Lung cancer screening for survivors of head and neck cancer

Head and neck cancer survivors with long smoking histories had a 2.5-fold greater risk of developing lung cancer than those without prior head and neck cancer, according to a secondary analysis of the National Lung Screening Trial (NLST) data.¹

The landmark NLST randomized more than 50,000 participants at high risk for lung cancer in a 1:1 ratio to either low-dose computed tomography (LDCT) or chest radiography for lung cancer detection. This ad hoc secondary analysis identified 171 head and neck cancer survivors (median 9 years since diagnosis) who took part in the NLST, 82 of whom were screened with LDCT and 89 with chest radiography.

Among the 171 patients, 12 second primary lung cancers were detected in the LDCT group (2,610 cases per 100,000 person-years) versus eight in the chest radiography group (1,594 cases per 100,000 person-years).

After adjustment for various factors including pack-years of smoking, lung cancer incidence among NLST participants with a history of head and neck cancer was more than doubled compared to those without such a history, at 2,080 versus 609 cases per 100,000 person-years (adjusted rate ratio [RR] 2.54, 95% CI 1.63-3.95).

In addition, a non-significant trend towards improved overall survival was observed among those with a history of head and neck cancer who underwent low-dose CT (LDCT) in the trial rather than chest radiography (HR 0.79, 95% CI 0.42-1.52). Moreover, there appeared to be a trend toward better detection of secondary lung cancer detection in those assigned to LDCT (RR 1.55, 95% CI 0.59-3.63).

The authors argued, “these results support routine annual low-dose CT chest screening for lung cancer in HNC [head and neck cancer] survivors with prior significant tobacco use who are fit enough to undergo treatment with curative intent.”

In a commentary accompanying the study, the authors noted the small sample of head and neck cancer survivors available for analysis, “which results in poor precision for several effect estimates.”²

But they said the study adds urgency to efforts to reduce head and neck cancer patients’ risk of lung cancer mortality, particularly regarding efforts to provide those patients with smoking cessation support.

“This recommendation is not specific to patients with HNC but is particularly relevant in this group in which smoking rates are high, and ongoing smoking dramatically increases the risk of treatment complications, recurrence, and death,” they wrote. “Additionally, there is likely substantial room for expansion of lung cancer screening in the HNC population considering the very low rate of lung cancer screening in the general population.”

References

1.   Cramer JD et al. Incidence of Second Primary Lung Cancer After Low-Dose Computed Tomography vs Chest Radiography Screening in Survivors of Head and Neck Cancer. A Secondary Analysis of a Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. Published online October 28, 2021. doi:10.1001/jamaoto.2021.2776

2.   Massa ST et al. Most Survivors of Head and Neck Cancer Should Be Offered Lung Cancer Screening. JAMA Otolaryngol Head Neck Surg. Published online October 28, 2021. doi:10.1001/jamaoto.2021.2813