Impact of Circulating Cell Free Tumor Tissue Modified Viral-HPV DNA Testing on Post-Treatment Imaging Surveillance Protocol in Oropharyngeal Carcinoma

References

1. Berger BM, Hanna GJ, Posner MR, et al. Detection of Occult Recurrence Using Circulating Tumor Tissue Modified Viral HPV DNA among Patients Treated for HPV-Driven Oropharyngeal Carcinoma. doi:10.1158/1078-0432.CCR-22-0562

2. Krist AH, Davidson KW, Mangione CM, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA - Journal of the American Medical Association. 2021;325(10):962-970. doi:10.1001/JAMA.2021.1117

3. Haddad RI, Hicks WL, Hitchcock YJ, et al. NCCN Guidelines Version 1.2023 Head and Neck Cancers Continue NCCN Guidelines Panel Disclosures. Published online 2022. Accessed March 13, 2023. https://www.nccn. org/home/member-

Current National Comprehensive Cancer Network (NCCN) recommended surveillance intervals lack head and neck cancer subsite specificity and risk stratified recommendations. Additionally, NCCN includes a wide range of variability with the current schedule of every 1 to 3 months for the first year, every 2 to 6 months for the second year, every 4 to 8 months for years 3 to 5, and annually thereafter.3 Limited benefit of PET/CT and a low positive predictive value in detecting local and regional recurrence have been demonstrated following a negative three month post definitive treatment scan.4 Recurrences are also more likely to be detected clinically two years after definitive treatment.5 These observations suggests a multimodal approach to HPV-associated OPSCC surveillance may be warranted.

In conclusion, ctDNA testing for OPSCC surveillance can decrease CSI of the neck and chest by 95% and 100%, respectively, in patients with low-risk smoking history. The impact of imaging reductions on health-system and individual-level costs, including patient financial toxicity, presents an area for future investigation. The potential to integrate surveillance ctDNA protocols may improve patient adherence to follow-ups and presents opportunities for novel remote tele-surveillance paradigms.

4. Ho AS, Tsao GJ, Chen FW, et al. Impact of positron emission tomography/ computed tomography surveillance at 12 and 24 months for detecting head and neck cancer recurrence. Cancer.

Manan H. Parekh, BA

Nithin Adappa, MD Robert M. Brody, MD University of Pennsylvania

Noncompete agreements are a form of restrictive covenant aimed at protecting employer investments and reducing the risk for unfair advantages amongst competitors.1 Among physicians, noncompete agreements are varied in scope and enforceability, leading to frustration and sometimes exploitation of physicians. A 2021 Medscape survey of 558 physicians showed greater than 90% of physicians had or have a noncompete agreement, indicating the commonplace nature of these restrictive clauses.2 On January 5, 2023, the Federal Trade Commission (FTC) announced an initiative to ban noncompete agreements almost unilaterally, prompting speculation about how this may impact physicians in various locations.3 The banning of noncompete agreements may empower physicians, increase wages, improve working environments, and improve patient care. However, the potential benefits of this ruling hinge on court rulings and legal definitions.

“The freedom to change jobs is core to economic liberty,” said FTC chair Lina M. Khan regarding the initial proposal launch in January. Noncompete agreements have limited physician bargaining power against their employers. While physicians benefit from hospital systems/corporate entities by being able to collaborate with other providers, improve standard of care, and develop a varied patient base, these noncompete agreements can limit their mobility in the job market.4 For physicians with established families, moving may not be feasible, making contract negotiations difficult. In Pennsylvania, noncompete clauses are enforceable, severely limiting local alternative prospects for physicians. Due to the possibility of termination without alternatives, physicians are unable or hesitant to bargain for better working conditions or pay, as they have little leverage against their employers. The banning of noncompete agreements would change this.

Noncompete agreements put the physician-patient relationship in the hands of the employer. The physician-patient relationship is particularly important in otolaryngology, where clinicians have a longitudinal relationship with patients treating conditions ranging from sinus complaints to hearing loss to voice complaints to head and neck cancer. Thus, patients should be able to see physicians with whom they have developed a trusting relationship. Noncompete agreements minimize choices for patients should the physician leave or be terminated. While the employer is focused on protecting their investments and business assets (i.e. the physician-patient relationship), patients are left out of the conversation which harms care and trust in physicians overall.

Pennsylvania has lofted the idea of banning noncompete agreements in recent history, and this FTC ruling is part of a nationwide employee-rights initiative.5 If enacted, this ruling prevents the signing of new noncompete agreements and makes existing ones non-enforceable. Private practice otolaryngologists can gain significant mobility; however, this may create turbulence within private practices at both the partner and associate levels. Whether this FTC ban permeates into the many hospital systems of Pennsylvania depends on key definitions. The new proposed rule states an entity not “organized to carry on business for its own profit or that of its members” is exempt. Academic and non-academic centers spanning the state fall into this classification of nonprofit entities (tax code 501c3). However, questions remain regarding the actual jurisdictional limitations of the FTC and the behavior of large nonprofit hospital systems which seek to maximize profits.6,7 To determine whether this FTC ruling will apply to nonprofit health systems, court examination of each system’s behavior and determination of whether its behavior matches its nonprofit classification will be needed. Thus, there may be a broad variation in how this

FTC ruling impacts otolaryngologists in Pennsylvania, particularly depending on their employment structure and rulings on FTC jurisdiction.

The public comment period for this ruling regarding noncompete agreements is open until April 19th. Following this comment period, there is a mandatory 180-day notice before the ruling goes into effect.

References

1. Harris SM. How reasonable non-compete clauses can protect your practice. ENTtoday. https:// www.enttoday.org/article/reasonable-noncompete-clauses-can-protect-practice/. Published October 18, 2016. Accessed March 26, 2023.

2. Reese SM. Docs suffer from noncompete clauses: Any hope for change? Medscape. https://www. medscape.com/viewarticle/948871. Published April 21, 2021. Accessed March 26, 2023.

3. Vedova H, Technology TFTCOof. FTC proposes rule to ban noncompete clauses, which Hurt Workers and Harm Competition. Federal Trade Commission. https://www.ftc.gov/news-events/ news/press-releases/2023/01/ftc-proposesrule-ban-noncompete-clauses-which-hurt-workersharm-competition. Published March 7, 2023. Accessed March 26, 2023.

4. Skerrett P. FTC's proposed ban on noncompete agreements could be a game changer for some physicians. STAT. https://www.statnews. com/2023/01/11/ftc-proposed-bannoncompete-agreements-game-changersome-physicians/. Published January 11, 2023. Accessed March 26, 2023.

5. Hollinger S. PA legislators propose to ban noncompete agreements in health care practitioners' employment contracts. Lamb McErlane PC. https://www.lambmcerlane.com/articles/ pa-legislators-propose-to-ban-non-competeagreements-in-health-care-practitionersemployment-contracts-2/. Published June 1, 2021. Accessed March 26, 2023.

6. Boden S. The FTC wants to end noncompete agreements. here's how it'll impact PittsburghArea Physicians. 90.5 WESA. https://www. wesa.fm/health-science-tech/2023-03-06/ the-ftc-wants-to-end-noncompete-agreementsheres-how-itll-impact-pittsburgh-area-physicians. Published March 7, 2023. Accessed March 27, 2023.

7. Bookman T. With $185 million in earnings, Hup is nation's seventh most profitable hospital. WHYY. https://whyy.org/articles/with-185-million-inearnings-hup-is-nations-seventh-most-profitablehospital/. Published May 3, 2016. Accessed March 27, 2023.