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.