As mentioned in a previous blog there are three stages of cancer care. The preparatory stage, the treatment stage and the surveillance stage.
Like the other stages it is a stressful stage because patients wonder whether the treatment worked and/or whether the cancer will come back.
The time to really start assessing the success of cancer treatment can vary depending on the severity of the disease and what treatment was given, but on average the soonest we start looking is at three months. The inflammatory effects of treatment can be longstanding and make surveillance difficult through this stage but it is especially difficult in the first three months.
Any visit to doctors within the first three months therefore, is largely about determining how the patient coped during the treatment. It’s about optimising the recovery and identifying concerns that will effect the long term quality of life of patients. In the head and neck for example, we focus a lot on swallowing, chewing, talking and weight loss.
It can be difficult for patients to know which doctor should take responsibility for surveillance if there have been many doctors involved. For head and neck cancer, this is generally the head and neck surgeon, even if the treatment did not involve surgery and perhaps only radiation. The reason for this is that many cancers originate in difficult to examine areas and it is the head and neck surgeon with our endoscopes that can examine these areas best.
After three months we start to consider what the best tools for surveillance are. It is of course different for every cancer, at every stage, for every person, but in general we use the clinical history with examination, and imaging as the primary tools.
History and examination involve identifying symptoms that concern us and findings such as swellings or ulcers that are not improving or getting worse. Persistent or worsening pain and masses that are not decreasing in size are often early warning signs of concern. We are also looking for the possibility of any new cancers developing.
History and examination usually guides us to decide what imaging to use as the next step. The most common imaging modalities are the neck ultrasound to assess for lymph nodes, the CT scan is excellent for both lymph nodes and primary tumours especially if there has been bone involvement. MRIs are also excellent soft tissue scans especially for nerves, brain, salivary glands and eyes. The PET CT scan is especially valuable when radiation has been involved.
The PET CT scan is both a physiological and anatomical scan assessing activity and position of possible cancer. The earliest it can be used is 12 weeks, but if we are clinically happy there has been an good response to treatment then we prefer 4-6 months after treatment has been completed. The reason for this is that false positive results are more likely the earlier the scan is done, which increase stress levels and results in good decisions difficult to make.
The chance of recurrence of head and neck cancer is highest in the first two years and therefore regular visits with doctors is important to pick up anything concerning quickly. The rationale behind this is that if surgical salvage is done early, it gives the best outcomes both from a cure and quality of life perspective.
Usually I see patients every 2-3 months for the first two years, every 3-4 months for the year after that and every 6-8 months for the following 2 years. We consider someone cured when they reach 5 years without recurrence, but we are always aware of the possibility of patients getting a new head and neck cancer elsewhere at any time. Not smoking and drinking go a long way to prevent recurrences or second cancers.