11. Aftercare – Oropharyngeal and Hypopharyngeal Carcinoma

Regular tumour follow-up care is an essential part of the overall treatment, which should be carried out on an interdisciplinary basis with the radio-oncologist in charge and in communication with the specialist colleague in charge. The importance of tumour follow-up can be seen from the fact that around a quarter of patients with oropharyngeal and hypopharyngeal carcinoma experience a local tumour recurrence, which usually occurs within the first two years; even in the third year after primary treatment has been completed, recurrences still develop in a few cases [743]. The main aim of tumour follow-up care is therefore the careful examination of the larynx and neck to rule out recurrent carcinomas, which, according to the results of a retrospective study, only lead to symptoms in 61% of cases and are therefore not noticed by 39% of patients [744]. A further benefit of tumour follow-up is the detection of metachronous secondary tumours in the upper aerodigestive tract and lungs, which are associated with a similar risk profile to oro- (excluding HPV) and hypopharyngeal carcinomas and occur in 4-33% of patients [743].

Furthermore, the assessment of the functional, aesthetic and psychological follow-up condition (speech and swallowing function), the pain status and the need for rehabilitative (speech therapy, swallowing training) or supportive measures (pain therapy, nutritional therapy, physiotherapy, psycho-oncological and social care, lymphatic drainage), as well as advice on possible operations to improve functioning is the task of tumour aftercare [745] [647] [706] (Ch. 10).

The maximum follow-up intervals are 3 months for the 1st and 2nd year and 6 months for the 3rd to 5th year (analogous to recommendations in the S3 Guideline for Laryngeal Carcinoma [2] and the S3 Guideline for Oral Cavity Carcinoma [1]). After the 5th year, an individual decision can be made as to whether further follow-up care appears necessary. In the event of a particular risk constellation or acute symptoms, more frequent examinations may be necessary in cooperation with the specialist colleagues providing care, which may also extend beyond 5 years.

The examinations required at each follow-up appointment are a careful and systematic inspection of the mouth, throat and larynx. In addition, an examination of the throat by palpation and possibly ultrasound is necessary. Indications of the possible presence of a tumour recurrence can also be ascertained by taking a history of pain, blood admixtures, weight loss, listlessness, etc. (for more details, see chapter 7.1).

Imaging plays an important role in the aftercare of oropharyngeal and hypopharyngeal cancer and is an important part of the aftercare examination alongside the ENT specialist's mirror examination/endoscopy. High-resolution CT is very sensitive in the area of the oropharynx and hypopharynx and is the procedure of first choice. In the same session, the lymphatic drainage channels of the neck can be visualized to detect or rule out metastases. MRI can be advantageous when it comes to the question of cartilage infiltration in hypopharyngeal carcinoma and the question of soft tissue contrast. Depending on the initial tumour category, the time interval for follow-up care should be determined by imaging. For larger carcinomas, the first imaging is recommended 3 months after the end of treatment. If there is an increased risk of distant metastasis, a CT thorax and abdomen should also be performed during the follow-up examination, possibly PET-CT [746] [747].

After definitive radiochemotherapy or radiotherapy with a good clinical response, contrast-enhanced baseline cross-sectional imaging of the head and neck area can be performed 8-12 weeks after the end of treatment to assess the post-therapeutic local findings. The choice of imaging modality (CT, MRI) should depend on the initial tumour location and the initial tumour or N category in accordance with the recommendations in the chapter on primary diagnostics (Section 7.3).

If a locoregional recurrence or residual tumour, distant metastasis or a second tumour is suspected on the basis of these examinations, FDG-PET/CT may be considered. There is no evidence that regular chest X-rays or the determination of tumour markers in serum have any benefit in tumour aftercare, so this is not recommended.

In March 2017, the Joint Federal Committee decided in accordance with Section 91 SGB V that, to avoid invasive procedures such as neck dissection and laryngoscopic biopsy, PET/CT for head and neck tumours will be covered by health insurance. This applies in particular to patients with laryngeal cancer following primary radiochemotherapy (Section 7.3).

In recent years, the risk of falling into a precarious economic situation due to cancer has increased significantly. On the one hand, expenses increase and on the other, income is often significantly reduced due to the receipt of sickness benefit or a reduced earning capacity pension. Illness as a cause of over-indebtedness is now a well-known problem.

For this reason, an important goal of the social and socio-legal counselling services is to secure material and economic existence as well as participation in working life and to enable access to social benefits. The following counselling services are therefore part of the social and socio-legal counselling:

• Comprehensive information on social law (health, pension, long-term care insurance, severely disabled person's pass)
• Assistance in filling out applications and submitting applications
• Advice on options for maintaining employment, initiating professional reintegration, initiating professional rehabilitation measures
• Psychosocial counselling on coping with illness, in conflict situations, participation in social life
• Information about counselling centres (integration service, addiction and debt counselling, pension insurance service centres)

In order to ensure psychosocial and socio-legal counselling, it is important that patients with laryngeal carcinoma receive initial oncological counselling from the social services of acute hospitals and rehabilitation facilities in an inpatient context. This is the only way to ensure that those affected and their relatives receive basic psychosocial information and that initial rapid interventions are possible if necessary.

Outpatient cancer counselling centres offer a low-threshold psychosocial counselling service for the phase after inpatient treatment on psychological, social and socio-legal burdens and provide information on self-help groups and other counselling services (analogous to the S3 Guideline for Larynx Carcinoma  [2]).