The American Head and Neck Society has reviewed the current utility of circulating tumour DNA in head and neck cancer, including the oncogenic viral DNA assays that have driven most of the interest — human papillomavirus in oropharyngeal cancer and Epstein-Barr virus in nasopharyngeal cancer.
The review's position is deliberately restrained. Viral circulating tumour DNA is promising in the diagnostic and surveillance settings across tumour types, and trials are ongoing in monitoring treatment response and measuring minimal residual disease. But several questions block routine use: test variability between platforms, and what to do about an inaccurate result in either direction. A false positive triggers imaging, anxiety and sometimes biopsy in a patient with no disease; a false negative reassures wrongly in a cancer where salvage depends on early detection.
The practical value of a society review like this is as a brake. These assays are commercially available and being marketed to surveillance clinics ahead of the evidence that they change outcomes. A rising value has intuitive appeal, and it is already being used in some centres to decide on imaging — which is a reasonable instinct and an unvalidated practice.
Epstein-Barr virus DNA in nasopharyngeal carcinoma deserves separate mention for this readership, because nasopharyngeal cancer is far more common in parts of India and the far east than in the populations most head and neck literature is drawn from. The plasma Epstein-Barr virus DNA evidence base is the most mature of the lot, and it is the assay most likely to reach routine use first.
- Do not use circulating tumour DNA to decide on treatment escalation or de-escalation outside a trial
- Ask which platform and which assay before interpreting a result someone else ordered — variability between tests is the stated problem
- Keep clinical examination and imaging as the surveillance backbone
- Have a plan for a positive result with negative imaging before ordering the test, not after
- Follow the Epstein-Barr virus DNA literature in nasopharyngeal carcinoma separately; it is further ahead than the rest
Why it matters
The assays are already purchasable and already being acted on, ahead of evidence that acting on them helps.
Don't overread it
This is a narrative society review of promise and ongoing trials, not evidence that circulating tumour DNA improves any outcome.
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