The Journal of laryngology and otology
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Practice Guideline
Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the aetiology and risk factors for head and neck cancer and the recommended interventions appropriate for each risk factor. Recommendations • Recent evidence synthesis from National Institute for Health and Care Excellence suggests that the following brief interventions for smoking cessation work should be used: ○ Ask smokers how interested they are in quitting (R) ○ If they want to stop, refer them to an intensive support service such as National Health Service Stop Smoking Services (R) ○ If they are unwilling or unable to accept a referral, offer a stop smoking aid, e.g. pharmacotherapy. (R) • Brief interventions are effective for hazardous and harmful drinking. (R) • Specialist interventions are effective in people with alcohol dependence. (R) • Most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment. (R) • Management of leukoplakia is not informed by high-level evidence but consensus supports targeted use of biopsy and histopathological assessment. (R) • The management of biopsy proven dysplastic lesions favours: ○ advice to reduce known environmental carcinogens such as tobacco and alcohol (R) ○ surgical excision when the size of the lesions and the patient's function allows (R) ○ long-term surveillance. (R) • Fanconi anaemia patients should: ○ be followed up in a multidisciplinary specialist Fanconi anaemia clinic (G) ○ have quarterly screening for head and neck squamous cell carcinoma and an aggressive biopsy policy (G) ○ receive prophylactic vaccination against high risk human papilloma virus (G) ○ receive treatment for head and neck squamous cell carcinoma with surgery alone where possible. (G).
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Practice Guideline
Recurrent head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Recurrent cancers present some of the most challenging management issues in head and neck surgical and oncological practice. This is rendered even more complex by the poor evidence base to support management options, the substantial implications that treatments can have on the function and quality of life, and the difficult decision-making considerations for supportive care alone. ⋯ Recommendations • Consider baseline and serial scanning with computed tomography and/or magnetic resonance (CT and/or MR) to detect recurrence in high-risk patients. (R) • Patients with head and neck cancer recurrence being considered for active curative treatment should undergo assessment by positron emission tomography combined with computed tomography (PET-CT) scan. (R) • Patients with recurrence should be assessed systematically by a team experienced in the range of management options available for recurrence including surgical salvage, re-irradiation, chemotherapy and palliative care. (R) • Management of patients with laryngeal recurrence should include input from surgeons with experience in transoral surgery and partial laryngectomy for recurrence. (G) • Expertise in transoral surgery and partial laryngectomy for recurrence should be concentrated to a few surgeons within each multidisciplinary teams. (G) • Transoral or open partial laryngectomy should be offered as definitive treatment modality for highly-selected patients with recurrent laryngeal cancer. (R) • Patients with OPC recurrence should have p16 human papilloma virus status assessed. (R) • Patients with OPC recurrence should be considered for salvage surgical treatment by an experienced team, with reconstructive expertise input. (G) • Transoral surgery appears to be an effective alternative to open surgery for the management of OPC recurrence in carefully selected patients. (R) • Consider elective selective neck dissections in patients with recurrent primaries with N0 necks, especially in advanced cases. (R) • Selective neck dissection (with preservation of nodal levels, especially level V, that are not involved by disease) in patients with nodal (N+) recurrence appears to be as effective as modified or radical neck dissections. (R) • Use salivary bypass tubes following salvage laryngectomy. (R) • Use interposition muscle-only pectoralis major or free flap for suture line reinforcement if performing primary closure following salvage laryngectomy. (R) • Use inlaid pedicled or free flap to close wound if there is tension at the anastomosis following laryngectomy. (R) • Perform secondary puncture in post chemoradiotherapy laryngectomy patients. (R) • Triple therapy with platinum, cetuximab and 5-fluorouracil (5-FU) appears to provide the best outcomes for the management of patients with recurrence who have a good performance status and are fit to receive it. If not fit, then combinations of platinum and cetuximab or platinum and 5-FU may be considered. (R) • Patients with non-resectable recurrent disease should be offered the opportunity to participate in phases I-III clinical trials of new therapeutic agents. (R) • Chemo re-irradiation appears to improve locoregional control, and may have some benefit for overall survival, at the risk of considerable acute and late toxicity. Benefit must be weighed carefully against risks, and patients must be counselled appropriately. (R) • Target volumes should be kept tight and elective nodal irradiation should be avoided. (R) • Best supportive care should be offered routinely as part of the management package of all patients with recurrent cancer even in the case of those who are being treated curatively. (R).
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Practice Guideline
Follow-up after treatment for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. In the absence of high-level evidence base for follow-up practices, the duration and frequency are often at the discretion of local centres. By reviewing the existing literature and collating experience from varying practices across the UK, this paper provides recommendations on the work up and management of lateral skull base cancer based on the existing evidence base for this rare condition. Recommendations • Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients. (G) • Patients should be followed up at least two monthly in the first two years and three to six monthly in the subsequent years. (G) • Patients should be seen in dedicated multidisciplinary head and neck oncology clinics. (G) • Patients should be followed up by dedicated multidisciplinary clinical teams. (G) • The multidisciplinary follow-up team should include clinical nurse specialists, speech and language therapists, dietitians and other allied health professionals in the role of key workers. (G) • Clinical assessment should include adequate clinical examination including fibre-optic rigid or flexible nasopharyngolaryngoscopy. (R) • Magnetic resonance imaging and positron emission tomography combined with computed tomography imaging should be used when recurrence is suspected. (R) • Narrow band imaging can be used in the follow-up in selected sites. (R) • Second primary tumours should be part of rationale of follow-up and therefore adequate screening strategies should be used to detect them. (G) • Patients should be educated with regard to the appearance and detection of recurrences. (G) • Patients with persistent pain should be investigated to exclude recurrent disease. (R) • Patients should be offered support with tobacco and alcohol cessation services. (R).
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Practice Guideline
Management of neck metastases in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. A rational plan to manage the neck is necessary for all head and neck primaries. With the emergence of new level 1 evidence across several domains of neck metastases, this guideline will identify the evidence-based recommendations for management. Recommendations • Computed tomographic or magnetic resonance imaging is mandatory for staging neck disease, with choice of modality dependant on imaging modality used for the primary site, local availability and expertise. (R) • Patients with a clinically N0 neck, with more than 15-20 per cent risk of occult nodal metastases, should be offered prophylactic treatment of the neck. (R) • The treatment choice of for the N0 and N+ neck should be guided by the treatment to the primary site. (G) • If observation is planned for the N0 neck, this should be supplemented by regular ultrasonograms to ensure early detection. (R) • All patients with T1 and T2 oral cavity cancer and N0 neck should receive prophylactic neck treatment. (R) • Selective neck dissection (SND) is as effective as modified radical neck dissection for controlling regional disease in N0 necks for all primary sites. (R) • SND alone is adequate treatment for pN1 neck disease without adverse histological features. (R) • Post-operative radiation for adverse histologic features following SND confers control rates comparable with more extensive procedures. (R) • Adjuvant radiation following surgery for patients with adverse histological features improves regional control rates. (R) • Post-operative chemoradiation improves regional control in patients with extracapsular spread and/or microscopically involved surgical margins. (R) • Following chemoradiation therapy, complete responders who do not show evidence of active disease on co-registered positron emission tomography-computed tomography (PET-CT) scans performed at 10-12 weeks, do not need salvage neck dissection. (R) • Salvage surgery should be considered for those with incomplete or equivocal response of nodal disease on PET-CT. (R).
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Practice Guideline
Education of trainees, training and fellowships for head and neck oncologic and surgical training in the UK: United Kingdom National Multidisciplinary Guidelines.
Since the previous edition of these guidelines, significant changes have taken place in the training and assessment of surgeons and oncologists who treat patients with head and neck cancer. For those intending to become head and neck surgeons, a fellowship in head and neck surgery is virtually mandatory. This paper summarises the current career structure to specialise in head and neck oncology and surgery in the UK. Recommendation • Trainees applying for head and neck surgical oncology consultant posts should have completed additional training in the subspecialty.