Head and neck cancer

Quick Reference Guide

The optimal care pathways describe the standard of care that should be available to all cancer patients treated in Australia. The pathways support patients and carers, health systems, health professionals and services, and encourage consistent optimal treatment and supportive care at each stage of a patient’s journey. Seven key principles underpin the guidance provided in the pathways: patient-centred care; safe and quality care; multidisciplinary care; supportive care; care coordination; communication; and research and clinical trials.

This quick reference guide provides a summary of the Optimal care pathway for people with head and neck cancer.

Please note that not all patients will follow every step of the pathway.

Support: Assess supportive care needs at every step of the pathway and refer to appropriate health professionals or organisations.

Prevention

Stop smoking and avoid exposure to second-hand tobacco smoke.
Avoid or reduce alcohol intake, ultraviolet exposure and occupational exposure to asbestos, wood dust, nickel alloy and silica dust.
Vaccinate against human papillomavirus.
Practise good oral hygiene.
Eat healthily and maintain a healthy body weight.

Risk factors

People who frequently smoke and consume alcohol are at the highest risk of head and neck cancer.

Risk factors include:

smoking, chewing tobacco or chewing betel quid
alcohol consumption
HPV exposure
UV skin exposure (for skin cancer)
pre-existing oral lesions
poor oral hygiene
age (over 40 years)
sex (male)
Epstein-Barr virus infection in genetically predisposed individuals (for nasopharyngeal cancer)
immunosuppression
ionising radiation exposure
inherited conditions
poor nutrition.

Screening recommendations

There are currently no formal screening programs in Australia for detecting head and neck cancer. Opportunistic screening should be conducted during general health examinations and dental check-ups.

Checklist

HPV vaccination

Recent weight changes discussed and the patient’s weight recorded

Alcohol intake discussed and recorded and support for reducing alcohol consumption offered if appropriate

Smoking status discussed and recorded and brief smoking cessation advice offered to smokers

Physical activity recorded

Referral to a dietitian considered

Referral to a physiotherapist or exercise physiologist considered

Education on being sun smart considered

Signs and symptoms

The following signs and symptoms should be investigated if they persist for more than 3 weeks, especially if more than one symptom is present:

mouth ulcer or mass
unexplained tooth mobility and/or nonhealing dental extraction site
white or red patches of the oral mucosa – leukoplakia
persisting lip ulcers or patches
changes in the voice, such as hoarseness
persistent sore throat (particularly together with earache) or cough
difficulty or pain when swallowing or chewing
coughing up blood (including spitting up blood)
persistent unexplained neck or parotid lump or sore
pain, pressure, unilateral ringing in the ear or hearing loss
unilateral paralysis of the muscles in the face
unilateral numbness, tingling, pins and needles or formication (feeling of insects crawling on the skin)
unilateral blockage of the nose, especially if associated with swelling or other problems with the eyes such as
double vision
trismus (lockjaw) or reduced jaw opening
unexplained weight loss.

Initial investigations may include:

structural imaging with ultrasound, CT and/or MRI
ultrasound-guided fine-needle aspiration cytology (USgFNAC) of a node, if malignancy is suspected or a neck lump persists or grows (including lumps in the thyroid, salivary gland or lymph node).

Excisional biopsy of potentially malignant lesions should not be undertaken.

Appropriately trained practitioners can consider biopsy of a primary site, but this should not delay referral. Lymph nodes should not have incisional or excisional biopsy without specialist input.

Referral options

At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, if there are likely to be out-of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.

Patients with head and neck cancer should only be referred to specialists who regularly participate in subspecialty head and neck multidisciplinary meetings. The patient must be informed about the improved outcomes achieved at centres that treat higher numbers of complex head and neck cases.

Communication

The GP’s responsibilities include:

explaining to the patient and/or carer who they are being referred to and why
supporting the patient and/or carer while waiting for specialist appointments
informing the patient and/or carer that they can contact Cancer Council on 13 11 20.

Checklist

Signs and symptoms recorded

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient notified of support services such as Cancer Council 13 11 20

Referral options discussed with the patient and/or carer including cost implications

Timeframe

Signs and symptoms should be investigated if they persist for more than 3 weeks, especially if more than one symptom is present.

The first specialist appointment should take place within 2 weeks of the initial referral from the general or dental practitioner.

Diagnosis and staging

The following investigations should be undertaken:

complete head and neck examination, including endoscopy
scans (ultrasound, CT, MRI or PET) to evaluate the primary site, regional lymph nodes and sites of possible distant metastases (scans should ideally be performed prior to biopsy to avoid the effect of upstaging from the oedema)
biopsy (arranged by a practitioner with appropriate training and current experience).

Genetic testing

There is no established role for genetic testing for most head and neck cancers. Nasopharyngeal carcinoma has a higher incidence in people of Chinese or Southern European background, but there is currently no genetic test to identify specific individuals at risk.

Treatment planning

The multidisciplinary team should discuss all newly diagnosed patients with head and neck cancer so that a treatment plan can be recommended. The first multidisciplinary team meeting (MDM) should be within 2 weeks of receiving the diagnosis and staging results.

Research and clinical trials

Consider enrolment where available and appropriate. Search for a trial.

Communication

The lead clinician’s (1) responsibilities include:

discussing a timeframe for diagnosis and treatment options with the patient and/or carer
explaining the role of the multidisciplinary team in treatment planning and ongoing care
encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs and expectations, and their ability to comprehend the communication
providing appropriate information and referral to support services as required
communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from MDMs.

1: Lead clinician – the clinician who is responsible for managing patient care.

The lead clinician may change over time depending on the stage of the care pathway and where care is being provided.

Checklist

Diagnosis confirmed

Full histology obtained

Performance status and comorbidities measured and recorded

Patient discussed at an MDM and decisions provided to the patient and/or carer

Clinical trial enrolment considered

Supportive care needs assessment completed and recorded and referrals to allied health services actioned as required

Patient referred to support services (such as Cancer Council) as required

Treatment costs discussed with the patient and/or carer

Timeframe

Diagnostic investigations should be completed within 2 weeks of the specialist appointment.

Establish intent of treatment

Curative
Palliative, which may include anticancer therapy to improve quality of life or longevity (or both) without expectation of cure, or symptomatic treatment only

Having access to specialist nursing and allied health disciplines (in particular specialist speech pathology, physiotherapy and dietetics) is important for managing the physical, psychological and social/practical needs that may arise with head and neck cancer treatment.

Surgery: Surgery can be used as the primary curative treatment modality in a number of head and neck cancers. It can be used to salvage residual or recurrent disease or as palliative treatment.

Radiation therapy: Radiation therapy can be used as the primary curative treatment in several head and neck cancers and may be given concurrently with systemic therapy. It can be given following surgery (postoperatively) for patients at high risk of locoregional recurrence. It can also be used as palliative treatment.

Systemic therapy: Systemic therapy, concurrent with radiation, can be used as the primary curative treatment or as an adjuvant treatment following surgery for several head and neck cancers.

Neoadjuvant systemic therapy (before radiation therapy) is also appropriate in a small number of specific clinical scenarios. Targeted biological agents and immunotherapy are the standards of care for some recurrent head and neck cancers. Systemic therapy can also be used as palliative treatment.

Palliative care: Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more, visit the Palliative Care Australia website.

Communication

The lead clinician and team’s responsibilities include:

discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
discussing advance care planning with the patient and/or carer where appropriate
communicating the treatment plan to the patient’s GP
helping patients to find appropriate support for exercise programs where appropriate to improve treatment outcomes.

Checklist

Intent of treatment established

Risks and benefits of treatments discussed with the patient and/or carer

Treatment plan discussed with the patient and/or carer

Treatment plan provided to the patient’s GP

Treating specialist has adequate qualifications, experience and expertise

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Early referral to palliative care considered

Advance care planning discussed with the patient and/or carer

Timeframe

Surgery should be scheduled within 4 weeks of the MDM.

Radiation therapy or systemic therapy as a primary treatment:

for curative intent – start within 4 weeks of the MDM
for palliative intent – start within 2 weeks of the MDM.

If systemic therapy is being used concurrently with radiation therapy, start within 1 week of radiation therapy.

Radiation therapy as an adjuvant treatment should start within 6 weeks after surgery.

Provide a treatment and follow-up summary to the patient, carer and GP outlining:

the diagnosis, including tests performed and results
tumour characteristics
treatment received (types and date)
current toxicities (severity, management and expected outcomes)
interventions and treatment plans from other health professionals
potential long-term and late effects of treatment and care of these
supportive care services provided
a follow-up schedule, including tests required and timing
contact information for key healthcare providers who can offer support for lifestyle modification
a process for rapid re-entry to medical services for suspected recurrence.

Communication

The lead clinician’s responsibilities include:

explaining the treatment summary and follow-up care plan to the patient and/or carer
informing the patient and/or carer about secondary prevention and healthy living
discussing the follow-up care plan with the patient’s GP.

Checklist

Treatment and follow-up summary provided to the patient and/or carer and the patient’s GP

Supportive care needs assessment completed and recorded and referrals to allied health services actioned as required

Patient-reported outcome measures recorded

Detection

Most cases of recurrent head and neck cancer will be detected at routine followup or by the patient presenting with symptoms before routine clinical follow-up.

Treatment

Evaluate each patient for whether referral to the original multidisciplinary team is appropriate. Treatment will depend on the location and extent of disease, previous management and the patient’s preferences.

Advance care planning

Advance care planning is important for all patients but especially those with advanced disease. It allows them to plan for their future health and personal care by thinking about their values and preferences. This can guide future treatment if the patient is unable to speak for themselves.

Survivorship and palliative care

Survivorship and palliative care should be addressed and offered early. Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis.

Communication

The lead clinician and team’s responsibilities include:

explaining the treatment intent, likely outcomes and side effects to the patient and/or carer and the patient’s GP.

Checklist

Treatment intent, likely outcomes and side effects explained to the patient and/or carer and the patient’s GP

Supportive care needs assessment completed and recorded and referrals to allied health services actioned as required

Advance care planning discussed with the patient and/or carer

Patient referred to palliative care if appropriate

Routine follow-up visits scheduled

Palliative care

Consider a referral to palliative care. Ensure an advance care directive is in place.

Communication

The lead clinician’s responsibilities include:

being open about the prognosis and discussing palliative care options with the patient
establishing transition plans to ensure the patient’s needs and goals are considered in the appropriate environment.

Checklist

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient referred to palliative care

Advance care directive in place

Visit our guides to best cancer care webpage for consumer guides. Visit our OCP webpage for the optimal care pathway and instructions on how to import these guides into your GP software.

Head and neck cancer QRG

Head and neck cancer QRG

Head and neck cancer

Quick Reference Guide