4.2 Treatment options
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.