Many head and neck cancer patients will benefit from surgery. Patients at high risk of locoregional recurrence will also benefit from adjuvant postoperative radiation treatment.

Surgery can be used as the primary treatment of a number of head and neck cancers with curative intent. It can be used to salvage residual or recurrent disease or in the palliative management of some patients.

Timeframe for starting treatment

Surgery should be scheduled within four weeks of the MDM.

The time from definitive surgery to starting adjuvant treatment (plus concomitant systemic therapy when indicated) should be not more than six weeks.

Training and experience required of the surgeon

Fellow of the Royal Australian College of Surgeons or equivalent, with adequate training and experience that enables institutional credentialing and agreed scope of practice in head and neck cancers (ACSQHC 2015).

It is also necessary for the surgeon to have ongoing and regular attendance at and a commitment to MDMs and continuing professional development in head and neck oncology. All cancer surgeons should actively participate in regular audits of their surgical results and their oncological outcomes with functional outcome measures.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with head and neck cancer and procedures to be undertaken, should be available.

Surgeons who undertake a high volume of resections have better clinical outcomes for complex cancer surgery and improved survival for their patients (David et al. 2017; Eskander et al. 2014; Liu et al. 2019).

Health service characteristics

To provide safe and high-quality care for patients having surgery, health services should have these features:

• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• appropriate nursing and theatre resources to manage complex head and neck surgery
• diagnostic imaging including access to instrumental swallowing assessments
• pathology
• nuclear medicine imaging
• nurses, dietitians, dentists and speech pathologists with training and current experience in managing patients with head and neck cancer
• a clearly defined path to emergency care and advice after hours
• a clearly defined path and assured access to inpatient care
• ability to perform or refer to ancillary study.

Radiation therapy can be used as the primary curative treatment of 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 is also useful in palliative care.

Patients should have access to a dietitian and a speech pathologist within the radiation therapy centre, who should liaise closely with their counterparts in the patient’s local support team.

Outcomes are improved for patients receiving curative radiation therapy for head and neck cancers when they are treated by radiation oncologists who have larger head and neck cancer caseloads (Boero et al. 2016; Wuthrick et al. 2014).

Timeframe for starting treatment

Radiation therapy as a primary treatment:

• for curative intent – start within four weeks of the MDM
• for palliative intent – start within two weeks of the MDM.

Radiation therapy as an adjuvant treatment should begin within six weeks after surgery.

Training and experience required of the appropriate specialists

Fellowship of the Royal Australian and New Zealand College of Radiologists or equivalent, with adequate training and experience, institutional credentialing and agreed scope of practice in head and neck cancers (ACSQHC 2015). It is also necessary for the radiation oncologist to have ongoing and regular attendance at and a commitment to MDMs and continuing professional development in head and neck oncology.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

• linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
• dedicated CT planning
• access to MRI and PET imaging
• automatic record-verify of all radiation treatments delivered
• a treatment planning system
• trained medical physicists, radiation therapists and nurses with radiation therapy experience
• nurses, dietitians, dentists, speech pathologists and social workers with training and current experience in managing patients with head and neck cancer
• on-site or an existing relationship with specialist dental services before fitting a treatment mask
• head and neck cancer–specific peer review
• a clearly defined path to emergency care and advice after hours
• a clearly defined path and assured access to inpatient care
• coordination for combined therapy with systemic therapy, especially where facilities are not co-located
• participation in Australian Clinical Dosimetry Service audits
• an incident management system linked with a quality management system.

Systemic therapy, concurrent with radiation therapy, can be used as the primary curative treatment or as an adjuvant treatment for several head and neck cancers. It has been shown to improve local control and add a survival benefit compared with radiation therapy alone in high-risk patients with good performance status. Neoadjuvant systemic therapy (before radiation therapy) is also appropriate in a small number of clinical scenarios. Targeted biological agents and immunotherapy are the standards of care for some recurrent head and neck cancers.

Systemic therapy is also used in palliative treatment.

Timeframes for starting treatment

Systemic therapy as a primary treatment:

• with curative intent – start within four weeks of the MDM
• for palliative intent – start within two weeks of the MDM
• if being used concurrently with radiation therapy, it should start within week one of radiation therapy.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

It is also necessary for the medical oncologist to have ongoing and regular attendance at and a commitment to MDMs and continuing professional development in head and neck oncology.

Cancer nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic drugs prepared in a pharmacy with appropriate facilities
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology access
• nurses, dietitians, dentists and speech pathologists with training and current experience in managing patients with head and neck cancer
• a clearly defined path and assured access to inpatient care.

The state of medical therapies for cancer is constantly changing, and new treatments are routinely being trialled. Any decision on the use of targeted and immune therapies should include input from a medical oncologist and the patient.

For many patients, a clinical trial will be the best way to manage them, and access to clinical trials should always be considered.

A number of emerging therapies are being investigated for head and neck cancers. Therapies that show promise for treating head and neck cancers include:

• targeted therapy
• immunotherapy (Santuray et al. 2018)
• cell therapy (Qureshi & Lee 2019).

Encourage enrolment in clinical trials where available. A pathway to clinical trials should be facilitated by the lead multidisciplinary team clinician.

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

• assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
• potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
• management of physical symptoms such as pain and fatigue
• management of oral side effects of head and neck cancer treatments, which may require input from a special needs dentist
• support for malnutrition, which can occur as a result of disease or treatment – validated malnutrition screening tools such as MST should be used at the key points in the care pathway to identify patients at risk of malnutrition and refer to a dietitian for early nutrition intervention (all patients with a head and neck cancer diagnosis receiving radiation therapy should be referred to a dietitian for assessment and intervention)
• dietitian management of nutrition intake (oral diet and enteral feeding), weight loss and symptom management through dietary counselling
• speech pathology for patients who present with symptoms of aspiration (coughing when eating or drinking), have undergone a laryngectomy, have communication impairments or have swallowing difficulties including trismus
• postoperative physiotherapy for respiratory assessment and treatment, including secretion management, particularly in the case of laryngectomy or temporary tracheostomy
• physiotherapy for musculoskeletal changes such as shoulder and neck pain or dysfunction following treatment
• physiotherapy or occupational therapy (therapist trained in lymphoedema) for neck mobility or head and neck lymphoedema
• occupational therapy for cancer fatigue/endurance
• occupational therapy or psychology support for social skills training and/or a social worker for family liaison to help to reduce psychosocial difficulties
• support with changes in physical appearance that impact on social and mental wellbeing
• support for breathing, swallowing or communicating if a long-term tracheostomy is required or if the patient underwent a total laryngectomy
• referral to prosthesis to restore facial appearance when necessary
• referral to a pharmacist for people managing multiple medications
• help with a decline in mobility or functional status as a result of treatment
• assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

• financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
• advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
• legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

Refer to Quitline 13 78 48 for information and support to quit smoking.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists, dentists, audiologists, prosthodontists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, addressing shoulder and neck musculoskeletal dysfunction, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

Rehabilitation also includes the longer term surgical rehabilitation of patients including adjunctive procedures to improve appearance, and for oral and head and neck functions.

The lead or nominated clinician should take responsibility for these tasks:

• discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
• providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
• encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
• initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

• the general practitioner’s role in symptom management, supportive care and referral to local services
• using a chronic disease management plan and mental health care management plan
• how to ensure regular and timely two-way communication about:
  • the treatment plan, including intent and potential side effects
  • supportive and palliative care requirements
  • the patient’s prognosis and their understanding of this
  • enrolment in research or clinical trials
  • changes in treatment or medications
  • the presence of an advance care directive or appointment of a substitute decision-maker
  • recommendations from the multidisciplinary team.

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.