We used an analytical cross-sectional study design and collected data during the period from June 1 to June 30, 2020. Head and neck surgeon members of the Saudi Society of Otolaryngology in Saudi Arabia were surveyed in this study.

All head and neck surgeons of the Saudi Society of Otolaryngology who worked in Saudi Arabia hospitals and consented to participate in this study were included. There were no exclusion criteria.

The total sample consisted of all head and neck surgeons of the Saudi Society of Otolaryngology in Saudi Arabia. A total of 22 participants were included in this study.

We adapted a questionnaire that consisted of 6 questions regarding actual practices and was previously designed and reviewed by Madana et al [10]. The questionnaire was used after obtaining permission from the main author. The questions inquired about the characteristics of routine lung screening during the posttreatment follow-up of patients with head and neck cancer [10]. The questionnaire was distributed to all head and neck surgeons of the Saudi Society of Otolaryngology in Saudi Arabia. No translation was needed, as the distributed form was written in the English language.

We used SPSS version 26 (IBM Corporation) to analyze the study data. Descriptive statistics were used to present the frequencies and percentages of the categorical variables.

We prepared an informed consent form for the participants and gave them a brief description of this study’s rationale and objectives. Afterward, we asked them to sign the consent form. The anonymity and confidentiality of data were maintained throughout the study. Records were retained in a password-protected computer, and they will be retained for at least 7 years. There were no conflicts of interest. The study was approved by the Unit of Biomedical Ethics Research Committee at King Abdulaziz University.

A high response rate among otolaryngology–head and neck surgeons across Saudi Arabia was achieved in our study (22/28, 78%). This shows a high level of interest in postoperative screening practices.

Head and neck cancer refers to a group of malignant neoplastic lesions that have similar biological behaviors and are found in the upper aerodigestive tract. Head and neck cancer is the sixth most common cancer in the world; each year, over 500,000 new cases are diagnosed and 200,000 related deaths occur [11,12]. The most common sites of distant metastases are the lungs, the skeletal system, and the liver [13]. Due to the high incidence rate of metastasis (90% of cases) in patients with HNSCC, the posttreatment examination of the pulmonary region is critical [14,15]. Patients with HNSCC need posttreatment care that does not end with the completion of definitive treatment.

Our nationwide survey was conducted among head and neck surgeon members of the Saudi Society of Otolaryngology. The purpose of this survey study was to assess otolaryngology–head and neck surgeons’ current beliefs and pulmonary screening practices with respect to the posttreatment surveillance of HNSCC in Saudi Arabia.

Regrettably, there is no consensus in the literature on the frequency and mode of posttreatment follow-up. Different investigational modalities each have their own set of advantages and disadvantages [16].

Similar to our results, another study, which was conducted by the Canadian Society of Otolaryngology to evaluate head and neck surgeons, reported that the majority of respondents performed routine lung screening and preferred chest radiography over low-dose CT or PET [10]. There is evidence however that PET/CT may be the most sensitive of these modalities, but further research is needed to show improvements in patient outcomes [16]. According to the Centers for Disease Control and Prevention, the most recommended method for lung cancer screening is low-dose CT [17]. Additionally, the present guidelines of the US Preventive Services Task Force suggest using the same method [18]. The reason why physicians prefer to avoid low-dose CT in follow-ups that are conducted after the treatment of head and neck cancer may be the modality’s low specificity. The overdiagnosis of lung cancer was reported in more than 18% of cancer cases during the screening process of the National Lung Screening Trial [19]. Depending on radiography however cannot be the correct decision to make since, in another study, radiography was proven to be a poor method for diagnosing lung tumors in more than 65% of patients with cancer, and these patients were later diagnosed with pulmonary cancer [20]. Thus, the most recent findings among physicians must be disseminated more frequently.

With regard to the number of years for which participants perform lung screening during follow-ups, the majority of participants (17/22, 77%) reported 5 years, and only 9% (2/22) have performed lifelong lung screening. The study conducted in Canada found that 60% of their respondents conduct lung screening for 5 years, some of their respondents conduct lifelong lung screening, and the fewest number of participants conduct lung screening for 10 years [10]. This difference in the number of years for which physicians perform lung screening can be attributed to the variations in the current evidence concerning the posttreatment follow-up of patients with head and neck cancer; some studies have suggested that physicians should continue to conduct follow-ups once per year after 5 posttreatment years [21]. However, there is little evidence that supports the effectiveness of conducting follow-ups for more than 5 years [22].

The British Association of Head and Neck Oncologists [23] recommends 4- to 6-week follow-up visits for the first 2 years after treatment, 3-month follow-up visits for the third posttreatment year, 6-month follow-up visits for the fourth and fifth posttreatment years, and annual visits after that. With regard to the frequency of lung screening, in our study, the majority of participants (17/22, 77%) conduct screening annually, 18% (4/22) conduct screening half-yearly, and 5% (1/22) conduct screening biennially.

The Canadian study reported that most respondents were screening their patients annually, while less than 15% screened patients biennially or half-yearly [10]. Variations in the number of follow-up visits have also been evident in the guidelines present in the literature and can account for the differences between Canada and Saudi Arabia, since clinicians from different countries can follow different guidelines [9]. The Saudi head and neck surgeons in our study stated that conducting scheduled visits is also the best way to provide adequate follow-ups to patients with HNSCC, since these follow-ups address many concerns and not just the early detection of recurrence or secondary primaries.

To date, no study has been conducted in Saudi Arabia to analyze the current practices of head and neck surgeons with respect to detecting post-HNSCC pulmonary metastasis. Our study provides a highly comprehensive view of current practices, given that all certified head and neck surgeons of the Saudi Society of Otolaryngology in Saudi Arabia participated in this study. Despite its exploratory nature, this study offers some insight into the lack of evidence-based practices for the posttreatment pulmonary surveillance of HNSCC. Conducting well-controlled trials to evaluate different modalities of surveillance for different subtypes and stages of HNSCC would shed light on the survival rates associated with and the cost-effectiveness of these modalities. However, we are limited by the cross-sectional nature of this study. We are also limited by the lack of literature on this topic and, hence, our inability to obtain enough confidence in our results.

The participants mainly used lung radiography (9/22, 41%), low-dose CT (7/22, 32%), or PET/CT (6/22, 27%) as a routine lung screening method during the posttreatment follow-up of patients with head and neck cancer for 5 years (17/22, 77%) or 10 years (3/22, 14%), and only a small percentage of participants have performed lifelong lung screening (2/22, 9%). Lung screening was mostly conducted annually or half-yearly. Such screening was believed to be very effective or somewhat effective. However, controversy still exists due to the lack of evidence-based protocols worldwide. Therefore, future research should explore the importance of this subject by using a more comprehensive methodology and enrolling patients with HNSCC in comparative studies. We also recommend conducting further follow-up studies to obtain more knowledge on the effects of the positions that physicians hold.