Assessment, Management of Upper Aerodigestive Tract Cancer-NICE Guideline 2016

Information Needs

For people with cancer of the upper aerodigestive tract and their carers:

• Provide consistent information and support at diagnosis.


• Review their needs throughout the care pathway including at the end of treatment.


• Tailor information and support to the person's needs (including the benefits and side effects of treatment, psychosocial and long-term functional issues).

Give people contact details for their allocated key worker, in line with the NICE service guidance on improving outcomes in head and neck cancer and recommendations of the National Peer Review Programme .

Give people details of peer support services that can help them throughout their care pathway.

Offer information about human papillomavirus (HPV) to people with HPV-related cancer of the upper aerodigestive tract.

Smoking Cessation

Inform patients and carers at the point of diagnosis about how continuing to smoke adversely affects outcomes such as:

• Treatment-related side effects


• Risk of recurrence


• Risk of second primary cancers

Offer help to people to stop smoking, in line with the NICE guideline on stop smoking services .

Investigation

Assessment of Neck Lumps

Consider adding ultrasound guidance to fine-needle aspiration cytology or core biopsy for people with a neck lump that is suspected of being cancer of the upper aerodigestive tract.

Consider having a cytopathologist or biomedical scientist assess the cytology sample adequacy when the procedure is carried out.

Identifying the Occult Primary

Consider a fluorodeoxyglucose positron emission tomography (FDG PET)-computed tomography (CT) scan as the first investigation to detect the primary site in people with metastatic nodal squamous cell carcinoma of unknown origin that is thought to arise from the upper aerodigestive tract.

Consider using narrow-band imaging endoscopy to identify a possible primary site when it has not been possible to do so using FDG PET-CT.

Offer a biopsy to confirm a possible primary site.

Offer surgical diagnostic assessment if FDG PET-CT does not identify a possible primary site. This may include:

• Guided biopsies


• Tonsillectomy


• Tongue base mucosectomy

Consider a magnetic resonance image (MRI) or CT scan before diagnostic surgery to help with radiotherapy treatment planning.

Clinical Staging – Who and How?

Offer systemic staging (see recommendations below) to all people with cancer of the upper aerodigestive tract except those with T1N0 or T2N0 disease.

Offer FDG PET-CT to people with T4 cancer of the hypopharynx or nasopharynx.

Offer FDG PET-CT to people with N3 cancer of the upper aerodigestive tract.

Offer conventional imaging (for example, chest CT) to people with cancer of the upper aerodigestive tract who require systemic staging (see recommendation above) but FDG PET-CT is not indicated for them.

Treatment of Early Stage Disease

Squamous Cell Carcinoma of the Larynx

Offer transoral laser microsurgery to people with newly diagnosed T1a squamous cell carcinoma of the glottic larynx.

Offer a choice of transoral laser microsurgery or radiotherapy to people with newly-diagnosed T1b–T2 squamous cell carcinoma of the glottic larynx.

Offer a choice of transoral surgery or radiotherapy to people with newly-diagnosed T1–T2 squamous cell carcinoma of the supraglottic larynx.

Management of the N0 Neck in T1–2 Squamous Cell Carcinoma of the Oral Cavity

Offer surgical management of the neck to all people with early oral cavity cancer (T1–T2, N0).

Offer sentinel lymph node biopsy instead of elective neck dissection to people with early oral cavity cancer (T1–T2, N0), unless they need cervical access at the same time (for example, free-flap reconstruction).

Squamous Cell Carcinoma of the Oropharynx (T1–2, N0)

Offer people the choice of transoral surgical resection or primary radiotherapy for T1–2 N0 tumours of the oropharynx.

Consider postoperative radiotherapy, with or without concomitant chemotherapy, for T1–2 N0 tumours of the oropharynx if pathologically adverse risk factors have been identified.

Treatment of Advanced Disease

Squamous Cell Carcinoma of the Larynx

Offer people with T3 squamous cell carcinoma of the larynx a choice of:

• Radiotherapy with concomitant chemotherapy, or


• Surgery with adjuvant radiotherapy, with or without concomitant chemotherapy

Discuss the following with people with T3 squamous cell carcinoma of the larynx and their carers, to inform their choice of treatment:

• The potential advantages of laryngeal preservation


• The risk of needing salvage laryngectomy (and its associated complications)


• The benefits of primary surgery in people with existing compromised swallowing and airway function


• Likely voice and swallowing function after treatment (including the need for a long-term feeding tube)

For people with T4a squamous cell carcinoma of the larynx consider surgery with adjuvant radiotherapy, with or without concomitant chemotherapy.

Squamous Cell Carcinoma of the Hypopharynx

Offer larynx-preserving treatment to people with locally-advanced squamous cell carcinoma of the hypopharynx if radiation and neo-adjuvant and/or concomitant chemotherapy would be suitable for them and they do not have:

• Tumour-related dysphagia needing a feeding tube


• A compromised airway


• Recurrent aspiration pneumonias

Offer radiotherapy with neo-adjuvant and/or concomitant chemotherapy if larynx-preserving treatment is suitable for the person.

Offer primary surgery followed by adjuvant radiotherapy to people if chemotherapy is not a suitable treatment for them.

Offer adjuvant radiotherapy to people having surgery as their primary treatment. Add concomitant chemotherapy if appropriate.

Palliation of Breathing Difficulties

Identify people at risk of airways obstruction for whom intervention is appropriate. Think about:

• Their performance status


• Treatment side effects and length of hospital stay


• Involving the palliative care team and other specialists when appropriate

Consider endoluminal debulking in preference to tracheostomy.

Establish a management plan if surgical intervention is not appropriate, in conjunction with the person, carers and clinical staff.

Assess and treat other causes of breathlessness in people with incurable upper aerodigestive tract cancer.

HPV-related Disease

HPV Testing

Test all squamous cell carcinomas of the oropharynx using p16 immunohistochemistry. Regard the p16 test result as positive only if there is strong nuclear and cytoplasmic staining in more than 70% of tumour cells.

Consider high-risk HPV deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) in-situ hybridisation in all p16-positive cancers of the oropharynx to confirm HPV status.

De-Intensification of Treatment

Do not offer de-intensification of curative treatment to people with HPV-positive cancer of the oropharynx, unless it is part of a clinical trial.

Less Common Upper Aerodigestive Tract Cancers

Carcinoma of the Nasopharynx

Offer intensity-modulated radiation therapy with concomitant chemotherapy to people with locally-advanced (stage II and above) nasopharyngeal cancer.

Consider adjuvant or neo-adjuvant chemotherapy for people with locally-advanced (stage II and above) nasopharyngeal cancer.

Carcinoma of the Paranasal Sinuses

Offer surgery as the first treatment for carcinoma of the paranasal sinuses if complete resection is possible.

Consider radiotherapy with or without concomitant chemotherapy before planned surgical resection of the paranasal sinuses if complete resection is not initially possible.

Unknown Primary of Presumed Upper Aerodigestive Tract Origin

Offer people with squamous cell carcinoma in the cervical lymph nodes with an unknown primary the choice of:

• Neck dissection and adjuvant radiation with or without chemotherapy, or


• Primary radiation with or without chemotherapy, with surgery for persistent disease

Consider no further treatment as an option in people with pN1 disease without extracapsular spread after neck dissection.

Consider including potential primary tumour sites when selecting the volume to be treated with radiotherapy.

Consider surgery and adjuvant radiotherapy for people with newly-diagnosed upper aerodigestive tract mucosal melanoma without systemic metastases.

Optimising Rehabilitation and Function

Enteral Nutrition Support

Assess people's need for enteral nutrition at diagnosis, including prophylactic tube placement. The multidisciplinary team should take into account:

• Performance status and social factors


• Nutritional status (weight loss, high or low body mass index [BMI], ability to meet estimated nutritional needs)


• Tumour stage


• Tumour site


• Pre-existing dysphagia


• Impact of planned treatment (such as radiation treatment volume and dose-fractionation, concomitant chemotherapy, and extent and site of surgery)

Follow the recommendations in NICE's guideline on nutrition support for adults for people aged 18 years and over.

Speech and Language Therapy Interventions

Consider swallowing-exercise programmes for people having radiotherapy.

Consider mouth-opening exercises for people having radiotherapy who are at risk of reduced mouth opening.

Consider voice therapy for people whose voice has changed because of their treatment.

Shoulder Rehabilitation

Consider progressive resistance training for people with impaired shoulder function, as soon as possible after neck dissection.

Follow-up of People with Cancer of the Upper Aerodigestive Tract and Management of Osteoradionecrosis

Follow-up

Ensure people with cancer of the upper aerodigestive tract and their carers have tailored information about the symptoms of recurrence and late effects of treatment at the end of curative therapy.

Consider structured, risk-adapted follow-up using locally-agreed protocols for people who have had curative treatment for cancer of the upper aerodigestive tract. Use the follow-up protocols to:

• Help improve quality of life, including discussing psychosocial issues


• Detect disease recurrence or second primary cancer, possibly including narrow-band imaging to improve detection

Management of Osteoradionecrosis

Consider surgery to remove necrotic bone and to establish soft tissue coverage in people with osteoradionecrosis.

Only consider hyperbaric oxygen therapy or medical management for treating osteoradionecrosis as part of a clinical trial.

Stages of Upper Aerodigestive Tract Cancer

The stages of upper aerodigestive tract cancer referred to in this guideline are listed below.

• T0: this means there is no primary tumour, but there may be abnormal cells that are precancerous.


• T1 to T4: this refers to the increasing size and/or extent of the primary tumour, with 1 being smallest and 4 largest.


• N0: no lymph nodes contain cancer cells.


• N1 and upwards: increasing involvement of lymph nodes by cancer cells.