Clinician perspectives on the factors influencing prognostic stratification by the American Joint Commission on Cancer Head and Neck Cutaneous Squamous Cell Carcinoma Staging.

BACKGROUND:The eighth edition of the American Joint Committee on Cancer Staging Manual includes a staging system for head and neck cutaneous squamous cell carcinoma for the first time. The pN categories for head and neck cutaneous squamous cell carcinoma and mucosal squamous cell carcinoma are identical, despite the vastly different biological behavior of these diseases. This study aimed to survey head and neck cancer specialists' views regarding the clinical utility of the American Joint Committee on Cancer Staging Manual for head and neck cutaneous squamous cell carcinoma and to identify avenues for improvement. DESIGN:An electronic survey of 19 questions relating to the prognostic utility of the staging system was designed based on the findings of a literature review. The survey was distributed internationally to specialists managing head and neck cutaneous squamous cell carcinoma. RESULTS:Literature review identified 9 articles describing primary research relevant to the performance of the American Joint Committee on Cancer Staging Manual for head and neck cutaneous squamous cell carcinoma, which recognized a lack of homogeneity, monotonicity, and distinctiveness in the pN staging system. One hundred and five survey responses were received: 71% indicated that mucosal and head and neck cutaneous squamous cell carcinoma require different nodal staging categories; 63% indicated that immunosuppression should be included in the staging system; 70% thought that soft tissue metastases portend a worse prognosis compared with extranodal extension; 38% almost never saw pN3a tumors; and 40% felt that the N stage is a poor predictor of survival. CONCLUSION:The views of head and neck cancer specialists across disciplines and countries align with evidence suggesting that head and neck cutaneous squamous cell carcinoma merits a staging system distinct from mucosal squamous cell carcinoma, that immunosuppression should be considered in prognostication, and that the use of extranodal extension should be modified.