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234 I. W. K. Tham and J. J. LuTable 18.1. Guidelines of follow-up management of nasopharyngeal cancer after definitive treatmentSummary of Guidelines by Professional OrganizationsNCCN (2009) ESMO (Chan et al. 2008) AHNS (2009)ModalityClinicalPhysical examinationYear 1: every 1–3 monthsYear 2: every 2–4 monthsYear 3–5: every 4–6 months>5 years: every 6–12 monthsSpeech, hearing, swallowing evaluation,and rehabilitation when indicatedPeriodic examination ofthe nasopharynx and neck,cranial nerve function, andsystemic complaintsPeriodic examinations (with optional useof endoscopy) as per NCCN scheduleClinical assessment for pituitary dysfunctionOphthalmic assessment if treatmentportals included the orbit or opticnerves/chiasmLaboratory TSH every 6–12 months Thyroid functionEBV serology (might beuseful)TSH and free T4 in the first year, thenrepeat if clinically indicated.Liver enzymes, annually.EBV titers every 6 months for 5 yearsin those patients whose titers wereelevated before therapy. (optional)ImagingOthersPost-treatment baseline imaging, thenrepeat when clinically indicatedChest imaging when clinically indicatedSmoking cessation counselingDental evaluationMRI with suggested frequencyEvery 4 months: first yearEvery 6 months: second yearYearly: thereafterAnnual chest X-rayPeriodic examination by dentistNCCN National Comprehensive Cancer Network; ESMO European Society for Medical Oncology; AHNS American Head andNeck Society; TSH thyroid-stimulating hormone; T4 thyroxine; EBV Epstein–Barr virus; MRI magnetic resonance imagingfrom SCCHN, adopting a common follow-up strategymay impede effective and efficient patient care, bothmedically and financially.The purpose of this chapter is to discuss the valueof the commonly utilized clinical studies includingphysical examination, laboratory and imaging tests,and their utilization in the follow-up of NPC afterdefinitive radiation, and propose an evidence-basedfollow-up schedule and regimen.18.2Pattern of Pathological Responseto TreatmentAlthough radiation-induced acute or subacuteadverse effects can persist for weeks or months afterthe completion of therapy, and should be addressedduring follow-up sessions, assessment of residualdisease should only be initiated 10–12 weeks afterthe completion of radiation therapy. A number ofclinical trials have addressed the pathologicalresponse of primary nasopharyngeal cancer toradiation therapy, and their results have indicatedthat primary tumor eradication could continue forweeks to months after the completion of treatment.In a prospective study reported by Sham et al.(1990), a series of biopsies performed twice a weekwere performed in patients with nonmetastaticNPC to study the pattern of tumor regression afterradical radiotherapy. The results demonstrated thatdisease in the primary area may be persistent until10 weeks after treatment, suggesting that residualdisease could only be confirmed 10 weeks or moreafter the completion of the radiotherapy. The results