speech pathology, social services and clinical research. This regular contact allows for earlier awareness about which patients are at greater risk for developing lymphedema, thus enabling early intervention (and patient education) in a timely manner.

Education of the patient, before cancer therapy, of the risks of lymphedema is very important. Before the implementation of the prehabilitation program, some patients did not fully comprehend what a painful and debilitating consequence of cancer treatment lymphedema could be.

Discussion

We introduced a prehabilitation program to detect and treat lymphedema in head and neck cancer patients in January 2012 part way through following an observation cohort from June2008 through June2015. Central to this, in our center, was the appointment of a nurse navigator whose primary focus was on head and neck cancer patients. We placed a high priority on the early detection and treatment of lymphedema because do so has been associated with better outcomes in other centers.

One immediate consequence of the inception of our program was the identification of more patients with external lymphedema. Our detected incidence rose significantly (P = .0002), from 27% in the period June 2008-December 20112010, before the program, to 48% during the January 2012-June 2015 period, after the inception of the program. This later incidence rate is in line with published incidence rates in most centers. However, it is still somewhat short of the 75% suggested in one center,⁹ which suggests we are either we are underdetecting lymphedema or there are differences in definition criteria or sensitivity levels for defining lymphedema.

There are currently no specific objective measures of lymphedema, so there is bound to be some variation in diagnosis rates. In our program, we rely heavily on the patient-reported outcome measures, the NDI instrument, and digital photography to detect and monitor lymphedema, starting with the pretreatment baseline values that are established for each patient.

The use of digital photography in our community hospital setting, which includes taking photographs before and after treatment and at each visit, motivates and encourages patients and provides a tool for clinical lymphedema therapists to visually document benefits of treatment. Patients’ motivation and compliance with their established home program for head and neck lymphedema self-management are essential. The elements of the home program may include self-manual lymph drainage, home-modified compression bandaging and garment wear, therapeutic exercises, and skin care. Patients with lymphedema who adhered closely with their therapy program were more than 8 times more likely to improve compared with noncompliant patients.¹⁷

Some groups of patients have a greater risk of developing lymphedema than others,⁵ so the development of an algorithm to predict lymphedema seemed possible. However, in our cohort of patients, only neck dissection, with its disruption of the lymphatic system of the neck, was strongly associated with external lymphedema (Table 3). It is important to note that some patients who did not undergo surgery developed lymphedema. In our patients, high doses of radiation alone did not seem to predispose to lymphedema. That suggests that no group of head and neck cancer patients should be ignored, which is why we did routine screening of all patients before, during, and after treatment.

Our protocol falls short in the detection of internal lymphedema. For example, information on swallowing gathered by our speech pathologists (in a different department) has not, so far, been included in our assessment. This is one opportunity to improve on our approach, especially because speech difficulties may be associated with internal lymphedema. In addition, we are not equipped for the requisite internal examinations. Unfortunately, there are no practical and successful treatments for patients suffering from internal swelling. This represents a challenge for the medical community to better meet this need. Therefore, although we are missing some assessments of internal lymphedema, this is of little therapeutic consequence at this time.

The increase in the detected incidence of external lymphedema points to a practice gap that has been resolved by the appointment of a dedicated nurse navigator who attends oncology reviews to share knowledge and information. Another educational effort has been made with the patients themselves to increase compliance and improve continuous care at home.

There is always room for improvement, however, either by feedback acquired from other institutions and hospitals or through the future introduction of more objective assessment techniques.

Conclusions

The introduction of the prehabilitation program at our center has coincided with a significantly improved detection rate for external lymphedema in head and neck cancer patients. It may be because the program emphasizes education about lymphedema that awareness of the condition has increased throughout the center. It is now widely recognized that all patients are at risk of lymphedema regardless of whether they fall into an acknowledged high-risk group. Our experience shows that there is no significant difference between treatment modalities apart from neck dissection. In our population, the use of this procedure is decreasing. External lymphedema can develop even in patients who do not have surgery. Therefore, there is no sound way to predict which patients are most likely to suffer from the accumulation of fluid in their head and neck after treatment for head and neck cancer. Thus, an assessment as described here, during and after treatment for all patients, is warranted. Patients are now being seen earlier as a part of the prehabilitation program, which facilitates access to complete decongestive treatment at an earlier stage, improves patient outcomes, and increases patient satisfaction with their treatment. Our prehabilitation program could serve as a model for other community hospital centers in achieving outcomes that are as good as those in academic centers.

Acknowledgments

The authors thank Irene Kadota and Heather Peters, from the Department of Radiation Oncology, and Julianne Courtenay, from the Department of Physical Therapy at the Disney Family Cancer Center, Burbank, California, for providing the original clinical data for analysis.

Lymphedema is the swelling of tissue caused by the accumulation of interstitial fluid in any area of the body where lymphatic flow has been compromised.¹ Secondary lymphedema is an acquired abnormality in lymph drainage^1,2 and is the type commonly seen in cancer patients. Secondary lymphedema can be described as external or internal. Internal lymphedema, swelling of deep structures and tissues, is very difficult to quantify.

Lymphedema in patients with head and neck cancers
Lymphedema is a complicating morbidity frequently seen in head and neck cancer patients who have undergone treatment with surgery, radiation, and chemotherapy. However, although it is one of the most prevalent side effects of treatment, it is both under-recognized and under-treated.³

In head and neck cancer patients, internal swelling may develop in the soft tissues of the upper aero-digestive tract,⁴ affecting articulation and swallowing. Currently, there does not seem to be an effective practical and reliable tool with which to measure internal lymphedema. In addition, it is generally accepted that there is no effective way to treat internal lymphedema. By contrast, external lymphedema is more readily observed, but both subjective and objective assessments are difficult. External swelling may occur in the face, jaw, and neck. However, the subjective scales currently available are insufficient to capture very important characteristics of external lymphedema.⁵ The Edge Task Force on Head and Neck Cancer in 2015 was not able to recommend any outcome measures for objectively quantifying external edema.⁶ Furthermore, objective measurements of head and neck lymphedema can be expensive and time consuming.

Extent and risk

A combination of both internal and external swelling is seen in more than 50% of patients.⁷ Risk factors include “throat” tumors, multicancer treatment approaches, higher total radiation dose, a greater number of radiation procedures, and radiation at the surgical site.⁵ More than 500,000 survivors of head and neck cancer in the United States are at risk of lymphedema.⁵ Although recent advances in treatment have reduced the incidence of other morbidities, 50% of patients who are treated for head and neck cancer may still develop lymphedema.^1,8 The reported incidence in some centers may be much higher, with up to 75% of patients developing lymphedema following treatment.⁹

Measurement modalities for clinical evaluation

There is little current research into lymphedema of the head and neck, despite the high prevalence of the condition.⁸ According to Deng and colleagues, measurement of head and neck lymphedema is a challenge, which has an impact on clinical assessment, diagnosis, and treatment of this under-recognized, under-reported and under-addressed problem in head and neck cancer patients.¹⁰ In a review of the literature, Deng and colleagues identified three measurement modalities available for clinical evaluation: patient-reported outcomes, clinician-reported outcomes, and technology.¹⁰ One major factor, though, in detecting lymphedema, is physician awareness: physicians, health care professionals, and even some lymphedema therapists are not well educated about this problem.⁸

Treatment

The effectiveness of traditional lymphedema treatment is not well defined.⁸ Currently, complete decongestive therapy (CDT), is considered the standard of care for lymphedema. The National Lymphedema Network has stated that modifications of CDT, especially manual lymphatic drainage and modified compressive garments for external lymphedema, have been shown to be beneficial for the treatment of lymphedema in head and neck cancer patients.¹¹ Most findings in lymphedema research, mainly in breast cancer patients, have shown that early intervention is the best management and yields the best outcomes. As with other chronic conditions, early identification and timely, appropriate treatment of lymphedema is critical to improve clinical outcomes, to decrease symptom burden and functional impairment, and to improve overall quality of life in head and neck cancer patients.¹⁰

Improving recognition and treatment

Head and neck oncologic treatment is increasingly offered outside the network of specialist academic hospitals, at hospitals serving more localized communities where the neediest, sickest patient groups may be receiving less than optimal care.³ This challenges community hospitals to provide optimal treatment, similar to that being offered at nationally recognized institutions. In January 2012, we implemented a prehabilitation program in our community hospital cancer center to provide early intervention for our patients based on the understanding that proper and prompt treatment for patients with early signs of lymphedema should be a priority.¹² In this article, we outline how we implemented the program and the describe improvements we observed before and after the implementation of the program.

The prehabilitation program

The role of the nurse navigator

Before the introduction of the prehabilitation program, our pattern of practice was to refer patients to oncology rehabilitation for lymphedema management after they had completed their medical treatment with surgery, radiation, and chemotherapy. In 2012, that was changed to a prehabilitation model of care that was overseen by a head and neck nurse navigator. This focus on prehabilitation begins with patients being referred to oncology rehabilitation at the time of cancer diagnosis for baseline assessment of head and neck swelling. In addition, there is assessment of the many possible other side effects associated with head and neck cancer and its treatment, namely loss of range of motion of the neck, jaw (trismus), and/or shoulders, postural deficits, functional loss, pain, balance dysfunction with fall risk, weakness, and fatigue. Therapeutic interventions are initiated as needed and appropriate. This process also raises awareness of a condition that has been described as under-recognized and under-treated.³

The nurse navigator sits in on each radiation oncology consultation and aids in “navigating” patients through their treatment. The nurse ensures that each patient is referred to different ancillary services from the outset, such as seeing a dietician, social worker, physical/occupational therapist and certified lymphedema therapist, speech pathologist, and financial assistance advisor, if necessary (Table 1).

Assessment of lymphedema

Measurement of head and neck lymphedema is a challenge.¹⁰ In our program, the physical therapy assessment also includes the evaluation of several other morbidities associated with head and neck cancer and its treatment, such as range of motion, weakness, fatigue, radiation fibrosis, balance dysfunction, and risk of falling (Table 2).

Although objective criteria for external lymphedema have not been established, simple measurements such as using a tape measure to record neck circumference, allow a useful longitudinal assessment. Digital photography may be effective in the documentation and subjective evaluation of changes of external lymphedema.^10,17 However, there are some limitations with photography because although external photographs (including digital photography and three-dimensional imaging) can capture some features, such as changes in contours, symmetry, and changes in skin quality and color, they do not detect changes in skin and soft tissue texture and compliance (Table 3).¹⁰

Impact on clinical outcomes

We retrospectively reviewed the medical records of 230 head and neck cancer patients who had been treated at our center between June 2008 and June 2015. Complete clinical data were available for 190 patients. The following information was extracted from each patient’s chart: whether they developed lymphedema, tumor stage, had surgery, radiation dose, type of chemotherapy given, their smoking history, if they had had a neck dissection and the primary site of the tumor (Table 3).

Incidence in different time periods. Of the 190 patients with complete records 78 (41%) were found to have lymphedema. These were all patients undergoing treatment for head and neck cancer during June 2008-June 2015. The prehabilitation program was initiated with the hiring of a nurse navigator for head and neck cancer, starting in January 2012. It is interesting to note that the incidence of lymphedema was 27% before the program was started, but after nurse navigator joined the team, the incidence increased significantly to 48% (P = .0002), in line with published expectations. This increase in recorded incidence may be attributable to the greater awareness of lymphedema intentionally fostered by the prehabilitation program.

Smoking history. Patients’ lifetime smoking history was retrieved from their medical records, based on their verbal admission of tobacco use. Most of the patients (n = 110) self-reported a history of smoking. Of those with a history of smoking, 36 (33%) developed external lymphedema after treatment for head and neck cancer, and 74 (67%) did not. However, this difference was not statistically significant. Hence, although smoking is a risk factor for head and neck cancer, it was not associated with the development of external lymphedema in our cohort of patients.

Type of tumor

Most of the patients (n = 156, 82%) had squamous cell carcinomas (SCC). Of those, 45% developed external lymphedema and 55% did not. Therefore, having SCC did not predispose to lymphedema. The other cancers were mixed type, mainly adenocaricoma, but their numbers were too small to draw statistical conclusions.

Stage of the tumor

About two thirds of the patients (n = 121, 64%) had stage 3 or 4 cancer. However, treatment of more advanced cancers was not associated with lymphedema development.

Site of the tumor

The literature suggests that patients with a primary tumor in the throat are at increased risk for lymphedema.⁵ The American Cancer Society has defined cancers of the oropharynx (throat) as including the base of the tongue (back third of the tongue), the soft palate, the tonsils, and the side and back walls of the throat.¹⁸ In our head and neck cancer cohort, patients with primary tumors of the oropharnyx were, perhaps, more susceptible to lymphedema (P = .044, Table 3). By contrast, in our cohort of patients, those with nasopharyngeal, hypopharyngeal, and parotid gland tumors were significantly less likely to develop lymphedema (Ps = .017, .04, .012, respectively).

No surgery

Half of our patients (n = 95) were not treated with surgery. In the patients who did not have surgery, 25 (26%) developed lymphedema, whereas 70 (74%) did not. Hence, although the incidence of lymphedema was significantly lower in patients who did not have surgery (P = .015), lymphedema did develop in patients who did not have a surgical procedure.

Resection of primary tumor without neck dissection

Of the 64 patients who had surgery, but without neck dissection, 35 (55%) developed external lymphedema. Compared with the no-surgery patients, the doubling of the incidence (from 26% to 55%) was highly significant (P = .0004). These findings are compatible with the literature reports that surgery increases the incidence of lymphedema, which is not surprising because surgery and subsequent scarring is known to compromise the lymphatic system.

Resection of primary tumor with neck dissection

The incidence of external lymphedema was increased to 69% when patients were subjected to both surgery and neck dissection. Compared with the June 2008-June 2015 cohort, there was a significant increase in the incidence of lymphedema in the neck dissection group (P = .007). Neck dissection involves the removal of lymph nodes and disruption of the lymphatic vessels, so it is not surprising that there is a higher incidence of external lymphedema. In our practice, neck dissections increased in frequency every year from June 2008 until December 2011, when 8 patients underwent neck dissections, 6 (75%) of whom developed lymphedema. Since January 2012, when the prehabilitation program was implemented, the number of neck dissections have declined, with more patients receiving chemoradiation and surgery being reserved for surgery. Hamoir and colleagues have reported that neck dissection is no longer justified unless there is clinically residual disease in the neck.¹⁹

Radiation

Lymphedema occurred in patients regardless of the dose of radiation received. Although the incidence of lymphedema seemed to be higher in patients who received more than 60 cGy, that difference was not statistically significant (Table 3). We had expected a relationship between radiation damage and greater lymphedema, but that was not evident in our patients.

Chemotherapy

The majority of patients (n = 131, 69%) received chemotherapy. The exposure to chemotherapy was not correlated with the risk of external lymphedema in our cohort of patients, with 58 of the 131 treated patients (44%) developing lymphedema, compared with 73 (56%) of treated patients who did not (Table 3).

Complete decongestive therapy

All patients with documented lymphedema were evaluated for complete decongestive therapy (CDT). Contraindications to CDT included congestive heart failure, renal failure, acute infection, peripheral artery disease, upper-quadrant deep vein thrombosis, and carotid artery stenosis. Eligible patients were referred to a certified lymphedema therapist for CDT. As the program evolved, patients at risk for lymphedema were referred for CDT early on, usually at the time of diagnosis, to improve early identification and surveillance of lymphedema.

CDT included manual lymph drainage, compression bandaging (Figure), decongestive exercises, skin care, and education in swelling self-management. Manual lymph drainage is a specialized light pressure hands-on technique that reduces swelling by enhancing lymphatic reabsorption and flow. Compressive bandaging/garments increase venous and lymphatic drainage and soften fibrotic tissue. Continued use of compression depends on progress. In head and neck cancer patients, the need for lifelong compression is not evident when they are treated early and there is good patient compliance.⁸ Therapeutic exercise enhances lymphatic and venous circulation, and good skin care reduces the risk of infection.

Communication and education

The head and neck cancer nurse navigator attends the cancer center’s multidisciplinary head and neck tumor board, which has representation from otolaryngology, diagnostic radiology, pathology, radiation oncology, medical oncology, reconstructive surgery, oncology rehabilitation (physical/occupational therapist), dietary services, speech pathology, social services and clinical research. This regular contact allows for earlier awareness about which patients are at greater risk for developing lymphedema, thus enabling early intervention (and patient education) in a timely manner.

Education of the patient, before cancer therapy, of the risks of lymphedema is very important. Before the implementation of the prehabilitation program, some patients did not fully comprehend what a painful and debilitating consequence of cancer treatment lymphedema could be.

Discussion

We introduced a prehabilitation program to detect and treat lymphedema in head and neck cancer patients in January 2012 part way through following an observation cohort from June2008 through June2015. Central to this, in our center, was the appointment of a nurse navigator whose primary focus was on head and neck cancer patients. We placed a high priority on the early detection and treatment of lymphedema because do so has been associated with better outcomes in other centers.

One immediate consequence of the inception of our program was the identification of more patients with external lymphedema. Our detected incidence rose significantly (P = .0002), from 27% in the period June 2008-December 20112010, before the program, to 48% during the January 2012-June 2015 period, after the inception of the program. This later incidence rate is in line with published incidence rates in most centers. However, it is still somewhat short of the 75% suggested in one center,⁹ which suggests we are either we are underdetecting lymphedema or there are differences in definition criteria or sensitivity levels for defining lymphedema.

There are currently no specific objective measures of lymphedema, so there is bound to be some variation in diagnosis rates. In our program, we rely heavily on the patient-reported outcome measures, the NDI instrument, and digital photography to detect and monitor lymphedema, starting with the pretreatment baseline values that are established for each patient.

The use of digital photography in our community hospital setting, which includes taking photographs before and after treatment and at each visit, motivates and encourages patients and provides a tool for clinical lymphedema therapists to visually document benefits of treatment. Patients’ motivation and compliance with their established home program for head and neck lymphedema self-management are essential. The elements of the home program may include self-manual lymph drainage, home-modified compression bandaging and garment wear, therapeutic exercises, and skin care. Patients with lymphedema who adhered closely with their therapy program were more than 8 times more likely to improve compared with noncompliant patients.¹⁷

Some groups of patients have a greater risk of developing lymphedema than others,⁵ so the development of an algorithm to predict lymphedema seemed possible. However, in our cohort of patients, only neck dissection, with its disruption of the lymphatic system of the neck, was strongly associated with external lymphedema (Table 3). It is important to note that some patients who did not undergo surgery developed lymphedema. In our patients, high doses of radiation alone did not seem to predispose to lymphedema. That suggests that no group of head and neck cancer patients should be ignored, which is why we did routine screening of all patients before, during, and after treatment.

Our protocol falls short in the detection of internal lymphedema. For example, information on swallowing gathered by our speech pathologists (in a different department) has not, so far, been included in our assessment. This is one opportunity to improve on our approach, especially because speech difficulties may be associated with internal lymphedema. In addition, we are not equipped for the requisite internal examinations. Unfortunately, there are no practical and successful treatments for patients suffering from internal swelling. This represents a challenge for the medical community to better meet this need. Therefore, although we are missing some assessments of internal lymphedema, this is of little therapeutic consequence at this time.

The increase in the detected incidence of external lymphedema points to a practice gap that has been resolved by the appointment of a dedicated nurse navigator who attends oncology reviews to share knowledge and information. Another educational effort has been made with the patients themselves to increase compliance and improve continuous care at home.

There is always room for improvement, however, either by feedback acquired from other institutions and hospitals or through the future introduction of more objective assessment techniques.

Conclusions

The introduction of the prehabilitation program at our center has coincided with a significantly improved detection rate for external lymphedema in head and neck cancer patients. It may be because the program emphasizes education about lymphedema that awareness of the condition has increased throughout the center. It is now widely recognized that all patients are at risk of lymphedema regardless of whether they fall into an acknowledged high-risk group. Our experience shows that there is no significant difference between treatment modalities apart from neck dissection. In our population, the use of this procedure is decreasing. External lymphedema can develop even in patients who do not have surgery. Therefore, there is no sound way to predict which patients are most likely to suffer from the accumulation of fluid in their head and neck after treatment for head and neck cancer. Thus, an assessment as described here, during and after treatment for all patients, is warranted. Patients are now being seen earlier as a part of the prehabilitation program, which facilitates access to complete decongestive treatment at an earlier stage, improves patient outcomes, and increases patient satisfaction with their treatment. Our prehabilitation program could serve as a model for other community hospital centers in achieving outcomes that are as good as those in academic centers.

Acknowledgments

The authors thank Irene Kadota and Heather Peters, from the Department of Radiation Oncology, and Julianne Courtenay, from the Department of Physical Therapy at the Disney Family Cancer Center, Burbank, California, for providing the original clinical data for analysis.

Lymphedema is the swelling of tissue caused by the accumulation of interstitial fluid in any area of the body where lymphatic flow has been compromised.¹ Secondary lymphedema is an acquired abnormality in lymph drainage^1,2 and is the type commonly seen in cancer patients. Secondary lymphedema can be described as external or internal. Internal lymphedema, swelling of deep structures and tissues, is very difficult to quantify.

Lymphedema in patients with head and neck cancers
Lymphedema is a complicating morbidity frequently seen in head and neck cancer patients who have undergone treatment with surgery, radiation, and chemotherapy. However, although it is one of the most prevalent side effects of treatment, it is both under-recognized and under-treated.³

In head and neck cancer patients, internal swelling may develop in the soft tissues of the upper aero-digestive tract,⁴ affecting articulation and swallowing. Currently, there does not seem to be an effective practical and reliable tool with which to measure internal lymphedema. In addition, it is generally accepted that there is no effective way to treat internal lymphedema. By contrast, external lymphedema is more readily observed, but both subjective and objective assessments are difficult. External swelling may occur in the face, jaw, and neck. However, the subjective scales currently available are insufficient to capture very important characteristics of external lymphedema.⁵ The Edge Task Force on Head and Neck Cancer in 2015 was not able to recommend any outcome measures for objectively quantifying external edema.⁶ Furthermore, objective measurements of head and neck lymphedema can be expensive and time consuming.

Extent and risk

A combination of both internal and external swelling is seen in more than 50% of patients.⁷ Risk factors include “throat” tumors, multicancer treatment approaches, higher total radiation dose, a greater number of radiation procedures, and radiation at the surgical site.⁵ More than 500,000 survivors of head and neck cancer in the United States are at risk of lymphedema.⁵ Although recent advances in treatment have reduced the incidence of other morbidities, 50% of patients who are treated for head and neck cancer may still develop lymphedema.^1,8 The reported incidence in some centers may be much higher, with up to 75% of patients developing lymphedema following treatment.⁹

Measurement modalities for clinical evaluation

There is little current research into lymphedema of the head and neck, despite the high prevalence of the condition.⁸ According to Deng and colleagues, measurement of head and neck lymphedema is a challenge, which has an impact on clinical assessment, diagnosis, and treatment of this under-recognized, under-reported and under-addressed problem in head and neck cancer patients.¹⁰ In a review of the literature, Deng and colleagues identified three measurement modalities available for clinical evaluation: patient-reported outcomes, clinician-reported outcomes, and technology.¹⁰ One major factor, though, in detecting lymphedema, is physician awareness: physicians, health care professionals, and even some lymphedema therapists are not well educated about this problem.⁸

Treatment

The effectiveness of traditional lymphedema treatment is not well defined.⁸ Currently, complete decongestive therapy (CDT), is considered the standard of care for lymphedema. The National Lymphedema Network has stated that modifications of CDT, especially manual lymphatic drainage and modified compressive garments for external lymphedema, have been shown to be beneficial for the treatment of lymphedema in head and neck cancer patients.¹¹ Most findings in lymphedema research, mainly in breast cancer patients, have shown that early intervention is the best management and yields the best outcomes. As with other chronic conditions, early identification and timely, appropriate treatment of lymphedema is critical to improve clinical outcomes, to decrease symptom burden and functional impairment, and to improve overall quality of life in head and neck cancer patients.¹⁰

Improving recognition and treatment

Head and neck oncologic treatment is increasingly offered outside the network of specialist academic hospitals, at hospitals serving more localized communities where the neediest, sickest patient groups may be receiving less than optimal care.³ This challenges community hospitals to provide optimal treatment, similar to that being offered at nationally recognized institutions. In January 2012, we implemented a prehabilitation program in our community hospital cancer center to provide early intervention for our patients based on the understanding that proper and prompt treatment for patients with early signs of lymphedema should be a priority.¹² In this article, we outline how we implemented the program and the describe improvements we observed before and after the implementation of the program.

The prehabilitation program

The role of the nurse navigator

Before the introduction of the prehabilitation program, our pattern of practice was to refer patients to oncology rehabilitation for lymphedema management after they had completed their medical treatment with surgery, radiation, and chemotherapy. In 2012, that was changed to a prehabilitation model of care that was overseen by a head and neck nurse navigator. This focus on prehabilitation begins with patients being referred to oncology rehabilitation at the time of cancer diagnosis for baseline assessment of head and neck swelling. In addition, there is assessment of the many possible other side effects associated with head and neck cancer and its treatment, namely loss of range of motion of the neck, jaw (trismus), and/or shoulders, postural deficits, functional loss, pain, balance dysfunction with fall risk, weakness, and fatigue. Therapeutic interventions are initiated as needed and appropriate. This process also raises awareness of a condition that has been described as under-recognized and under-treated.³

The nurse navigator sits in on each radiation oncology consultation and aids in “navigating” patients through their treatment. The nurse ensures that each patient is referred to different ancillary services from the outset, such as seeing a dietician, social worker, physical/occupational therapist and certified lymphedema therapist, speech pathologist, and financial assistance advisor, if necessary (Table 1).

Assessment of lymphedema

Measurement of head and neck lymphedema is a challenge.¹⁰ In our program, the physical therapy assessment also includes the evaluation of several other morbidities associated with head and neck cancer and its treatment, such as range of motion, weakness, fatigue, radiation fibrosis, balance dysfunction, and risk of falling (Table 2).

Although objective criteria for external lymphedema have not been established, simple measurements such as using a tape measure to record neck circumference, allow a useful longitudinal assessment. Digital photography may be effective in the documentation and subjective evaluation of changes of external lymphedema.^10,17 However, there are some limitations with photography because although external photographs (including digital photography and three-dimensional imaging) can capture some features, such as changes in contours, symmetry, and changes in skin quality and color, they do not detect changes in skin and soft tissue texture and compliance (Table 3).¹⁰

Impact on clinical outcomes

We retrospectively reviewed the medical records of 230 head and neck cancer patients who had been treated at our center between June 2008 and June 2015. Complete clinical data were available for 190 patients. The following information was extracted from each patient’s chart: whether they developed lymphedema, tumor stage, had surgery, radiation dose, type of chemotherapy given, their smoking history, if they had had a neck dissection and the primary site of the tumor (Table 3).

Incidence in different time periods. Of the 190 patients with complete records 78 (41%) were found to have lymphedema. These were all patients undergoing treatment for head and neck cancer during June 2008-June 2015. The prehabilitation program was initiated with the hiring of a nurse navigator for head and neck cancer, starting in January 2012. It is interesting to note that the incidence of lymphedema was 27% before the program was started, but after nurse navigator joined the team, the incidence increased significantly to 48% (P = .0002), in line with published expectations. This increase in recorded incidence may be attributable to the greater awareness of lymphedema intentionally fostered by the prehabilitation program.

Smoking history. Patients’ lifetime smoking history was retrieved from their medical records, based on their verbal admission of tobacco use. Most of the patients (n = 110) self-reported a history of smoking. Of those with a history of smoking, 36 (33%) developed external lymphedema after treatment for head and neck cancer, and 74 (67%) did not. However, this difference was not statistically significant. Hence, although smoking is a risk factor for head and neck cancer, it was not associated with the development of external lymphedema in our cohort of patients.

Type of tumor

Most of the patients (n = 156, 82%) had squamous cell carcinomas (SCC). Of those, 45% developed external lymphedema and 55% did not. Therefore, having SCC did not predispose to lymphedema. The other cancers were mixed type, mainly adenocaricoma, but their numbers were too small to draw statistical conclusions.

Stage of the tumor

About two thirds of the patients (n = 121, 64%) had stage 3 or 4 cancer. However, treatment of more advanced cancers was not associated with lymphedema development.

Site of the tumor

The literature suggests that patients with a primary tumor in the throat are at increased risk for lymphedema.⁵ The American Cancer Society has defined cancers of the oropharynx (throat) as including the base of the tongue (back third of the tongue), the soft palate, the tonsils, and the side and back walls of the throat.¹⁸ In our head and neck cancer cohort, patients with primary tumors of the oropharnyx were, perhaps, more susceptible to lymphedema (P = .044, Table 3). By contrast, in our cohort of patients, those with nasopharyngeal, hypopharyngeal, and parotid gland tumors were significantly less likely to develop lymphedema (Ps = .017, .04, .012, respectively).

No surgery

Half of our patients (n = 95) were not treated with surgery. In the patients who did not have surgery, 25 (26%) developed lymphedema, whereas 70 (74%) did not. Hence, although the incidence of lymphedema was significantly lower in patients who did not have surgery (P = .015), lymphedema did develop in patients who did not have a surgical procedure.

Resection of primary tumor without neck dissection

Of the 64 patients who had surgery, but without neck dissection, 35 (55%) developed external lymphedema. Compared with the no-surgery patients, the doubling of the incidence (from 26% to 55%) was highly significant (P = .0004). These findings are compatible with the literature reports that surgery increases the incidence of lymphedema, which is not surprising because surgery and subsequent scarring is known to compromise the lymphatic system.

Resection of primary tumor with neck dissection

The incidence of external lymphedema was increased to 69% when patients were subjected to both surgery and neck dissection. Compared with the June 2008-June 2015 cohort, there was a significant increase in the incidence of lymphedema in the neck dissection group (P = .007). Neck dissection involves the removal of lymph nodes and disruption of the lymphatic vessels, so it is not surprising that there is a higher incidence of external lymphedema. In our practice, neck dissections increased in frequency every year from June 2008 until December 2011, when 8 patients underwent neck dissections, 6 (75%) of whom developed lymphedema. Since January 2012, when the prehabilitation program was implemented, the number of neck dissections have declined, with more patients receiving chemoradiation and surgery being reserved for surgery. Hamoir and colleagues have reported that neck dissection is no longer justified unless there is clinically residual disease in the neck.¹⁹

Radiation

Lymphedema occurred in patients regardless of the dose of radiation received. Although the incidence of lymphedema seemed to be higher in patients who received more than 60 cGy, that difference was not statistically significant (Table 3). We had expected a relationship between radiation damage and greater lymphedema, but that was not evident in our patients.

Chemotherapy

The majority of patients (n = 131, 69%) received chemotherapy. The exposure to chemotherapy was not correlated with the risk of external lymphedema in our cohort of patients, with 58 of the 131 treated patients (44%) developing lymphedema, compared with 73 (56%) of treated patients who did not (Table 3).

Complete decongestive therapy

All patients with documented lymphedema were evaluated for complete decongestive therapy (CDT). Contraindications to CDT included congestive heart failure, renal failure, acute infection, peripheral artery disease, upper-quadrant deep vein thrombosis, and carotid artery stenosis. Eligible patients were referred to a certified lymphedema therapist for CDT. As the program evolved, patients at risk for lymphedema were referred for CDT early on, usually at the time of diagnosis, to improve early identification and surveillance of lymphedema.

CDT included manual lymph drainage, compression bandaging (Figure), decongestive exercises, skin care, and education in swelling self-management. Manual lymph drainage is a specialized light pressure hands-on technique that reduces swelling by enhancing lymphatic reabsorption and flow. Compressive bandaging/garments increase venous and lymphatic drainage and soften fibrotic tissue. Continued use of compression depends on progress. In head and neck cancer patients, the need for lifelong compression is not evident when they are treated early and there is good patient compliance.⁸ Therapeutic exercise enhances lymphatic and venous circulation, and good skin care reduces the risk of infection.

Communication and education

The head and neck cancer nurse navigator attends the cancer center’s multidisciplinary head and neck tumor board, which has representation from otolaryngology, diagnostic radiology, pathology, radiation oncology, medical oncology, reconstructive surgery, oncology rehabilitation (physical/occupational therapist), dietary services, speech pathology, social services and clinical research. This regular contact allows for earlier awareness about which patients are at greater risk for developing lymphedema, thus enabling early intervention (and patient education) in a timely manner.

Education of the patient, before cancer therapy, of the risks of lymphedema is very important. Before the implementation of the prehabilitation program, some patients did not fully comprehend what a painful and debilitating consequence of cancer treatment lymphedema could be.

Discussion

We introduced a prehabilitation program to detect and treat lymphedema in head and neck cancer patients in January 2012 part way through following an observation cohort from June2008 through June2015. Central to this, in our center, was the appointment of a nurse navigator whose primary focus was on head and neck cancer patients. We placed a high priority on the early detection and treatment of lymphedema because do so has been associated with better outcomes in other centers.

One immediate consequence of the inception of our program was the identification of more patients with external lymphedema. Our detected incidence rose significantly (P = .0002), from 27% in the period June 2008-December 20112010, before the program, to 48% during the January 2012-June 2015 period, after the inception of the program. This later incidence rate is in line with published incidence rates in most centers. However, it is still somewhat short of the 75% suggested in one center,⁹ which suggests we are either we are underdetecting lymphedema or there are differences in definition criteria or sensitivity levels for defining lymphedema.

There are currently no specific objective measures of lymphedema, so there is bound to be some variation in diagnosis rates. In our program, we rely heavily on the patient-reported outcome measures, the NDI instrument, and digital photography to detect and monitor lymphedema, starting with the pretreatment baseline values that are established for each patient.

The use of digital photography in our community hospital setting, which includes taking photographs before and after treatment and at each visit, motivates and encourages patients and provides a tool for clinical lymphedema therapists to visually document benefits of treatment. Patients’ motivation and compliance with their established home program for head and neck lymphedema self-management are essential. The elements of the home program may include self-manual lymph drainage, home-modified compression bandaging and garment wear, therapeutic exercises, and skin care. Patients with lymphedema who adhered closely with their therapy program were more than 8 times more likely to improve compared with noncompliant patients.¹⁷

Some groups of patients have a greater risk of developing lymphedema than others,⁵ so the development of an algorithm to predict lymphedema seemed possible. However, in our cohort of patients, only neck dissection, with its disruption of the lymphatic system of the neck, was strongly associated with external lymphedema (Table 3). It is important to note that some patients who did not undergo surgery developed lymphedema. In our patients, high doses of radiation alone did not seem to predispose to lymphedema. That suggests that no group of head and neck cancer patients should be ignored, which is why we did routine screening of all patients before, during, and after treatment.

Our protocol falls short in the detection of internal lymphedema. For example, information on swallowing gathered by our speech pathologists (in a different department) has not, so far, been included in our assessment. This is one opportunity to improve on our approach, especially because speech difficulties may be associated with internal lymphedema. In addition, we are not equipped for the requisite internal examinations. Unfortunately, there are no practical and successful treatments for patients suffering from internal swelling. This represents a challenge for the medical community to better meet this need. Therefore, although we are missing some assessments of internal lymphedema, this is of little therapeutic consequence at this time.

The increase in the detected incidence of external lymphedema points to a practice gap that has been resolved by the appointment of a dedicated nurse navigator who attends oncology reviews to share knowledge and information. Another educational effort has been made with the patients themselves to increase compliance and improve continuous care at home.

There is always room for improvement, however, either by feedback acquired from other institutions and hospitals or through the future introduction of more objective assessment techniques.

Conclusions

The introduction of the prehabilitation program at our center has coincided with a significantly improved detection rate for external lymphedema in head and neck cancer patients. It may be because the program emphasizes education about lymphedema that awareness of the condition has increased throughout the center. It is now widely recognized that all patients are at risk of lymphedema regardless of whether they fall into an acknowledged high-risk group. Our experience shows that there is no significant difference between treatment modalities apart from neck dissection. In our population, the use of this procedure is decreasing. External lymphedema can develop even in patients who do not have surgery. Therefore, there is no sound way to predict which patients are most likely to suffer from the accumulation of fluid in their head and neck after treatment for head and neck cancer. Thus, an assessment as described here, during and after treatment for all patients, is warranted. Patients are now being seen earlier as a part of the prehabilitation program, which facilitates access to complete decongestive treatment at an earlier stage, improves patient outcomes, and increases patient satisfaction with their treatment. Our prehabilitation program could serve as a model for other community hospital centers in achieving outcomes that are as good as those in academic centers.

Acknowledgments

The authors thank Irene Kadota and Heather Peters, from the Department of Radiation Oncology, and Julianne Courtenay, from the Department of Physical Therapy at the Disney Family Cancer Center, Burbank, California, for providing the original clinical data for analysis.

CHICAGO – Genomic testing for all cancer patients was shown to be feasible and productive in a recent study, with a trend toward longer survival among those patients who received recommended targeted treatment.

Molecular profiling, including genetic sequencing and copy number variation analysis, was performed in 1944 tumors from patients with advanced tumors enrolled in the profiLER study. Of the tumors screened, mutations deemed actionable were identified in 1,004 (52%), with 394 patients having two or more actionable targets, and the remainder having one identified targeted treatment. A molecular targeted treatment was recommended for 676 patients (35% of those tested).

“We showed that the patients who did receive the molecular targeted agents were doing better in terms of overall survival,” said Olivier Tredan, MD, PhD, the study’s lead investigator. Noting that these are trends as the trial was not randomized, he reported that the overall survival (OS) for those receiving targeted treatments was 53.7% at 3 years, compared with 46.1% for those who did not receive targeted treatment. The trend continued out to 5 years, with the OS for the targeted treatment group at 34.8%, compared with 28.1% OS for those who did not receive targeted treatment, he said at the annual meeting of the American Society of Clinical Oncology.

[email protected]
On Twitter @karioakes

CHICAGO – Genomic testing for all cancer patients was shown to be feasible and productive in a recent study, with a trend toward longer survival among those patients who received recommended targeted treatment.

Molecular profiling, including genetic sequencing and copy number variation analysis, was performed in 1944 tumors from patients with advanced tumors enrolled in the profiLER study. Of the tumors screened, mutations deemed actionable were identified in 1,004 (52%), with 394 patients having two or more actionable targets, and the remainder having one identified targeted treatment. A molecular targeted treatment was recommended for 676 patients (35% of those tested).

“We showed that the patients who did receive the molecular targeted agents were doing better in terms of overall survival,” said Olivier Tredan, MD, PhD, the study’s lead investigator. Noting that these are trends as the trial was not randomized, he reported that the overall survival (OS) for those receiving targeted treatments was 53.7% at 3 years, compared with 46.1% for those who did not receive targeted treatment. The trend continued out to 5 years, with the OS for the targeted treatment group at 34.8%, compared with 28.1% OS for those who did not receive targeted treatment, he said at the annual meeting of the American Society of Clinical Oncology.

[email protected]
On Twitter @karioakes

CHICAGO – Genomic testing for all cancer patients was shown to be feasible and productive in a recent study, with a trend toward longer survival among those patients who received recommended targeted treatment.

Molecular profiling, including genetic sequencing and copy number variation analysis, was performed in 1944 tumors from patients with advanced tumors enrolled in the profiLER study. Of the tumors screened, mutations deemed actionable were identified in 1,004 (52%), with 394 patients having two or more actionable targets, and the remainder having one identified targeted treatment. A molecular targeted treatment was recommended for 676 patients (35% of those tested).

“We showed that the patients who did receive the molecular targeted agents were doing better in terms of overall survival,” said Olivier Tredan, MD, PhD, the study’s lead investigator. Noting that these are trends as the trial was not randomized, he reported that the overall survival (OS) for those receiving targeted treatments was 53.7% at 3 years, compared with 46.1% for those who did not receive targeted treatment. The trend continued out to 5 years, with the OS for the targeted treatment group at 34.8%, compared with 28.1% OS for those who did not receive targeted treatment, he said at the annual meeting of the American Society of Clinical Oncology.

[email protected]
On Twitter @karioakes

Oral cancer has a low 5-year survival rate compared with other major types of cancer, and the rate hasn’t improved much in recent years, say researchers from China Medical University, Asia University, Taichung Veterans General Hospital, and National Yang-Ming University; all in Taichung, Taiwan. That may be due in part to delay in treatment, they say. Their analysis of data of 21,263 patients with oral cavity squamous cell carcinoma (OCSCC) bears out their theory.

Related: Predicting Tongue Cancer Recurrence

About 40% of the patients presented with stage IV disease. More than one-third had tongue cancer. The average time from diagnosis to treatment was 24 days. Most patients (86%) were treated within 30 days of diagnosis; 12% were treated between 31 and 120 days after diagnosis, and 2.7% received treatment 120 days after diagnosis. Surgery was usually the first treatment.

The time interval from diagnosis to treatment (the phrase the researchers prefer to “treatment delay” or “wait time”) was an independent prognostic factor in OCSCC patients. The average interval was 24 days. Those treated within 30 days tended to have a higher survival rate. Treatment after 120 days from diagnosis increased the risk of death by 1.32-fold.

The average follow-up period was 44 months. When the researchers stratified patients according to the time between diagnosis and treatment, they found patients aged ≥ 65 years or who had advanced cancer were more likely to be treated later. Patients treated initially with radiotherapy or chemotherapy were more likely to have a longer mean time interval when compared with those who were treated first with surgery.

Related: Shorter Length of Stay May Not Mean Higher Readmission Rates

The researchers also found that patients treated in private hospitals had a shorter time interval compared with those treated in public hospitals (although the latter were more likely to survive). Patients who received treatment in hospitals with a low- to medium-service volume had a longer interval compared with those treated in hospitals with a high-service volume. Other predictors of longer survival included being female, younger, primary tumor site at the tongue, and earlier stage disease.

The researchers cite a study that found the median duration of clinical upstaging from early to late stage was 11.3 months, whereas the average period from advanced tumor to untreatable tumor was 3.8 months. That might explain why they found that the longer delay to treatment increased the risk of death, they suggest. The researchers also point to reasons such as pending second opinions, shortages of therapeutic instruments and manpower, and lack of public awareness.

Related: IBD and the Risk of Oral Cancer

All told however, the researchers conclude, the reasons for the increased time interval from diagnosis to treatment of OCSCC patients remain “multifaceted, integrated, and poorly understood.”

Source:
Tsai WC, Kung PT, Wang YH, Huang KH, Liu SA. PLoS One. 2017;12(4):e0175148.
doi: 10.1371/journal.pone.0175148.

Oral cancer has a low 5-year survival rate compared with other major types of cancer, and the rate hasn’t improved much in recent years, say researchers from China Medical University, Asia University, Taichung Veterans General Hospital, and National Yang-Ming University; all in Taichung, Taiwan. That may be due in part to delay in treatment, they say. Their analysis of data of 21,263 patients with oral cavity squamous cell carcinoma (OCSCC) bears out their theory.

Related: Predicting Tongue Cancer Recurrence

About 40% of the patients presented with stage IV disease. More than one-third had tongue cancer. The average time from diagnosis to treatment was 24 days. Most patients (86%) were treated within 30 days of diagnosis; 12% were treated between 31 and 120 days after diagnosis, and 2.7% received treatment 120 days after diagnosis. Surgery was usually the first treatment.

The time interval from diagnosis to treatment (the phrase the researchers prefer to “treatment delay” or “wait time”) was an independent prognostic factor in OCSCC patients. The average interval was 24 days. Those treated within 30 days tended to have a higher survival rate. Treatment after 120 days from diagnosis increased the risk of death by 1.32-fold.

The average follow-up period was 44 months. When the researchers stratified patients according to the time between diagnosis and treatment, they found patients aged ≥ 65 years or who had advanced cancer were more likely to be treated later. Patients treated initially with radiotherapy or chemotherapy were more likely to have a longer mean time interval when compared with those who were treated first with surgery.

Related: Shorter Length of Stay May Not Mean Higher Readmission Rates

The researchers also found that patients treated in private hospitals had a shorter time interval compared with those treated in public hospitals (although the latter were more likely to survive). Patients who received treatment in hospitals with a low- to medium-service volume had a longer interval compared with those treated in hospitals with a high-service volume. Other predictors of longer survival included being female, younger, primary tumor site at the tongue, and earlier stage disease.

The researchers cite a study that found the median duration of clinical upstaging from early to late stage was 11.3 months, whereas the average period from advanced tumor to untreatable tumor was 3.8 months. That might explain why they found that the longer delay to treatment increased the risk of death, they suggest. The researchers also point to reasons such as pending second opinions, shortages of therapeutic instruments and manpower, and lack of public awareness.

Related: IBD and the Risk of Oral Cancer

All told however, the researchers conclude, the reasons for the increased time interval from diagnosis to treatment of OCSCC patients remain “multifaceted, integrated, and poorly understood.”

Source:
Tsai WC, Kung PT, Wang YH, Huang KH, Liu SA. PLoS One. 2017;12(4):e0175148.
doi: 10.1371/journal.pone.0175148.

Oral cancer has a low 5-year survival rate compared with other major types of cancer, and the rate hasn’t improved much in recent years, say researchers from China Medical University, Asia University, Taichung Veterans General Hospital, and National Yang-Ming University; all in Taichung, Taiwan. That may be due in part to delay in treatment, they say. Their analysis of data of 21,263 patients with oral cavity squamous cell carcinoma (OCSCC) bears out their theory.

Related: Predicting Tongue Cancer Recurrence

About 40% of the patients presented with stage IV disease. More than one-third had tongue cancer. The average time from diagnosis to treatment was 24 days. Most patients (86%) were treated within 30 days of diagnosis; 12% were treated between 31 and 120 days after diagnosis, and 2.7% received treatment 120 days after diagnosis. Surgery was usually the first treatment.

The time interval from diagnosis to treatment (the phrase the researchers prefer to “treatment delay” or “wait time”) was an independent prognostic factor in OCSCC patients. The average interval was 24 days. Those treated within 30 days tended to have a higher survival rate. Treatment after 120 days from diagnosis increased the risk of death by 1.32-fold.

The average follow-up period was 44 months. When the researchers stratified patients according to the time between diagnosis and treatment, they found patients aged ≥ 65 years or who had advanced cancer were more likely to be treated later. Patients treated initially with radiotherapy or chemotherapy were more likely to have a longer mean time interval when compared with those who were treated first with surgery.

Related: Shorter Length of Stay May Not Mean Higher Readmission Rates

The researchers also found that patients treated in private hospitals had a shorter time interval compared with those treated in public hospitals (although the latter were more likely to survive). Patients who received treatment in hospitals with a low- to medium-service volume had a longer interval compared with those treated in hospitals with a high-service volume. Other predictors of longer survival included being female, younger, primary tumor site at the tongue, and earlier stage disease.

The researchers cite a study that found the median duration of clinical upstaging from early to late stage was 11.3 months, whereas the average period from advanced tumor to untreatable tumor was 3.8 months. That might explain why they found that the longer delay to treatment increased the risk of death, they suggest. The researchers also point to reasons such as pending second opinions, shortages of therapeutic instruments and manpower, and lack of public awareness.

Related: IBD and the Risk of Oral Cancer

All told however, the researchers conclude, the reasons for the increased time interval from diagnosis to treatment of OCSCC patients remain “multifaceted, integrated, and poorly understood.”

Source:
Tsai WC, Kung PT, Wang YH, Huang KH, Liu SA. PLoS One. 2017;12(4):e0175148.
doi: 10.1371/journal.pone.0175148.

Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.

“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.

jarun011/Thinkstock

Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.

“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.

jarun011/Thinkstock

Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.

“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.

jarun011/Thinkstock

The U.S. Preventive Services Task Force recommends against screening asymptomatic adults for thyroid cancer, because the harms of such screening outweigh the benefits, according to a recommendation statement published May 9 in JAMA.

The USPSTF makes recommendations about the effectiveness of specific health care services for patients who don’t have related signs or symptoms. In this case, the recommendation statement addresses screening of adults who have no signs or symptoms of thyroid cancer by using neck palpation or ultrasonography, said Kirsten Bibbins-Domingo, MD, PhD, chair of the organization and lead author of the recommendation statement, and her associates (JAMA. 2017 May 9;317[18]:1882-7).

This document is an update of the previous USPSTF recommendation statement issued in 1996 and was undertaken because there have been several major advances related to the disease since that time.

However, despite a comprehensive review of the current literature, the group found no direct evidence supporting a change to their original advice against such screening.

They emphasized that this applies only to asymptomatic adults, not to those who have hoarseness, throat pain, difficulty swallowing, lumps in the neck, swelling, or asymmetry of the neck; nor to those who have a history of exposure to ionizing radiation, a family history of thyroid cancer, or a genetic susceptibility to the disease.

The results of the literature review were summarized in an evidence report by Jennifer S. Lin, MD, of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates. They examined 67 studies involving nearly 584,000 patients, including 10 studies that addressed screening test performance, 3 that addressed the possible harms of screening, 2 that addressed treatment benefits, and 52 that addressed treatment harms.

No good-quality studies assessed the net benefit of thyroid cancer screening, nor whether “early” treatment of screen-detected cancers improved patient outcomes. However, the preponderance of evidence suggested that most thyroid cancers detected by screening are indolent.

So, treatment is likely unnecessary but exposes patients to “nontrivial” harms, including an increased risk of second primary malignancy, permanent adverse effects on the salivary glands, laryngeal nerve injury, hypoparathyroidism, and the need for lifelong thyroid replacement therapy and monitoring for cancer recurrence, Dr. Lin and her associates said in their evidence report (JAMA. 2017 May 9;317[18]:1888-1903).

The task force noted that no professional medical society currently recommends population-based screening for thyroid cancer. The American Cancer Society, American Thyroid Association, American Association of Clinical Endocrinologists, and American College of Endocrinology all have no specific recommendations for screening asymptomatic patients, while the American Academy of Family Physicians recommends against such screening, said Dr. Bibbins-Domingo, who is also a professor of medicine at the University of California, San Francisco, and her associates.

Further information regarding the recommendation statement and the evidence report is available at www.uspreventiveservicestaskforce.org.

The USPSTF is an independent voluntary group supported by the Agency for Healthcare Research and Quality. The authors’ conflict of interest disclosures are available at www.uspreventiveservicestaskforce.org.

The U.S. Preventive Services Task Force recommends against screening asymptomatic adults for thyroid cancer, because the harms of such screening outweigh the benefits, according to a recommendation statement published May 9 in JAMA.

The USPSTF makes recommendations about the effectiveness of specific health care services for patients who don’t have related signs or symptoms. In this case, the recommendation statement addresses screening of adults who have no signs or symptoms of thyroid cancer by using neck palpation or ultrasonography, said Kirsten Bibbins-Domingo, MD, PhD, chair of the organization and lead author of the recommendation statement, and her associates (JAMA. 2017 May 9;317[18]:1882-7).

This document is an update of the previous USPSTF recommendation statement issued in 1996 and was undertaken because there have been several major advances related to the disease since that time.

However, despite a comprehensive review of the current literature, the group found no direct evidence supporting a change to their original advice against such screening.

They emphasized that this applies only to asymptomatic adults, not to those who have hoarseness, throat pain, difficulty swallowing, lumps in the neck, swelling, or asymmetry of the neck; nor to those who have a history of exposure to ionizing radiation, a family history of thyroid cancer, or a genetic susceptibility to the disease.

The results of the literature review were summarized in an evidence report by Jennifer S. Lin, MD, of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates. They examined 67 studies involving nearly 584,000 patients, including 10 studies that addressed screening test performance, 3 that addressed the possible harms of screening, 2 that addressed treatment benefits, and 52 that addressed treatment harms.

No good-quality studies assessed the net benefit of thyroid cancer screening, nor whether “early” treatment of screen-detected cancers improved patient outcomes. However, the preponderance of evidence suggested that most thyroid cancers detected by screening are indolent.

So, treatment is likely unnecessary but exposes patients to “nontrivial” harms, including an increased risk of second primary malignancy, permanent adverse effects on the salivary glands, laryngeal nerve injury, hypoparathyroidism, and the need for lifelong thyroid replacement therapy and monitoring for cancer recurrence, Dr. Lin and her associates said in their evidence report (JAMA. 2017 May 9;317[18]:1888-1903).

The task force noted that no professional medical society currently recommends population-based screening for thyroid cancer. The American Cancer Society, American Thyroid Association, American Association of Clinical Endocrinologists, and American College of Endocrinology all have no specific recommendations for screening asymptomatic patients, while the American Academy of Family Physicians recommends against such screening, said Dr. Bibbins-Domingo, who is also a professor of medicine at the University of California, San Francisco, and her associates.

Further information regarding the recommendation statement and the evidence report is available at www.uspreventiveservicestaskforce.org.

The USPSTF is an independent voluntary group supported by the Agency for Healthcare Research and Quality. The authors’ conflict of interest disclosures are available at www.uspreventiveservicestaskforce.org.

The U.S. Preventive Services Task Force recommends against screening asymptomatic adults for thyroid cancer, because the harms of such screening outweigh the benefits, according to a recommendation statement published May 9 in JAMA.

The USPSTF makes recommendations about the effectiveness of specific health care services for patients who don’t have related signs or symptoms. In this case, the recommendation statement addresses screening of adults who have no signs or symptoms of thyroid cancer by using neck palpation or ultrasonography, said Kirsten Bibbins-Domingo, MD, PhD, chair of the organization and lead author of the recommendation statement, and her associates (JAMA. 2017 May 9;317[18]:1882-7).

This document is an update of the previous USPSTF recommendation statement issued in 1996 and was undertaken because there have been several major advances related to the disease since that time.

However, despite a comprehensive review of the current literature, the group found no direct evidence supporting a change to their original advice against such screening.

They emphasized that this applies only to asymptomatic adults, not to those who have hoarseness, throat pain, difficulty swallowing, lumps in the neck, swelling, or asymmetry of the neck; nor to those who have a history of exposure to ionizing radiation, a family history of thyroid cancer, or a genetic susceptibility to the disease.

The results of the literature review were summarized in an evidence report by Jennifer S. Lin, MD, of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates. They examined 67 studies involving nearly 584,000 patients, including 10 studies that addressed screening test performance, 3 that addressed the possible harms of screening, 2 that addressed treatment benefits, and 52 that addressed treatment harms.

No good-quality studies assessed the net benefit of thyroid cancer screening, nor whether “early” treatment of screen-detected cancers improved patient outcomes. However, the preponderance of evidence suggested that most thyroid cancers detected by screening are indolent.

So, treatment is likely unnecessary but exposes patients to “nontrivial” harms, including an increased risk of second primary malignancy, permanent adverse effects on the salivary glands, laryngeal nerve injury, hypoparathyroidism, and the need for lifelong thyroid replacement therapy and monitoring for cancer recurrence, Dr. Lin and her associates said in their evidence report (JAMA. 2017 May 9;317[18]:1888-1903).

The task force noted that no professional medical society currently recommends population-based screening for thyroid cancer. The American Cancer Society, American Thyroid Association, American Association of Clinical Endocrinologists, and American College of Endocrinology all have no specific recommendations for screening asymptomatic patients, while the American Academy of Family Physicians recommends against such screening, said Dr. Bibbins-Domingo, who is also a professor of medicine at the University of California, San Francisco, and her associates.

Further information regarding the recommendation statement and the evidence report is available at www.uspreventiveservicestaskforce.org.

The USPSTF is an independent voluntary group supported by the Agency for Healthcare Research and Quality. The authors’ conflict of interest disclosures are available at www.uspreventiveservicestaskforce.org.

Is ultrasonography really useful in distinguishing between benign and malignant thyroid nodules? The reality facing many physicians, say researchers from the University of Alberta, is that ultrasonography reports originate from multiple sites and are dictated by physicians of varying experience, practice volumes, and styles of documentation. The researchers say although thyroid ultrasonography provides accurate results, few ultrasound reports contain the necessary information to predict malignancy and guide management.

The Thyroid Imaging and Reporting System (TI-RADS) was developed to standardize risk stratification according to nodule characteristics: size, marked hypoechogenicity, taller-than-wide shape, microcalcifications, irregular margins, and solid component. The researchers reviewed ultrasound reports using TI-RADS criteria for 329 patients who had undergone thyroidectomy and then assessed whether individual or multiple criteria were associated with malignancy.

Related: New Treatment Options for Metastatic Thyroid Cancer

About 42% of the nodules were malignant. The most common carcinoma was papillary thyroid cancer. Benign disease was predominantly cases of multinodular goiter. The difference in size between benign and malignant neoplasms was not significant. About 11% of the specimens exhibited incidental microcarcionomas.

Nearly all the reports documented nodule size. But > 90% noted ≤ 3 of the remaining TI-RADS criteria. In fact, nearly 40% included 1 or no criterion beyond the description of size. The number of features reported did not reflect an increased risk of malignancy. The researchers found no associations among reporting criteria—for example, the presence of microcalcifications did not trigger targeted comments about any other factor—and this was true for all of the criteria, they note.

Related: Tracking a Tumor

Half of the reports with a comment noted solid or cystic nodules and echogenicity. The description of a hypoechoic nodule or a solid nodule was significantly more likely to be identified in malignant neoplasms. The presence of microcalcifications was the most sensitive marker of malignancy (90%), and documentation of irregular margins was the most specific indicator.

Overall, the researchers say, it was clear that microcalcifications, hypoechogenicity, irregular margins, and solid nodules were significantly more likely to be found in malignant neoplasms. The absence of these nodules predicted benign disease. But because so few reports consistently documented all criteria, the overall ability of thyroid ultrasonography to discriminate between lower- and higher-risk nodules is limited.

Source:
Gamme G, Parrington T, Wiebe E, et al. Can J Surg. 2017;60(2):134-139
doi:10.1503/cjs.010316

Is ultrasonography really useful in distinguishing between benign and malignant thyroid nodules? The reality facing many physicians, say researchers from the University of Alberta, is that ultrasonography reports originate from multiple sites and are dictated by physicians of varying experience, practice volumes, and styles of documentation. The researchers say although thyroid ultrasonography provides accurate results, few ultrasound reports contain the necessary information to predict malignancy and guide management.

The Thyroid Imaging and Reporting System (TI-RADS) was developed to standardize risk stratification according to nodule characteristics: size, marked hypoechogenicity, taller-than-wide shape, microcalcifications, irregular margins, and solid component. The researchers reviewed ultrasound reports using TI-RADS criteria for 329 patients who had undergone thyroidectomy and then assessed whether individual or multiple criteria were associated with malignancy.

Related: New Treatment Options for Metastatic Thyroid Cancer

About 42% of the nodules were malignant. The most common carcinoma was papillary thyroid cancer. Benign disease was predominantly cases of multinodular goiter. The difference in size between benign and malignant neoplasms was not significant. About 11% of the specimens exhibited incidental microcarcionomas.

Nearly all the reports documented nodule size. But > 90% noted ≤ 3 of the remaining TI-RADS criteria. In fact, nearly 40% included 1 or no criterion beyond the description of size. The number of features reported did not reflect an increased risk of malignancy. The researchers found no associations among reporting criteria—for example, the presence of microcalcifications did not trigger targeted comments about any other factor—and this was true for all of the criteria, they note.

Related: Tracking a Tumor

Half of the reports with a comment noted solid or cystic nodules and echogenicity. The description of a hypoechoic nodule or a solid nodule was significantly more likely to be identified in malignant neoplasms. The presence of microcalcifications was the most sensitive marker of malignancy (90%), and documentation of irregular margins was the most specific indicator.

Overall, the researchers say, it was clear that microcalcifications, hypoechogenicity, irregular margins, and solid nodules were significantly more likely to be found in malignant neoplasms. The absence of these nodules predicted benign disease. But because so few reports consistently documented all criteria, the overall ability of thyroid ultrasonography to discriminate between lower- and higher-risk nodules is limited.

Source:
Gamme G, Parrington T, Wiebe E, et al. Can J Surg. 2017;60(2):134-139
doi:10.1503/cjs.010316

Is ultrasonography really useful in distinguishing between benign and malignant thyroid nodules? The reality facing many physicians, say researchers from the University of Alberta, is that ultrasonography reports originate from multiple sites and are dictated by physicians of varying experience, practice volumes, and styles of documentation. The researchers say although thyroid ultrasonography provides accurate results, few ultrasound reports contain the necessary information to predict malignancy and guide management.

The Thyroid Imaging and Reporting System (TI-RADS) was developed to standardize risk stratification according to nodule characteristics: size, marked hypoechogenicity, taller-than-wide shape, microcalcifications, irregular margins, and solid component. The researchers reviewed ultrasound reports using TI-RADS criteria for 329 patients who had undergone thyroidectomy and then assessed whether individual or multiple criteria were associated with malignancy.

Related: New Treatment Options for Metastatic Thyroid Cancer

About 42% of the nodules were malignant. The most common carcinoma was papillary thyroid cancer. Benign disease was predominantly cases of multinodular goiter. The difference in size between benign and malignant neoplasms was not significant. About 11% of the specimens exhibited incidental microcarcionomas.

Nearly all the reports documented nodule size. But > 90% noted ≤ 3 of the remaining TI-RADS criteria. In fact, nearly 40% included 1 or no criterion beyond the description of size. The number of features reported did not reflect an increased risk of malignancy. The researchers found no associations among reporting criteria—for example, the presence of microcalcifications did not trigger targeted comments about any other factor—and this was true for all of the criteria, they note.

Related: Tracking a Tumor

Half of the reports with a comment noted solid or cystic nodules and echogenicity. The description of a hypoechoic nodule or a solid nodule was significantly more likely to be identified in malignant neoplasms. The presence of microcalcifications was the most sensitive marker of malignancy (90%), and documentation of irregular margins was the most specific indicator.

Overall, the researchers say, it was clear that microcalcifications, hypoechogenicity, irregular margins, and solid nodules were significantly more likely to be found in malignant neoplasms. The absence of these nodules predicted benign disease. But because so few reports consistently documented all criteria, the overall ability of thyroid ultrasonography to discriminate between lower- and higher-risk nodules is limited.

Source:
Gamme G, Parrington T, Wiebe E, et al. Can J Surg. 2017;60(2):134-139
doi:10.1503/cjs.010316