Association for Palliative Medicine (APM)

British Association of Endocrine & Thyroid Surgeons (BAETS)

British Association of Head & Neck Oncologists (BAHNO)

It gives me great pleasure to write a foreword for the 6th edition of the Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines.

In the five years since the last edition was published, a significant evidence base has accrued in the management of head and neck cancer, especially for oropharyngeal cancer and recurrent metastatic cancer. Additionally, the impact of the coronavirus disease pandemic, which has been felt across all domains of clinical practice, has certainly changed practice in the realms of cancer diagnoses.

Professors Jarrod Homer and Stuart Winter are to be congratulated on compiling this edition of the guidelines, with comprehensive multidisciplinary stakeholder engagement, which significantly builds on the previous edition. Having very carefully sieved through the 30 chapters that comprise the guidelines, I believe this truly captures the best of British expertise in head and neck cancer care. The multidisciplinary authorship reflects the clinicians, researchers and thought leaders in the specialty, who make recommendations based on existing evidence and current practice. I am only too well aware of the long and arduous hours it takes to put together a work of this kind, and the quality of the contributions indicates that the guidelines will be well received by the head and neck oncology community.

In addition to the clinical recommendations, these guidelines have also used a new approach to generate consensus across areas that are not supported by high-level evidence. Working collaboratively with six stakeholder organisations, novel comprehensive methodology was used to achieve consensus recommendations; this is demonstrated to good effect for the unknown primary.

On behalf of the British Association of Head & Neck Oncologists, I whole heartedly endorse these guidelines for practice within these Isles and beyond.

British Association of Head & Neck Oncology Nurses (BAHNON)

On behalf of the British Association of Head & Neck Oncology Nurses Committee, we are delighted to endorse this document. This multidisciplinary document will have a positive impact on the delivery of the highest standard of research-based patient care for many years to come. It will be a valuable resource to all members of the multidisciplinary team. I would like to take the opportunity to thank the authors and editors for all their hard work.

British Association of Oral and Maxillofacial Surgeons (BAOMS)

On behalf of the British Association of Oral and Maxillofacial Surgeons, as the Oncology Subspecialty Interest Group Leads, it is a privilege to write a foreword for this essential scientific document.

Best practice is driven by robust guidelines, which in turn must derive from a high-quality evidence base. The complexity and relatively low incidence of head and neck cancer renders this task extremely challenging.

The 6th edition of Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines embrace the current best available evidence, with comprehensive multidisciplinary specialist team consensus, for practices in caring for head and neck cancer patients.

The publication addresses the challenges met in the complex field of head and neck cancer, but also offers succinct insight into new scientific approaches, such as non-surgical systemic treatments and minimally invasive procedures, either for diagnosis or definitive management.

Whilst cure is the primary goal in the management of patients with head and neck cancer, the document also guides us well regarding the palliative patient, with a focus on quality of life, and updates on psychosocial support and targeted novel treatments.

With a high calibre authorship of renowned experts, this guidance document undoubtedly offers a state-of-the-art overview in head and neck cancer and its management.

We congratulate the cohesive collegiate teamwork in producing this superb set of guidelines.

British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS)

On behalf of the British Association of Plastic, Reconstructive and Aesthetic Surgeons, I am delighted to endorse the publication of these guidelines, and for British Association of Plastic, Reconstructive and Aesthetic Surgeons to be involved in such a collaborative effort, bringing together the knowledge of a truly multidisciplinary group of specialists involved in the management of patients suffering from cancer of the head and neck. The latest guidelines will continue to support multidisciplinary teams and to help provide the best possible outcome for patients.

ENT-UK

I am delighted to write a short introduction to the 6th edition of the Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines. I have been privileged to contribute to all of the previous excellent editions, and without doubt this edition of the guidelines is the most comprehensive to date. The multidisciplinary team (MDT) model is the core of head and neck services in the UK, and the list of authors clearly demonstrates the truly multidisciplinary nature of these guidelines. There was no shortage of excellent authors from all specialties who were keen to contribute to these guidelines, which indicates how important this established publication has become amongst the head and neck specialty. Stuart Winter and Jarrod Homer should be congratulated on the tremendous amount of work they have put in, and it is reflected in a comprehensive, concise, contemporary and eminently readable textbook. These guidelines will be essential reading for all those involved in the management of head and neck cancer, and will form an excellent reference to help inform MDT decisions.

Restorative Dentistry – UK (RD-UK)

We are fortunate to have so many talented and dedicated colleagues involved in delivering healthcare across the UK. Our patients benefit so much more when we work together, within well-structured multidisciplinary teams. We therefore have the opportunity, and, indeed, the responsibility, to collaborate with others, sharing what we currently believe is best practice, caring deeply for our patients, and being open to both teaching and learning, so that we are well prepared for those who will need us in the future.

On behalf of Restorative Dentistry – UK and our specialty of restorative dentistry, I am delighted to endorse the 6th edition of these essential guidelines, and welcome the recognition of our specialty as a core member of the multidisciplinary head and neck cancer team. Restorative dentistry is for those patients who have complex dental problems, requiring multidisciplinary, specialist care for their oral rehabilitation. These guidelines confirm the need for and benefit of restorative dentistry at all stages of the head and neck cancer pathway, ensuring better clinical and personal outcomes for our patients, throughout their treatment and recovery.

These guidelines are, once again, a considerable step towards ensuring that high standards of care are delivered to our patients. We congratulate and thank all those who have contributed to writing, collating and publishing this edition.

Royal College of Speech and Language Therapists (RCSLT)

The Royal College of Speech and Language Therapists is pleased to endorse this high-quality document, in which a great deal of thought and effort has gone into its creation. It will be a very useful resource for speech and language therapists working in head and neck cancer, providing key point summaries and detailed information on speech and language therapy interventions at different stages of the cancer pathway. Clear guidance will be invaluable to speech and language therapists, enabling them to perform their best, which will benefit patients and their families, and foster interprofessional working.

The Royal College of Pathologists (RCPath)

On behalf of The Royal College of Pathologists, I am delighted to endorse the latest update of these guidelines, and I thank the editors and authors for their hard work, particularly Drs Betts, Damato, Robinson and Thavaraj and Prof. Hunter, who contributed the pathology content. The guidelines are testament to the importance of collaborative working between specialties in the treatment of head and neck cancer, and rightly acknowledge cellular pathology as a core component of this. An exciting addition to the guidelines is the molecular testing of head and neck tumours, which has developed immeasurably since the last edition, and places cellular pathology at the centre of diagnosis, prognostication and therapy. This quality-assured pathology guidance provides reassurance to clinical teams that pathology information is based on good evidence, robustly accredited, and has the confidence of members of the College. Congratulations on an excellent document.

The Royal College of Radiologists (RCR)

On behalf of The Royal College of Radiologists, I am delighted to welcome this 6th edition of the Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines. These guidelines are a key clinical resource for all those involved in the treatment of patients with head and neck cancer, and I hope this new edition will continue to support essential multidisciplinary working in this field and promote the highest possible standards of patient care. I would like to congratulate the editors and authors – who include a number of Fellows of the Royal College of Radiologists – for their hard work and dedication in producing these excellent guidelines.

Section 1: Generic issues in head and neck cancer management

Chapter 1: Provision of head and neck cancer services for diagnosis and treatment centres (Sinclair M Gore, Jarrod J Homer, Tom Roques, Francis W Stafford* and Leandros Vassiliou) 9

Chapter 2: Clinical assessment, diagnosis and imaging (Katharine S Davies, Yatin Jain, Glyndwr W Jenkins and Laura Warner*) 13

Chapter 3: Head and neck cancer pathology (Guy Betts, Stephen Damato, Keith D Hunter, Max Robinson and Selvam Thavaraj*) 19

Chapter 4: Non-surgical head and neck cancer treatment (Kirsten Laws, Robin J D Prestwich, Tom Roques*, David J Thomson, Amy Ward and Christina Wilson) 24

Chapter 5: Follow up, surveillance and recurrent disease (Anthony Kong, Paul Nankivell*, Claire Paterson and Andy Scarsbrook) 29

Chapter 6: Epidemiology of head and neck cancer: definitions, trends and risk factors (David I Conway*, Andrew G Schache, Grant Creaney, Mark Gormley and Kate Ingarfield) 34

Chapter 7: Reconstructive considerations in head and neck surgical oncology (Brian Bisase*, Mani Ragbir* and Sajid Sainuddin*) 36

Section 2: Patient support

Chapter 8: Patient preparation for treatment and enhanced recovery (Val Bryant, Linda Cantwell, Clare Conlon, Samantha Holmes, Pádraig McDonnell, Zoe Merchant, John Moore*, Ruth Price, Steve Sweeney and Laura-Jayne Watson*) 42

Chapter 9: Nutritional management in the treatment of head and neck cancer (Florence Cook*, Lesley Freeman, Deborah Howland, Rebekah Smith and Kelly Wade-McBane) 48

Chapter 10: Speech, voice and swallowing rehabilitation for head and neck cancer (Grainne C Brady, Gemma Clunie, Margaret Coffey, Roganie Govender, Joanne M Patterson*, Justin W G Roe, Diane Sellstrom, Jane Thornton and Laura-Jayne Watson) 58

Chapter 11: Physiotherapy and exercise (Harriet Finze, Beth Fordham, Victoria Gallyer, Toby Oliver Smith* and Lisa Stoner) 63

Chapter 12: The clinical nurse specialist role in head and neck cancer care (Joanne Greedy, Andrea Nelson, Sarah Orr*, Louise Pearson, Ian J Salmon, Audrey Scott, Maria Smith* and Hollie Watts) 69

Chapter 13: Restorative dentistry and orofacial rehabilitation for patients with head and neck cancer (Pallavi Gaitonde, Sachin Jauhar, Sarra Jawad, William Keys, Lorna K McCaul*, Ailsa J Nicol, Meena S Ranka, Praveen Sharma and Carly L Taylor) 74

Chapter 14: Psychological management in head and neck cancer (Gerald Humphris*) 80

Chapter 15: Palliative care in head and neck cancer (Elizabeth C Abbey, Matthew R Cooper, Mohammed M A S Foridi, Katherine E Frew, Catriona R Mayland*, James Palmer, Rachel S Parry, Cherith J Semple, Kay Stewart, Donna Wakefield and Chui-Yan Yip) 83

Chapter 16: Management of treatment effects and complications (Peter Brennan*, Declan Costello*, Joe Davies, Mark R D Edmond, Stefano Fedele*, Kristina Isand, Anastasios Kanatas*, Emma V King*, Valeria Mercadante, James T O'Hara*, Stephen Ross Porter, Richard J Shaw*, Rabin P Singh*, John Waas* and Stuart C Winter*) 95

Section 3: Site-specific guidelines

Chapter 17: Oral cavity and lip cancer (Jonathan M Bernstein, Sinclair M Gore, Cyrus J Kerawala, Claire Paterson, Andrew G Schache*, Selvam Thavaraj and Christina Wilson) 107

Chapter 18: Oropharyngeal squamous cell carcinoma (Eleanor Aynsley, Arun Batra, Ben Cosway, Shane Lester*, Max Robinson, Stuart C Winter and Winson Wong) 114

Chapter 19: Nasopharyngeal carcinoma (Melvin L K Chua, Andrew McPartlin, Robin J D Prestwich* and Sriram Vaidyanathan) 120

Chapter 20: Hypopharyngeal cancer (Aina Brunet, Teresa Guerrero Urbano, Anthony Kong, Aleix Rovira and Ricard Simo*) 125

Chapter 21: Laryngeal cancer (Guy Betts, Bernadette H Foran, David W Hamilton, Yatin Jain and James T O'Hara*) 129

Chapter 22: Management of lateral skull base cancer (Patrick Axon, Navin Mani*, Rupert Obholzer, Matthew Potter and David J Thompson) 135

Chapter 23: Nasal/paranasal sinus and anterior skull base cancer (Peter Clarke, Jason C Fleming*, Samuel C Leong, Matthew Potter, Ann Sandison, Andrew G Schache, Jagrit Shah and David J Thomson) 142

Chapter 24: Salivary gland cancer (Jonathan M Bernstein, Preetha Chengot, James McCaul and Sanjai Sood*) 149

Chapter 25: Management of thyroid cancer (Reshma Agrawal, Ashish Chandra, Neil J A Cozens, Fraser W Gibb, Jarrod J Homer, Radu Mihai, Mufaddal T Moonim, Sonali Natu, Kate Newbold, Iain J Nixon*, David N Poller and Neil S Tolley) 156

Chapter 26: Management of neck metastases in head and neck cancer (Hiba Aga, Alina D Dragan, Daljit K Gahir, Vinidh Paleri and Somiah Siddiq*) 165

Chapter 27: Management of head and neck squamous cell carcinoma of unknown primary (John C Hardman*, Kevin Harrington, Vinidh Paleri*, Tom Roques, Sanjai Sood and Francis W Stafford) 172

Chapter 28: Non-melanoma skin cancer (Stephen Keohane, Paolo L Matteucci*, Carrie Newland, Jonathan Pollock and Andrew Sykes) 176

Chapter 29: Head and neck mucosal melanoma (Derfel ap Dafydd, Izhar N Bagwan, Donna Begg, Mark R D Edmond, Kevin Harrington, Cyrus J Kerawala, Emma V King*, Ken Lingley, Pablo Nenclares, Vinidh Paleri, Gillian Patterson, Miranda Payne, Priyamal Silva, Neil Steven, Nancy Turnbull and Kent Yip) 186

Chapter 30: Paraganglioma of the head and neck (Takhar Arunjit, Jonathan M Bernstein*, Colin Bicknell, Yong Du, Dorothy Gujral, Jarrod J Homer, Richard Irving, Fiona Lalloo, Miles Levy and Gitta Madani) 189

Appendices

Appendix 1: List of reviewers 195

Appendix 2: Management of head and neck squamous cell carcinoma of unknown primary (Chapter 27) – initiative collaborators 196

*Indicates chapter lead author

Key recommendations

• • Head and neck cancer services should be organised around specialist multidisciplinary teams (MDTs), comprising health professionals within a head and neck cancer treatment centre including surgical and oncological services that can provide comprehensive treatment and management for patients with head and neck cancers (essential (E))

• • Diagnostic services outside of the head and neck cancers should have agreed protocols with the referral centre regarding the diagnosis and referral of patients with head and neck cancer (E)

• • In-reach models of service delivery in which surgeons primarily located at a peripheral diagnostic unit travel to a centre to perform cancer surgery is not recommended (desirable (D))

• • Where geographically possible, there should be the maximum consolidation into as few head and neck treatment centres as possible. In these circumstances, a head and neck treatment centre should comprise a single surgical centre and a single oncological centre (D)

Introduction and current service provision

The initial development of head and neck cancer services in UK was based upon the National Institute for Health and Care Excellence (NICE) Improving Outcomes Guidelines 2004.¹ Subsequent UK guidelines, standards, quality assessment metrics and commissioning standards essentially all mirror the structure outlined in the original NICE Improving Outcomes Guidelines.

Head and neck cancer services in the UK are generally based on a hub-and-spoke model of treatment centres (surgery and oncology) (Figure 1), in which MDTs are centrally based, and peripheral ‘spoke’ diagnostic units offer diagnostic services, as well as, ideally, ongoing post-treatment support and follow up, closer to patients’ homes. There is variation in the nature of this set-up. Diagnostic units are important, potentially maximising the proportion of the patient journey closer to home.

Figure 1. Hub-and-spoke model of treatment centres.

Diagnostic units can be entirely separate from treatment centres, provided that patient-centred communication and co-ordination is not compromised, and the pathway remains streamlined (Figure 2). This requires clinicians working to agreed MDT diagnostic and follow-up guidelines. However, the alternative arrangement is that MDT surgeons from the treatment centre may ‘out-reach’ to provide diagnostic and follow-up services in peripheral units. Less commonly and less ideally, surgeons from a peripheral unit ‘in-reach’ to the treatment centre to perform surgery on patients who are diagnosed with cancer in their unit. Many have concerns over this model, with a limited presence in the main surgical treatment centre and disjointed care models. Similar in-reach and out-reach models can be applied to other disciplines, such as allied health and specialised nursing professionals.

Figure 2. In-reach and out-reach model of treatment centres.

There is variation in this model in the UK, and variation in MDT size (e.g. as defined by the population served). In England, in 2017, one region had a population of 2.4 million with 1 MDT and an annual caseload of 548 new patients. Another with a population of 2.7 million had 6 MDTs and a caseload of 584, with only 2 of the units seeing more than 100 new cases. Some MDTs have more than one surgical and radiotherapy centre. In addition, the incidence of head and neck cancers in the UK varies significantly. The UK average is 18.8 per 100 000 per year, higher in Scotland and Wales.²

The economic and clinical value in various different set-ups is unclear, and may vary according to population density, incidence, and geographical area and spread.

Diagnostics and follow-up units

The purpose of diagnostic units is to provide early diagnosis and appropriate investigation, as well as staging, for patients with head and neck cancer in the locality which they serve. Additionally, where appropriate, patient follow up can be delivered in these units, at least in part, maximising care nearer to home. Each head and neck cancer centre will also act as the diagnostic unit for its locality or secondary referral population. The process of diagnostic investigation is discussed in Chapter 2 of these guidelines. Essential and desirable specifications are shown below (Table 1).

Table 1. Diagnostic units: essential and desirable

* The facility to request a positron emission tomography/computed tomography (PET-CT) scan (rather than provide PET-CT scans). H&N = head and neck; USS = ultrasound scanning; FNAC = fine needle aspiration cytology; CT = computed tomography; MRI = magnetic resonance imaging; MDT = multidisciplinary team; SLT = speech and language therapist

Head and neck cancer treatment centres

A treatment centre must provide comprehensive management for all patients with head and neck cancer. The head and neck cancer MDT is at the heart of this, comprising all health professionals and allied staff required to provide this and support patients. Suggested core and extended MDT members are listed in Table 2. Core members are required to provide input into patients’ care, and should be available for every patient who needs their expertise or input. Whether this takes the form of physical attendance at the MDT meeting and/or at an MDT clinic with the patients will vary, but, in general, core members are expected to attend (physically or virtually) the weekly MDT meeting (see below). Extended members are professionals whose input is less regular, and who would not be expected to routinely attend MDT meetings and clinics.

Table 2. H&N MDT members

H&N = head and neck; MDT = multidisciplinary team; SLT = speech and language therapist

Multidisciplinary team meetings

Head and neck MDT meetings improve decision-making and diagnosis, impacting positively on both staging and treatment.^{Reference Bergamini, Locati, Bossi, Granata, Alfieri and Resteghini3–Reference Wheless, McKinney and Zanation8} Effective MDTs reduce the time from diagnosis to definitive treatment. An MDT management approach is associated with improved survival rates after treatment for head and neck cancer.^{Reference Shang, Feng, Gu, Hong, Hong and Hou9}

The MDT meetings to record a patient's care will take place at different stages during a cancer journey. This includes:

• • Upon initial diagnosis, to ensure diagnosis and staging is accurate, that no further investigations are required, and to determine appropriate treatment options according to agreed national and local protocols

• • After surgery, to discuss histopathology and options for post-operative adjuvant treatment

• • After primary chemoradiotherapy, where there is concern for residual disease on post-treatment imaging

• • For suspected or confirmed recurrence, or second primary cancers, after initial diagnosis and treatment

The MDT should meet at least weekly. Every meeting should have appropriate input from core members (see above). External imaging is generally reviewed by an MDT radiologist. Some or all external pathology findings may also need reviewing according to local policy.

The MDT meeting offers an opportunity to collect data and to offer clinical trials, where appropriate, for eligible patients.

Each head and neck cancer MDT should have an operational policy setting out the roles and responsibilities of its core members, including attendance required at MDT meetings. These will vary between specialist groups: all surgeons and oncologists should be expected to attend most meetings, whilst radiologists and pathologists may attend according to a rota. Most core member groups need at least two individuals, to allow for cover in case of leave.

The MDT meeting should have an appropriately trained chair who leads the meeting; this individual also ensures that a clear summary is documented after each case is discussed and that recorded data are accurate. The agreed diagnosis and staging, relevant discussions, and treatment plans should be documented in real time and circulated to the MDT members immediately afterwards, along with the person responsible for confirming the outcome to the patient. The MDT co-ordinator role is crucial to the preparation and smooth running of the meeting, and in disseminating information after the meeting. Enquiries for the co-ordinator should be sent to a generic monitored e-mail address, so that absence is covered. The co-ordinator(s) are also responsible for uploading data to cancer waiting times databases and cancer registries.

An annual report documenting MDT activity, including workload, outcomes, significant events such as staff changes, waiting time targets, critical incidents, and ‘never events’ should be written.

The head and neck MDT should have formal links with inter-dependent MDTs for other related tumour types, such as skull base or neurosurgical, sarcoma, skin cancer and melanoma, thyroid, teenage and young adult, cancer of unknown primary, and lung MDTs.

Following MDT discussions, patients should be reviewed in an MDT clinic, in which core members can provide input for each patient depending on their needs in one visit. This would typically include, for example:

• • Primary clinician(s) (surgical or oncological) offering prime treatment or explaining treatment options

• • Clinical nurse specialist

• • Allied health professionals (speech and language therapy, or dietetics), as required

• • Dental assessment including orthopantomagram X-ray

• • Anaesthetic assessment (ideally) for patients needing surgery

• • Clinical trial nurse if clinical trial option is available

Surgery and radiotherapy within treatment centre

Surgery

A comprehensive head and neck cancer centre should be able to offer all patients the surgical treatment they require. It is accepted that not every head and neck cancer surgical centre will offer treatment for rarer cancers, or in niche areas, such as skull base cancer surgery.

Surgeons should have job plans reflecting their commitment to specialist practice. Subspecialty training in head and neck oncology is essential, ideally including a fellowship after completion of training.

Staffing numbers in all aspects of care need to be large enough to provide a sustainable service 24 hours a day, 7 days a week, allowing cover for holidays and unexpected absences. Case numbers need to be large enough to maintain individual expertise amongst all the personnel, whilst providing case experience for trainees.

The essential and desirable services that the main head and neck cancer surgical centres should offer are shown in Table 3 below. This assumes the provision of the MDT members listed above.

Table 3. Essential and desirable services that the main H&N cancer surgical centre (the ‘hub’) should provide

H&N = head and neck; CT = computed tomography; MRI = magnetic resonance imaging; USS = ultrasound scanning; AHP = allied health professional; SLT = speech and language therapist; 24/7 = 24 hours a day, 7 days a week; RIG = radiologically inserted gastrostomy; PEG = percutaneous endoscopic gastrostomy; 3D = three-dimensional

Radiotherapy

Radiotherapy is already centralised in 62 UK centres, most but not all of which treat head and neck cancer. Case numbers are relatively small – there were 5987 courses of curative head and neck cancer radiotherapy delivered in England in 2017, compared with 30 708 for breast cancer.¹⁰ In 2020, there were 149 UK clinical oncologists treating head and neck patients.¹¹

Head and neck radiotherapy is one of the most complex treatments given by clinical oncologists. The 2019 NHS England Service Specification for Radiotherapy Operational Delivery Networks states that each consultant clinical oncologist should be responsible for at least 25–50 cases of radical radiotherapy per year for each tumour site treated.¹² The ‘25–50’ number is empirical and not supported by strong evidence. As different head and neck subsites are also managed differently, it could be argued that nasopharyngeal cancer, for example, is so rare in the UK and so different to other tumour subsites that it should be super-specialised and treated by a very small number of clinical oncologists.

Rather than trying to establish an ideal number of cases to be treated by a radiotherapy team, it is perhaps more sensible for commissioners to examine surrogate indicators of radiotherapy quality which are likely to reduce unwarranted variation between clinical teams and centres (Table 4).

Table 4. Surrogate indicators of radiotherapy service quality

H&N = head and neck; NICE = National Institute for Health and Care Excellence; BAHNO = British Association of Head and Neck Oncologists; RCR = Royal College of Radiologists; SLT = speech and language therapy; RT = radiotherapy; NCRN = National Cancer Research Network

Follow up and data collection

The purpose of interactions with patients following treatment for head and neck cancer is not just about tumour surveillance. Restoring quality of life is as important as cancer cure. Follow-up services should have speech and language therapists, dietitians, clinical nurse specialists, and restorative dentistry at their core, delivered as close to home as possible. Psychological support is often less readily available.

The collection of survival metrics, patient-reported outcome and experience measures is key to assess and improve care. Each MDT should be able to collect and publish its outcomes. Follow-up services should be designed and funded with the ability to collect such data from every patient. Completing simple, validated digital tools before a clinic visit can enable more patient-focused appointments, and their analysis can help drive improvements in the quality of the clinical service.

The future: evidence for minimal treatment volumes and further centralisation?

The importance of concentrating patient volumes in specialised head and neck services through reconfiguration and centralisation has been illustrated in reports from Canada, USA, UK and Europe. The weight of opinion has moved away from the 100 new cases recommended by the NICE Improving Outcomes Guidelines in 2004.

The questions that arise are: what is the minimum or optimal size of a head and neck cancer centre?; and is it practical and affordable? The difficulty in addressing these within the UK is exemplified by the lack of any update on guidance since 2004.

There are consistent data that support a relationship between hospital or institutional volume or caseload and various measures of quality, mainly improved patient survival and a reduction in complications.^{Reference Eskander, Irish, Groome, Freeman, Gullane and Gilbert13–Reference Robertson, Robertson, Soutar, Burns, Hole and McCarron17} However, the definition of what defines a low-volume and high-volume unit are often empirical. The largest analysis of 351 052 head and neck squamous cell carcinoma cases treated in 1229 centres found that low-volume units treating less than 54 cases per year had significantly higher mortality rates than moderate volume units (54–164 cases per year), and high-volume units with over 165 cases per year were even better.^{Reference Torabi, Benchetrit, Kuo, Cheraghlou, Savoca and Tate18}

The recent Getting It Right First Time review of oral and maxillofacial surgery services^{Reference Morton19} suggested that the figure of 250 new cases per MDT was optimal.

Figures taken from analysis of the 2013 Data for Head and Neck Oncology (‘DAHNO’) audit, and presented by the initial head and neck surgery clinical reference group to NHS England, formed the basis of estimated caseload, and effect upon MDT numbers was considered if alterations were made to the required caseload. The data were illustrative, rather than definitive, and are shown in Table 5.

Table 5. Projected number of surgical treatments based on annual H&N MDT caseload

H&N = head and neck; MDT = multidisciplinary team

If it is assumed that a centre must have a comprehensive free-flap service, then a minimum number of free flaps per year (and per reconstructive surgeon) could be considered. There is no UK consensus on this. Canadian guidelines stipulate 20 free flaps per surgeon per year. Assuming 3 surgeons are required to support a 24 hours a day, 7 days a week service, but perhaps factoring in more than 1 reconstructive surgeon per case, this would suggest an annual case load of at least 300 might be required (Table 5). The figures in Table 5 (essentially 1 free flap per 10 new patients with head and neck cancer) are consistent with the known incidence of head and neck cancer in England (average of 10 053 cases in 2016–2018)² and coded free flaps per year for head and neck cancer (average of 1184 cases in 2003–2013).^{Reference Nouraei, Middleton, Hudovsky, Branford, Lau and Clarke20}

Hence, it is difficult to define a metric that defines minimal caseload or throughput. The variance in cancer incidence and geographical spread or population density within the UK also needs to be factored in.

A reasonable conclusion is that, where geographically possible, the provision of head and neck cancer services should follow the evidence, i.e. have as high volume as possible. Within cities and conurbations, there should be the maximum consolidation into as few head and neck treatment centres as possible. In these circumstances, a head and neck treatment centre should comprise a single surgical centre and a single oncological centre (and co-location is ideal). For more rural, less populated areas, a practical compromise might entail having smaller centres within a service offering restricted services (e.g. no microvascular surgery) linked to a large centre with the same operational policies and linked MDT meetings.

Public awareness and referral from primary to secondary care

Recommendations

• • Co-ordinated public awareness campaigns to boost recognition of the early signs of head and neck cancer should be promoted (desirable (D))

• • Improved primary care awareness of the early signs of head and neck cancer is needed to reduce time to diagnosis and emergency late-stage presentation (D)

• • Collaboration between cancer alliances and primary care is required to agree upon clear and appropriate two-week-wait referral criteria (essential (E))

• • Use and adoption of validated risk calculators is recommended to assist with urgent referral (accepted standard of care (evidence-based recommendation (R))

On average 100 000 new head and neck referrals are seen in each year, with only 2.8 per cent on the cancer waiting time pathway resulting in a cancer diagnosis; yet only 35–56 per cent of patients diagnosed with cancer present via this route in England.^21,22

These data demonstrate deficiencies in the current referral process for head and neck cancer. Whilst urgent clinics are full of patients without cancer, nearly half of head and neck malignancies present via other routes, too frequently with advanced disease. The negative impact of delayed diagnosis upon survival and quality of life is well proven.^{Reference Seoane, Takkouche, Varela-Centelles, Tomás and Seoane-Romero23}

The National Institute for Health and Care Excellence (NICE) refined their referral guidelines in 2015 to include symptoms with a positive predictive value above 3 per cent (Table 1).²⁴ These adjustments were made in response to consistent data proving no discernible difference between the numbers of patients being diagnosed through the urgent and non-urgent pathways. Regrettably, the detection rate remains low despite these changes.^{Reference Gao, Qin, Freeman, Oskooee and Hughes25}

Table 1. NICE guidelines 2015

NICE = National Institute for Health and Care Excellence

An alternative list of referral criteria has been proven to correlate well with a head and neck cancer diagnosis (Table 2).^{Reference Tikka, Pracy and Paleri26} This has formed the basis for a risk calculator to guide primary care referral or triage (www.orlhealth.com/risk-calculator.html). This has been refined and validated, and shown to be effective for triage during the coronavirus disease 2019 (Covid-19) pandemic. It uses symptoms such as intermittent hoarseness and globus sensation as negative predictors of malignancy.^{Reference Tikka, Kavanagh, Lowit, Jiafeng, Burns and Nixon27,Reference Hardman, Tikka and Paleri28}

Table 2. Suggested referral criteria after Tikka et al.^{Reference Tikka, Pracy and Paleri26}

FOSIT = feeling of something in throat

More fundamentally, early diagnosis is contingent on patients seeking medical attention with suspicious symptoms. Public awareness campaigns have successfully increased numbers of patients with lung cancer referred and diagnosed at an early stage. The same is required for head and neck cancer, particularly in deprived populations.

Assessment in secondary care and best timed pathways

Recommendations

• • Use of validated risk calculators is recommended to assist initial assessment and triage (evidence-based recommendation (R))

• • Trusts should commit to achieving the faster diagnosis standard, with communication of the outcome to patients and general practitioners (essential (E))

• • Patients with suspected cancer should be seen in a dedicated ENT, oral and maxillofacial surgery or neck lump specialist clinic (R)

• • Best timed pathways centred around one-stop clinics for diagnosis of head and neck cancers should be implemented, enabling same-day investigations and expedient booking of diagnostic imaging and general anaesthesia procedures (R)

• • Equipment for endoscopy, and biopsy in clinic and dental procedures must be readily available (R)

• • Video monitors and facilities for photographic documentation should be available (good practice point (G))

• • Narrow band imaging or optical florescence imaging can assist with the identification of malignancy and dysplasia (R)

• • Diagnostic imaging should be performed prior to biopsy under anaesthesia if possible, but biopsy in clinic should not be delayed and should be carried out initially if possible (G)

• • Patients with cervical lymphadenopathy require fibre-optic nasopharyngolaryngoscopy (R)

• • A neck lump clinic should include same-day ultrasound and ultrasound-guided biopsy (fine needle aspiration cytology (FNAC) or core biopsy) (G)

• • Ultrasound-guided biopsy should be performed by an experienced head and neck radiologist, ultrasonographer, or appropriately trained surgeon capable of performing diagnostic ultrasound imaging and both FNAC and core needle biopsy (G)

• • Immediate FNAC adequacy checking improves the rate of diagnostic sampling (R)

• • Rapid cytopathological assessment of FNAC samples is desirable (G)

The National Health Service's (NHS's) long-term plan aims to achieve 55 000 extra patients surviving five years after treatment, with an early-stage diagnosis for 75 per cent of patients (with a commitment to achieving a ‘faster diagnosis standard’, either confirming malignancy or the exclusion thereof, within 28 days of referral).²⁹

Alternative methods of assessment using tele- and video-consultations, straight-to-test pathways, and so on were implemented in response to Covid-19 and may prove to be effective post-pandemic. Although originally intended to assist with the selection of cases for urgent referral from primary care, the refined and validated risk calculator (www.orlhealth.com/risk-calculator.html) has been shown to be effective for initial telephone triage or assessment during the Covid-19 pandemic.^{Reference Hardman, Tikka and Paleri28} This appears to be a safe and effective means of selecting those patients who should remain on an urgent diagnostic pathway and determining those who can be seen routinely. At this stage, allocation to the appropriate clinic can be carried out (e.g. ENT clinic, oral and maxillofacial surgery clinic, neck lump clinic). Hence, assessment in secondary care may comprise any of the following steps:

• • Triage

• • Initial telephone assessment

• • Investigations before clinic attendance

• • Clinic attendance

• • Investigations during or after clinic attendance

For those patients on an urgent diagnostic pathway in secondary care, best practice or optimal pathways should be adopted and implemented. This involves early, appropriate investigations and a reduction of unnecessary investigations, together with the simplification of diagnostic pathways. Such pathways may vary and be tailored to the facilities and practices within the hospital concerned.

Imaging in head and neck cancer

Recommendations

• • Magnetic resonance imaging is recommended for supra-hyoid primary lesions, and for cases of carcinoma with an unknown primary (good practice point (G))

• • Computed tomography is recommended to assess bony involvement where required (evidence-based recommendation (R))

• • Computed tomography thorax is mandated for systemic staging in advanced disease and may be used to exclude synchronous primary lung malignancies in the early stage of disease (R)

• • Positron emission tomography/CT is advocated for the assessment of distant metastasis in advanced tumour (T) stage (T₄) nasopharyngeal and hypopharyngeal malignancies, and in examination of nodal (N) stage N₃ cancers (R)

• • Positron emission tomography/CT is recommended for the post-treatment assessment of nodal disease following non-surgical treatment (R)

• • Post-treatment assessment of primary tumours should follow the original modality used for primary staging (G)

The roles of imaging for head and neck cancers are: to assess and characterise a suspected lesion, and to stage local, regional and distant metastatic disease; and to detect second primary malignancy. The Royal College of Radiologists published guidelines in 2014.³⁸

Post-treatment imaging

Post-treatment imaging is primarily aimed at identifying residual or recurrent disease but also detects late effects of treatment and second primary malignancies.

Positron emission tomography/CT is advocated for patients who have been treated with radical chemoradiotherapy for oropharyngeal, hypopharyngeal or laryngeal primaries with nodal involvement, following the outcomes of the ‘PET-NECK’ trial,^{Reference Mehanna, Wong, McConkey, Rahman, Robinson and Hartley51} typically at 10–12 weeks post treatment.

For other tumours, imaging usually follows the original modality used for staging, to allow for comparison. In some of these situations, for example in laryngeal cancer without nodal disease treated non-surgically, PET-CT demonstrates non-inferiority in comparison to direct laryngoscopy, as shown within the ‘RELAPS’ (REcurrent LAryngeal carcinoma PET Study) trial.^{Reference de Bree, van der Putten, van Tinteren, Wedman, Oyen and Janssen52}

Having a post-treatment baseline scan is also useful for the comparison of future imaging, should it be needed; thus, the effects of surgery and radiotherapy on imaging can be factored in through reference to the baseline imaging.

A summary of recommended imaging is shown in Table 3. More specific detail can be found in the relevant site-specific chapters.

Table 3. Summary of recommended imaging

* Positron emission tomography/computed tomography (PET-CT) is recommended instead for nodal stage N₃ disease, tumour stage T₄ cancer of the nasopharynx and T₄ cancer of the hypopharynx. MRI = magnetic resonance imaging; CT = computed tomography; CUP = carcinoma of unknown primary

Staging of head and neck cancer

In conjunction with the Union for International Cancer Control (‘UICC’), the eighth edition of the TNM Classification of Malignant Tumours was released in December 2016.^{Reference Brierley, Gospodarowicz and Wittekind53} The major changes from the seventh edition are as follows:

• • A new classification group for HPV-associated oropharyngeal cancers

• • Carcinoma of unknown primary: stage groupings now differentiate between non-viral, HPV-related and Epstein–Barr virus (EBV)-related

• • A new N_3b stage reflecting the prognostic importance of extra-nodal extension

• • Oral cavity T-staging: the impact of depth of invasion

• • Thyroid cancer staging reflects survival rather than risk of recurrence

The detail of the staging for each site can be found in the relevant chapter.

The eighth edition of the TNM Classification of Malignant Tumours acknowledges the distinct biological behaviour of HPV-associated oropharyngeal cancers with a new classification group. The main difference relates to regional metastasis, where there is recognition that multiple ipsilateral lymph nodes are frequently encountered in HPV-associated disease and do not carry the poor prognosis seen in non-HPV-related cancers. It also differentiates the clinical and post-surgical nodal staging.

Carcinoma of unknown primary stage groupings now differentiate between non-viral, HPV- and EBV-related. Alterations reflect differences in prognosis, with non-HPV-related carcinoma of an unknown primary including only stages III and IV, and EBV-related carcinoma of an unknown primary including stages II–IV, to acknowledge the poorer prognosis when compared to HPV-associated disease which includes stages I–IV. In other non-viral related cancers there are new clinical and pathological nodal staging categories, where the prognostic implication of extra-nodal extension is recognised with a new N_3b stage.

Changes in oral cavity T-staging recognise the impact of depth of invasion, and in nasopharyngeal cancers amendments to both the primary tumour and nodal staging are seen. The changes to the staging of differentiated and anaplastic thyroid malignancies in the eighth edition of the TNM Classification of Malignant Tumours aims to represent the risk to life from a thyroid cancer diagnosis, as opposed to risk of recurrence as seen in previous staging and risk stratification systems.

Exclusion of second primary malignancies

Recommendations

• • Patients with new and recurrent upper aerodigestive tract cancers should undergo comprehensive clinical examination, including endoscopic nasopharyngolaryngoscopy, as part of diagnostic investigation (evidence-based recommendation (R))

• • Cross-sectional imaging, appropriate for tumour site, should be performed to screen for upper aerodigestive tract and thoracic second primary cancer (good practice point (G))

Head and neck cancers have the highest propensity of all malignancies for synchronous and metachronous cancers,^{Reference Tanjak, Suktitipat, Vorasan, Juengwiwattanakitti, Thiengtrong and Songjang54} with reported incidences of around 13 per cent.^{Reference Coca-Pelaz, Rodrigo, Suárez, Nixon, Mäkitie and Sanabria55} Second head and neck primaries are commonest, followed by oesophageal cancers and lung cancers.^{Reference Kuhlin, Kramer, Nefas, Rotter and Aderhold56}

The rate of synchronous second primary malignancies, i.e. present at or around the time of diagnosis of the index tumour, is around 5 per cent.^{Reference Coca-Pelaz, Rodrigo, Suárez, Nixon, Mäkitie and Sanabria55}

These sites are usually encompassed by imaging performed for the primary diagnosis and staging (including the thorax).

Panendoscopy under general anaesthetic offers a low diagnostic yield in the absence of significant symptoms in patients with head and neck cancers,^{Reference McGarey, O'Rourke, Owen, Shonka, Reibel and Levine57} and has fallen out of favour as a screening tool in this population. Incidental second oesophageal primaries are more likely to be better detected with out-patient endoscopy and imaging alone. However, transnasal oesophagoscopy could play an important role in the exclusion of both second head and neck and oesophageal primaries.^{Reference Abou-Nader, Wilson and Paleri31}

Best timed pathways

Best timed pathways (also known as optimal pathways) put together all the elements described above, with a view to fast diagnosis in as few hospital visits as possible. They are somewhat idealised and can be difficult to adhere to (e.g. when an initial biopsy is non-diagnostic).

Examples of these have been described by NHS Wales.⁵⁸

Simplified examples for neck lumps and upper aerodigestive tract symptoms can be found in Figure 2. The selection of the investigations will depend on the clinical situation, and this has been described in earlier sections.

Figure 2. Twenty-eight-day best practice timed pathway for neck lumps and upper aerodigestive tract symptoms. GP = general practitioner; GDP = general dental practitioner; OMF = oral and maxillofacial; MRI = magnetic resonance imaging; OPG = orthopantomogram; ROSE = rapid on-site evaluation; CT = computed tomography; LA = local anaesthetic; EUA = examination under anaesthesia; GA = general anaesthetic; MDT = multidisciplinary team; PET = positron emission tomography; OPA = out-patient appointment; CNS = clinical nurse specialist; FDS = faster diagnosis standard; pre-op = pre-operative

Important issues to be answered

These include:

• • Refinement and development of cost-effective methods to improve rates of early-stage diagnosis

• • Optimisation of systems to discern suspicious head and neck symptoms from those suggestive of benign disease

• • Understanding of the role of transnasal oesophagoscopy in diagnosis and detection of second primary malignancies

Clinical trials due to report

‘EVEREST-HN’ (2022–2028): EVolution of a patiEnt-REported symptom-based risk stratification sySTem to redesign the suspected Head and Neck cancer referral pathway (https://fundingawards.nihr.ac.uk/award/NIHR202862).

Key recommendations

• • The head and neck multidisciplinary team (MDT) should understand the scope and limitations of histopathology and cytopathology in order to inform multidisciplinary discussion. This requires effective communication between clinicians and pathologists within the MDT (evidence-based recommendation (R))

• • A clinically suspected diagnosis of malignancy should be confirmed by biopsy or cytology prior to oncological treatment (R)

• • Participation in the National Head and Neck Histopathology External Quality Assurance Scheme is essential (R)

• • The current World Health Organization (WHO) dysplasia grading system for oral cavity and larynx should be used (R)

• • The meaning of the descriptors ‘carcinoma in situ’ and ‘severe epithelial dysplasia’ should be well understood between the reporting pathologist and the MDT (good practice point (G))

• • Correct orientation of resection specimens and accompanying clinical information are essential (R)

Head and neck pathology services

Tissue pathways

Patient management should be guided primarily by pre-operative biopsy and/or fine needle aspiration cytology (FNAC).

Squamous cell carcinoma of upper aerodigestive tract

Histopathology reporting

Tumour–node–metastasis classification

For the purposes of local treatment protocols and continuity in clinical trial stratification, both the seventh and eighth editions of the TNM Classification of Malignant Tumours should be referred to. It is important to note the difference in clinical and pathological neck staging in p16 positive oropharyngeal cancer (Table 1),^{Reference Brierley, Gospodarowicz and Wittekind91} which reflects the need for different stratification of patients having primary radiotherapy (with or without chemotherapy) versus the need for adjuvant treatment in patients receiving primary surgery.

Table 1. Differences between clinical and pathological neck staging for p16 positive oropharyngeal cancer

Other important advances in the seventh and eighth editions of the TNM Classification of Malignant Tumours are:

• • The incorporation of the depth of invasion for tumour (T) category in oral cavity carcinoma

• • Separate staging systems for p16 positive and p16 negative oropharyngeal carcinoma

• • The inclusion of extra-nodal extension for neck staging in all head and neck cancer except mucosal melanoma, nasopharyngeal and p16 positive oropharyngeal carcinoma

• • A separate staging system for carcinoma of unknown primary, head and neck skin cancer^{Reference Schutte, Takes, Slootweg, Arts, Honings and van den Hoogen33, Reference Cozens34}

Dysplasia

Squamous cell carcinoma results from a combination of genetic alterations, some of which may manifest as precursor lesions characterised by morphological changes in epithelial cells, collectively referred to as dysplasia. An increasing degree of dysplasia is positively correlated with a greater risk of transformation to carcinoma. The various commonly used grading systems utilise the cumulation of microscopic architectural and cytological features to provide a continuous spectrum. The current WHO grading system for dysplasia of the oral cavity and larynx is recommended, summarised in Table 2.^{Reference El-Naggar, Chan, Grandis, Takata and Slootweg65}

Table 2. Summary of WHO grading system for oral cavity and laryngeal dysplasia

WHO = World Health Organization

Management of dysplasia should take account of the microscopic grade of the lesion and its clinically assessed extent. While dysplasia grading remains subjective, with suboptimal inter-observer agreement, consensus reporting is likely to enhance diagnostic reliability.^{Reference Kujan, Khattab, Oliver, Roberts, Thakker and Sloan96–Reference Speight, Abram, Floriano, James, Vick and Thornhill98} Clear communication between the pathologist and clinician is necessary to convey the degree of concern regarding malignant transformation. ‘Carcinoma in situ’ is often used interchangeably with ‘severe epithelial dysplasia’, and may be appropriate in certain circumstances if the meaning is well understood between the reporting pathologist and the MDT. It is important to note the small but significant risk of concurrent invasive carcinoma in lesions biopsied and reported as severe epithelial dysplasia. The presence of severe epithelial dysplasia at resection margins should be included in pathology reports of resection specimens, as it may predict local recurrence.^59,61

Diagnosis and management of neck lumps

Lymphoma, sarcoma, skin cancer and mucosal melanoma

The diagnostic and tissue pathways for lymphoreticular neoplasms, sarcomas, skin cancers and mucosal melanomas should be subject to local and cancer network standard operating procedures.

Role of pathologist in clinical trials

The Standard Protocol Items: Recommendations for Interventional Trials (‘SPIRIT’) statement provides evidence-based recommendations for the minimum content of clinical trial protocols, and is widely endorsed by the research community.^{Reference Chan, Tetzlaff, Gotzsche, Altman, Mann and Berlin102} The Cellular Molecular Pathology Initiative (‘CM-Path’), hosted by the National Cancer Research Institute, has recently published an extension to the Standard Protocol Items: Recommendations for Interventional Trials statement, to provide the details required to effectively incorporate pathology support into clinical trial protocols; the guidance is called ‘SPIRIT-Path’.^{Reference Kendall, Robinson, Brierley, Lim, O'Connor and Shaaban103}

Important questions to be answered

Head and neck pathology is a rapidly evolving field that is continuously being shaped by technological advances. Developments likely to influence the practice of head and neck pathology in the near future include the following points.

• • Routine use of diagnostic digital pathology. This is likely to facilitate streamlining of the diagnostic pathway and rapid pathology review across cancer networks. High throughput digital pathology will also advance artificial intelligence algorithms for computer-assisted diagnosis and the development of biomarkers. Incorporation of whole slide images linked to tissue biobanks, with associated clinical metadata, will underpin the drive to greater refinement of personalised medicine.

• • Characterisation of the tumour microenvironment. Better understanding of the function of interplay between the tumour, immune cells and the extracellular matrix is likely to lead to the identification of individuals most likely to benefit from immunomodulatory oncology drugs.

• • Whole genome sequencing. Routine whole genome sequencing of fresh tumour samples in selected tumour types may identify actionable mutations in head and neck cancer.¹⁰⁴

• • Integration of pathology support in clinical trials. There is a growing need for clinical trials with pathology support for biomarker-driven stratification and embedded translational studies, to develop novel molecular-based diagnostic, prognostic and predictive biomarkers.

• • Multiplex risk stratification. The integration of morphological, molecular and digital pathology signatures with radiomic, microbiome and serological biomarkers can be used to improve the stratification of patients with a risk of tumour recurrence and determine progression.

Curative radiotherapy

Recommendations

• • Use intensity-modulated radiotherapy techniques and international consensus contouring guidance when treating head and neck cancers with curative intent (evidence-based recommendation (R))

• • Use Royal College of Radiologists’ recommended dose fractionation schedules e.g. 70 Gy in 35 fractions over seven weeks and 65–66 Gy in 30 fractions over six weeks (R)

• • Review patients weekly during treatment by a multidisciplinary team (MDT), with particular focus on nutrition and swallowing assessment and therapy (R)

• • Dental assessment with extraction if necessary should be carried out before radiotherapy for dentate patients (R)

• • Smoking cessation management is a key component of radiotherapy treatment (R)

Definitive or ‘radical’ radiotherapy treatment offers the potential for cure with organ preservation for many head and neck cancer anatomical sites.

Radiotherapy planning initially involves fabrication of a mask to keep the patient still and precisely positioned for each fraction of treatment, followed by a planning computed tomography (CT) scan performed whilst in the mask, usually with the administration of intravenous contrast. There is then a period of time whilst planning takes place before treatment is ready to be commenced. For a course of radical radiotherapy, a clinician will contour target volumes using diagnostic imaging such as magnetic resonance imaging (MRI), CT and positron emission tomography (PET)-CT, sometimes co-registered to improve the accuracy of target delineation. This is followed by the generation of a radiotherapy plan by dosimetrists or physicists using advanced computing.

Intensity-modulated radiotherapy is now the standard of care – highly conformal dose distributions are achieved by shaping or modulating multiple beams, allowing the sparing of nearby organs at risk. It has been demonstrated that intensity-modulated radiotherapy offers superior disease control for nasopharyngeal carcinoma and a reduction in radiotherapy-induced xerostomia.^{Reference Zhang, Mo, Du, Wang, Liu and Wei105,Reference Nutting, Morden, Harrington, Urbano, Bhide and Clark106} Intensity-modulated radiotherapy allows the delivery of different doses to differing target volumes (e.g. tumour-bearing tissues and elective lymph node regions) within each fraction of treatment. For each fraction, a patient will typically be in the treatment room for 10–20 minutes. Image-guided verification of treatment accuracy is a key part of modern radiotherapy treatment with the recently updated UK guidelines.¹⁰⁷

Recommended dose fractionation schedules are summarised in the Royal College of Radiologists’ guidance.¹⁰⁸ Schedules of 70 Gy in 35 fractions over seven weeks and 65–66 Gy in 30 fractions over six weeks are radiobiologically similar, and represent standard schedules in the UK for definitive radiotherapy. For primary non-surgical treatment of locally advanced disease, combining radiotherapy with concurrent chemotherapy is standard for patients aged less than 70 years with a good performance status.^{Reference Lacas, Carmel, Landais, Wong, Licitra and Tobias109} For patients unsuitable for chemotherapy, modest acceleration of radiotherapy (e.g. delivering six rather than five fractions per week) has been shown to offer some improvement in local control but not overall survival, with the benefit diminishing with increasing age.^{Reference Lacas, Bourhis, Overgaard, Zhang, Grégoire and Nankivell110} For early glottic cancer, hypofractionated schedules are superior to conventional fractionation e.g. 55 Gy in 20 fractions over four weeks.

Radiotherapy often has both short-term (acute) and long-term (late) side effects, which are dependent upon the dose delivered, target volumes, and patient fitness and co-morbidity. Short-term side effects gradually build up during a course of fractionated treatment, and can last for weeks or months after treatment. These include skin reaction, mucositis, xerostomia, dysgeusia, throat secretions, risk of aspiration pneumonia and voice changes. Common toxicity criteria are often used to grade acute toxicity. Table 1 summarises grading for acute radiation-related skin, mucositis and dysphagia toxicity.^{Reference Trotti, Byhardt, Stetz, Gwede, Corn and Fu111} Long-term side effects are highly variable, and can include long-term swallowing dysfunction, osteoradionecrosis, xerostomia, dysgeusia, lymphoedema, hypothyroidism, skin and subcutaneous fibrosis, and radiotherapy-induced cancer in the treated area many years later.

Table 1. Summary of Radiotherapy Therapy Oncology Group Common Toxicity Criteria 2.0 scoring for skin, oral mucositis and pharynx

IV = intravenous

The provision of supportive care prior to, during and after a course of treatment is a key component of the delivery of radiotherapy. This includes restorative dental, nursing, dietetic, and speech and language therapy input. Some patients may suffer with significant treatment-related anxiety and claustrophobia, and can receive individualised support. Continued smoking during head and neck radiotherapy has been shown to approximately double the risk of locoregional treatment failure and the risk of mortality, along with increased late toxicity.^{Reference Smith, Nastasi, Tso, Vangaveti, Renison and Chilkuri112} Smoking cessation management is a key component of radiotherapy treatment.

Unscheduled interruptions in radiotherapy for head and neck cancers can allow tumours to repopulate, with a detrimental impact upon cure rates. The Royal College of Radiologists has published guidance on the appropriate management of unavoidable gaps in treatment, with options including weekend or bi-daily treatment administration.¹¹³

Response to (chemo)-radiotherapy is often best assessed clinically. A PET-CT performed three months after treatment is often used in node-positive disease to assess the need for a neck dissection, as evidenced by the ‘PET-NECK’ trial.^{Reference Mehanna, Wong, McConkey, Rahman, Robinson and Hartley51} It can be helpful to repeat diagnostic imaging (e.g. MRI) three months after radiation, but it can be difficult to distinguish radiotherapy-induced oedema from tumour recurrence with imaging alone.

Post-operative radiotherapy

Recommendations

• • Discuss all surgical resection histology at an MDT meeting with input from a clinical oncologist, pathologist and operating surgeon, to decide on suitability for post-operative radiotherapy (evidence-based recommendation (R))

• • Commence post-operative radiotherapy within six weeks of surgery if the patient has recovered well enough (R)

Radiotherapy should be considered after surgery when there is a significant risk of locoregional recurrence. In practice, this usually means considering post-operative radiotherapy in pathologically staged T_3/4 tumours, node-positive disease or combinations of other risk factors. There are some specific cases where radiotherapy is also recommended in early stage disease, for example adenoid cystic cancer. As a rule of thumb, locoregional recurrence rates are halved by post-operative radiotherapy, but with relatively little effect on overall survival.

Tumour histology should be discussed at an MDT meeting with the surgeon present. The team should consider indications for irradiating the primary site, dissected neck and undissected neck. Absolute and relative indications for post-operative radiotherapy are summarised in Table 2 and discussed further in the relevant site-specific chapters.

Table 2. Absolute and relative indications for post-operative radiotherapy

Some patients may not feel able to undertake six weeks of adjuvant radiotherapy having just recovered from a major operation if the benefit of radiotherapy is relatively small. The decision to administer post-operative radiotherapy may depend as much on patient fitness, their support network and their preferences as on the tumour factors listed above. If patients present with disease that is locally advanced (e.g. T₄ disease or with obvious extra-nodal extension on diagnostic imaging) a plan to offer surgery and post-operative radiotherapy should be discussed with the patient and oncologist before the operation. Putting someone through a major resection for locally advanced disease when they cannot complete post-operative radiotherapy may not be to their advantage.

Post-operative radiotherapy should ideally commence within six weeks of surgery. This can be challenging to achieve, particularly if there have been post-operative complications. It generally takes several weeks from a decision to offer adjuvant radiotherapy to commencing treatment, so efficient MDT organisation is important in order to review post-operative pathology promptly and to allow the oncologist to meet the patient in a timely fashion. Sometimes it may be advantageous to organise post-operative radiotherapy before histology results are available (e.g. in a tumour that was T₄ at diagnosis), or to start radiotherapy planning, but not treatment itself, before a fistula or wound is fully healed. The absence of a tumour to contour and the altered anatomy after surgery often make radiotherapy contouring more challenging for the oncologist than in definitive radiation cases. Marginal and out-of-field recurrences are more common than following definitive radiotherapy, and hence target volume delineation needs to be generous.^{Reference Waldram, Taylor, Whittam, Iyizoba-Ebozue, Murray and Frood114}

As with curative radiotherapy, the support of an MDT, comprising dietitians, speech and language therapists, clinical nurse specialists, and therapy radiographers, is critical to ensure patients complete the treatment course.

Palliative radiotherapy

Recommendations

• • Consider palliative radiotherapy to ameliorate local symptoms in people who are not able to receive curative treatment (evidence-based recommendation (R))

Primary palliative radiotherapy can be used as a first-line treatment in those who are not fit enough to undergo curative-intent treatment with surgery or radiation. The aims of this include longer-term local control of an incurable tumour, and short-term palliation of distressing symptoms such as pain, bleeding or fungation. Typical dose fractionation schedules can range from a single fraction to 30 Gy in 10 fractions or even longer schedules.¹⁰⁸

Radiation toxicity during and after treatment can temporarily make symptoms worse, so patient selection is key, and the overall aims of treatment need to be carefully considered. Doses should be chosen to minimise toxicity and travelling where possible. Close working with palliative care teams can be invaluable.

Palliative re-irradiation can be considered for symptomatic local recurrences after a prior definitive or adjuvant radiotherapy treatment, though the increased availability of systemic treatments such as immune checkpoint inhibitors means other treatment options may be preferable. The role of stereotactic ablative radiotherapy in this context remains uncertain and it is not routinely commissioned within the National Health Service (NHS).

Palliative radiotherapy has a role in the management of symptomatic systemic metastatic disease, especially for painful bone metastasis. Stereotactic ablative radiotherapy is increasingly used in oligometastatic disease. This is defined as the presence of one to three sites of metastatic disease, typically within the lung, bone, lymph nodes or liver, presenting six months or more after primary treatment. This has been shown to be well tolerated, with local control rates of 80–90 per cent, and the promise of improved overall survival in other cancer types.^{Reference Tree, Khoo, Eeles, Ahmed, Dearnaley and Hawkins115,Reference Palma, Olson, Harrow, Gaede, Louie and Haasbeek116}

Proton beam therapy

Recommendations

• • Consider proton beam therapy for adults with head and neck cancer who meet appropriate commissioning criteria, or as part of randomised, controlled trials (evidence-based recommendation (R))

Proton beam therapy is routinely used in preference to standard photon radiotherapy for children and young adults, where the reduced integral dose lessens effects on organ growth and lowers the risk of secondary cancers.^{Reference Xiang, Chang and Pollom117} Because of the complex anatomy and proximity of sensitive organs at risk in the head and neck region, proton beam therapy may also benefit adult patients, by reducing early and late treatment toxicities, or by improved optimisation of target volume coverage in areas of dose-limiting structures, for example the base of the skull.

The distinct physical properties of protons result in a sharp distal fall-off in dose beyond the target volume, with minimal ‘exit-dose’.^{Reference Newhauser and Zhang118} Compared with standard treatment using photons, there is a reduction in the low-to-intermediate dose delivered to normal tissues. Proton treatment planning is complex; it factors in possible variation in the relative biological effectiveness (protons compared to photons),^{Reference Paganetti, Niemierko, Ancukiewicz, Gerweck, Goitein and Loeffler119} as well as the nature of tissues the beam passes through, changes in patient weight or variation in air cavity, all of which can alter the dose distribution. Changes in patient anatomy are carefully monitored for alteration in the dose distribution, with re-planning routinely needed during head and neck cancer treatments.

There are observational data to support the benefits of proton beam therapy for the treatment of head and neck cancers. In oropharynx cancer, patients were less likely to require a feeding tube during treatment;^{Reference Gunn, Blanchard, Garden, Zhu, Fuller and Mohamed120} or to develop grade 3 weight loss or require a feeding tube at three months (odds ratio = 0.44; 95 per cent confidence interval (CI) = 0.19–1.0; p = 0.05) or one year after treatment (odds ratio = 0.23; 95 per cent CI = 0.07–0.73; p = 0.01).^{Reference Blanchard, Garden, Gunn, Rosenthal, Morrison and Hernandez121} Patients with nasopharynx cancer were less likely to develop any grade 2 or higher acute adverse events (odds ratio = 0.15; 95 per cent CI = 0.03–0.60; p = 0.01)^{Reference Li, Kitpanit, Lee, Mah, Sine and Sherman122} or require feeding tube placement (20 per cent vs 65 per cent; p = 0.02).^{Reference Holliday, Garden, Rosenthal, Fuller, Morrison and Gunn123} In a systematic review of non-comparative sinonasal cancer observational studies, subgroup analysis showed higher disease-free survival at five years (relative risk = 1.44, 95 per cent CI = 1.01–2.05; p = 0.045) and locoregional control at the longest follow up (relative risk = 1.26, 95 per cent CI = 1.05–1.51; p = 0.011) using proton beam therapy.^{Reference Patel, Wang, Wong, Murad, Buckey and Mohammed124}

NHS England now has high-energy proton beam therapy centres in Manchester and London, and is well-placed to systematically evaluate the potential benefits of proton beam therapy, through a combination of randomised clinical trials,^{Reference Price, Hall, West and Thomson125} pre-commissioning studies and outcome monitoring.^{Reference Burnet, Mackay, Smith, Chadwick, Whitfield and Thomson126} Rigorous assessments are needed to justify the routine use of a specialist and constrained resource, the increased treatment costs, and the inconvenience to patients and their families in accessing a centralised service.

Chemotherapy and other drugs concomitant with radiotherapy

Recommendations

• • Offer concomitant cisplatin with curative radiotherapy to patients who are young and fit enough to tolerate the likely increased toxicity when they have T_3/4 tumours and/or node-positive disease (evidence-based recommendation (R))

• • Offer concomitant cisplatin with post-operative radiotherapy to patients with R1 (presence of microscopic cancer cells) or R2 (presence of macroscopic residual tumour) resections, or extracapsular nodal extension (R)

Concomitant chemotherapy given with radiotherapy is now a standard of care in advanced disease, both in the primary and adjuvant setting. It has been shown to improve locoregional control, and adds a small survival benefit to radiotherapy alone but with the downside of greater toxicity. The mechanism of action is still not fully understood. Chemotherapy may act as a radiosensitiser by impairing pathways to repair tumour DNA damage caused by radiotherapy. It may also have a role in sterilising microscopic metastatic disease cells.^{Reference Boeckman, Trego and Turchi127}

The Meta-Analysis of Chemotherapy in squamous cell Head and Neck Cancer (‘MACH-NC’) database demonstrated that concomitant chemotherapy improved overall survival. The 2021 update assessed 19 805 patients in 107 trials (excluding nasopharyngeal cancer) and showed an absolute survival benefit of 6.5 per cent at 5 years and 3.6 per cent at 10 years for concomitant chemotherapy compared to radiotherapy alone. The benefit decreased with increasing age, with no significant benefit for patients aged over 70 years (hazard ratio of 0.78 for those aged less than 50 years, compared with 0.97 for those aged 70 years or more).^{Reference Lacas, Carmel, Landais, Wong, Licitra and Tobias109} Concomitant cisplatin should be considered for patients who are young and fit enough to tolerate the likely increased toxicity when curative radiotherapy is used for T_3/4 tumours and/or with node-positive disease.

Concomitant chemotherapy in the post-operative setting has also been shown to improve local control and survival in those with poor prognostic factors and a high recurrence risk, particularly if there are involved resection margins or extracapsular nodal extension. In a separate meta-analysis, the five-year absolute benefit rate with concomitant chemotherapy versus radiotherapy alone was 7.9 per cent.^{Reference Winquist, Oliver and Gilbert128,Reference Dauzier, Lacas, Blanchard, Le, Simon and Wolf129}

The international standard treatment regimen is cisplatin 100 mg/m^{Reference Nutting, Morden, Harrington, Urbano, Bhide and Clark106} three-weekly, but because of the intensiveness and morbidity of treatment, chemotherapy modification (delays, omission and dose modification) is not uncommon. Weekly cisplatin 30–40 mg/m^{Reference Nutting, Morden, Harrington, Urbano, Bhide and Clark106} is preferred by some centres in the belief that it is better tolerated and more flexible in delivery, as occasional weeks can be missed with less risk of compromising total dose. Regardless of treatment schedule, it has been shown in studies that a cumulative dose of around 200 mg/m^{Reference Nutting, Morden, Harrington, Urbano, Bhide and Clark106} gives the best therapeutic benefit.

A meta-analysis published in 2017 concluded that, although no difference in treatment efficacy was seen for three-weekly versus weekly cisplatin regimens, the studies analysed were often flawed in terms of balance and study numbers, and few trials were prospective and randomised.^{Reference Szturz, Wouters, Kiyota, Tahara, Prabhash and Noronha130,Reference Szturz, Wouters, Kiyota, Tahara, Prabhash and Noronha131} Subsequently, Noronha et al. reported a prospective phase 3 randomised study of 300 patients (93 per cent adjuvant), and showed a two-year locoregional control benefit rate of 58.5 per cent for weekly cisplatin versus 73.1 per cent for three-weekly.^{Reference Noronha, Joshi, Patil, Agarwal, Ghosh-Laskar and Budrukkar132} Other studies have reported conflicting results and so conclusions remain difficult to draw.^{Reference Helfenstein, Riesterer, Meier, Papachristofilou, Kasenda and Pless133}

Cetuximab has also been extensively investigated in combination with radiotherapy. Although the initial major study showed a benefit for cetuximab compared to radiotherapy alone, subsequent studies have shown cetuximab to be inferior to cisplatin, particularly in human papillomavirus (HPV)-positive groups.^{Reference Bonner, Harari, Giralt, Cohen, Jones and Sur134–Reference Mehanna, Robinson, Hartley, Kong, Foran and Fulton-Lieuw136}

Immunotherapy (discussed in the next section for recurrent and metastatic disease) may have a place in the radical setting in combination with surgery and/or radiotherapy. The global multicentre, multicohort phase I/II trial ‘Checkmate-358’ assessed the safety of neo-adjuvant nivolumab prior to surgery, and the ‘CompARE’ (Comparing Alternative REgimens for escalating treatment of intermediate and high-risk oropharyngeal cancer) trial is currently recruiting patients with intermediate and high-risk oropharyngeal tumours receiving radical (chemo)radiotherapy with durvalumab as one of the investigation arms. There are many more studies open or in development that are focused on assessing the benefit of immune checkpoint inhibitors; this is an exciting era for concomitant systemic therapy in radical head and neck cancer.

Palliative systemic therapies

Recommendations

• • Explain the potential benefits of different systemic therapies and their possible negative effects (side effects, time taken for treatment, likelihood of treatment not working) to patients and families before agreeing a treatment plan (evidence-based recommendation (R))

• • Measure PD-L1 (programmed death-ligand 1) biomarkers in all patients who are considering systemic palliative therapies (R)

• • Offer palliative immunotherapy as an alternative to chemotherapy, in line with current NHS commissioning guidance* (R)

*NHS England currently funds single-agent pembrolizumab for untreated metastatic or unresectable recurrent head and neck squamous cell carcinoma (SCC), provided the combined positive score is 1 or more. Nivolumab is funded for patients who have progressed during or within six months of platinum-based chemotherapy.

Palliative chemotherapy can be considered in cases of recurrent or metastatic head and neck SCC that are not amenable to local therapies and where the patient continues to have a good World Health Organization performance status classification, of 0–2 (ranging from asymptomatic to symptomatic and in bed less than 50 per of the day). In recurrent and metastatic disease, overall survival is generally poor, and measured between 6 and 12 months in most series. Responses to systemic therapies can be of limited duration and toxicity rates can be high, so it is important to discuss the risks of treatment compared to best supportive care alone, particularly taking into account a patient's fitness for treatment and their preferences and wishes when life expectancy is short. Medications and strategies aimed at improving symptom control are essential, along with good palliative care and clinical nurse specialist and allied health professional support. It is important to consider clinical trials if available.

Current trials that may change practice and future directions

The National Cancer Research Institute supports a wide variety of clinical trials in head and neck cancer. Studies that are open to recruitment or in the set-up stage can be viewed here via: https://www.ncri.org.uk (search portfolio maps). Major USA trials undertaken by the NRG co-operative group can be viewed here: https://www.nrgoncology.org/Clinical-Trials/Protocol-Search. There are perhaps three major research areas that may change practice within the next five years.

In HPV-associated oropharyngeal cancer, there are many studies exploring different de-intensification strategies: reducing radiation dose, treatment volumes or concomitant therapies in order to maintain high cure rates with less toxicity. There is almost a risk that the plethora of trials with different strategies will make the optimal treatment paradigm difficult to assess. Key UK phase III trials that should report in the next few years are ‘PATHOS’ (a trial of risk-stratified, reduced-intensity adjuvant treatment in patients undergoing transoral surgery for HPV-positive oropharyngeal cancer) and Torpedo (a trial of intensity-modulated proton beam therapy vs intensity-modulated radiotherapy for multi-toxicity reduction in oropharyngeal cancer).

The cure rates for other head and neck SCC have not changed much for decades, so trials are also exploring improving survival rates in these cancers, often by adding new treatment options such as immunotherapy to existing protocols. In the UK, the ‘CompARE’ trial has almost completed accrual.

Systemic therapy for many cancers has changed hugely in the last decade, with major advances being made in melanoma and lung cancer in particular. It is hoped that continued immunotherapy and targeted-therapy research will also improve survival rates in head and neck cancers.

The head and neck oncology community worldwide has produced an excellent series of practical guidelines for radiotherapy target volume contouring and selection in the last decade.^{Reference Grégoire, Ang, Budach, Grau, Hamoir and Langendijk144–Reference Biau, Lapeyre, Troussier, Budach, Giralt and Grau146} These have been supplemented with the Royal College of Radiologists’ head and neck cancer consensus statements, and other associated UK national guidance on topics such as radiotherapy contour quality assurance and dose fractionation.^107,108,147 If implemented in every radiotherapy centre, such guidelines have huge potential to reduce variation and improve outcomes. Future guidelines, for example on post-operative radiotherapy contouring, are eagerly awaited.

Follow up

Recommendations

• • Patients should undergo follow up on at least a two-monthly basis for two years, then three- to six-monthly thereafter for a minimum of five years (good practice point (G))

• • Patients should be able to access urgent clinical assessment for suspicious symptoms at any time during follow up (evidence-based recommendation (R))

• • Follow up and clinical examination with imaging, if indicated, should aim to identify cancer recurrence as early as possible and to detect second primary tumours (R)

• • Patients should undergo follow up in clinics at, or linked to, a head and neck treatment centre, and have access to the wider multidisciplinary team (MDT), including clinical nurse specialists, speech and language therapists, and dieticians (R)

• • Patients receiving radiotherapy or chemoradiotherapy for stage 3 and 4 disease should undergo post-treatment surveillance imaging to assess for disease response, as well as for baseline imaging (R)

• • Baseline imaging should be considered after primary surgery in which anatomy is altered (G)

• • Patients should undergo regular thyroid function monitoring after treatment for head and neck cancer (R)

Recurrent disease

Recommendations

• • Consider curative, palliative and supportive options for patients with recurrent disease (evidence-based recommendation (R))

• • Biopsy is required before active treatment and should include PD-L1 (programmed death-ligand 1) testing for immunotherapy (R)

• • The decision-making process is highly complex and requires multidisciplinary input (R)

• • Patients and their families should be aware of the prognosis, chance of treatment efficacy and complications when making decisions about possible treatment (R)

• • Consider PET-CT before active treatment (good practice point (G))

Important questions to be answered and future developments

Key points

• • Both globally and in the UK, head and neck cancer incidence is increasing, and is projected to continue to rise, largely driven by increases in oropharyngeal cancer.

• • Mortality rates in the UK over the last decade have started to increase, reflecting the rising incidence and static survival rates.

• • The major risk factors for oropharyngeal cancer are: tobacco smoking, alongside alcohol consumption and tobacco used in combination; betel chewing in Southeast Asian populations; and human papillomavirus (HPV).

• • Head and neck cancers are clearly socio-economically patterned, with individuals from the most deprived backgrounds having the greatest burden and poorest survival outcomes, and this socio-economic risk is not entirely explained by smoking and alcohol consumption behaviours.

• • Head and neck cancer incidence is higher among men than women, and is more common in older age groups, although oropharyngeal cancer incidence peaks around 10 years younger at around 60–65 years.

Definitions of head and neck cancer

Approximately 90 per cent of head and neck cancers are squamous cell carcinoma that arise from the epithelial lining of the oral cavity, pharynx and larynx.^{Reference Sanderson and Ironside195} There are many types of head and neck cancer, which are discretely categorised on the basis of their anatomical location using the International Classification of Diseases, 10th revision (‘ICD-10’), from the World Health Organization.¹⁹⁶ In addition, the subsites that are included under the definition of ‘head and neck cancer’ often vary across studies, particularly with relation to the oral cavity and oropharynx.^{Reference Conway, Purkayastha and Chestnutt197,Reference Kaste, Dolecek, Zavras and Radosevich198} Because of differences in definition, it is important that anatomical subsites are clearly specified when reviewing the epidemiological literature (ideally by using corresponding International Classification of Diseases codes).

Global incidence trends in head and neck cancer

Head and neck cancer is the seventh most common cancer globally, accounting for more than 660 000 new cases and 325 000 deaths annually. The overall incidence of the disease continues to rise, with a predicted increase of 30 per cent (over one million) new cases annually by 2030.^{Reference Sung, Ferlay, Siegel, Laversanne, Soerjomataram and Jemal199,Reference Johnson, Burtness, Leemans, Lui, Bauman and Grandis200} This increase in incidence has been recorded across both developed and developing countries.^{Reference Bravi, Lee, Hashibe, Boffetta, Conway and Ferraroni201} Southeast Asia and Asia-Pacific regions have particularly high incidences of oral cancer, which are strongly associated with chewing of the areca nut (betel quid), with or without tobacco.^{Reference Shield, Ferlay, Jemal, Sankaranarayanan, Chaturvedi and Bray202} Oral cancer is therefore expected to rise within Southeast Asia, in line with population growth.^{Reference Cheong, Vatanasapt, Yi-Hsin, Zain, Kerr and Johnson203} The increasing rates of head and neck cancer in the USA and Europe have been attributed to a rise in oropharyngeal cancer, linked to HPV infection (Figures 1 and 2).^{Reference Mehanna, Beech, Nicholson, El-Hariry, McConkey and Paleri204,Reference Gillison, Chaturvedi, Anderson and Fakhry205} Over the next 20 years, it is expected that the majority of head and neck cancers will be HPV-positive, with projections that in some European countries, such as the UK, oropharyngeal cancer incidence will overtake cancer of the oral cavity.^{Reference Conway, Purkayastha and Chestnutt197}

Figure 1. Global age-standardised incidence rates (ASR) of head and neck cancer. Reprinted with permission from the World Health Organization International Agency for Research on Cancer ‘Cancer Today – Data visualization tools for exploring the global cancer burden in 2020’ (in: http://gco.iarc.fr/today, accessed August 2021). The map was generated using the Global Cancer Observatory (‘Globocan’) website mapping tool by selecting the ‘lip, oral cavity’, ‘oropharynx’, hypopharynx’ and ‘larynx’ cancer sites. Estimated age-standardised rates of head and neck cancer incidence worldwide are shown for both sexes.

Figure 2. Age-standardised incidence rates (ASR) of head and neck cancer, by continent. Reprinted with permission from World Health Organization International Agency for Research on Cancer ‘Cancer Today – Data visualization tools for exploring the global cancer burden in 2020’ (in: http://gco.iarc.fr/today, accessed August 2021). The map was generated using the Global Cancer Observatory (‘Globocan’) website mapping tool by selecting the ‘lip, oral cavity’, ‘oropharynx’, hypopharynx’ and ‘larynx’ cancer sites. Estimated age-standardised rates of head and neck cancer incidence by continent are shown for both sexes.

Worldwide, laryngeal cancer incidence and prevalence have increased by 12 per cent and 24 per cent, respectively, during the past three decades.²⁰⁶ However, age-adjusted rates for new laryngeal cancer cases have been falling in countries with a higher sociodemographic index, perhaps reflecting changes in smoking and alcohol drinking behaviours.²⁰⁶ Overall, head and neck cancer affects males two to four times more than females, with estimates reaching over 20 per 100 000.^{Reference Miranda-Filho and Bray207} For men in developing countries, lip and oral cavity cancer is the second most common cancer (10 per 100 000). Male incidence of oral and oropharyngeal cancer has declined over recent years in France (−12.6 per cent), Slovakia (−4.0 per cent), Spain (−10.8 per cent), Brazil (−26.7 per cent) and Hong Kong (−10.5 per cent), while it increased in the UK (18.8 per cent), Australia (8.7 per cent), Japan (21.3 per cent) and in the USA (3.7 per cent).^{Reference Bosetti, Carioli, Santucci, Bertuccio, Gallus and Garavello208} The risk of head and neck cancer increases with age across populations, with the majority of cases diagnosed in those aged over 50 years.^{Reference Warnakulasuriya209} Similarly, there has been a rise in cases amongst females, predominantly in European countries, which may be explained by sex-specific patterns of tobacco and alcohol consumption.^{Reference Miranda-Filho and Bray207,Reference Bosetti, Carioli, Santucci, Bertuccio, Gallus and Garavello208}

Trends in head and neck cancer in the UK

As described previously, head and neck cancer rates are also rising in the UK. Studies have shown that from 1995 to 2011, oropharyngeal cancer incidence increased by 7.3 per cent for males and 6.5 per cent for women in England, with oral cavity cancer showing a 2.8 per cent rise in men and 3.0 per cent rise in women over the same period.^{Reference Louie, Mehanna and Sasieni210} Incidence rates are highest in Scotland, where oropharyngeal cases were shown to have increased by 85 per cent from 2011 to 2012.^{Reference Purkayastha, McMahon, Gibson and Conway211} These rates are continuing to rise according to most recent UK Cancer Registry Data, which show a 34 per cent increase in total cases diagnosed across the four nations from 2011 to 2018. The burden of head and neck cancer is strongly socio-economically patterned, with the highest rates being observed among people living in the most socio-economically deprived communities.^{Reference Purkayastha, McMahon, Gibson and Conway211,212} These cancer registry data also demonstrate that the majority of head and neck cancers are diagnosed at an advanced stage.²¹³ For the UK as a whole, 58.5 per cent of head and neck cancers with a known stage are diagnosed at an advanced stage, III or IV, in accordance with the TNM Atlas, seventh edition.^{Reference Brierley, Asamura, van Eycken and Rous214} The highest rates of advanced disease are found in Scotland and Northern Ireland, where 67.6 per cent are at an advanced stage. Stage IV is the most common stage at diagnosis for oral and oropharyngeal cancer, whereas stage I is most common for laryngeal cancer.²¹³

Mortality and survival trends in head and neck cancer in the UK

In 2018, there were 4078 deaths attributable to head and neck cancer in the UK, accounting for approximately 2 per cent of all cancer deaths annually.²¹⁵ Variation in national head and neck cancer mortality rates (European age-standardised rate per 100 000 population) was apparent between nations of the UK: Scotland (rate = 8.7) and Northern Ireland (rate = 8.4) had worse outcomes than England (rate = 6.2) and Wales (rate = 5.8). Age-specific mortality that is attributable to head and neck cancer rises from the fifth decade of life onwards, towards a peak mortality in those aged over 90 years – a phenomenon most pronounced in males. In the UK, since the early 1970s, the combined head and neck cancer mortality for men and women has fallen by 11 per cent overall (age-standardised rate per 100 000 population = 7.3 in 1971 and 6.5 in 2018); however, the last decade has seen a gradual rise in mortality rates from a low in 2006 (age-standardised rate per 100 000 population = 5.6), possibly reflecting the changes in disease incidence and static survival rates.²¹⁵

Survival rates can vary significantly according to geographical location, tumour site, HPV association (associated with increased chances of survival),^{Reference Du, Mazul, Farquhar, Brennan, Anantharaman and Abedi-Ardekani216} and, most prominently, stage at diagnosis. Those diagnosed with advanced disease have notably poorer outcomes than those with early disease. Analysis of a large cohort in the USA showed that patients with HPV-positive cancers had a better chance of long-term survival compared to those with non-HPV cancers, confirming previous studies also suggesting this phenomenon.^{Reference Du, Mazul, Farquhar, Brennan, Anantharaman and Abedi-Ardekani216} There are several studies within the recently established Head and Neck Cancer in South America and Europe (‘HEADSpAcE’) international consortium²¹⁷ that are exploring the factors associated with relatively poor survival among people with head and neck cancer. Analysis of routinely collected data and from large prospective cohort studies, such as Head and Neck 5000,^{Reference Ness, Waylen, Hurley, Jeffreys, Penfold and Pring218} have demonstrated that significant socio-economic inequalities in head and neck cancer survival exist in the UK, not all of which can be explained by behavioural factors.^{Reference Ingarfield, McMahon, Hurley, Toms, Pring and Thomas219}

Risk factors associated with head and neck cancer

Tobacco smoking and alcohol consumption are well established risk factors for head and neck cancer. However, a detailed understanding of these somewhat complex behaviours in terms of precise estimates of risk, recognising the joint tobacco–alcohol effect, the dose–response, and the benefits of quitting both smoking and alcohol, remains less well established. The role of other risk factors in head and neck cancer risk, such as smokeless tobacco, betel chewing, diet, oral health and hygiene, and hormonal, genetic, occupational and socio-economic status, is also poorly understood. A major challenge in elucidating detailed information from the epidemiological literature is the heterogeneity in study designs and populations from often small observational studies. The dominant effects of tobacco smoking and alcohol drinking also overshadow other minor risk factors.

A recent umbrella review of systematic reviews and meta-analyses (Conway et al.^{Reference Conway, Hashibe, Boffetta, Wunsch-Filho, Muscat and La Vecchia220}) has been combined with pooled analyses at the individual level data from studies from around the world, by The International Head And Neck Cancer Epidemiology (‘INHANCE’) Consortium.²²¹ These data confirm that tobacco smoking and alcohol drinking behaviours, separately and in combination, are major risk factors for head and neck cancer, accounting for 72 per cent of cases when used in combination.^{Reference Hashibe, Brennan, Chuang, Boccia, Castellsague and Chen222} Recent evidence has shown an independent causal effect of alcohol consumption, when controlling for smoking (odds ratio = 2.1), suggesting that the role of alcohol may have been previously underestimated.^{Reference Gormley, Dudding, Sanderson, Martin, Thomas and Tyrrell223}

High-risk HPV, especially HPV type 16, is a major risk factor for oropharyngeal cancer,^{Reference Hobbs, Sterne, Bailey, Heyderman, Birchall and Thomas224} thought to be sexually transmitted via oro-genital contact.^{Reference Gillison, Chaturvedi, Anderson and Fakhry205} Smoking has been shown to interact with HPV and increase risk.^{Reference Anantharaman, Muller, Lagiou, Ahrens, Holcátová and Merletti225} Those who have HPV-negative oropharyngeal tumours are more likely to be heavier smokers, with an increased risk of death for every additional pack-year, compared to HPV-positive cases.^{Reference Ang, Harris, Wheeler, Weber, Rosenthal and Nguyen-Tan226} Genetic susceptibility to head and neck cancer has also been investigated,^{Reference Vukovic, Stojanovic, Vecchioni, Pastorino and Boccia227} with the largest genome-wide association study of oral and pharyngeal cancer (6034 cases and 6585 controls from Europe, North America and South America), detecting seven unique loci.^{Reference Lesseur, Diergaarde, Olshan, Wunsch, Ness and Liu228} Genetic variants in alcohol-metabolising genes, such as alcohol dehydrogenase (ADH), are associated with increased head and neck cancer risk. This study also found a strong protective association at a chromosome within the human leukocyte antigen class II region in oropharyngeal subgroup analysis.^{Reference Lesseur, Diergaarde, Olshan, Wunsch, Ness and Liu228} Going forward, this could help explain why some individuals are more at risk of developing the disease following HPV infection.

Key recommendations

• • Microsurgical free-flap reconstruction should be the primary reconstructive option for most defects of the head and neck that need tissue transfer (good practice point (G))

• • Composite free tissue transfer should be offered as the first choice to all patients needing mandibular reconstruction (evidence-based recommendation (R))

• • Free flaps should be offered as the first choice of reconstruction for all patients needing circumferential pharyngoesophageal reconstruction (R)

• • Free-flap reconstruction should be offered for patients with class III or higher defects of the maxilla (R)

• • Patients undergoing salvage total laryngectomy should be considered for vascularised flap reconstruction, to reduce pharyngocutaneous fistula rates (R)

• • For reconstruction involving the upper and lower jaws, or involving rhinectomy or orbital exenteration, pre-operative multidisciplinary decision-making should include restorative dentistry or dental prosthodontists (R)

• • Tubing over and use of a salivary bypass tube appear to decrease complication rates with anterolateral thigh and radial forearm free flaps (G)

• • Each head and neck centre should have a protocol for free-flap monitoring and rescue (G)

Oral cavity soft tissues

Oral soft tissues include the tongue, floor of mouth, buccal mucosa and the retromolar trigone extending to the tonsillar area. Because of the close proximity of these areas, cancers of these sites occasionally cross over to one another. Reconstructive access is usually determined by the extent and access of the surgical resection.

Free tissue transfer provides the mainstay of oral soft tissue reconstruction, as it allows importation of large volumes of healthy tissue from sites distant to prior surgical or radiotherapy fields. The radial artery forearm flap and anterolateral thigh perforator flap remain the ‘go to’ options for most significant oral soft tissue defects. Other options exist, as detailed in Table 2.^{Reference Chalmers, Rahman, Young, Kennedy, Endersby and Adams229,Reference Green, Rahman, Owen, Paleri, Adams and Ahmed230}

Table 2. Mainstream and promising options for oral cavity soft tissue reconstruction

Regional flaps such as pectoralis major, submental island artery, supraclavicular artery island and nasolabial flaps can be effective in importing tissue, but are not optimal choices.

Mandible

Reconstruction of the mandible must address the site and size of the bony defect, associated soft tissue loss and the desirability of dental rehabilitation. Free tissue transfer is the mainstay of mandibular reconstruction, as it allows the importation of bone which can be tailored to fit the desired shape, is well vascularised and is amenable to osseointegration. The main flap options are:

• • Fibula flap

• • Deep circumflex iliac artery flap

• • Scapular flap

Dental rehabilitation is a key part of most mandibular reconstructions, and pre-operative liaison with the restorative team, including consideration of 3D planning and osseo-integrated implants, is recommended (see Chapter 13).

The fibular flap allows harvest of a long piece of bone that is of adequate height for osseointegration and can be osteotomised several times for contouring. This is now made easier with the availability of 3D software to plan the osteotomies at the mandible and on the fibula prior to transfer. It is relatively easy to harvest as an osseous or osteoseptocutaneous flap, with or without muscle. This versatility means it is the workhorse for mandibular reconstruction in most centres. One drawback of the flap is its relative lack of height.

The deep circumflex iliac artery flap provides for a high bony segment, and the natural curve of the ilium lends itself to lateral mandibular defects where an osteotomy may not be necessary. The donor site defect can be problematic (pain restricting mobility, hernia and mesh infection), and its skin paddle is usually reserved for external use although muscle can be incorporated for oral reconstruction.

The scapular flap allows for harvest of a relatively small amount of bone. The main advantage of this flap is the large volume of skin and muscle (latissimus dorsi), which can be used in a chimeric fashion. The bone is a good height, but two-team flap harvesting is generally not possible.

A composite radial forearm flap is rarely used for bone reconstruction as only a small volume of bone of low height can be harvested. There is also a risk of subsequent fracture of the radius, which can be debilitating.

A new classification of the mandibular defect has been described based on the four corners of the mandible, which are both angles and both canines (Figure 1).^{Reference Brown, Barry, Ho and Shaw231}

Figure 1. Classification of mandibular defects.^{Reference Brown, Barry, Ho and Shaw231}

Although not in the official classifications in Figure 1, posterior mandibular defects distal to the second lower molar, involving the ramus of the mandible but sparing the subcondylar/condylar segment, may be amenable to a soft tissue only flap with a reinforced titanium plate. This is on the premise that dental rehabilitation is not required, but it risks plate fracture or extrusion. In order to minimise the latter, a robust chimeric flap such as an anterolateral thigh flap with vastus muscle would be recommended.

Maxilla and midface

The level of evidence is very weak in all areas of reconstruction, but more particularly in the maxilla and midface because of the differing complexity of the defects, and the potential for skull base involvement.

All cases involving the loss or ablation of the maxilla and/or midface should be discussed in a multidisciplinary setting. The choice of reconstruction or prosthetics requires discussion among the ablative and reconstructive teams, prosthodontist, maxillofacial technician, patient and family. There are clear advantages in simplifying the surgery and using prosthetic options, but this choice becomes more difficult to deliver, and makes it more difficult for the patient to cope, as the defect becomes larger and more complex.

The use of the maxillectomy defect classification is recommended (Figure 2).^{Reference Brown and Shaw232}

Figure 2. Classification of the maxillary and midface defects. Classes I–VI relate to the vertical component of the defect, including orbitomaxillary (class V) and nasomaxillary (class VI) defects, when often the palate and dental alveolus are intact. Classes a–d relate to the increasing size of the palatal and dento-alveolar parts of the defect, indicating increasing difficulty in obtaining good results with obturation.^{Reference Brown and Shaw232}

The choice of a prosthetic option or reconstruction depends on the nature of the defect. In class I and II defects, an obturator is a reasonable option, but this becomes less favourable with orbital adnexae involvement (class III), orbital exenteration (class IV), and when the midface defects are of an orbitomaxillary (class V) or nasomaxillary (class VI) nature. In addition to the vertical component, the extent of the dental or alveolar part of the resection is relevant to the prosthodontist in deciding on appropriate obturation. A summary of the options can be found in Table 3.

Table 3. Recommended reconstruction method, according to midface and maxillectomy defect classification^{Reference Brown and Shaw232}

Letters (a, b, c) refer to the horizontal classification (Figure 2). *Supplies the iliac crest. ^†Supplies the scapula tip. + = recommended; − = not recommended

Class I: Resections of the alveolar bone not resulting in an oroantral fistula can either be left to granulate or treated with a local flap. Palatal defects can be obturated or reconstructed with a soft tissue flap. For larger defects not requiring implants, a vastus lateralis muscle flap based on the descending branch of the lateral circumflex femoral artery may be used. This has a low donor site morbidity, and matures with shrinkage and some fibrosis to mimic the pre-morbid hard palate.

Class II: This is the standard hemi-maxillectomy not involving the orbital floor or adnexae. Obturation is often very successful for this form of defect, as the orbit does not require support, and if the defect is small enough for retention and stability of the prosthesis. In more extensive cases (classes IIc–d), the options are an implant-retained prosthesis or composite flap. Reconstruction with the fibula flap has also shown good outcomes. The deep circumflex iliac artery flap, with greater height, and which includes the iliac crest and internal oblique muscle, will give better support to the peri-nasal area. The scapula flap can be supplied by the circumflex scapular artery that supplies the lateral scapula (scapula flap) through periosteal perforators along its length, or the angular branch of the thoracodorsal artery which supplies the scapula tip. The advantage of the scapula tip option is that the pedicle is considerably longer than the circumflex scapula artery option, which is a great advantage in the maxilla and midface as the recipient vessels are more distant.

Class III: In these cases, there is loss of the orbital support, and often a part of the nasal bones may also require reconstruction. There is good consensus in the literature that the restoration of orbital support with vascularised tissue (pedicled or free flap) is essential to ensure healing of the bone graft, and to reduce soft tissue problems such as epiphora and ectropion. The deep circumflex iliac artery with internal oblique provides the best solution if an implant-retained prosthesis is planned, but the scapula tip flap using latissimus dorsi muscle is also a good option with a more reliable pedicle. The fibula is also described for this defect, but considerable skill in the adaptation of this flap for the defect is required, with variable results. Obturation alone will result in facial collapse, poor support of the orbit, and a high risk of vertical orbital dystopia and ectropion. In children, the scapula tip will probably be the best option, as the iliac crest has a cartilaginous cover and the vessels are much smaller.

Class IV: Reasonable results can be achieved with a soft tissue flap alone such as rectus abdominus or vastus lateralis, but this will result in poor definition of the orbital defect and some facial collapse. The choice is similar to class III in that the iliac crest with internal oblique offers better implant options, but the scapula tip and fibula flaps are also good options.

Class V: In the orbitomaxillary defect, the main aim is not to obturate the orbital space with too much soft tissue, to allow space for an orbital prosthesis. The temporalis or temporoparietal flap are ideal, but in more extensive defects it is worth considering the radial or anterolateral thigh flap in a thinner patient. Some patients may prefer the natural ‘eye patch’ option provided by a thicker flap to a prosthesis. Thicker flaps will atrophy in time and can be thinned secondarily.

Class VI: If there is loss of the facial skin between the orbits and nasal bones, then free tissue transfer is probably essential. The composite radial artery forearm flap can be ideal if harvested with fascia to line the nasal side of the radial strut and the skin to restore the face. This can be augmented with a glabella or forehead flap.

A classical rhinectomy can be rehabilitated with a prosthesis, and of course the surgeon can check the margins of resection and resect more tissue if required. There are very successful full rhinectomy reconstructions performed, which can give a permanent biological solution if preferred. In this defect, attention must be paid to the restoration of the cartilaginous scaffolding and nasal bones with vascularised tissue, to prevent complications during and following radiotherapy. Frequently used combinations are radial artery forearm flap (inner lining), non-vascularised auricular cartilage and bone grafts, and a paramedian forehead flap (external surface).

Skull base reconstruction

The primary intentions are to seal the cranial cavity off and prevent cerebrospinal fluid leaks. This critical defect requires careful planning by all teams and surgeons involved in the case. This is discussed in more detail in Chapters 22 (lateral skull base) and 23 (anterior skull base).

Oropharyngeal reconstruction

Most tumour ablation involving the oropharynx is now transoral, after which there is usually no requirement for reconstruction. However, transoral surgery for tumour recurrence after radiotherapy may require reconstruction, for example, if the carotid sheath is left exposed, as the vitality of remaining tissue will have already been compromised. Other indications include soft palate reconstruction and tongue base reconstruction.

When required, radial artery forearm flap can be used and inset transorally following transoral tumour ablation. Anterolateral thigh flaps might be useful when more bulk is required. A posteromedially based musculomucosal flap, facial artery musculomucosal flap or radial artery forearm flap microvascular flaps can be used for soft palate reconstruction.^{Reference Meccariello, Montevecchi, Sgarzani, De Vito, D'Agostino and Gobbi233}

When open surgery is performed, microvascular options are preferred, mainly radial artery forearm or anterolateral thigh flaps.

Pharyngolaryngectomy reconstruction

Reconstruction of soft tissue neck defects

After extended neck dissections for neck disease with skin involvement, with loss of skin, a pectoralis major myocutaneous flap should be considered. Most of these cases will also involve loss of the sternocleidomastoid muscle, and this provides both skin cover and protection of the otherwise exposed carotid artery through its volume and muscle. A supraclavicular artery island flap can also be used for skin cover, but does not have the bulk.

In cases without a skin defect, when the neck dissection has included the sacrifice of the sternocleidomastoid muscle, and either chemoradiotherapy is planned or the neck dissection is for salvage treatment of recurrent disease after chemoradiotherapy, a pectoralis major myofascial flap can be considered in order to provide vascularised carotid artery cover and lessen the risk of breakdown causing catastrophic haemorrhage.

Care of patients after microvascular free-flap surgery

Microvascular reconstruction using free tissue transfer is standard practice in head and neck reconstruction. The literature demonstrates success rates in excess of 95 per cent.^{Reference Walia, Lee, Jackson, Hardi, Bollig and Graboyes240,Reference Pohlenz, Klatt, Schön, Blessmann, Li and Schmelzle241} The early detection of and intervention for flap failure forms an important part of ensuring low failure rates.

There is no universally agreed protocol regarding the duration and method of flap monitoring. However, the following should be considered:

• • The critical period for flap vascular complications is 24–48 hours post-operatively^{Reference Pohlenz, Klatt, Schön, Blessmann, Li and Schmelzle241}

• • The probability of flap salvage is inversely related to the duration of ischaemia, and successful flap salvage is highly unlikely after 12 hours^{Reference Pohlenz, Klatt, Schön, Blessmann, Li and Schmelzle241}

• • Clinical flap monitoring includes using capillary refill, skin colour, cutaneous temperature and arterial Doppler signal. It is highly accurate and effective, with 85–95 per cent flap success rates using clinical assessment alone^{Reference Han, Guo, Liu, Li, Zhou and Wei242}

• • The use of an implantable Doppler may be considered for buried flaps or to augment clinical monitoring, with some improvement in reducing flap failure but possibly at the expense of false alarms^{Reference Han, Guo, Liu, Li, Zhou and Wei242}

A typical protocol for monitoring is:

• • One-hourly observation on post-operative day 1

• • Two-hourly observation on post-operative day 2

• • Four-hourly observation on post-operative day 3

While late flap vascular complications are reported, even at day 7 post-operatively, both the probability of their occurrence and their salvage is low, as these are usually related to intrinsic flap problems, which are not easily correctable.^{Reference Zoccali, Molina and Farhadi243}

Key points

• • Patients and family members should be at the centre of their care. They should receive education and information regarding prehabilitation and enhanced recovery after surgery early in their pathway, so that they can provide informed consent and engage in preparation.

• • Prehabilitation and enhanced recovery after surgery relies on interdisciplinary teams involving a range of professionals, including those who may traditionally fall outside healthcare, e.g. voluntary sector, health and leisure centres, to ensure that the optimum patient outcome is achieved.

• • Healthcare workers require the appropriate training, governance and operational support to be able to enact this guidance and embed the recommendations into their practice. It is recommended that clinical services identify champions within their organisation to effectively implement organisational change with appropriately resourced audit data collection.

• • There may be barriers present for some head and neck cancer patients that prevent them from engaging in prehabilitation and enhanced recovery after surgery programmes; for example, difficulty in changing maladaptive behaviours, and/or psychological factors including the lived experience of trauma. All attempts should be made to gain awareness of such barriers, and to support patients in overcoming these issues in order to achieve the benefits offered from prehabilitation and enhanced recovery after surgery programmes.

• • Prehabilitation and enhanced recovery after surgery programmes are more effective when delivered across a pathway that also includes rehabilitation.

Prehabilitation

Cancer prehabilitation is an intervention commonly defined as occurring from the time of diagnosis to the commencement of acute treatment. Macmillan prehabilitation guidance (2019)²⁴⁴ outlines a set of principles to empower people with cancer to prepare for treatment, through promoting healthy behaviours and needs-based prescribing of exercise, nutrition and psychological interventions. We would suggest that cancer prehabilitation is best viewed as a continuum throughout the patients’ journey, from diagnosis to treatment, into rehabilitation and to survivorship.^{Reference Silver and Baima245}

The treatments for head and neck cancer are often multimodal and complex, and include primary surgery and reconstruction, and/or adjuvant radiotherapy with or without chemotherapy. These treatments are associated with both acute nutrition impact symptoms and long-term side effects, including dysphagia, pain, taste changes, mucositis and dry mouth, which result in a decline in nutritional and physical function that negatively affects quality of life (QoL) and survivorship.^{Reference Langius, van Dijk, Doornaert, Kruizenga, Langendijk and Leemans246,Reference Langendijk, Doornaert, Verdonck-de Leeuw, Leemans, Aaronson and Slotman247} In addition, many patients present with higher rates of smoking and alcohol consumption, low socio-economic status, and many co-morbidities; these result in low physical, nutritional and emotional well-being, which can negatively impact treatment outcomes. On diagnosis, up to 60 per cent of patients have been identified as malnourished or are at risk of malnutrition.^{Reference Jager-Wittenaar, Dijkstra, Dijkstra, Bijzet, Langendijk and van der Laan248} Subsequent treatment often serves to worsen malnutrition status, and leads to sarcopenia development in over 50 per cent of head and neck cancer patients, which is associated with worse outcomes.^{Reference Findlay, White, Lai, Luo and Bauer249}

Despite the downward trend of smoking, the incidence of head and neck cancer in the UK continues to rise, with approximately 50 per cent of oropharyngeal cases related to human papillomavirus.^{250,Reference Schache, Powell, Cuschieri, Robinson, Leary and Mehanna251} With this increasing prevalence, and the significant patient burden of head and neck cancer disease and treatment, interventions such as prehabilitation are particularly attractive, as they aim to improve the patient's physical, nutritional and mental resilience. This process aims to mitigate against the impact of treatment-related side effects, and to improve QoL as well as longevity.

A review of the literature identified several systematic reviews demonstrating the positive impact of prehabilitation amongst cancer patients.^{Reference Boereboom, Doleman, Lund and Williams252–Reference Gillis, Buhler, Bresee, Carli, Gramlich and Culos-Reed256} Prehabilitation that includes an exercise component can improve physical function prior to surgery, and demonstrates positive effects on length of hospital stay and post-operative surgical complications.^{Reference Boereboom, Doleman, Lund and Williams252,Reference Singh, Newton, Galvao, Spry and Baker255} One review, which aimed to identify whether prehabilitation improves health outcomes (physical function, nutritional status and patient-reported outcome measures) after more than 30 days post-treatment, concluded that prehabilitation improved gait, cardiopulmonary function, urinary continence, lung function and mood.^{Reference Faithfull, Turner, Poole, Joy, Manders and Weprin253} In a study of older adults with cancer that examined the efficacy of nutritional and exercise interventions on health-related QoL, the majority of interventions were exercise only, with variations in exercise modalities, duration and location.^{Reference Forbes, Swan, Greenley, Lind and Johnson254} Despite this heterogeneity, improvements in QoL were identified, highlighting the potential benefits of prehabilitation in the older adult population. Further robust and personalised interventions are recommended.

Implementing prehabilitation strategies commonly requires motivation, self-efficacy support and behaviour change in patient cohorts. Eating As Treatment (‘EAT’) is a psychological intervention that aims to improve the nutritional status in patients undergoing radiotherapy.^{Reference Britton, Baker, Wolfenden, Wratten, Bauer and Beck257} Dietitians were trained to include motivational interviewing and cognitive behavioural therapy strategies into their dietary counselling. This resulted in positive significant differences in nutritional status, as measured by the Patient-Generated Subjective Global Assessment (‘PG-SGA’) Short Form, weight loss and treatment interruptions. In addition, although not significant, global QoL was reported to have improved.

Currently, recommendations for head and neck cancer prehabilitation and its optimal delivery are limited by the volume of published research. This is likely because of the difficulties posed by the more complex treatment pathways in head and neck cancer when compared with abdominal and thoracic cancer resection surgery, which have tended to dominate the large prehabilitation trials. There is also a focus on more urgency in head and neck cancer surgery, potentially giving less time for prehabilitation interventions to be included in patient pathways. Additionally, there can often be difficulties associated with delivering treatment across increased geographical areas, as the head and neck cancer tertiary centre model may make the distance for patients to travel appear impractical.

Despite these challenges, there is confirmed safety and efficacy for exercise and nutrition interventions during chemo/radiotherapy in head and neck cancer patients.^{Reference Bye, Sandmael, Stene, Thorsen, Balstad and Solheim258} Exercise interventions included a combination of strength and aerobic exercises and were performed up to five times per week. Nutritional interventions were predominantly dietary counselling personalised to meet estimated energy and protein requirements, with oral nutritional supplements being used to meet any deficit. Additionally, a 7-day prehabilitation intervention in head and neck cancer and abdominal surgery patients, including a nutritional (oral nutritional supplements), exercise (step targets), breathing technique and skin cleaning regimen, has confirmed the feasibility of short interventions by demonstrating significant improvements in post-operative mobility and improved prevention of pulmonary morbidity.^{Reference Moore, Scoggins, Philips, Egger, Tennant and Little259}

Despite the paucity of published research specifically in head and neck cancer, it is clear from the burden of the disease and its treatment that this group of patients can significantly benefit from many of the processes inherent in prehabilitation. These recommendations have been developed by drawing upon the current evidence, clinical expertise in head and neck, knowledge from established prehabilitation programmes, and the lived experience of head and neck cancer proton pump inhibitor (PPI) groups.

Pre-treatment (general to all head and neck cancers)

The recommendations are summarised in Table 1.^{Reference Grimmett, Bradbury, Dalton, Fecher-Jones, Hoedjes and Varkonyi-Sepp260–Reference Gillis, Li, Lee, Awasthi, Augustin and Gamsa262}

Table 1. Prehabilitation: pre-treatment recommendations general to all head and neck cancers

* See chapter on nutritional management in the treatment of head and neck cancer for further details. ^†See chapter on psychological management for further details. ^‡See chapter on speech, voice and swallowing rehabilitation for head and neck cancer for further details. OMFS = oral and maxillofacial surgery; PG-SGA SF = Patient-Generated Subjective Global Assessment Short Form; NRS = nutrition risk screening; MUST = Malnutrition Universal Screening Tool; SARC-F = Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls questionnaire; BIA = bioelectrical impedance analysis; CT = computed tomography; DEXA = dual-energy X-ray absorptiometry; HbA1c = haemoglobin A1c; IAPT = improving access to psychological therapies; SLT = speech and language therapy; EORTC = European Organization for the Research and Treatment of Cancer; QLQ-30 = 30-item Quality of Life Questionnaire Core Module; QLQ-H&N35 = 35-item Quality of Life Questionnaire Head and Neck Module; PCI = Patient Concerns Inventory; SF-36 = 36-item Short Form Health Survey; QoL = quality of life

During treatment

Surgery-specific

The recommendations are summarised in Table 2.

Table 2. Prehabilitation: intra-treatment recommendations specific to surgery

Chemo/radiotherapy-specific

The recommendations are summarised in Table 3.^{Reference Capozzi, Nishimura, McNeely, Lau and Culos-Reed263,Reference Starmer, Yang, Gourin, Kumar, Jones and McNutt264}

Table 3. Prehabilitation: intra-treatment recommendations specific to chemo/radiotherapy

Chemo/RT = chemo/radiotherapy; SLT = speech and language therapy

Post-treatment (general to all head and neck cancers)

The recommendations are summarised in Table 4.

Table 4. Prehabilitation: post-treatment recommendations general to all head and neck cancers

QoL = quality of life; SMART goals = specific, measurable, achievable, relevant and time-bound goals

Enhanced recovery

Enhanced recovery after surgery pathways are used in some surgical pathways with the aim of improving post-operative recovery by optimising pre-operative function and by reducing the post-operative stress response.^{Reference Melnyk, Casey, Black and Koupparis265} Whilst novel in its application to head and neck cancer surgical pathways, enhanced recovery after surgery has been implemented for decades in both general and colorectal surgery, with demonstrated long-term improvements in patient outcomes.^{Reference Muller, Zalunardo, Hubner, Clavien and Demartines266} Established enhanced recovery after surgery pathways in these specialties recommend principles that could be applied to head and neck cancer patients, including pre-operative counselling, nutrition optimisation, standardised analgesic and anaesthetic regimens, and early post-operative mobilisation for all surgical patients.

Despite this proven evidence for benefit in other cancers and surgical specialties, current research exploring enhanced recovery after surgery in head and neck cancer surgery remains limited in number and variable in study design.^{Reference Watson and Ewers267} The key concepts that have been explored to date focus on early oral feeding following major head and neck cancer surgery,^{Reference Seven, Calis and Turgut268–Reference Prasad, Sreedharan, Dannana, Prasad and Chandra271} early tracheostoma fistula closure, and aspects of service delivery including predictors of complications.^{Reference Brookes, Seikaly, Diamond, Mechor and Harris272–Reference Farwell, Reilly, Weymuller, Greenberg, Staiger and Futran276} Dort and colleagues’ (2017)^{Reference Dort, Farwell, Findlay, Huber, Kerr and Shea-Budgell273} systematic review of recommendations for peri-operative care in head and neck cancer surgery with free-flap reconstruction identified 17 topic areas, and reported their evidence levels. Ten of these topic areas are applicable to all head and neck cancer patients, and are supported by other research.^{Reference Worrall, Tanella, DeMaria and Miles277} It is for this reason that they are included in this guideline.

Whilst there are acknowledged limitations in the current literature, findings from the most recent studies are encouraging;^{Reference Dort, Farwell, Findlay, Huber, Kerr and Shea-Budgell273,Reference Worrall, Tanella, DeMaria and Miles277} and it must be recognised that the concept of enhanced recovery after surgery has potential to positively influence head and neck cancer patient outcomes and service provision.^{Reference Watson and Ewers267} For this to be achieved, audit cycles of changes in clinical practice should be conducted in all head and neck cancer services adopting enhanced recovery after surgery protocols in the UK.

As we know, there are a wide range of head and neck cancer surgical procedures offered to patients in the UK, ranging from ‘minor’ to ‘major’ surgery. Some enhanced recovery after surgery principles may vary depending on the extent of surgery (e.g. timing of re-commencing oral intake); however, the general principles of enhanced recovery after surgery should be applicable to all head and neck cancer surgery patients, irrespective of their surgery.

Therefore, the following recommendations are generalised to all head and neck cancer patients undergoing surgical procedures, pre-treatment, during treatment and post-treatment care. These guidelines have been developed based on critical literature appraisal, expert consensus and PPI involvement. It is recommended that they be used as a model for clinical services and applied to patients on an individualised basis. We recommend referring to the speech and language therapy chapter for more specific recommendations on laryngectomy, if required.

Pre-treatment

The recommendations are summarised in Table 5.

Table 5. Pre-treatment recommendations for enhanced recovery

* See chapter on nutritional management of head and neck cancer for further information. ^†An anaesthetist who specialises in the management of difficult airways. SLT = speech and language therapy; pre-op = pre-operative; COPD = chronic obstructive pulmonary disease; ERAS+ = enhanced recovery after surgery plus; intra-op = intra-operative; post-op = post-operative

During treatment

The recommendations are summarised in Table 6.

Table 6. Intra-treatment recommendations for enhanced recovery

* Indicates the use of more than one modality to control pain. Intra-op = intra-operative; VTE = venous thromboembolism; peri-op = peri-operative; H&N = head and neck; post-op = post-operative

Post-treatment

The recommendations are summarised in Table 7.

Table 7. Post-treatment recommendations for enhanced recovery

post-op = post-operative; SLT = speech and language therapy; UTI = urinary tract infection

Research

The evidence base for both prehabilitation and enhanced recovery after surgery in head and neck cancer is emerging, with promising outcomes. In addition, trials that aim to investigate the effectiveness of prehabilitation within the head and neck cancer population are underway.²⁷⁸

However, there is a continuing need for high-quality studies with replicable methods and statistical analysis. This will support the implementation and evaluation of evidence-based standardised prehabilitation programmes and peri-operative enhanced recovery after surgery pathways for head and neck cancer patients. This is reinforced by a number of National Cancer Research Institute (‘NCRI’) key research priorities.²⁷⁹

In order to evaluate the effectiveness of developed programmes or pathways, there are key research questions and areas that should be addressed in future studies:

• • Patient-reported outcomes or experiences are not currently routinely represented in enhanced recovery after surgery literature. These should be explored in both prehabilitation and enhanced recovery after surgery services, and outcomes should be incorporated into any future pathway development to measure outcomes, ensuring the patient report and experience are at the core

• • Clinician-reported experiences are not currently represented in the literature. Future work should explore this, as a deeper understanding of clinician perspectives could benefit implementation through increasing compliance with enhanced recovery after surgery pathways

• • There should be understanding of cost-effectiveness and workforce provision of prehabilitation and enhanced recovery after surgery interventions, to support services in providing prehabilitation and enhanced recovery after surgery

• • Facilitator and barriers to the integration of prehabilitation with enhanced recovery after surgery programmes should be investigated

• • Prehabilitation that includes patients undergoing primary (chemo)radiotherapy treatment should be explored

• • Comprehensive multimodal prehabilitation trials should be conducted, which include a combination of nutrition, exercise, behaviour and/or swallowing interventions

• • The impact of delaying treatment to enable prehabilitation should be assessed

• • The impact of including peer, caregiver and family support within prehabilitation and enhanced recovery after surgery programmes should be evaluated

Future research into both prehabilitation and enhanced recovery after surgery must demonstrate quality improvement, efficiency and embed patient-reported outcomes. This will enable prehabilitation and enhanced recovery after surgery models to become the standard of care, and allow thorough evaluation of the services offered to head and neck cancer patients in the UK. This also supports a number of National Cancer Research Institute key research priority questions, including: (1) How can the short-term, long-term and late effects of cancer treatments be (a) prevented, and/or (b) best treated and managed?; and (2) What specific lifestyle changes (e.g. diet, exercise and stress reduction) help with recovery from treatment, restore health and improve QoL?

Future aspects of prehabilitation and enhanced recovery after surgery

Prehabilitation and enhanced recovery after surgery programmes have the potential to benefit long-term patient outcomes and experience, as well as cost-effectiveness of clinical services. Participants of the Greater Manchester Prehab4Cancer and recovery programme^{Reference Moore, Scoggins, Philips, Egger, Tennant and Little259} provided clear positive feedback around being able to ‘take back control’ of their cancer journey. Many patients anecdotally felt stronger than the cohort of patients with similar conditions who did not take part. One patient said, ‘I was out of bed faster than everyone on my ward’. They were unanimous about the positive mental benefits of the exercise programme. Engagement with personal trainers was critically important, as well as feeling part of a group within an environment in which they could participate and share experiences with other patients. The group universally would recommend an exercise dose as part of their cancer journey, and felt this should be offered to all relevant cancer patients. This should be considered in future aspects of both prehabilitation and enhanced recovery after surgery services.

Head and neck cancer services in the UK will need to be expanded to achieve optimum prehabilitation and enhanced recovery after surgery services. These services should have interdisciplinary working at their core, so that the optimum patient outcome is achieved. This recommendation is echoed by feedback (from a head and neck cancer PPI group), with one person saying: ‘I think setting bespoke individual goals is an excellent idea if constructed in an achievable way. I like goals, things to aim for but emphasis must be on the positive’.

Therefore, both prehabilitation and enhanced recovery after surgery services should have access to:

• • Community well-being and leisure services that support engagement in exercise

• • Patient and public involvement groups

• • Digital healthcare technology

• • Social prescribing and other primary care personalised care initiatives

• • Third sector provision such as Macmillan and Maggie's charities, for information and support

Key points

• • Specialist dietitians should be part of head and neck cancer multidisciplinary teams (MDTs) throughout patients’ continuum of care.

• • Clear pathways between primary, secondary and tertiary care across organisational boundaries should be maintained, reviewed and monitored to ensure seamless delivery of dietetic support.

• • Patients with head and neck cancer are at a high risk of malnutrition because of the impact of disease and subsequent treatment.

• • At diagnosis, all patients should be screened for malnutrition using validated tools, e.g. Malnutrition Universal Screening Tool (‘MUST’). Any patient at risk of malnutrition, or likely to become malnourished as a result of treatment should be referred to a dietitian for early intervention, and assessed for malnutrition using validated tools, e.g. Patient-Generated Subjective Global Assessment (‘PG-SGA’). Malnutrition screening and assessment should be repeated at various intervals throughout patients’ continuum of care.

• • All patients should receive a pre-treatment appointment prior to any treatment that is expected to impact on the ability to maintain nutritional status. This should include counselling on enteral tube feeding options, where appropriate.

• • Nutritional requirements can be estimated using evidence-based equations; however, patients’ anthropometry and tolerance of nutrition support should be monitored to ensure adequacy of intake.

• • Prophylactic gastrostomy placement should be considered on an individualised basis, where the MDT should take account of the following: performance status and social factors, baseline nutritional status, tumour stage, tumour site, pre-existing dysphagia, and impact of planned treatment.

• • Patients having nasogastric tubes in the community should all have a nasogastric tube risk assessment completed.

• • All patients undergoing a surgical intervention should be provided with carbohydrate loading and have tube feeding initiated within 24 hours of surgery (where oral intake is contraindicated) as part of enhanced recovery after surgery protocols.

• • All patients at severe nutritional risk, who are not meeting nutritional requirements, should receive nutrition support for 10–14 days prior to surgery. Delaying surgery to achieve this may be necessary but has to be weighed against the risk of delaying treatment.

• • All patients undergoing radiotherapy should receive a dietetic review at least once weekly during treatment, fortnightly for six weeks after treatment, and as appropriate thereafter for up to a minimum of three to six months.

• • Dietitians can become advanced clinical practitioners and extend their scope of practice within their MDTs. This includes becoming non-medical supplementary prescribers with appropriate supervision in place from MDT members.

• • All patients having palliative treatment should have access to a dietitian. The advantages and disadvantages of nutrition support and/or artificial feeding should be discussed with the MDT based on a goal of maintaining patients’ quality of life.

• • Patients who have completed rehabilitation and are no longer at risk of malnutrition should be offered cancer prevention and healthy eating advice. Where appropriate, this should include encouraging physical activity as per national recommendations.

• • Dietitians should offer telehealth appointments where appropriate to support service flexibility.

• • Dietetic provision in proton beam therapy services should mirror existing intensity-modulated radiation therapy services.

Head and neck cancer dietetic service provision and delivery

Nutritional intervention and support is integral in the management of head and neck cancer patients. It is estimated that 35–75 per cent of patients present malnourished at diagnosis.^{Reference Ravasco, Monteiro-Grillo, Marques Vidal and Camilo280,Reference Hébuterne, Lemarié, Michallet, de Montreuil, Schneider and Goldwasser281} In addition, the obesity epidemic has led to more patients presenting as overweight or obese at diagnosis, and recent research suggests that these individuals have increased rates of malnutrition and sarcopenia during treatment.^{Reference Brown, Ross, Jones, Hughes and Banks282}

Dietetic services within head and neck cancer units should be seamless, and ensure access at each stage of the patient pathway from diagnosis to survivorship and/or palliation. As part of the National Health Service (NHS) ‘Long Term Plan’, ‘Cancer Plan’ and ‘Cancer Reform Strategy’, head and neck cancer services in the UK have been restructured to facilitate the centralisation of services, MDT unification and the streamlining of surgical treatments at tertiary centres.²⁸³ Dietitians are key stakeholders in ensuring that the process of centralisation allows access to adequate nutritional screening, support and intervention, to optimise patients’ experience and outcomes (Table 1). Furthermore, it is integral that pathways are maintained and reviewed, to ensure continuity of care between primary, secondary and tertiary facilities across organisational boundaries in order to prevent fragmented service delivery.^{Reference Melnychuk, Vindrola-Padros, Aitchison, Clarke, Fulop and Levermore284}

Table 1. Recommendations for dietetic provision in head and neck cancer services

HNC = head and neck cancer; MDT = multidisciplinary team

The British Association of Head and Neck Oncologists recommend that all head and neck cancer units have a specialist dietitian with at least 50 per cent of their time dedicated to head and neck cancer.^{Reference Schache, Kerawala, Ahmed, Brennan, Cook and Garrett71} Early, frequent dietetic counselling is associated with improvements in nutrition, patient-centred outcomes, quality of life, compliance and tolerance to treatment (Table 1).^{Reference Ho, Yeh, Hsueh, Hung, Lu and Tsang285}

Malnutrition and body composition screening

Emerging research highlights the importance of body composition on identifying malnutrition, sarcopenia and/or cachexia. These can affect treatment outcomes, hence should be taken into consideration by the MDT when planning treatment.^{Reference Findlay, Brown, De Abreu Lourenço, White and Bauer286}

Malnutrition within cancer is the negative energy balance and skeletal muscle loss driven by a combination of reduced food intake and metabolic derangements. It is adversely associated with survival, morbidity, mortality, quality of life and treatment response, impacting on clinical outcomes, cost and patient experience.^{Reference Muscaritoli, Arends, Bachmann, Baracos, Barthelemy and Bertz287} Table 2 depicts how malnutrition can be generally identified, and the consequences, but it is important that screening and assessment for this is undertaken. Patients with head and neck cancer are at risk of malnutrition because of the site of their cancer, the impact of the disease process and treatment, and lifestyle factors.^{288,Reference Müller-Richter, Betz, Hartmann and Brands289} More recently, it has been reported that patients who are overweight or obese at baseline are at higher risk of becoming malnourished during and after head and neck cancer treatments.^{Reference Brown, Ross, Jones, Hughes and Banks282}

Table 2. Identification and consequences of malnutrition

BMI = body mass index

Unintentional weight loss (independent of presenting body mass index) of 10 per cent or more in the six months preceding diagnosis^{288,Reference Gourin, Couch and Johnson290} can lead to the adverse effects detailed in Table 2.^{Reference Müller-Richter, Betz, Hartmann and Brands289–Reference Cederholm, Jensen, Correia, Gonzalez, Fukushima and Higashiguchi291}

Cancer cachexia is difficult to diagnose as it is multifactorial in nature. It is characterised by the loss of weight, skeletal muscle and adipose tissue, alongside an imbalance of metabolic regulation and reduced food intake. It negatively affects treatment outcomes and quality of life. Management is difficult in light of limited agreed treatment options. Evidence to support pharmacological treatments remains inconclusive. Improvement has been reported with fish oil supplements; however, palatability limits compliance.^{Reference Ni and Zhang292}

Sarcopenia can be defined by the combination of low grip strength plus low muscle mass.^{Reference Cruz-Jentoft, Baeyens, Bauer, Boirie, Cederholm and Landi293} Sarcopenia and myosteatosis (infiltration of muscle with fat) can be significant negative predictors of overall survival, and muscle status evaluation should be considered during treatment planning.^{Reference Findlay, Brown, De Abreu Lourenço, White and Bauer286} Methods for identifying sarcopenia include the Strength, Assistance with walking, Rising from a chair, Climbing stairs and Falls (‘SARC-F’) questionnaire, computed tomography (CT) defined assessment, anthropometry, and bioelectrical impedance. Treatment for sarcopenia requires a combined approach, including physical activity and nutrition support, which should be offered as part of a prehabilitation programme (see ‘Patient preparation for treatment and enhanced recovery’ chapter for further information).

Screening and assessment

Malnutrition screening tools are used to identify patients promptly who are at risk of malnutrition and require further dietetic intervention, and should be used throughout the patient's pathway. Subsequently, malnutrition assessment tools can be used to diagnose malnutrition.^{Reference Muscaritoli, Arends, Bachmann, Baracos, Barthelemy and Bertz287,Reference Mendes, Barros, Rosa and Franceschini294} Some examples are illustrated in Table 3.^{Reference Muscaritoli, Arends, Bachmann, Baracos, Barthelemy and Bertz287} Several of these tools have been validated, but this may differ for various parameters including age and clinical settings. The most highly recommended assessment tool is the Patient-Generated Subjective Global Assessment. Screening should be agreed locally using a validated screening tool for the patient population. Following this, any patient identified at risk of malnutrition should be referred to a dietitian for full nutritional assessment (detailed in Table 4) using a validated nutritional assessment tool.

Table 3. Malnutrition screening and assessment tools^{Reference Muscaritoli, Arends, Bachmann, Baracos, Barthelemy and Bertz287}

MNA-SF = Mini Nutritional Assessment Short-Form; PG-SGA = Patient-Generated Subjective Global Assessment; HNC = head and neck cancer; NIS = nutritional impact symptoms

Table 4. Nutritional screening and assessment recommendations

HNC = head and neck cancer; MUST = Malnutrition Universal Screening Tool; PG-SGA = Patient-Generated Subjective Global Assessment

Patients who are malnourished, or at risk of malnutrition, may be identified by various members of the MDT, and should be referred to the dietitian for assessment. Dietitians should attend MDT meetings and MDT head and neck cancer clinics to support rapid referral (Table 5).

Table 5. MDT and combined head and neck clinic recommendations

MDT = multidisciplinary team; HNC = head and neck cancer; SLT = speech and language therapist

Nutrition support

Interventions can have a profound impact on the ability to eat and drink or take adequate nutrition orally, related to loss of function and treatment side effects such as nausea, vomiting, xerostomia, pain, mucositis and dysphagia.

Pre-treatment

All patients scheduled to undergo treatment that is likely to impact on nutritional status should be offered a dietetic pre-treatment appointment in order to assess baseline nutritional status, and provide dietary intervention as appropriate to maintain nutritional status and prevent decline (Table 6).^{Reference Findlay, Rankin, Shaw, White, Boyer and Milross295,Reference Talwar and Findlay296} The British Dietetic Association care pathway (Table 7) should be used to collect relevant baseline information alongside a malnutrition assessment tool.²⁹⁷

Table 6. Pre-treatment assessment recommendations

HNC = head and neck cancer; SLT = speech and language therapist; MDT = multidisciplinary team; NG = nasogastric

Table 7. Nutritional assessment and dietetic care pathway recommendations²⁹⁷

*Denotes ideal body weight. ^†Denotes body mass index (BMI) of 18.5–30 kg/m². ^‡Denotes BMI of 18.5–30 kg/m². Adjust for obesity (use 75 per cent value for BMI over 30 kg/m²; 65% value for BMI over 50 kg/m²; start at upper end of range for BMI less than 18.5 kg/m² and monitor regularly). BMI = body mass index; HNC = head and neck cancer; MDT = multidisciplinary team; SLT = speech and language therapy; ESPEN = European Society for Parenteral and Enteral Nutrition; BDA = British Dietetic Association

The appointment should also provide counselling to assist informed decision-making and manage expectations on the impact of upcoming treatment on nutritional status. This includes possible changes to dietary textures, the requirement for enteral tube feeding in the short and long term, and side effects of treatments affecting the ability to take nutrition.^{Reference Parr, Johnson, Langley and Richardson298}

Refeeding syndrome

Refeeding syndrome consists of metabolic disturbances that occur as a result of the reintroduction of nutrition (namely carbohydrates) to patients who are severely malnourished. Head and neck cancer patients may be at a high risk of refeeding syndrome, and it can occur irrespective of nutrition route.^{Reference da Silva, Seres, Sabino, Adams, Berdahl and Citty303}

Refeeding syndrome is characterised by hypophosphataemia, hypokalaemia and hypomagnesaemia, as well as abnormal sodium and fluid balance, changes in glucose, protein and fat metabolism, and thiamine deficiency.^{Reference Todorovic and Mafrici302,Reference da Silva, Seres, Sabino, Adams, Berdahl and Citty303}

Management for refeeding syndrome includes the gradual reintroduction of nutrition, supplementation of thiamine/B vitamins, and monitoring, with or without replacement of electrolytes. Latest guidance from the American Society of Parenteral and Enteral Nutrition (‘ASPEN’) have been included (Tables 8 and 9), but clinicians should also be guided by locally agreed policies for identification, avoidance and management. Identification and management will differ for paediatric patients; guidance is available from the American Society of Parenteral and Enteral Nutrition.^{Reference da Silva, Seres, Sabino, Adams, Berdahl and Citty303}

Table 8. Refeeding syndrome identification for adults*

* American Society of Parenteral and Enteral Nutrition (‘ASPEN’) consensus criteria for identifying adult patients at risk for refeeding syndrome, adapted and reproduced with permission.^{Reference da Silva, Seres, Sabino, Adams, Berdahl and Citty303 †}Please note electrolytes may be normal despite total body deficiency, which is believed to increase the risk of refeeding syndrome. ^‡These include: acquired immunodeficiency syndrome; chronic alcohol or drug use disorder; dysphagia and oesophageal dysmotility (e.g. eosinophilic oesophagitis, achalasia, gastric dysmotility); eating disorders (e.g. anorexia nervosa); food insecurity and homelessness; failure to thrive, including physical and sexual abuse and victims of neglect (particularly children); hyperemesis gravidarum or protracted vomiting; major stressors or surgery without nutrition for prolonged periods of time; malabsorptive states (e.g. short-bowel syndrome, Crohn's disease, cystic fibrosis, pyloric stenosis, maldigestion, pancreatic insufficiency); cancer; advanced neurological impairment or general inability to communicate needs; post-bariatric surgery; post-operative patients with complications; prolonged fasting (e.g. individuals on hunger strikes, anorexia nervosa); refugees; protein malnourishment. BMI = body mass index

Table 9. Refeeding syndrome management for adults*

*American Society of Parenteral and Enteral Nutrition (‘ASPEN’) consensus recommendations for avoidance and treatment of refeeding syndrome in at-risk adults, adapted and reproduced with permission.^{Reference da Silva, Seres, Sabino, Adams, Berdahl and Citty303 †}Management will depend on local refeeding syndrome guidelines and policies; thus, these recommendations should be used as a general guide only. IV = intravenous

Nutrition support

Nutrition support should be considered where malnutrition is diagnosed following screening and assessment, to optimise nutritional status. There are three main methods of nutrition support: oral, enteral and parenteral. Parenteral nutrition is rarely used in head and neck cancer, but should be considered if clinically indicated e.g. chyle leak, post-operative ileus, no enteral access route.

Oral nutrition support

Oral nutritional support aims to address deficiencies and minimise further nutritional compromise. Nourishing dietary advice including food-first fortification should be recommended, but may not meet the nutritional deficit alone because of the impact of disease and treatment. In order to meet these deficits, more intensive support such as nutritionally complete oral nutritional supplements can also be prescribed. There are a wide variety of products available, and choice will depend on patient preference, compliance and local policy.

Enteral nutrition

Enteral feeding is often required to support patients in meeting their nutritional requirements, to prevent weight loss, and to maintain good nutritional status on a short- and long-term basis. Enteral feeding tubes include the nasogastric tube, nasojejunal tube, orogastric tube, oesophageal-fistulae tube, gastrostomy tube (with or without jejunal extension) and jejunostomy tube. The type of tube placed should account for tumour type and size, treatment plan, anticipated length of enteral feeding, and patient choice, with patients being included in the decision-making process.^{Reference Williams, White, Sen and Prestwich304}

The most common approaches for head and neck cancer patients with tube feeding in the community are prophylactic gastrostomies and reactive nasogastric tubes. The impact of tube type and timing in head and neck cancer is controversial, leading to variation in practice. Controversy exists because of a lack of consensus on whether a prophylactic or reactive approach leads to improved patient outcomes.

Prophylactic approaches mainly consist of gastrostomy placement prior to head and neck cancer treatment where it is likely that enteral feeding will be required for a long-term period. ‘Long-term’ is not always well defined; within the UK, the National Institute for Health and Care Excellence (NICE) suggests gastrostomy tubes should be considered when enteral feeding is required for more than four weeks.²⁸⁸ The advantages of prophylactic gastrostomy include improved nutritional outcomes and quality of life, in addition to reduced incidences of malnourished patients, hospital admissions or treatment interruptions when compared with reactive feeding approaches.^{Reference Brown, Banks, Hughes, Lin, Kenny and Bauer305} The disadvantages include the risk that some tubes are not used,^{Reference Madhoun306} but patient compliance and appropriateness of decision-making for tube placement in such studies are unclear. Furthermore, it has been argued that prophylactic gastrostomies lead to poorer swallowing outcomes related to prolonged tube use. These conclusions are limited because of a lack of high-quality studies including a nutritional outcome analysis. Recent studies have not shown a relationship between long-term swallowing dysfunction and prophylactic gastrostomy.^{Reference Axelsson, Silander, Nyman, Bove, Johansson and Hammerlid307}

Gastrostomy placement is generally considered a safe procedure, but can result in complications; however, major complications are rare. Placement can be endoscopic, radiological or surgical, and no nationally agreed selection criterion on placement method currently exists. All patients should be screened and assessed for suitability and optimal method, accounting for local resources and policy. Endoscopic placement is generally associated with fewer complications compared to radiological gastrostomy; however, the former may be contraindicated in head and neck cancer (e.g. tumour location, trismus), and gastrotomy tubes are often retained by an internal bumper which requires endoscopic removal.^{Reference Strijbos, Keszthelyi, Bogie, Gilissen, Lacko and Hoeijmakers308} Radiologically placed tubes are usually retained with a balloon filled with water, which can be deflated and removed at bedside. This is advantageous for enabling prompt removal, but corresponds with an increased risk of unintentional tube dislodgement.

Reactive approaches involve the placement of a gastrostomy or nasogastric tube during or after treatment. Advantages of this approach include avoidance of: the risk of placing a tube that may not be used and gastrostomy-related complications. Nasogastric tubes have the advantage of being quick to insert and remove, and thus may remain in place for less time than a gastrostomy tube. Dietitians can be trained to become competent with tube insertions, to streamline services. Disadvantages of this approach include tube visibility, dislodgement, discomfort, fear or worry of tube displacement, pharyngeal irritation, and the public reaction, which has been reported negatively by service users.^{Reference Williams, White, Sen and Prestwich304} In addition, complications associated with tube management in the community are not well documented (e.g. tube displacement requiring emergency department attendance, with or without tube replacement and chest X-ray).

In the UK, the discharge of patients with a nasogastric tube from the acute to community setting is not always permitted by some NHS trusts because of the potential risk of feeding into the lungs causing a ‘never event’. This has resulted in many district nursing services refusing to support patients with nasogastric tubes in the community, but continuing to provide support for gastrostomy tubes. Therefore, patients who require a nasogastric tube at home are often expected to self-manage or have family support. This can complicate discharge planning, thus early identification is crucial. The NHS requires all patients discharged with a nasogastric tube to have an MDT-supported nasogastric tube risk assessment completed, and a care plan in place to assess suitability and mitigate any risks.³⁰⁹ Success with prolonged nasogastric tube use (more than 28 days) in the community has been reported,^{Reference Espeli, Vergotte, Dietrich, Pichard and Siano310} with some units developing out-patient nasogastric tube services, which is advantageous in reducing in-patient admissions.^{Reference McCloskey, Duffy, Brown, Irwin and Faloon311} These factors highlight the importance of dietetic pre-treatment appointments to aid informed decision-making on feeding options, accounting for individualised needs and preference at the point of diagnosis.^{Reference Hazzard, Gulliver, Walton, McMahon, Milosavljevic and Tapsell312}

In summary, the evidence base remains inconclusive, with insufficient evidence to suggest an optimal feeding route.^{Reference Hazzard, Gulliver, Walton, McMahon, Milosavljevic and Tapsell312–Reference McClelland, Andrews, Chaudhry, Teckie and Goenka314} Guidelines have been developed based on predictors of prolonged tube use to aid clinicians with appropriate decision-making for placing prophylactic gastrostomy tubes. These include overall clinical stage, tumour site, clinical tumour (T) and nodal (N) stage, and patient age.^{Reference Brown, Spurgin, Ross, Tripcony, Keller and Hughes315,Reference Brown, Getliffe, Banks, Hughes, Lin and Kenny316} The NICE guidelines suggest individualised multidisciplinary decision-making at diagnosis, accounting for predictors as detailed in Table 10.³¹⁷

Table 10. Gastrostomy selection criteria in head and neck cancer*

* Adapted from National Institute for Health and Care Excellence with permission.³¹⁷ MDT = multidisciplinary team; BMI = body mass index

There are a wide variety of enteral nutrition products available, and the volume and type will depend upon the patient's requirements, tolerance and local contractual agreements.²⁸⁸

Monitoring nutrition support

The monitoring of enteral feeding regimens is essential given issues of: potential inaccuracies of nutritional requirement equations, compliance, and tolerance. Dietitians should be informed by any member of the MDT if signs of intolerance are reported, to ensure an optimal regimen is in place, and adjustments made accordingly.

On treatment

Chyle leaks

If a chyle leak is suspected, it can be confirmed by testing for triglycerides and chylomicrons. Nutritional interventions (Table 11) are often used alongside medical options, such as somatostatin analogues, pressure dressings and suction drainage. (Further information can be found in the ‘Complications of treatment’ chapter.)

Table 11. Nutritional management recommendations for surgery, including suspected and confirmed chyle leak cases

ERAS = enhanced recovery after surgery; HNC = head and neck cancer; H&N = head and neck; MDT = multidisciplinary team; SLT = speech and language therapists

Radiotherapy

Dietary counselling during radiotherapy for head and neck cancer patients with nutrition support is recommended to manage treatment-induced toxicities (e.g. mucositis, pain, increased secretions, odynophagia, dysphagia), to prevent weight loss (Table 12). Significant weight loss (more than 10 per cent) cannot be completely prevented by nutritional counselling and intervention alone,^{Reference Weimann, Braga, Harsanyi, Laviano, Ljungqvist and Soeters301} and can lead to re-planning of radiotherapy fields and interruptions in treatment. Patients should be reviewed by a dietitian at least once a week during radiotherapy, and some centres offer twice-weekly review.

Table 12. Recommendations for management during radiotherapy

SLT = speech and language therapist; NG = nasogastric; MDT = multidisciplinary team; HNC = head and neck cancer; PPI = proton pump inhibitor

Patients should be encouraged with optimising the nutrition and tolerance of oral diet for as long as safely possible during radiotherapy, in conjunction with speech and language therapy advice. Enteral feeding should be considered if treatment impacts on swallowing and the ability to meet full nutritional requirements orally for weight maintenance. The timing and type of enteral feeding is controversial (discussed in the ‘enteral feeding’ section). The choice of tube should be MDT led, and should account for local resources, patient preference and high-risk factors of prolonged tube use (oral plus bilateral chemoradiotherapy, midline oropharyngeal/nasopharyngeal/pharyngeal plus chemoradiotherapy, dysphagia and/or severe malnutrition at presentation).³¹⁷ Patients should be counselled on an individualised basis, with the risks and benefits of both reactive and prophylactic approaches discussed before treatment.

Post-treatment care

All head and neck cancer patients should be reviewed in the first three months post radiotherapy or major surgery to prevent decline in nutritional status, and thereafter on an individual basis. The goal of dietetic input post treatment is to reduce reliance on enteral feeding and/or nutritional supplements if possible, whilst assisting a return to healthy eating, accounting for possible chronic changes, e.g. texture modification (Table 13). It should be noted that patients’ experiences after treatment will vary greatly, with some returning to pre-treatment function rapidly and others needing long-term input.

Table 13. Post-treatment care recommendations

SLT = speech and language therapist/therapy; QoL = quality of life; PINNT = Patients on Intravenous & Nasogastric Nutrition Therapy

Head and neck cancer patients can experience treatment-related side effects in the short and long term that may impact quality of life and functional status. These include xerostomia, dysphagia, trismus, dental problems, difficulty chewing, taste alterations and mucositis.^{Reference Brook323} Patients may need ongoing nutrition support to manage these symptoms, and weight loss has been shown to continue for up to a year post treatment.^{Reference Vlooswijk, van Rooij, Kruize, Schuring, Al-Mamgani and de Roos324}

Late effects of treatment such as progressive dysphagia, pharyngoesophageal stenosis and osteoradionecrosis can lead to ongoing poor nutritional intake, and food avoidance may lead to vitamin and mineral deficiencies.^{Reference Crowder, Douglas, Yanina Pepino, Sarma and Arthur325,Reference Crowder, Najam, Sarma, Fiese and Arthur326} This may necessitate further dietetic input, and nutrition screening should continue in order to identify these patients if they have been previously discharged from dietetics.^{Reference Vlooswijk, van Rooij, Kruize, Schuring, Al-Mamgani and de Roos324}

In the absence of disease recurrence or late effects, cancer survivors who are no longer at risk of malnutrition should be offered healthy eating and physical activity advice, to prevent long-term morbidity. This should be tailored on an individualised basis given the complexity of head and neck cancer.^{Reference Muscaritoli, Arends, Bachmann, Baracos, Barthelemy and Bertz287}

Palliative care

Patients may be offered palliative chemotherapy, radiotherapy or immunotherapy to reduce symptoms caused by cancer. Patients should be nutritionally assessed early in this pathway, and the aim of nutritional interventions should be to maintain quality of life and reduce the symptoms, with early anticipation of any deterioration (Table 14). Dietitians should discuss the advantages and disadvantages of artificial feeding with patients and their family, as nutrition is likely to be affected by treatment and disease progression.

Table 14. Palliative care management recommendations

QoL = quality of life; MDT = multidisciplinary team

Palliative care patients can develop symptoms as a result of the tumour, and may also be suffering from the long-term side effects of previous cancer treatment.^{Reference Goldstein, Genden and Morrison327} Dietitians should work collaboratively with other MDT members to ensure that informed decisions are made regarding palliative and end-of-life care, including the appropriateness of commencing artificial feeding and/or gastrostomy tube placement within the context of risk, benefit and prognosis.^{Reference Sciubba328} Further information is discussed in the palliative care chapter.

Future aspects and important research questions

Extended scope of practice

There is opportunity for dietitians to become advanced clinical practitioners and extend their scope of practice within their MDTs (Table 15). Some options include post-graduate training for non-medical supplementary prescribing, assisting with enteral tube placement and care, and prehabilitation. The agreed scope of practice should be documented formally within job plans, with a clear framework, mentorship and supervision in place.

Table 15. Future considerations for dietitians working in head and neck cancer services

PBT = proton beam therapy; IMRT = intensity-modulated radiation therapy; SGA = Subjective Global Assessment; PG-SGA = Patient-Generated Subjective Global Assessment; MDT = multidisciplinary team

Non-medical supplementary prescribing may include reviewing symptoms of acute radiotherapy toxicity, alongside their impact on nutritional intake, and prescribing medication where appropriate. This aims to alleviate side effects within the agreed patient clinical management plan, whilst liaising closely with the medical team.³³⁴

Key points

• • Patients with speech, voice or swallowing dysfunction should be identified, assessed, and offered rehabilitation by a speech and language therapist with specialist skills.

• • All multidisciplinary teams (MDTs) should have rehabilitation patient pathways covering all stages of the patient's journey, including multidisciplinary and pre-treatment clinics, with clear mechanisms for re-entry.

• • Rehabilitation needs to begin early in the care pathway, involving comprehensive evaluation and tailored evidence-based interventions, from pre-treatment and including end-of-life care.

• • Instrumental evaluation is integral to assessment and rehabilitation pathways given the complex relationships between function and altered anatomy and pathophysiology in head and neck cancer patients.

• • Services should strive for robust collection of functional outcome measures at specified time points to incorporate clinician-rated and patient-reported tools.

• • Healthcare professionals need to remain vigilant for signs of late treatment effects where the downward trajectory of speech, voice and swallowing function, and airway compromise pose complex challenges and involve careful MDT management.

• • Although speech and language therapists hold a key role, MDT discussion is essential to attain optimal patient outcomes. This may involve collaboration with other healthcare professionals, as appropriate, to optimise care, e.g. oral hygiene and laryngectomy stoma care.

• • The support of carers is an important part of the speech and language therapist's role when gathering and delivering information, developing a tailored rehabilitation package, and/or guiding patients in a decision-making process.

• • Patient involvement in decision-making is crucial, with high importance being attributed to functional outcomes when weighing up treatment and management options. Speech and language therapists engage in eliciting patient priorities and values, and give realistic information about alterations to function and the impact on daily living and health.

• • Speech and language therapists are involved in generating and contributing towards research and audit for improved patient outcomes and service delivery.

• • Clear pathways for access and re-referral to speech and language therapists need to be in place, with excellent communication between central and locality-based services with a robust training and supervision programme for specialist knowledge and skill development and maintenance.

Pre-treatment

The majority of individuals undertaking head and neck cancer treatment are likely to experience some level of difficulty or alteration to their swallowing and/or communication during their cancer care journey, with as many as 60 per cent presenting with problems at diagnosis.^{Reference Russi, Corvò, Merlotti, Alterio, Franco and Pergolizzi344} The impact of oncological interventions on function and the likely trajectory of recovery can reasonably be predicted,^{Reference Patterson, McColl, Carding, Hildreth, Kelly and Wilson345,Reference Robbins, Levine, Wood, Roecker and Luschei346} which therefore offers an opportunity for early intervention. A pre-treatment consultation should thus include informational counselling about the upcoming cancer treatment, and about the impact on swallowing and communication, and, where indicated, could provide a window for prehabilitation that may include prophylactic swallowing exercises (Table 1).^{Reference Govender, Smith, Barratt, Gardner and Taylor347}

Table 1. Recommendations for MDT meetings and combined head and neck clinic

MDT = multidisciplinary team; SLT = speech and language therapist; HNC = head and neck cancer

Early post-operative phase

Surgery results in loss of tissue, with changes to the anatomy and structural relationships. Post-operative voice, speech and swallowing impairments can change over time, with oedema and/or pain being more prevalent in the early post-operative period, and atrophy or scarring with a reduced range of motion being more common in the long term.^{Reference Patterson, Brady and Roe348} Surgery can also result in nerve damage, leading to motor and sensory deficits. The severity of voice, speech and swallowing impairment depends on factors such as tumour site, the volume resected and the nature of the reconstruction. The inevitable functional impairments coupled with aesthetic changes, in addition to activity limitations and participation restrictions, can have a profound psychological impact on the patient. Rehabilitation, including very early engagement and interaction, can be both healing and therapeutic for patients (Table 2).^{Reference Dawson, Pracy, Patterson and Paleri349}

Table 2. Recommendations for early post-operative management

MDT = multidisciplinary team; SLT = speech and language therapist; IDDSI = International Dysphagia Diet Standardisation Initiative

During radiotherapy

Painful and uncomfortable mucositis side effects, xerostomia, dysgeusia, and increased secretions are frequently experienced by patients during radiation treatment. There is an increasing body of evidence investigating strategies introduced before or during radiation treatment to reduce the incidence and severity of dysphagia.^{Reference Perry, Lee, Cotton and Kennedy350,Reference Greco, Simic, Ringash, Tomlinson, Inamoto and Martino351} Patients are encouraged to continue to eat and drink throughout radiotherapy, where safe, avoiding periods of nil by mouth status.^{Reference Patterson, Brady and Roe348} On-treatment rehabilitation is generally provided in an MDT setting to ensure that analgesia and mouth care are optimised, to allow ongoing oral intake and exercises as indicated (Table 3).^{Reference Starmer, Ayoub, Byward, Kizner, Le and Hara352–Reference Occomore and Knight354}

Table 3. Recommendations for management during radiotherapy

SLT = speech and language therapy/therapist; MDT = multidisciplinary team

Rehabilitation following head and neck cancer treatment

Rehabilitation of swallowing should aim to optimise oral intake, reduce reliance on enteral feeding and supplements, and facilitate psychosocial adjustment. Studies support the use of exercises to improve swallowing function.^{Reference Malandraki and Hutcheson355–Reference Van Daele, Langmore, Krisciunas, Lazarus, Pauloski and McCulloch358} Postures such a chin tuck and head rotation can be effective in controlling bolus flow, to reduce or eliminate aspiration.^{Reference Pauloski359} Manoeuvres including the super supraglottic swallow^{Reference Logemann, Pauloski, Rademaker and Colangelo360} and effortful swallow^{Reference Clark and Shelton361} can also be utilised to control specific aspects of the oropharyngeal swallow, improving function. The use of expiratory muscle strength training may improve airway protection in those with chronic radiation-induced aspiration.^{Reference Hutcheson, Hammer, Rosen, Jones and McCulloch362} Combining cognitive behavioural therapy with swallowing therapy has highlighted the importance of addressing the emotional, behavioural and cognitive components of dysphagia alongside the physical impairment.^{Reference Patterson, McColl, Carding and Wilson363}

Voice can be impaired by both radiotherapy and chemotherapy,^{Reference Radhakrishna, Yamini, Kadam, Shivashankar, Vishwanathan and Javarappa364,Reference Lazarus365} and by laser surgery.^{Reference Aaltonen, Rautiainen, Sellman, Saarilahti, Mäkitie and Rihkanen366} Phonatory changes as a result of head and neck cancer treatment may include reduced vocal intensity, impaired pitch, compromised breath support, as well as roughness, breathiness, hoarseness and vocal fatigue. Specific therapy techniques^{Reference Verdolini-Marston, Burke, Lessac, Glaze and Caldwell367,Reference Stemple, Lee, D'Amico and Pickup368} utilised with non-cancer patients may be considered to enable the patient to achieve the optimum voice quality.

Speech may be impaired as a result of surgical resection, or chemoradiotherapy side effects such as xerostomia and trismus. Intelligibility will largely be dependent on the site of the lesion, the extent of the resection and the flexibility of tissue. In some instances, referral for dental or prosthetic enhancement may optimise communication and/or swallowing function (Table 4).

Table 4. Recommendations for rehabilitation

Total laryngectomy

Laryngectomy surgery results in permanent anatomical and physiological changes that affect communication,^{Reference Sharpe, Camoes Costa, Doubé, Sita, McCarthy and Carding369} swallowing,^{Reference Coffey, Tolley, Howard, Drinnan and Hickson370,Reference Lee, Govender, Roy, Vaz and Hilari371} breathing,^{Reference Macri, Bogaardt, Parrilla, Minni, D'Alatri and de Vincentiis372} olfaction^{Reference Longobardi, Parrilla, Di Cintio, De Corso, Marenda and Mari373} and appearance.^{Reference van Sluis, Kornman, van der Molen, van den Brekel and Yaron374} Intervention from speech and language therapy is essential along each stage of the pathway, from diagnosis to long-term management, to support individuals in reaching and adjusting to their new optimum functional potential (Table 5).

Table 5. Recommendations for total laryngectomy

SLT = speech and language therapy; MDT = multidisciplinary team; HME = heat and moisture exchanger; FEES = fibre-optic endoscopic evaluation of swallowing; SVR = surgical voice restoration

Late treatment effects

Progressive functional deterioration following treatment for head and neck cancer needs careful MDT assessment and management. Where disease recurrence is excluded, these symptoms are likely to represent ‘late-stage’ treatment effects. The gradual and insidious development over a period of time can make early identification of patients challenging,^{Reference Patterson375} but healthcare professionals need to remain vigilant. Education of the wider MDT and community teams is key, so they are alert to ‘red flag’ symptoms like chest infections, dehydration, weight loss and airway difficulties.

Patients may report increased swallowing difficulty, weight loss, recurrent chest symptoms, as well as speech, voice and breathing changes.^{Reference Dong, Ridge, Li, Lango, Churilla and Bauman376,Reference Davies-Husband, Murphy, Kelly, Drinnan and Paleri377} The sequelae can be devastating on both physical and emotional well-being,^{Reference Hutcheson, Lewin, Barringer, Lisec, Gunn and Moore339,Reference Aylward, Abdelaziz, Hunt, Buchmann, Cannon and Lloyd378} as complex choices between airway, swallowing and voice functions can be required (Table 6).^{Reference Clunie, Kinshuck, Sandhu and Roe379}

Table 6. Recommendations for late effects of treatment

SLT = speech and language therapy

Palliative care

Patients with advanced incurable head and neck cancer have a high number and diverse range of complex symptoms. Difficulty eating and weight loss are some of the most frequently reported problems.^{Reference Cocks, Ah-See, Capel and Taylor380,Reference Mayland, Ho, Doughty, Rogers, Peddinti and Chada381} These symptoms can result in numerous hospital visits, which is particularly problematic with the centralisation of head and neck cancer services.

Early identification of functional changes is essential to providing high-quality and pre-emptive speech and language therapy services, with good communication between central and locality-based therapists and the wider palliative care team (Table 7).

Table 7. Recommendations for palliative care

SLT = speech and language therapy/therapist; HNC = head and neck cancer

Outcome measures

A combination of clinician- and patient-reported outcome measures should be collected at pre-determined time intervals. Systems should be developed to enable data to be collected, stored and protected in a robust manner. At a local level, data can be used for clinical purposes to: highlight rehabilitation needs for individuals; inform the MDT of functional outcomes post treatment; direct future service developments; and provide stakeholders with information regarding effectiveness. On a larger scale, quality data can identify trends in functional changes. This is especially relevant for new and emerging treatment regimens where gaps in understanding can be identified, providing direction for future research topics. Patient-reported outcome measures provide a subjective evaluation of symptom burden.^{Reference Schache, Kerawala, Ahmed, Brennan, Cook and Garrett71} Quality of life patient-reported outcome measures are integral to a complete dataset, and can be collected by any member of the head and neck cancer MDT (Table 8).^{Reference Hirano382–Reference Starmer, Drinnan, Bhabra, Watson and Patterson398}

Table 8. Recommendations for outcome measures

SLT = speech and language therapy; GRBAS scale = grade, roughness, breathiness, asthenia, strain scale; PSS-HN = Performance Status Scale for Head and Neck Cancer Patients; PROM = patient-reported outcome measure; MDADI = MD Anderson Dysphagia Inventory; TOMs = therapy outcome measures; DIGEST = Dynamic Imaging Grade of Swallowing Toxicity

Important research questions

Over the next few years, results from national and international trials will further our knowledge on whether alterations to treatment modalities – including intensity-modulated radiation therapy versus dysphagia optimised intensity-modulated radiation therapy,^{Reference Petkar, Bhide, Newbold, Harrington and Nutting399} de-escalation of post-operative adjuvant (chemo)radiotherapy for oropharyngeal cancer,^{Reference Owadally, Hurt, Timmins, Parsons, Townsend and Patterson400} intensity-modulated proton beam therapy^{Reference Price, Hall, West and Thomson125} – impact on swallowing outcomes. Secondary analysis of these data will inform our understanding of swallowing outcome measures. Findings may then be translated into treatment selection, improved shared decision-making tools and more accurate patient information.

Further work is indicated in the arena of speech and language therapy interventions, to include: exploration of novel technologies; investigation of specific time points, e.g. early post-operative and late effects of dysphagia; examination of defined populations, e.g. recurrent disease; and consideration of impairment, as well as the psychosocial sequelae of speech, voice and swallowing problems. It is also important to take a holistic view, being inclusive of the needs of carers. These interventions are defined as ‘complex’; specifically, they have a number of interacting components, require new behaviours by those receiving the intervention and can have a variety of outcomes (e.g. patient-reported outcomes, measurements of physiology). For this reason, it is imperative that we understand issues of take-up, adherence and retention, in conjunction with testing for effectiveness.

The context of coronavirus disease 2019 has bought many challenges in the delivery of speech and language therapy services and rehabilitation. In response to this, future research needs to address:^{Reference Patterson, Govender, Roe, Clunie, Murphy and Brady401}

• • Reliability and validity of non-invasive voice and swallowing screening and assessment tools, including those that can be conducted remotely

• • Collection of standardised outcome measures, utilising digital technologies where possible

Service delivery and models of care need evaluation and further development as to how we can best support patients, the workforce and the National Health Service as a whole. Examples of priorities include:

• • Provision of remote highly specialist care for our most vulnerable patients

• • Models of telehealth for ENT speech and language therapy services

• • Implementation of ENT speech and language therapist-led clinics and triaging

Key points

• • The evidence base is of low-quality or very low-quality evidence, based on underpowered trials that are of high risk of bias.

• • There is insufficient evidence to understand whether and how pre-operative rehabilitation should be provided to patients prior to neck dissection for head and neck cancer.

• • There is low-quality evidence to justify the role of physiotherapy during the in-patient stay, and uncertainty over what exercise prescription should be offered to patients following neck dissection. Given the heterogeneity in the clinical presentation and functional impairments of these individuals, each patient should be assessed for the potential for post-operative complications, and exercises should be prescribed, tailored to the individual, which aim to prevent complications, optimise range of motion and symptom management, and enhance function.

• • There is very low-quality evidence supporting the provision of exercises for people who undergo neck dissection following hospital discharge. There is uncertainty regarding what these exercises should be, but there is some promise that progressive resistance and strengthening exercises may offer benefit over simple range of motion exercises. There is evidence that out-patient physiotherapy may offer benefit over self-directed exercises, but this is based on underpowered trials.

• • Further evidence is required to understand what components of treatment are required for this population, and to determine when they should be offered.

• • There remains uncertainty as to whether some patients are at greater risk of poor outcome and would benefit more from physiotherapy. It is suggested that people who experience an intra-operative spinal accessory nerve injury may be at risk. Further evidence is required to determine whether this population should routinely be reviewed in out-patient physiotherapy, and explore whether certain patients are of lower risk of poor outcome and may be better managed through a self-directed approach.

Pre-operative physiotherapy and exercise prescription

No studies were identified that assessed the effectiveness of pre-operative physiotherapy interventions for people before neck dissection for head and neck cancer. This is a major limitation to the evidence base. Table 1 outlines the essential and desirable pre-operative physiotherapy and exercise recommendations, based solely on clinical recommendations and transferable evidence in other surgical specialties.

Table 1. Recommendations for pre-operative physiotherapy and exercise intervention

Based on other surgical specialties such as general surgery, there is moderate quality evidence that a multimodal prehabilitation intervention, including respiratory and whole-body exercises, education and advice, and psychological support, may be beneficial for patients in terms of reducing length of hospital stay (mean difference = 3.68 days; 95 per cent confidence interval (CI) = 0.92, 6.44).^{Reference Waterland, McCourt, Edbrooke, Granger, Ismail and Riedel416} There was moderate quality evidence that this may improve pre-operative functional capacity, as measured in terms of 6-minute walk test distance (mean difference = 33.09 metres; 95 per cent CI = 17.69, 48.50), but this may not necessarily translate into a reduced risk of post-operative complications (odds ratio = 0.81; 95 per cent CI = 0.55, 1.18) or post-operative mortality (odds ratio = 0.95; 95 per cent CI = 0.43, 2.09).^{Reference Waterland, McCourt, Edbrooke, Granger, Ismail and Riedel416}

Across the pre-operative (non-head and neck cancer) literature, there is evidence that pre-operative education is important for patients and their family members to prepare for surgery. This may concern shaping expectations of the hospital admission and post-hospital discharge recovery, and particularly to inform of the risks of spinal accessory nerve injury during surgery, and associated neck and shoulder complications.^{Reference Gane, Michaleff, Cottrell, McPhail, Hatton and Panizza417} This may also include practical recommendations on ‘normal’ recovery, preparing the home and living arrangements for after surgery, or liaising with workplaces and other people important in the patients’ home and work life to prepare for before and after hospital.

There is insufficient evidence on how and when prehabilitation interventions should be delivered for people undergoing neck dissection for head and neck cancer.^{Reference Thomas, Tahir, Bongers, Kallen, Slooter and van Meeteren418} Given the timescales between listing for surgery and the hospital admission, it may not be feasible to provide prehabilitation interventions weeks in advance of surgery. However, there is potential that patients may receive support pre-operatively, with tailored guidance on their personal prehabilitation programme before surgery.

Post-operative physiotherapy and exercise prescription – hospital admission

The recommendations for a post-operative physiotherapy and exercise intervention commencing during the in-patient hospital phase for patients undergoing neck dissection for head and neck cancer are presented in Table 2. Two trials have investigated physiotherapy interventions prescribed to patients following neck dissection surgery in the hospital setting.^{Reference Steegmann, Bartella, Kloss-Brandstatter, Kamal, Holzle and Lethaus419,Reference Takamura, Miyauchi, Tomoda, Uruno, Ito and Miya420}

Table 2. Recommendations for post-operative physiotherapy and exercise intervention commenced during the in-patient hospital phase

Takamura et al.^{Reference Takamura, Miyauchi, Tomoda, Uruno, Ito and Miya420} assessed the prescription of a stretching and range of motion exercise programme to improve and optimise shoulder and neck motion. This programme was monitored by a nurse or doctor whilst in hospital, and was supported with an exercise leaflet. Outcomes were compared to a comparator group who were encouraged to return to normal movement, but without a specific stretching or exercise programme. There was low-quality evidence, downgraded because of risk of bias and imprecision, that those who received the supported exercise programme were less likely to experience pain at 1 month (odds ratio = 0.55; 95 per cent CI = 0.36, 0.84), 6 months (odds ratio = 0.47, 95 per cent CI = 0.28, 0.78) or 12 months (odds ratio = 0.47; 95 per cent CI = 0.27, 0.83) post-operatively. There was no difference in the probability of experiencing a complication between the groups (odds ratio = 1.17; 95 per cent CI = 0.39, 3.53). There was no substantial difference between the groups in terms of length of hospital stay (mean difference = 0.50 days; 95 per cent CI = 1.02, 0.02).

In the study by Steegmann et al.,^{Reference Steegmann, Bartella, Kloss-Brandstatter, Kamal, Holzle and Lethaus419} both the comparator and experimental groups received range of motion shoulder and neck exercises; patients allocated to the experimental group received those exercises and an individual cardiovascular exercise programme. Based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, there was low-quality evidence (downgraded because of risk of bias and imprecision) of a significant difference between the groups in terms of length of hospital stay, with those who received mobilisation and general exercise demonstrating a mean difference of 5.40 days (95 per cent CI = 8.08, 2.72) compared to the control group. Whilst there was no difference in complication score (assessed using a 0–10 visual analogue scale) for neurological, cardiovascular, respiratory, musculoskeletal, sleep, concentration or anxiety complications (p > 0.05), there was low-quality evidence (downgraded because of risk of bias and imprecision) that those patients randomised to the general exercise group experienced fewer complications regarding their digestion (mean difference = 2.10 points; 95 per cent CI = 3.48, 0.72) and less fatigue (mean difference = 1.60 points; 95 per cent CI = 2.98, 0.22) compared to the range of motion alone exercise group.

There was no evidence identified concerning the requirement for a respiratory assessment or the need to assess for factors for a safe discharge to the post-hospital residence. The review authors recommend that these aspects are considered, in addition to an assessment of whether patients require post-discharge physiotherapy, to ensure safe and effective hospital care. A recent survey of UK provision of physiotherapy following neck dissection surgery acknowledged that 78 per cent of the nine regional centres surveyed offered post-discharge physiotherapy for those who had symptoms.^{Reference Robinson, Ward, Mehanna, Paleri and Winter414} The assessment of symptoms is therefore important within the pre-discharge assessment, and may be particularly important for those with spinal accessory nerve neuropraxia. Whilst there remains insufficient evidence justifying the essential recommendation for physiotherapists to ensure that patients are given advice regarding goal-setting, pacing, pain management, scar management and limb positioning (when appropriate), these are considered potentially valuable skills that can be taught to patients prior to discharge.^{Reference Lauchlan, McCaul and McCarron421} It is therefore considered desirable that these skills are shared with patients, particularly those who are experiencing or at risk of complications following discharge.^{Reference Lauchlan, McCaul and McCarron421}

Post-operative physiotherapy and exercise prescription – post-hospital admission

The recommendations for physiotherapy and exercise interventions for patients undergoing neck dissection for head and neck cancer following hospital discharge are presented in Table 3. A number of different physiotherapy programmes for people who have undergone neck dissection surgery for head and neck cancer, which begin after hospital discharge, have been evaluated and reported in the literature. These include: the assessment of progressive resistance exercises, muscle energy technique exercise programmes, the use of acupuncture, the provision of self-help interventions, the prescription of yoga and the use of a multimodal rehabilitation programme.

Table 3. Recommendations for post-operative physiotherapy and exercise intervention commenced following hospital discharge

Three trials (reported across four papers) have assessed the outcome of progressive shoulder resistance exercise training compared to active shoulder range of motion exercise programmes.^{Reference McNeely, Parliament, Courneya, Seikaly, Jha and Scrimger422–Reference McNeely, Parliament, Seikaly, Jha, Magee and Haykowsky424} On meta-analysis that pooled outcomes, there were no differences between those who received progressive shoulder resistance exercises compared to active shoulder range of motion exercises in terms of flexion range of motion at 12 weeks (mean difference = 9.27 degrees; 95 per cent CI = −2.97, 17.51) or abduction at 12 weeks (mean difference = 15.93 degrees; 95 per cent CI = −0.92, 32.78), although those who were randomised to the progressive resistance exercise programme demonstrated significantly greater external rotation range at 12 weeks (mean difference = 12.0 degrees; 95 per cent CI = 1.56, 22.44). McGarvey et al.^{Reference McGarvey, Hoffman, Osmotherly and Chiarelli425} reported 12-month data. There were no differences between the two exercise programmes at this timepoint in terms of flexion (mean difference = 1.70 degrees; 95 per cent CI = −14.10, 17.50) or abduction (mean difference = −4.50; 95 per cent CI = −31.28, 22.28). There was no difference in health-related quality of life when measured using the Functional Assessment of Cancer Therapy – General (‘FACT-G’) questionnaire^{Reference Cella, Tulsky, Gray, Sarafian, Linn and Bonomi426} at 12 weeks (mean difference = 7.18 points; 95 per cent CI = −0.85, 15.24) or at 12 months (mean difference = 1.50 points; 95 per cent CI = −7.20, 10.20). This was the same for pain at 12 weeks, which was assessed in McNeely et al.^{Reference McNeely, Parliament, Courneya, Seikaly, Jha and Scrimger422} (mean difference = 1.60 points; 95 per cent CI = −17.50, 20.70), and for shoulder function both at 12 weeks (standardised mean difference = 0.01; 95 per cent CI = −0.35, 0.38) and 12 months (standardised mean difference = 0.18; 95 per cent CI = −0.45, 0.82). However, for all outcomes, this evidence was judged as very low-quality based on the GRADE assessment, downgraded because of risk of bias, imprecision and inconsistency.

Two trials investigated outcomes comparing physiotherapy when delivered in a supervised out-patient setting compared to being self-directed by patients at home, after receiving instructions on hospital discharge.^{Reference Lauchlan, McCaul and McCarron421,Reference Su, Chen, Leong, Huang, Chiang and Chen427} There was very low-quality evidence, based on the GRADE assessment (downgraded because of risk of bias, imprecision and inconsistency), that those randomised to out-patient-based physiotherapy had significantly greater neck and shoulder function at 6 weeks (mean difference = 29.68 points; 95 per cent CI = 15.27, 44.09) but no difference at 12 weeks (mean difference = −9.81 points; 95 per cent CI = −23.18, 3.56). However, there were no differences in shoulder range of motion in respect to: flexion at 6 weeks (mean difference = 1.40 degrees; 95 per cent CI = −9.78, 12.58) or 12 weeks (mean difference = 3.65 degrees, 95 per cent CI = −7.80, 15.10); abduction at 6 weeks (mean difference = 4.08 degrees; 95 per cent CI = −17.54, 25.70) or 12 weeks (mean difference = 8.09 degrees; 95 per cent CI = −11.63, 27.81); or external rotation at 6 weeks (mean difference = 3.87; 95 per cent CI = −2.61, 10.35) or 12 weeks (mean difference = −2.98; 95 per cent CI = −9.40, 3.44). There was no difference between the groups in respect to pain scores at 6 weeks (mean difference = 1.11 points; 95 per cent CI = −0.36, 2.58) or 12 weeks (mean difference = 1.20 points; 95 per cent CI = −0.15, 2.55).

Thomas et al.^{Reference Thomas, D'Silva, Mohandas, Pais and Samuel428} compared the prescription of a muscle energy technique exercise programme for the shoulder versus an active range of motion exercise programme for this population. They reported that whilst there was no difference between the exercise programmes at 10 days for abduction (mean difference = −1.28 degrees; 95 per cent CI = −11.12, 8.56) or internal rotation range (mean difference = 1.06 degrees; 95 per cent CI = −3.70, 5.82), those who received the muscle energy technique exercises demonstrated greater flexion (mean difference = 15.35 degrees; 95 per cent CI = 6.34, 24.36) and external rotation (mean difference = 5.94 degrees; 95 per cent CI = 0.82, 11.06). There was no difference between the groups in pain scores at 10 days (mean difference = 0.13 points; 95 per cent CI = −0.79, 0.53). However, the evidence was judged as very low-quality given a high risk of bias and imprecision, being based on a single, underpowered trial.

One trial was identified that investigated the use of acupuncture following neck dissection, assessing outcomes at six weeks post-intervention.^{Reference Pfister, Cassileth, Deng, Yeung, Lee and Garrity429} They reported very low-quality evidence (downgraded three levels because of risk of bias and imprecision) indicating that, whilst there was no difference between people who received acupuncture versus those who did not and followed the usual care for shoulder function at six weeks (mean difference = 6.30 points; 95 per cent CI = −3.73, 16.33), the acupuncture patients demonstrated significantly lower pain scores at this timepoint (mean difference = 2.20; 95 per cent CI = −3.41, −0.99).

One trial (reported in two papers) compared the outcomes of prescribing a self-help exercise programme and self-care education programme versus a self-care education programme alone.^{Reference Jansen, Eerenstein, Cnossen, Lissenberg-Witte, de Bree and Doornaert430,Reference Jansen, Coupe, Eerenstein, Cnossen, van Uden-Kraan and de Bree431} They reported that, whilst there was no difference in health-related quality of life, measured using the European Organization for the Research and Treatment of Cancer 30-item Quality of Life Questionnaire (‘EORTC QLQ-C30’) (global health status)^{Reference Aaronson, Ahmedzai, Bergman, Bullinger, Cull and Duez432} at three months (mean difference = 4.80; points; 95 per cent CI = −4.39, 13.99), those who received self-directed education and exercise demonstrated greater health-related quality of life compared to people who only received self-directed education (mean difference = 8.00 points; 95 per cent CI = 0.48, 15.52). Similarly, people who received both self-directed exercises and education demonstrated better pain outcomes compared to those who only received education, both at three months (mean difference = −14.60 points; 95 per cent CI = −25.44, −3.76) and at six months follow up (mean difference = −12.20 points; 95 per cent CI = −22.75, −1.65). There was also a significant benefit in favour of people who received the education and exercise intervention for neck and shoulder function when measured using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (functional scale)^{Reference Aaronson, Ahmedzai, Bergman, Bullinger, Cull and Duez432} at three months (mean difference = 10.40 points; 95 per cent CI = 3.39, 17.41) and at six months (mean difference = 8.80 points; 95 per cent CI = 0.54, 17.06). Whilst providing support for the provision of exercises with education, the evidence for these outcomes was based on low-quality evidence, downgraded for risk of bias and imprecision. It is interesting to note that only one-quarter of these patients were randomised within six months of their operation, suggesting patients might still be able to benefit from physiotherapy input later post-operatively.

One trial reported the outcomes of shoulder range of motion, pain and anxiety in people who were prescribed a yoga programme for eight weeks compared to those who did not and followed usual care following neck dissection for head and neck cancer.^{Reference Adair, Murphy, Yarlagadda, Deng, Dietrich and Ridner433} The data were presented as medians and interquartile ranges, precluding the ability to perform meta-analysis. The paper reported significantly greater shoulder range of motion for active and passive abduction and external rotation for those who receive the yoga compared to those who did not (p < 0.05). They also reported significantly lower pain interference scores and anxiety scores, both at four weeks and eight weeks, compared to the usual care group (p < 0.05). The evidence was judged low in quality because of a high risk of bias and being underpowered.

Chen et al.^{Reference Chen, Lin, Liang and Huang434} used a multimodal intervention that included pain management, scar massage, stretching, active and passive shoulder range of motion and scapular setting exercises, with education on scapular setting and positioning. Their control group was the same multimodal programme, but without the scapular setting component. Both groups commenced their intervention post-operatively for the first three weeks post-discharge. The authors reported a significant improvement in shoulder abduction within the scapular setting group compared to the general shoulder exercise group (p < 0.05). Whilst pain significantly decreased in both groups over the three-week follow-up period, there was no significant difference between the groups for pain score (p > 0.05).

Important research questions

As highlighted, the current evidence base presents a number of issues. Recommendations are largely based on clinical reasoning rather than robust evidence. There is therefore a major gap in knowledge that urgently requires addressing. Key research themes arising from the current state of the evidence base are listed below.

Future aspects of physiotherapy

There is evidence that patients value physiotherapy following neck dissection conducted to treat head and neck cancer.^{Reference Gallyer, Smith, Fordham, Dutton, Chester-Jones and Lamb435} However, the provision of such treatment is restricted by service provision and capacity. This may be overcome by healthcare providers if a stronger evidence base existed to justify the clinical and cost-effectiveness of physiotherapy for these patients. The role of physiotherapy for these patients may therefore develop as the evidence develops.

Neck dissection surgery is frequently undertaken in a smaller number of specialist centres in the UK.^{Reference Robinson, Ward, Mehanna, Paleri and Winter414} This is particularly the case for more complex head and neck cancer surgery. In such an instance, patients are frequently required to travel distances for follow-up care and, if provided, specialist physiotherapy. With the growing interest in offering telerehabilitation through video conferencing and computer platforms, physiotherapy for this patient group may develop through a more virtual approach.^{Reference Gilbert, Jones, Stokes and May436} However, this may present with challenges, particularly when assessing neuromusculoskeletal function where face-to-face examination may be preferable, and when patients present with communication challenges post-operatively that may be exacerbated in a virtual rather than face-to-face approach. Consideration of the approaches of such a platform may be examined in the future.

The population who are treated with neck dissection for head and neck cancer is changing. Historically, this was an older population whose risk of developing head and neck cancer was increased through smoking and alcohol consumption. More recently, people affected by and surviving head and neck cancer in the UK are younger and more active than previous generations,^{Reference Louie, Mehanna and Sasieni210} attributed to human papillomavirus^{Reference Schache, Powell, Cuschieri, Robinson, Leary and Mehanna251} being an increasing cause of the disease. With this change in demographic, there has been a change in recovery expectation, with patients now being more physically active, with social and occupational pursuits, interests and requirements. However, still approximately 50 per cent of patients are unable to return to their work post-surgery.^{Reference Rogers, Ferlito, Pellitteri, Shaha and Rinaldo408,Reference Roerink, Coolen, Schenning, Husson, Smit and Marres413} The role of physiotherapy has adapted accordingly. Therefore, a greater emphasis on vocational rehabilitation and a return to occupational goals is required to support the personal needs of our patients. Consideration on how we deliver this, and how this relates to the timing of other interventions such as chemotherapy or radiotherapy, should be considered.^{Reference Gallyer, Smith, Fordham, Dutton, Chester-Jones and Lamb435}

Key points

All multidisciplinary teams (MDTs) should make adequate provision of clinical nurse specialist posts or individuals to ensure the following essential care elements can be provided at all times:

• • Clinical nurse specialist contact with individuals at the time of diagnosis

• • Clinical nurse specialist involvement in all MDT meetings

• • Psychosocial support and care co-ordination for all individuals being managed within the MDT (to varying extents) by all modalities of treatment

• • Availability to provide co-ordination of multiprotection care pathways

• • Accessibility as a point of contact for expert advice to primary care physicians, district nurses, specialist palliative care teams etc. (e.g. tracheostomy and gastrostomy care, wound care)

• • Co-ordinated, tailored approach to the provision of support for individuals living with the effects of cancer and long-term consequences of cancer treatment. This should include end of treatment summaries, health and well-being advice, signposting to resources available, and appropriate follow up

Specific aspects of clinical nurse specialist role

The role of the clinical nurse specialist is diverse, involving the co-ordination and signposting of patients and carers, for advice, information and support, from diagnosis through to the later stages of disease. Clinical nurse specialists act as the gate-keeper to the patients' cancer pathway, to deliver a seamless journey.^{Reference Dempsey, Orr, Lane and Scott437}

There are specific core aspects of the clinical nurse specialist role; these are described within this chapter (Table 1).^438–442 It is essential that the clinical nurse specialist works closely with the speech and language therapy and dietetic teams as significant others, in order to deliver a multidisciplinary approach in which to achieve the best possible outcomes. Whilst the roles may overlap, their reliance on one another is imperative.

Table 1. Specific aspects of clinical nurse specialist role

HPV = human papillomavirus; NHS = National Health Service; SLT = speech and language therapy

Surgery

Surgery is one of the key modalities used in head and neck cancer treatment. Surgery can have permanent effects on structures essential for normal human activities, therefore affecting speech, mastication and breathing.⁴⁴³

Head and neck cancer is complex and life-changing, often having a traumatic and devastating impact on the patient and their family, both physically and psychologically, because of the impact on highly important functions.^{Reference Iftikhar, Islam, Shepherd, Jones and Ellis444}

Support is required before, during and after treatment, to help the patient adjust to the physical, social and emotional effects, sometimes with disfigurement, on quality of life (Tables 2 and 3).^{Reference Davidson and Williams445}

Table 2. Role of clinical nurse specialist pre-treatment (pre-surgery)*

* Multidisciplinary team (MDT) meeting and combined head and neck clinic. CNS = clinical nurse specialist; AHP = allied health professional; HNC = head and neck cancer; GP = general practitioner

Table 3. Role of clinical nurse specialist during admission for surgery

The head and neck cancer clinical nurse specialist plays a pivotal role throughout the disease trajectory. For example, information given at diagnosis often includes working uniquely with the MDT (speech therapist, dietician, physiotherapist, oncologist etc.), setting realistic expectations with patients and their families before ‘life-changing surgery or treatment’, and this is often a challenging process. In addition, managing disease symptoms and treatment side effects requires complex care management with issues such as complex airway management, or bleeding that could signify a life-threatening situation and which needs to be urgently assessed and addressed. This highlights the importance of advocacy, which is an MDT responsibility.^{Reference Dawson, Roe, Starmer, Brady, Nund and Coffey446}

The clinical nurse specialist can develop a unique relationship with the patients and their carers. This is established through using expert clinical skills, decision-making skills and judgement, together with experience and intuition. Practising within this field can be both challenging and rewarding.

From surgery through to post-treatment care, the clinical nurse specialist helps to build an appropriate care pathway for each patient given their everyday challenges. By providing rationale and advice for each treatment option, the patient is included in the decision-making process and feels engaged in their care.^{Reference Robson447}

‘It has been recognised that care co-ordination individualised to the patient during and after treatment is vital to deliver appropriate person-centred care’.^{Reference Dempsey, Orr, Lane and Scott437}

Prehabilitation is vital in the preparation for potentially life-changing surgery and treatment. It is a continuum to rehabilitation, and focuses on personal empowerment by improving physiological function and psychological well-being, therefore improving resilience to the effects of cancer treatment.^{Reference Dawson, Roe, Starmer, Brady, Nund and Coffey446}

Prehabilitation, described in detail in a separate dedicated chapter, should be implemented as soon after diagnosis as possible to enable maximal benefit in advance of treatment. These interventions aim to reduce post-operative complications and minimise functional decline following surgery.

Macmillan Cancer Support published ‘Principles and guidance for prehabilitation within the management and support of people with cancer’ in 2019.⁴⁴⁸ This document sets out principles with which people with cancer can be prepared for treatment, through a multimodal approach that promotes healthy behaviours, exercise prescription, nutrition and psychological interventions appropriate to their needs.

Early intervention, engagement and interaction can be both healing and therapeutic for patients post-surgery.^{Reference Dawson, Adams and Fenlon449} Regular patient reviews for support and information are vital in the recovery, as this is often a particularly anxious time for the patient and family as they adjust to the post-operative changes. Recent research has also indicated that the prevalence of mental health disorders in people with head and neck cancer increases by 10 per cent after diagnosis.^{Reference Dawson, Adams and Fenlon449}

The head and neck nursing team also play an active role in educating junior nursing staff, student nurses, allied health professionals and medical staff whilst reviewing patients in the clinical environment. The clinical nurse specialist's experience, mentoring and educational support of colleagues is a valuable resource.

In 2020, the British Association of Head and Neck Oncologists set out clear guidance for the management of head and neck cancer patients, both in the hospital and community setting, as described below.^{Reference Schache, Kerawala, Ahmed, Brennan, Cook and Garrett71}

Role of clinical nurse specialist during oncology treatment

The role of the oncology clinical nurse specialist is equally as important (Table 4). This can be a difficult period for patients as they move from one treatment modality to another. Anxiety is often high and information is key.

Table 4. Role of clinical nurse specialist during oncology treatment

MDT = multidisciplinary team; SLT = speech and language therapist; CNS = clinical nurse specialist; NCI = National Cancer Institute; CTCAE = Common Terminology Criteria for Adverse Events; HNC = head and neck cancer

Supportive care, appropriate information and individualised care planning is key to improving the experience of the patient and the carer.^{Reference Dempsey, Orr, Lane and Scott437}

This is also often a point of change of key worker. It is vital the oncology clinical nurse specialist meets the patient and carer at the start of the oncology treatment period. This starts at the pre-treatment clinics, where there is an opportunity for patients and carers to meet the clinical nurse specialist and other allied health professionals prior to treatment. It allows the giving of information, the explanation of treatment and the implementation of a health needs assessment. A health needs assessment ensures that the patients’ and carers’ physical, emotional and social needs are met in a timely and appropriate way, and that advice and support are available from the right source at the right time.⁴⁵⁰

Radiotherapy or chemoradiotherapy side effects from treatment are often debilitating. Up to 89 per cent of patients having treatment develop oral mucositis and require analgesia.^{Reference Muzumder, Srikantia, Udayashankar, Kainthaje and John Sebastian451} Patients should have a clear explanation of what to expect during this period. Side effects build during treatment to a peak on the final week and the week after completion. In general, side effects develop from week two onwards, and treatment toxicity should be assessed and scored with a recognised grading tool. This can help guide consultations and required interventions. Patients should have weekly reviews to ensure compliance with medications and supportive measures. Effective MDT communication will be vital in supporting the patients through this period. Offer onward referral for psychological support if required and if the patient is struggling with treatment.

The clinical nurse specialist should always be a source of information and comfort for the patient undergoing treatment. They should be contactable within working hours and available to review the patient outside of the clinic setting if needed (either face to face or by telephone).

Those patients undergoing chemotherapy or immunotherapy only are generally on treatment with palliative intent. In addition to toxicity management, the clinical nurse specialist should assess the level of support required and arrange community palliative care support if required.

Living with cancer

An individual approach to living with cancer (last 12 months of life), including clear documentation and communication with each relevant team providing palliative care, must be employed for all individuals. This may include liaison with primary care and specialist palliative care teams. Clear offers must be made to discuss and implement advance care plans with all patients. These may reasonably include patients’ preferred place of care, agreed thresholds or ceilings of treatment.

For those recognised to be dying (last days of life), an individualised care plan should support care for all individuals.

Late effects of treatment

The role of the clinical nurse specialist incorporates support with late effects of treatment, in relation to chemotherapy, radiotherapy, surgery or combined modality treatment (Table 5).^{440–442,Reference Gunn, Gilbert, Nenclares, Soliman, Newbold and Bhide452} Macmillan defines ‘late effects’ as side effects that do not disappear after treatment, or that do not materialise until months or even years after treatments have taken place.^{Reference Dawson, Roe, Starmer, Brady, Nund and Coffey446} Such effects differ between patients, both in terms of the effects and the timing at which they occur.

Table 5. Late effects of treatment and role of clinical nurse specialist

NHS = National Health Service; SLT = speech and language therapy

The clinical nurse specialist works closely with other team members in supporting patients with late effects, such as lymphoedema teams, late effects radiographers and core members of the MDT.

Community, palliative and supportive care

The head and neck clinical nurse specialist is instrumental in ensuring that support, advice and appropriate signposting is available to patients and their carers when a referral to the acute setting for suspected cancer is made (Table 6).^{Reference Dempsey, Orr, Lane and Scott437,443,450}

Table 6. Palliative and supportive care

HNC = head and neck cancer; CNS = clinical nurse specialist; GP = general practitioner

If discussions at the MDT meeting conclude that it is not possible to cure a patient of their cancer, a less radical course of treatment known as ‘treatment with palliative intent’ may be offered to help control symptoms and slow down progression of the disease. For some patients, it may be recommended that no active treatment be given, if the MDT feels treatment would not be beneficial or may worsen their current symptoms; this is known as ‘supportive care’. Whilst a diagnosis for palliative treatment or supportive care may be given at initial presentation to the acute service, a patient may also be given this diagnosis at any later stage of the pathway, even if the initial intention was for cure. In any case, the clinical nurse specialist acts as the patient's advocate at the MDT, and ensures that sufficient support and advice are available whilst the patient remains under the care of the hospital team.⁴⁴³

Community care

As a patient’s condition deteriorates, there is frequently an emphasis on managing palliative patients within the community setting (Table 7). This concerns those patients with distant metastasis, late-stage disease or cancer that is life-limiting, and/or those with a prognosis of 6–12 months. Given that head and neck cancer is a very specialised area of care, some localities provide hospital out-reach services for their patients, which can be beneficial in supporting community staff to manage more complex and specialised situations.

Table 7. Community care

In order to facilitate greater community working, the clinical nurse specialist should have the skills listed in Table 7.

Psychology in the management of head and neck cancer

A diagnosis of head and neck cancer is often described by patients as physically and psychologically debilitating, with significant psychosocial implications on physical, emotional, spiritual, financial and interpersonal interactions (Table 8). Unlike other tumour sites, head and neck cancer and its treatment cannot be hidden, often because of disfigurement, altered anatomy, and lasting effects on eating and communication. Whilst some patients adapt to their altered anatomy with little support, others experience a loss of confidence in social interactions because of self-image,^{Reference Nayak, Pai and George454} and go through significant periods of adjustment to obtain an acceptable level of quality of life. Windon et al.^{Reference Windon, D'Souza, Faraji, Troy, Koch and Gourin455} identified that head and neck patients experienced feelings of regret post treatment, particularly following multiple treatment modalities despite curative treatment intention. This signifies the crucial role that psychological support has within the complex and challenging management of head and neck cancer.

Table 8. Psychological support*

* Psychology management in head and neck cancer

Often patients share a fear of recurrence as a primary concern, whilst milestones such as post-treatment investigations, follow-up appointments and physical reminders of treatment frequently trigger patients back into psychological turmoil. Collectively, head and neck cancer patients display an increased frequency of depression associated with the multifaceted consequences of cancer and the effects of treatment decreasing quality of life for patients.^{Reference Lin, Starmer and Gourin456} Declines in performance status and functional ability collectively impact on many aspects of daily living, including employment, in the head and neck patient.^{Reference Yilmaz, Yener, Yollu, Akil, Haciyev and Yargic457} Interviews have shown that survivors of head and neck cancer call themselves the ‘visible minority’, stemming from their noticeable disfigurement.^{Reference Henry, Ho, Lambert, Carnevale, Greenfield and MacDonald458} The need for psychological support is supported by the author's reflection on a case study, whereby, despite the patient's remission, he was left looking in the mirror at a reflection that overwhelmed him with feelings of shock and regret. This patient acknowledged that the late and physically permanent effects of cancer treatment were undoubtedly worse than the initial cancer diagnosis itself.

As key worker and patient advocate, the clinical nurse specialist is level 2 trained in providing timely psychological interventions, utilising advanced communication skills. The clinical nurse specialist ensures frequent opportunities for one-to-one supportive conversation to meet patients’ information needs around their cancer diagnosis and potential treatment options, but also identifying and responding to psychological needs. This undoubtedly helps to inform therapeutic relationships, and enhance holistic patient-centred care and choice. Involving patients in decisions around their care will help to enable a sense of partnership between the patient and healthcare professional. Screening for psychological distress using a recognised tool and providing ongoing psychological support throughout the entire pathway are imperative in improving the quality of life of those diagnosed with head and neck cancer.

Future roles and development

Advanced nursing roles such as clinical nurse specialist advanced practitioner and advanced nurse practitioner are clinical expert roles that require academic degrees. Healthcare delivered by nurses in these advanced roles has proven to impact important care quality factors such as patients’ experiences, safety, symptom burden and cancer care co-ordination. By improving communication between and within the teams, advanced nursing care can reduce re-admissions. Advanced nursing roles can contribute to improving clinical practice and patient centeredness, through education, developing guidelines and spanning organisational boundaries, to progress the patient through the system.

The clinical nurse specialist is the clinical nursing role with in-depth knowledge of cancer care and symptom management, supporting both the patient and their families through the cancer journey. The clinical nurse specialist's knowledge enables them to offer expert care to patients with all stages of cancer, including screening for early detection, making a diagnosis, administrating treatments, and discussing survivorship. Most clinical nurse specialists perform advanced tasks; these can be nurse-led clinics for pre-treatment, on treatment and after treatment, with clinical nurse specialists often seeing the patient weekly to support with symptom management. The clinical nurse specialist is recognised as the first point of contact for patients.

Some clinical nurse specialists offer additional advanced roles, which include nurse-led tracheostomy tube changes for patients requiring long-term airway management, and joint valve clinics with speech and language therapists. In order to address local demands, nurses working in partnership with physicians may select a group of patients that can be seen independently within a risk-stratified nurse-led clinic, which could include nasendoscopy follow up and working alongside ultrasound clinics for rapid access.

Key points

• • Consultants in restorative dentistry are core multidisciplinary team (MDT) members. Their close collaboration with the MDT is essential. The restorative dentistry consultant should be proactive in the MDT, contribute to research and audit, and act as an advocate for optimum oral health outcomes.

• • Consideration of oral rehabilitation needs to begin early in the surgical and non-surgical treatment pathways. By managing the pre-treatment pathway optimally, the restorative dentistry consultant can facilitate prevention or reduction of complications.

• • Patient involvement in decision-making regarding the oral and dental care plans is essential, and should be underpinned by written and verbal information regarding the expected impact of treatment on appearance, ability to speak, eat and chew. A clear understanding of patient expectations and priorities is essential to providing individual counselling on likely outcomes and personalised plans.

• • The possibility of implant rehabilitation should always be considered early, as timely implant rehabilitation can improve patient outcomes, reduce overall treatment times and decrease costs where appropriate.

• • Referral pathways for management post treatment should be clear.

Pre-treatment

Patients whose cancer treatment will affect oral and dental function and appearance will require oral rehabilitation planning (Tables 1 and 2).^461,462,465 This generally includes patients scheduled for surgical intervention that alters oral anatomy, patients requiring radiotherapy where the treatment field includes any part of the maxilla, mandible or salivary glands, and patients with specific dental concerns or pre-existing conditions.

Table 1. Pre-oral and maxillofacial surgery and ENT surgery planning

MDT = multidisciplinary team; CRD = consultant in restorative dentistry; OMFS = oral and maxillofacial surgery; 3D = three-dimensional

Table 2. Pre-radiotherapy planning

MDT = multidisciplinary team; CRD = consultant in restorative dentistry; SLT = speech and language therapist

Clinically edentulous patients may have retained roots, buried teeth or local bony pathology, and should also be considered for prehabilitation. This stage is often referred to as ‘screening’ or ‘assessment’, which belies a highly complex planning and initial treatment stage with time pressures. It should be more accurately viewed as planning or oral and dental prehabilitation. It presents challenges, as the outcomes of cancer treatment for the individual patient are not yet known. Risk assessment for adverse oral and dental outcomes, therefore, is key.

Some dental pathology is preventable if appropriate early interventions are put in place. Primary implant placement should always be considered as part of surgical planning. For patients having dual modality treatment, this may be the only opportunity to place implants. Secondary implant placement may extend the rehabilitation pathway, but allows more time for comprehensive planning and assessment of any post-treatment challenges. However, implants may not be appropriate in some cases. Patients should be counselled by the restorative dentistry consultant regarding expected prosthodontic oral rehabilitation outcomes from the start.

Success in implant rehabilitation is improved by early digital planning. Digital workflows can greatly facilitate the planning and execution of implant based orofacial rehabilitation, allowing rapid treatment completion.^{Reference Levine, Bae, Soares, Brecht, Saadeh and Ceradini466,Reference Witjes, Schepers and Kraeima467} The restorative dentistry consultant should be involved in planning with surgical colleagues from the outset.

Software used for digitally planned osseous reconstruction following resection allows dental implant planning with guided surgical stents, and should be undertaken jointly with the restorative dentistry consultant and maxillofacial surgeons during the early planning stage utilising a prosthetically driven approach to optimise rehabilitation outcomes.^{Reference Rodby, Turin, Jacobs, Cruz, Hassid and Kolokythas468} This helps achieve more predictable outcomes in terms of function, biology and aesthetics,^{Reference Schubert, Schweiger, Stimmelmayr, Nold and Guth469} which contribute to improving QoL.

Dental extractions for head and neck cancer patients can be a traumatic, highly emotive experience. Extraction of teeth, if indicated, should be organised as early as possible after the cancer treatment plan is known, to maximise healing time and expedite the pathway. However, care should be taken to avoid unnecessary dental extractions, especially where the cancer treatment plan is not yet clarified. Where multimodality treatment is definite or where gross dental pathology exists, extraction during primary surgery should be considered.

The essential and desirable aspects of the pre-treatment restorative planning appointment before surgery and before radiotherapy are outlined in Table 1.

Peri-treatment

Osseointegrated implants can improve the support and retention of prostheses, help raise self-esteem and body image, and improve overall QoL.^{Reference Rogers, McNally, Mahmoud, Chan and Humphris470} Primary implant placement in head and neck cancer patients involves placing dental implants at the time of the ablative surgery, to allow osseointegration to take place prior to any necessary adjunctive radiotherapy. It facilitates more rapid rehabilitation,^{Reference Patel, Antov and Nixon471} while avoiding further surgery and further in-patient treatment costs. Disadvantages include reduced planning time, and the risk of implants not being used because of tumour recurrence or changed anatomy during or following surgery.^{Reference Alberga, Vosselman, Korfage, Delli, Witjes and Raghoebar472}

Peri-surgical maxillectomy defect management can involve prosthetic obturation or surgical reconstruction of the defect. Dental implants can help to retain an obturator or can support a fixed dental bridge in conjunction with a free flap. The latter may involve placing implants into native bone, composite free flaps or remote anchorage in the zygomatic buttress. Overall, the literature fails to demonstrate the superiority of obturation or reconstruction, as a result of unique patient presentation and a lack of data reporting standardisation.^{Reference dos Santos, de Caxias, Bitencourt, Turcio, Pesqueira and Goiato473} Limited evidence suggests that surgical reconstruction may offer improved QoL over prosthodontic rehabilitation.^{Reference Sharaf, Ibrahim, Eskander and Shaker474} Individual studies have demonstrated comparable masticatory function with implant supported obturators and surgical reconstruction, both superior to conventional obturation in low-level defects.^{Reference Buurman, Speksnijder, de Groot, Kessler and Rieger475,Reference Buurman, Speksnijder, Engelen and Kessler476} Implants can also be used to help retain facial prostheses, obviating the need for tissue adhesives. There are multiple case reports and case series on the use of zygomatic implants for orofacial and nasal prostheses, with good results.^{Reference King, Abbott, Dovgalski and Owens477}

Zygomatic implants have been used for over 20 years. They can be used splinted or un-splinted. There are multiple implant designs for post-resection orofacial rehabilitation.^{Reference Branemark478} A recent review highlighted current evidence for the use of zygomatic implants in the midface and maxillary rehabilitation of patients with head and neck cancer.^{Reference Hackett, El-Wazani and Butterworth479} Overall survival rates of 77–100 per cent were reported, with few complications.

Zygomatic implant positioning for intra-oral prostheses should be restoratively driven.^{Reference Pellegrino, Basile, Relics, Ferri, Grande and Tarsitano480} Involvement of the restorative dentistry consultant in planning and surgical placement should reduce the risks of malposition and improve the potential for rehabilitation (Table 3).^{Reference Ramezanzade, Yates, Tuminelli, Keyhan, Yousefi and Lopez-Lopez481}

Table 3. Peri-treatment

OMFS = oral and maxillofacial surgery; CRD = consultant in restorative dentistry; SLT = speech and language therapist

Post-treatment

Some of the most commonly reported issues for patients during the early post-treatment phase are dry mouth, problems with chewing or eating, dental health and teeth issues, fear of recurrence, and salivation problems.^{Reference Rogers, Alvear, Anesi, Babin, Balik and Batstone482} As the late effects of treatment develop, oral and dental concerns are a noted priority for patients in most patient-related outcome measures. Ongoing management of dental issues is, therefore, essential.^{Reference Rogers and Barber483}

For some patients, placement of osseointegrated implants can positively impact health-related QoL outcomes.^{Reference Korfage, Schoen, Raghoebar, Roodenburg, Vissink and Reintsema484}

Post-surgery

Following maxillofacial surgery for head and neck cancer, most patients will have residual dental or orofacial derangement in their anatomy (Table 4).^{Reference Dholam and Gurav485} This may be a result of pre-surgical dental extractions, and/or the removal of teeth and hard or soft tissues to achieve clear margins. Prosthetic replacement of teeth and associated hard and soft tissue may be achieved using conventional or implant-retained prostheses. Dental implants have been shown to be an appropriate treatment modality.^{Reference Javed, Al-Hezaimi, Al-Rasheed, Almas and Romanos486} Smokers, patients who cannot maintain adequate oral hygiene and those with a history of previous osteoradionecrosis are less suitable for implant treatment because of an increased risk of complications.

Table 4. Post-maxillofacial surgery

OMFS = oral and maxillofacial surgery; CRD = consultant in restorative dentistry

A post-resection assessment should be undertaken – ideally in formal joint restorative dentistry and maxillofacial clinics – to discuss prosthetic oral rehabilitation, and to plan any pre-prosthetic surgery such as vestibuloplasty, the release of tethered flaps and the use of free gingival grafts needed to facilitate prosthetic rehabilitation. Second-stage surgery to expose primary implants will also be planned at this stage.

Where primary implants have not been placed, secondary intra-oral implants may now be planned and placed in native (maxillary, zygomatic or mandibular) bone, or in grafted bone. Implants may also be used extra-orally for orofacial prostheses.

In a scoping literature review, the pooled five-year survival rate for primary placed implants was 92.8 per cent (95 per cent confidence interval (CI) = 87.1–98.5), and for secondary placed implants it was 86.4 per cent (95 per cent CI = 77.0–95.8), demonstrating a higher rate for primary placement. A higher survival rate has been reported for primary implants when compared to secondary implants;^{Reference Alberga, Vosselman, Korfage, Delli, Witjes and Raghoebar472,Reference In 't Veld, Schulten and Leusink487} however, a confounding factor may be that less complex cases are selected for primary implant placement, whereas delayed placement is favoured in more complex cases or more extensive tumours, which inadvertently affects survival rates. In a systematic review by Barber et al.,^{Reference Barber, Butterworth and Rogers488} primary implants had a survival rate of 96–100 per cent, with a follow up ranging from 15 to 96 months.

Implants placed in grafted bone have been shown to require further surgical soft tissue manipulation because of the lack of keratinised mucosa around the implants,^{Reference Patel, Antov and Nixon471} but still have a survival rate of 82–100 per cent up to 12 years later.^{Reference Zhang, Ding, Liu, Sun, Xie and Zhou489}

Dental implants can be placed before or after radiotherapy. The survival of dental implants placed 12 months before or after radiotherapy showed no significant difference,^{Reference Chrcanovic, Albrektsson and Wennerberg490} although those placed 6–12 months after radiotherapy have shown a minimally greater risk of failure than those delayed further.^{Reference Claudy, Quevedo Miguens, Celeste, Parente, Gonzalez Hernandez and da Silva491} Studies prior to 2007 show a difference in survival between implants placed in radiated and non-radiated bone, but more recent studies fail to show a difference.^{Reference Schiegnitz, Al-Nawas, Kaemmerer and Grotz492} In irradiated bone, the survival rates are 74–97 per cent.^{Reference Nobrega, Santiago, de Faria Almeida, dos Santos, Pellizzer and Goiato493–Reference Zen Filho, Tolentino and Silva Santos495} Radiotherapy doses over 55 Gy have been shown to impact on implant success,^{Reference Ettl, Junold, Zeman, Hautmann, Hahnel and Kolbeck496,Reference Nooh497} but bone grafting, smoking and implant positioning have an even greater impact, with higher failure rates in irradiated grafted bone.^{Reference Nooh497} Radiotherapy should therefore not be considered a frank contraindication to implant placement,^{Reference Zen Filho, Tolentino and Silva Santos495} although doses over 60 Gy should be considered with caution, especially when placing implants in the maxilla.^{Reference Shugaa-Addin, Al-Shamiri, Al-Maweri and Tarakji494}

Placing secondary implants in irradiated patients carries the risk of osteoradionecrosis development. The results of the ‘HOPON’ (Hyperbaric Oxygen for the Prevention of Osteoradionecrosis) trial do not recommend consideration of hyperbaric oxygen for dental extractions or implant placement in irradiated mandibles.^{Reference Shaw, Butterworth, Silcocks, Tesfaye, Bickerstaff and Jackson498}

Because of the increased time to rehabilitation in secondary implant cases^{Reference Patel, Antov and Nixon471}, and the lack of evidence that radiotherapy post-placement results in implant failure or osteoradionecrosis,^{Reference Koudougou, Bertin, Lecaplain, Badran, Longis and Corre499} there is an increasing trend to support primary placement where this is logistically possible. However, costs and resources such as 3D scanning and implant planning software can be a limiting factor.^{Reference Negreiros, Teixeira, Peixoto and Regis500}

Post-(chemo)radiotherapy

Patients who were seen prior to radiotherapy will be reviewed again soon after treatment is completed given the increased risk of dental disease in the immediate post-(chemo)radiotherapy phase (Table 5). The main oral side effects of trismus, xerostomia, caries and osteoradionecrosis are assessed. Periodontal therapy prior to (chemo)radiotherapy, and periodontal maintenance thereafter, is advised.^{Reference Hong, Hu, Haverman, Stokman, Napeñas and Braber501}

Table 5. Post-(chemo)radiotherapy

CRD = consultant in restorative dentistry; SLT = speech and language therapist

Treatment of head and neck cancer and its associated side effects can adversely affect patients’ health-related QoL.^{Reference Vartanian, Rogers and Kowalski502} Health-related QoL is integral for patient care^{Reference Rogers, Semple, Babb and Humphris503} and should be regularly assessed. Information from health-related QoL questionnaires can help improve patient care and can be used in treatment decisions.^{Reference Vartanian, Rogers and Kowalski502} The patient will remain under the care of the restorative dentistry consultant until oral side effects have stabilised and are manageable by the patient. Discharge to primary care can then take place, with clear instructions on providing care for the patient as well as information on when to refer back, if needed.^{Reference Beech, Robinson, Porceddu and Batstone504}

Research

Predicting and managing the oral and dental complications of head and neck cancer treatment is complex, and requires the input of highly specialised clinicians. Following the NHS Getting It Right First Time approach, Restorative Dentistry UK have produced clear guidance on best practice.⁴⁶⁵

The quality of patient care and outcomes can be improved by developing clinical networks. The Restorative Dentistry UK Head and Neck Cancer Clinical Excellence Network aims to connect consultants and specialty trainees in restorative dentistry across the UK in order to work at improving outcomes, facilitating multicentre research and audit, and reducing variation, so that the quality of, and access to, patient care are improved. Crucially, the Restorative Dentistry UK Head and Neck Cancer Clinical Excellence Network works with the other MDT clinical specialties, including ENT and maxillofacial surgery, oncology, cancer specialist nurses, dietitians, and speech and language therapists, so that outcomes are meaningful and not produced in a clinical vacuum.

Now that 100 per cent of Scottish and Welsh MDTs and over 80 per cent of English MDTs have restorative dentistry consultant input, the development of multicentre studies is possible. As part of holistic, patient-centred care, future research and audit should aim to improve dentally focused pre-surgical planning, as supported by patient-related outcome measures with the use of the Patient Concerns Inventory. A focused Patient Concerns Inventory in relation to oral and dental health would be useful. The introduction of minimum dataset collection – including the number of decayed, missing and filled permanent teeth (‘DMFT’), and implant placement and rehabilitation – will help inform future research. Service delivery and workforce data from various centres will help develop and deliver best treatment to patients of this cohort.

In the future, the role of the restorative dentistry consultant will continue to evolve to address oral impacts of emerging technologies such as robotic surgery, immune therapy and proton beam therapy. Ongoing engagement with consultants in restorative dentistry will be essential to maximise the benefit of these technologies for patients.

Key points

• • Develop information services for patients and carers. Consider introducing new technology to collect routine patient self-report data on health behaviour, psychological responses to care received, outlining of key messages and outcome assessments.

• • Develop decision-making tools (such as explanatory tablet applications, e.g. Patient Concerns Inventory) to aid patients in entering into discussion with the multidisciplinary team (MDT) to agree on a treatment plan.

• • Collect routine psychological assessments at key points during the course of care. These indicators must be supported with dedicated and tailored interventions to prevent neglecting identified psychological distress or depression.

• • Focus on the level of support and intervention that the current team can realistically provide with the current level of resources; remain cautious when introducing change, but strengthen and build upon supports already available.

• • Develop more comprehensive support services by improving generic communication skills training for current staff, and ensure consistency of message-giving to patients and/or carers across the MDT.

• • Introduce staff training to assist with the management of potential burnout in MDT staff; consider flexible responses including secondments, study breaks and peer-support programmes.

• • Audit current psychological services applied in the head and neck cancer service; identify current usage and gaps in service, and develop forward plans to address these gaps.

• • Assess current capability of specialist clinical nurse skills to support head and neck cancer patients psychologically, and introduce dedicated training and supervision programmes.

• • Actively search for clinical psychology service input and negotiate improved access and response time; estimate likely demand of service.

• • Consider appointing sessional input of a clinical or counselling psychologist or psychotherapist to the cancer network.

• • Identify liaison psychiatry service, and negotiate referral pathway and response time.

Communication of diagnosis and treatment

Evidence from areas of treating cancer at other sites has demonstrated clearly that the way in which the diagnosis is presented to the patient is important to their psychological response to the disease and treatment.^{Reference Badr, Carmack and Diefenbach511,Reference Back, Arnold, Baile, Fryer-Edwards, Alexander and Barley512} It is important that the patient is told explicitly that they have a cancer and its nature is described, and that all treatment available is presented to them in an unambiguous manner. This information needs to be relayed consistently by all members of the team, so that the patient and carer are able to adapt, especially to be sensitive in the relaying of ‘bad’ news. This needs to be closely exercised, as this is often the first contact the patient has with the head and neck team. The initial contact has great impact, over and above the actual time spent. Evidence shows that delivering information without interruption, avoiding jargon and showing appropriate empathy are important features of the diagnostic interview that help prevent illness concerns developing.^{Reference Back, Arnold, Baile, Fryer-Edwards, Alexander and Barley512} Decision-making and designing of tools to improve communication between clinician and patient are improving rapidly, and highlight an important growth area for the future of head and neck cancer care where complex choices are discussed and commitments made with patients.^{Reference Newton513,Reference Austin, Mohottige, Sudore, Smith and Hanson514} Surgery, a major treatment modality, has received considerable attention regarding how to assist patients in coping with procedures. Providing early psychological support and frequent distress screening were features identified for improving outcomes.^{Reference Grimmett, Heneka and Chambers515}

Delivering information about treatment and recovery

Considerable efforts have been expended to determine the information needs of head and neck cancer patients.^{Reference Chen, Lai, Liao, Chang and Lin516,Reference Humphris and Ozakinci517} Poor satisfaction with information supplied by the team was predictive of patients’ lowered mood and quality of life (QoL) in the longer term.^{Reference Llewellyn, McGurk and Weinman518} More information was required on financial advice, support groups and ability to return to work. Virtually no studies have been reported on patients’ desire to be involved in treatment decision-making. The nature of the disease and its complex profile of mixed treatment methods have favoured the MDT's sole authority to determine treatment regimens. However, large datasets of ‘normative’ QoL estimates linked to various treatment options have been compiled, which enable the team to start sharing the potential risks and benefits of certain treatment packages, and tailoring to patient preferences of retained functions on recovery.^{Reference Ethunandan, Rennie, Hoffman, Morey and Brennan519}

Managing psychological distress

The use of routine assessments for psychological distress such as the Distress Thermometer and the Hospital Anxiety and Depression Scale are being considered as means to identify those patients who may suffer during the process of treatment preparation, the treatment itself, the initial stages of recovery and the follow-up out-patient appointments.^{Reference Mitchell520} These assessments have the ability to capture those patients who would not necessarily be identified by the MDT as needing psychological support.^{Reference Semple, Dunwoody, Kernohan and McCaughan521} Two issues are raised, however: an increased number of patients in need of assistance; and screening measures that may indicate substantial distress when there is none because of measurement error. Hence, it is recommended as essential that service heads organise links with local health service providers to input directly into the MDT and create a referral pathway.

The types of psychological distress require attention and definition. The classical typology of mental distress includes anxiety and depression. In addition, assessments of recurrence fears (the most frequently reported concern of head and neck cancer patients), facial disfigurement, body image, loneliness and sexual dysfunction may also be compiled within an MDT assessment profile library for occasional use when required.^{Reference Hodges and Humphris522,Reference Hagedoorn and Molleman523} Recurrence fears have been found to be linked closely to depression in patients, and some evidence exists that patients can stimulate these fears in their carers.^{Reference Rogers, Scott, Lowe, Ozakinci and Humphris524} Furthermore, it is now recognised that high recurrence fears promote more requests for medical services, incurring higher treatment and surveillance costs.^{Reference Williams, Pearce and Smith525} Acknowledgement of the patient's experience of the severity and longevity of these fears is important, and more in-depth approaches may be required to alleviate debilitating distress.^{Reference Groß, Nitzsche, Gloede, Ansmann, Street and Pfaff526} It is widely accepted that the patient's treatment and tumour characteristics are not good predictors of who will experience high fear of cancer recurrence levels.^{Reference Casswell, Gough, Drosdowsky, Bressel, Coleman and Shrestha527,Reference Simard, Thewes, Humphris, Dixon, Hayden and Mireskandari528} The exception to this generality is patient age. The young patient reports a greater reported fear of cancer recurrence level.^{Reference Lim and Humphris529} Gender may also be implicated, but less so.^{Reference Pang and Humphris530,Reference Rogers, Monssen, Humphris, Lowe and Kanatas531} Two types of patient experience of fear of cancer recurrence have been found in the six months following diagnosis. The first is a ‘low declining’ group and a sizeable minority (20 per cent) of ‘high stable’ fear of cancer recurrence sufferers.^{Reference Deuning-Smit, Custers, Miroševič, Takes, Jansen and Langendijk532} This fear of cancer recurrence characterisation of head and neck cancer patients strongly suggests that regular assessment of fear of cancer recurrence using a brief assessment is indicated, especially as patients tend not to volunteer their concern unless explicitly questioned.^{Reference Ozakinci, Swash, Humphris, Rogers and Hulbert-Williams533}

The profile of staff expertise and skills needs close inspection to enable a flexible and tailored matching of needs to professional training of support or specialist staff. The MDTs need to plan their services to provide an escalating level of care according to the specific psychological difficulties presented by the patient. Stepped-care approaches are being developed and tested.^{Reference Butow, Lebel, Shaw and Humphris534} Initial support and educational approaches can be offered widely by the MDTs, with brief structured interventions provided by staff with additional training or a mental health qualification (counselling) to those patients with an identifiable psychological problem. More extensive interventions for patients with complex psychological difficulties can be offered, usually by referral to clinical psychologists, psychotherapists and liaison psychiatrists. A recent review and meta-analysis of fear of cancer recurrence structured interventions has been conducted.^{Reference Tauber, O'Toole, Dinkel, Galica, Humphris and Lebel535} The effect size of the Adjustment to the Fear, Threat or Expectation of Recurrence (‘AFTER’) intervention designed for patients with head and neck cancer is comparable to other well developed but more general programmes (‘Conquer Fear’ and Survivors’ worries of recurrent disease (‘SWORD’) interventions). The services offered would consist of complex psychotherapeutic approaches. A simple example of a stepped-care pathway is presented (Figure 1) for those patients with moderate or extensive fears of cancer recurrence. The pathway is triggered by simple and regular assessments using a four-question patient-rated outcome measure called the Fear of Cancer Recurrence scale (‘FCR4’) (Figure 2).^{Reference Humphris, Watson, Sharpe and Ozakinci536}

Figure 1. Example of a stepped-care pathway for managing patients’ fear of cancer recurrence (FCR). FCR4 = four-item Fear of Cancer Recurrence scale^{Reference Humphris, Watson, Sharpe and Ozakinci536}

Figure 2. ‘FCR4’ – four-item Fear of Cancer Recurrence scale.^{Reference Humphris, Watson, Sharpe and Ozakinci536}

The changes in service delivery precipitated by the coronavirus disease 2019 (Covid-19) pandemic, some of which may continue, can produce feelings of isolation and abandonment for those diagnosed with head and neck cancer.^{Reference Dermody and Shuman537} Close attention is needed to offset the use of triage procedures due to the virus or delays in diagnostic reports. Successful communication of the team members becomes even more vital to provide consistency of messaging to patients and carers.

Family and social support

Developments are progressing to design interventions that assist communication between patient and carers, with initial results indicating success.^{Reference Gremore, Brockstein, Porter, Brenner, Benfield and Baucom538} It is important for the MDT to raise survivorship issues with patients.^{Reference Badr, Yeung, Lewis, Milbury and Redd539} Not only does the patient remain watchful for indicators and symptoms that may raise concern for life-reducing disease processes, but also to maintain function for as long as possible. Two areas are pertinent here. First, carers and spouses should be encouraged to use techniques to enhance the adherence of follow-up MDT recommendations. Second, and closely related, is the use of social media to link other members of the local community with similar health conditions and survivorship concerns, who can share information and provide extended social support outside the hospital boundaries. Finally, use of brief telephone contact to assist fear of cancer recurrence concerns, for example, may be considered cost-effective,^{Reference Davidson, Malloch and Humphris540} and, in some cases, online psychological interventions may be offered as a way to reduce face-to-face contact.^{Reference Yang, Zhang, Li, Liu, Liu and Li541}

End-of-life issues

Communication with the patient assumes even greater importance when curative treatment options are not available and care focuses towards a palliative approach.^{Reference Sciubba542} Areas such as assessing patient preferences concerning life expectancy and control of pain, and managing fears of uncertainty and family reactions, are features of these discussions with the staff of the MDT and palliative care services.

Pressure on multidisciplinary teams and staff burnout

The psychological burden to staff requires recognition, supervision and training. A recent qualitative study identified themes that describe staff experiences in providing a comprehensive service to patients.^{Reference Gibson, O'Connor, White, Baxi and Halkett543} The authors recommended advanced communication skills training, trauma sensitivity training and self-compassion. Excellent leadership qualities are essential in running such MDTs.^{Reference Brenner, Hickson, Boothman, Rushton and Bradford544} This field requires further study and development to enable staff to maintain their exemplary service levels.^{Reference Alabi, Hietanen, Elmusrati, Youssef, Almangush and Mäkitie545}

Key points

The key points concerning the role of specialist palliative care teams within the provision of palliative care are:

• • Integration of a multidisciplinary, person-centred approach to care (good practice point (G))

• • Liaison with both primary care and specialist palliative care teams (G)

• • Clear communication of treatment options to facilitate decision-making on the treatment pathway (G)

How palliative care should be delivered

Palliative care for those with head and neck cancer, in its broadest remit, should be delivered within a multi-professional context. As a minimum, this should include a surgeon, oncologist, specialist palliative care clinician, clinical nurse specialist, dietitian, speech and language therapist, emotional support team, and community team, all embedded within a clear communication framework across the acute and community settings. Developing effective working relationships, pathways and closer integration of specialist palliative care teams and the referring surgical and oncology teams is imperative.^{Reference Ferrell, Temel, Temin, Alesi, Balboni and Basch547–Reference Quill and Abernethy549} Models within the in-patient and out-patient setting have been developed,^{Reference Ferrell, Temel, Temin, Alesi, Balboni and Basch547,Reference Hui, Mori, Watanabe, Caraceni, Strasser and Saarto550} e.g. ‘co-rounding’ of specialist palliative care and oncology teams.^{Reference Meijuan Yang, Kanesvaran, Hui-Shan Neo, Chung Pheng Yee, Block and Bun Cheung551} When there is a shift in treatment intent from curative to incurable, this should correlate with a directional move of care delivery from the surgical and oncology team to include the specialist palliative care MDT.

Open and honest communication is fundamental to enable optimal delivery of palliative care, as advanced head and neck cancer can be unpredictable, necessitating complex decisions with uncertain outcomes. Discussions should be centred on prognostication information, and the establishment of treatment goals based on patient and family priorities. Research has demonstrated that head and neck cancer patient preferences and clinicians’ priorities are often out of line,^{Reference Lin, Kang, Donermeyer, Teknos and Wells-Di Gregorio552} which accentuates the need for skilful communication by the healthcare team to explicitly inform patients of anticipated benefits and burdens of available treatments. Palliative care delivery should be underpinned by the principles of person-centred care, shared decision-making and respect for patients, given the vulnerability of this patient population.^{Reference North, Carson, Sharp, Patterson and Hamilton553}

When specialist palliative care teams should be involved

The importance of timely identification of head and neck cancer patients who may benefit from specialist palliative care services is widely recognised.^{Reference Lin, Kang, Donermeyer, Teknos and Wells-Di Gregorio552,Reference Mayland, Ho, Doughty, Rogers, Peddinti and Chada381} The key challenges for clinical teams are identifying who should be referred to specialist palliative care services and determining when is the optimal time (Table 1). When referrals are too late, head and neck cancer patients can be denied the full benefit of specialist palliative care, including timely symptom management and advance care planning conversations.^{Reference Hoesseini, Offerman, van de Wall-Neecke, Sewnaik, Wieringa and Baatenburg de Jong554} Conversely, referrals that are too early may result in patients with few concerns being assessed, thus inappropriate use of a specialist resource.^{Reference Hui, Mori, Watanabe, Caraceni, Strasser and Saarto550}

Table 1. Reasons to prompt referral for specialist palliative care team involvement

Common physical symptoms

Within this section, we have focused on pain, nausea and vomiting, constipation, and the management of secretions. This is not an exhaustive list; for other details about specific symptoms and medications, we would advise reference to texts such as the Palliative Care Formulary ^{Reference Wilcock, Howard and Charlesworth555} and British National Formulary.^{Reference :556} As the evidence base has limitations, we have provided advice for commonly used medications. Consultation with the local pharmacy and specialist palliative care teams is advisable in case of regional variations. Within specialist palliative care teams, medications that are ‘off-label’ or used in unlicensed ways are generally accepted. Note that ‘unlicensed medicine’ refers to a medicinal product that does not have a UK marketing authorisation;^{Reference Wilcock, Howard and Charlesworth555} ‘off-label use’ refers to the use of a medicine with a UK marketing authorisation for an indication outside of its licensing.^{Reference Wilcock, Howard and Charlesworth555}

Pain

Key recommendations for the management of pain:

• • A detailed, individualised pain history should be taken (evidence-based recommendation (R))

• • Awareness of the signs and symptoms of opioid toxicity is important. This may include drowsiness, confusion, vivid dreams, hallucinations, myoclonus and pin-point pupils, occurring before respiratory rate reduces and level of consciousness decreases (good practice point (G))

• • Consider the addition of adjuvant medications, local analgesics and disease-modifying treatments when managing pain (G)

• • First-line adjuvants include gabapentin, pregabalin and amitriptyline (R)

• • Review and reassess effectiveness (G)

An estimated two-thirds of patients with advanced head and neck cancer have severe pain requiring management with opioids (Table 2).^{Reference Chua, Reddy, Lee and Patt557} The pain is often multifactorial, relating directly to the tumour and/or occurring as a result of treatment. Initiating analgesia can be guided by using the WHO analgesic ‘pain ladder’, a simple three-step approach to managing cancer pain (Figure 1).^{558,Reference Fallon, Dierberger, Leng, Hall, Allende and Sabar559}

Table 2. Detailed pain assessment*

* Including, but not limited to, the listed factors

Figure 1. The World Health Organization analgesic ladder.⁵⁵⁸ *Note that recent evidence^{Reference Fallon, Dierberger, Leng, Hall, Allende and Sabar559} supports that step 2 may be omitted. An individualised approach should be taken, tailored to the patient.

This approach, however, must be used as a general guide only, alongside an individualised assessment of pain and a management plan tailored to the individuals’ specific needs. In practice, especially for those with severe uncontrolled cancer pain, it would be appropriate to progress directly to step 3 and prescribe a strong opioid, with steps 1–2 being omitted.^{Reference Caraceni, Hanks, Kaasa, Bennett, Brunelli and Cherny560} A recent open-label randomised, controlled trial^{Reference Fallon, Dierberger, Leng, Hall, Allende and Sabar559} supported a two-step approach (omitting the weak opioid step) as an alternative option for cancer pain management, which is associated with few side effects and is cost-effective.

Assessing pain

A detailed pain assessment should be conducted (Table 2).^{Reference Hui and Bruera561} This can help identify the primary cause of the pain and in turn indicate which treatment(s) might be most effective, including the use of non-pharmacological interventions and disease-modifying treatments. Consideration should be given to the overall holistic needs of the patient, as additional factors such as psychological, social and spiritual problems can influence the patient's pain experience and response to treatment, a concept referred to as ‘total pain’.^{Reference George, Minello, Allano, Maindet, Burnod and Lemaire562}

Types of pain and their management

Nociceptive pain may be present as a result of direct tumour invasion of soft tissue and bone. Oral morphine would usually be the first choice because of familiarity and availability (Tables 3 and 4).^{Reference Hanks, Conno, Cherny, Hanna, Kalso and McQuay563,564} It is important to explain clearly to patients the difference between the immediate release and modified release preparations, as confusion can lead to opioid toxicity (Table 3).

Table 3. Commonly prescribed short-acting opioids

Note: when initiating opioids, make patients aware of the associated driving regulations.^{Reference Prichard, Norton and Bharucha574} CSCI = continuous subcutaneous infusion; IV = intravenous; eGFR = estimated glomerular filtration rate (in ml/minute/1.73 m²)

Table 4. Commonly prescribed long-acting opioids*

Note: when initiating opioids, make patients aware of the associated driving regulations.⁵⁶⁴ *Including syringe drivers, which although are short-acting preparations, are administered over 24 hours and so provide long-acting pain relief. NG = nasogastric; CSCI = continuous subcutaneous infusion

Neuropathic pain may be present because of the compression or infiltration of nerves. Opioids may provide limited relief for such pain, and the use of an adjuvant (a drug that has a primary indication for something other than pain, but which can have an analgesic effect) may be required. First-line adjuvants would be amitriptyline, gabapentin or pregabalin (Table 5).^{Reference Mishra, Bhatnagar, Goyal, Rana and Upadhya565,566} The choice of medication can be influenced by factors such as side effect profile, contraindications, patient co-morbidities and dosing regimen.

Table 5. Commonly prescribed neuropathic pain agents

o.d. = once a day; t.d.s. = three times a day; b.d. = twice a day

Oral mucosal pain is common in head and neck cancer patients, but there is a lack of robust evidence supporting the management of oral mucositis.^{Reference Saunders, Rouleau, Cheng, Yarom, Kandwal and Joy567} Treatment should focus on the underlying cause, maintaining oral hygiene, providing pain relief, protecting ulcerated areas and treating any secondary infection. Topical anaesthetics such as benzydamine and/or oxetacaine can be used. The regular application of coating agents (such as Orabase^™ and Gelclair^™) may provide some short-term relief. The use of topical opioids can be helpful, although immediate release morphine (oral solution, which contains alcohol) may exacerbate oral pain. Some centres can prepare a special-order morphine, which can be held in the mouth for a local analgesic effect. Otherwise, consider the use of oxycodone liquid, as this is alcohol-free.

Patients may have other types of pain related to their cancer, including visceral pain from metastatic disease. The same approach to pain assessment should be taken, with additional consideration given to specific types of pain. For example, patients with liver capsule pain may benefit from a trial of dexamethasone. Pain management can be complex and supported through discussion with the specialist palliative care team, including escalation to medications used under specialist supervision such as methadone or ketamine, if required.

Nausea and vomiting

Key recommendations for the management of nausea:

• • Identification of the underlying cause(s) can help direct management (good practice point (G))

• • Non-pharmacological and pharmacological methods should be used to manage nausea and vomiting (G)

• • Choose the most suitable anti-emetic depending on the likely cause(s) (G)

• • Consider the most appropriate route of administration, formulation and dose (G)

Nausea is defined as an ‘unpleasant sensation of the need to vomit’, presenting with or without vomiting,⁵⁶⁸ and often in conjunction with other autonomic symptoms, e.g. cold sweats, tachycardia and diarrhoea. Persistent nausea and frequent vomiting significantly reduce quality of life, and can result in complications like dehydration and malnutrition.^{Reference Leach569} In a similar approach to pain management, comprehensive assessment is needed to identify and treat the cause(s), and both non-pharmacological (Table 6) and pharmacological methods should be used.

Table 6. Non-pharmacological interventions to manage nausea and vomiting

Many different causes can contribute to nausea and vomiting in those with head and neck cancer (Table 7).^568–570 Identification of the underlying cause(s) can help direct pharmacological management (Table 8).^{Reference Wilcock, Howard and Charlesworth555,568,Reference Leach569,Reference Smyth571} We have not specifically mentioned chemotherapy- or radiotherapy-induced nausea and vomiting, or post-operative causes, as local management guidelines are often in place.

Table 7. Choosing most suitable anti-emetic by possible cause of nausea and vomiting

Table 8. Common choices of anti-emetics used in pharmacological management of nausea and vomiting

t.d.s. = three times a day; NG = nasogastric; 5-HT = 5-hydroxytryptamine; IV = intravenous; CSCI = continuous subcutaneous infusion; max = maximum; o.d. = once a day; GABA = γ-aminobutyric acid

Generally, the oral route of administration may not be available or appropriate (if there is persistent nausea or vomiting); therefore, the subcutaneous route and continuous subcutaneous infusions can be used. Intravenous and intramuscular administration is usually avoided because of issues with venous access and pain on or after administration. In patients unable to swallow or who have enteral feeding tubes, the NEWT Guidelines^{Reference Smyth571} can be used to help identify alternative routes and administration methods.

Constipation

Key recommendations for the management of constipation:

• • Assess stool frequency and consistency, to determine whether stimulant and/or softener required (good practice point (G))

• • Assess patient's previous experience of laxatives and tolerability (taste, volume, frequency) (G)

• • When initiating opioids, also prescribe a regular low-dose stimulant or osmotic agent (G)

Constipation is a distressing symptom, and those with head and neck cancer are particularly vulnerable because of dietary factors (struggling to obtain adequate fibre or hydration), and iatrogenic causes (opioid analgesia, serotonin antagonists for nausea, and chemotherapeutic agents). Favourable management of constipation is preventative, ensuring patients are adequately provided with laxatives if requiring constipating therapies.^{Reference Larkin, Cherny, La Carpia, Guglielmo, Ostgathe and Scotte572,Reference Muller-Lissner, Bassotti, Coffin, Drewes, Breivik and Eisenberg573} Individual patient needs should be considered, so if a patient has prior experience with laxatives, the preferred agent may be revealed. Otherwise, consider factors such as available routes and tolerance of volume for your patient. Generally, continue with one agent from each class and titrate (Table 9). It is worth noting that an additional class of ‘bulk-forming’ laxatives exist, but are not generally recommended in palliative care. Suppositories may be required, followed by enemas, to prevent faecal impaction in severe cases.

Table 9. Commonly prescribed types of laxatives

b.d. = twice a day; o.d. = once a day

Opioid-induced constipation is common, so, when initiating opioid treatment, also start a regular low-dose stimulant or osmotic agent, and titrate to affect.^{Reference Prichard, Norton and Bharucha574} If constipation persists beyond a few days despite regular laxatives, a rectal examination with or without enema is the next step. If these methods fail, specialist palliative care advice can be sought for use of peripheral opioid antagonists such as naloxegol and methylnaltrexone.^{Reference Muller-Lissner, Bassotti, Coffin, Drewes, Breivik and Eisenberg573,Reference Prichard, Norton and Bharucha574}

Secretions

Key recommendations for the management of secretions:

• • Identification of the underlying cause(s) of secretions will help identify potentially reversible causes of the secretions (good practice point (G))

• • Detailed assessment of the types of secretions is essential, as thick or thin or secretions at the end of life are managed differently (G)

• • Non-pharmacological methods should be considered to help manage all types of secretions (G)

Although xerostomia (dry mouth) is common in head and neck cancer patients, excess secretions and/or the inability to swallow or clear secretions are often troublesome.^{Reference Bomeli, Desai, Johnson and Walvekar575,576} Potentially reversible causes should be considered (Table 10).^{Reference Wilcock, Howard and Charlesworth555,576,577}

Table 10. Choosing most suitable treatment by possible cause of secretions

IV = intravenous; H₂ = histamine type 2; PPI = proton pump inhibitors

Reduced salivary production, xerostomia and thick salivary secretions are the most commonly observed complication of radiotherapy.^{Reference Bomeli, Desai, Johnson and Walvekar575} The management of thick, tenacious secretions involves largely conservative measures, such as suctioning, using pineapple juice as a lytic agent, employing a cough assist device, and reducing or stopping the medication potentially causing the secretions if appropriate.^{Reference Bomeli, Desai, Johnson and Walvekar575,Reference McGeachan and McDermott578} Humidification, sodium chloride nebules and mucolytics can be considered as treatment for these secretions. Sodium chloride nebules can help loosen the secretions; however, they are unsuitable for patients who cannot expectorate, as it can increase production of liquid sputum. Mucolytics can reduce the viscosity of the secretions, especially in the context of chronic obstructive airways disease (Table 11).^{576,Reference McGeachan and McDermott578,579}

Table 11. Choice of medication to help with thick, tenacious secretions

q.d.s. = four times a day; t.d.s. = three times a day; b.d. = twice a day; o.d. = once a day

Drooling or sialorrhoea

The role for palliative care in the management of drooling or sialorrhea will be primarily for patients who have not previously received radiotherapy. Despite the burden of excessive saliva accumulation (sialorrhea) and subsequent drooling having a significant negative impact on the patient's quality of life, there is little research to guide management.^{Reference Bomeli, Desai, Johnson and Walvekar575} Pharmacological management would include antimuscarinics or tricyclic antidepressants (Table 12).^{Reference Bomeli, Desai, Johnson and Walvekar575} Occasionally, under specialist supervision, botulinum toxin injection could be considered if standard treatment is ineffective.^{Reference Bomeli, Desai, Johnson and Walvekar575}

Table 12. Choice of medication to help with sialorrhoea

Secretions at end of life

Noisy secretions caused by fluid collecting in the upper airways, also known as the ‘death rattle,’ occur in about 50 per cent of dying patients.^{Reference Wilcock, Howard and Charlesworth555,Reference Wee and Hillier580} If unconscious, this is unlikely to be distressing to the patient, but can cause distress to family and friends witnessing it, so reassurance is important.^{Reference Wilcock, Howard and Charlesworth555,576,Reference Wee and Hillier580} Non-pharmacological treatment such as positioning, suctioning and mouthcare can help.^{576,Reference Wee and Hillier580} Antibiotics may be indicated for symptom relief if the secretions are caused by profuse purulent sputum in a semi-conscious patient.^{Reference Wilcock, Howard and Charlesworth555,576} Pharmacological treatment should be initiated as soon as the first sign of secretions occurs, as they reduce further secretion production, but do not dry out existing secretions.^{Reference Wilcock, Howard and Charlesworth555,576} A Cochrane review suggests subcutaneous antimuscarinics are of limited benefit, but established practice accepts their use for patients approaching the end of life (Table 13).^{Reference Wilcock, Howard and Charlesworth555,576,Reference Wee and Hillier580} If the rattle is associated with distressing breathlessness in a semi-conscious patient, supplement the recommendations above with an opioid and an anxiolytic sedative.^{Reference Wilcock, Howard and Charlesworth555}

Table 13. Choice of antimuscarinic medication for secretions at end of life

Note: The dose of the syringe driver should be increased if two or more ‘when required’ doses are needed. CSCI = continuous subcutaneous infusion

Bleeding, airway and wound management

Key recommendations for bleeding, airway and wound management in the palliative context:

• • Rule out any reversible cause, e.g. infection or contributing medications, and consider whether oncological or surgical intervention remains appropriate (good practice point (G))

• • Be proactive in initiating advance care planning discussions, especially where risks of acute events could arise (G)

• • In an acute, potentially life-threatening event, it is vital that the patient is never left alone (G)

• • Manage distress and associated symptoms with both pharmacological and non-pharmacological measures (G)

Generally, it is important to identify individuals with head and neck cancer who are at risk of acute, potentially life-threatening events such as a bleeding episode or airway difficulties. These types of events are estimated to occur for 6–11 per cent of head and neck cancer patients.^{Reference Mayland, Ingarfield, Rogers, Dey, Thomas and Waylen581} Identification of the risk enables timely discussions to occur within the MDT about whether further investigation and interventions may be indicated, such as embolisation or radiotherapy.

Bleeding

The identified risk factors for minor and potentially terminal bleeds are shown in Table 14.

Table 14. Risk factors for bleeding

Note: there may be no warning at all. CT = computed tomography

Minor bleeding

A minor or ‘herald’ bleed resolves spontaneously or with minimal intervention. They often, however, signal a risk of ongoing acute events, including terminal bleeding, and should trigger advance care planning discussions. Several factors and treatments should be considered to reduce the risk of bleeding and taken into account when treating minor bleeds (Table 15).

Table 15. Prevention and treatment of minor and major bleeding

NSAIDs = non-steroidal anti-inflammatory drugs; IV = intravenous; IM = intramuscular

Terminal haemorrhage

Three to four per cent of head and neck cancer patients experience a terminal haemorrhage, where the volume of blood loss causes circulatory collapse.^{Reference Harris and Noble582} In the majority of terminal haemorrhages, the patient will lose consciousness before any medication can be administered or have time to take effect. Remaining with the patient for psychological support is the most important treatment (Table 15).^{Reference Harris and Noble582}

Airway management and breathlessness

Airway management in a palliative situation, where a definitive treatment or procedure is not planned, involves measures to control symptoms. These include tracheostomy and laryngectomy care (if already in place), and the use of adrenaline nebulisers and steroids (despite a lack of supporting evidence),^{Reference Hardy, Haywood, Rickett, Sallnow and Good583} and are usually guided by local policies. Additionally, end-of-life guidance on managing breathlessness may have local variation, but is likely to include the use of opioids and benzodiazepines (Table 16).

Table 16. Management of breathlessness and distress

CSCI = continuous subcutaneous infusion; max = maximum; IM = intramuscular; IV = intravenous

If the patient survives an acute event but remains terminal, the use of continuous benzodiazepines and opioids (e.g. via a syringe driver) will control ongoing symptoms. If the patient survives an event and is able to take oral medication, consider benzodiazepines and/or opioids.

Complex wound management

Head and neck cancers often result in wounds that are unusually shaped, in a prominent position, are painful, result in fistulas or gross disfigurement, can bleed, become infected, or are malodorous. Once nutritional status and pressure area care are optimised, and palliative oncological or surgical intervention have been considered, a stepwise management approach can be taken:

• • Exclude or confirm infection by microbiology swabbing and treat appropriately: for systemic or local infections, see local antibiotic policies; for malodour, use metronidazole, orally or topically). Infection can change a wound – make it more painful, induce colour change, cause healing to remain static or deteriorate, and worsen pain, odour or exudate. Superadded infection, particularly of a fungating wound, is an important reversible cause for minor bleeding.

• • Treat the pain (as per previous subsection); consider topical opioid on a dressing and providing pain relief prior to anticipated dressing changes.

• • Appropriate dressings – general principles are outlined in Table 17; refer to local tissue viability formularies.

• • Psychological support for the patient or carers if disfigured. This could be a simple conversation whilst changing dressings, or more formal psychological support if available.

Table 17. Key considerations in wound management

Advance care planning and end-of-life care

Key recommendations for advance care planning and end-of-life care:

• • Consider advance care planning whenever there is a ‘trigger’ or transition in care (good practice point (G))

• • Prepare for end-of-life care at the earliest opportunity and discuss preferences ahead of time (G)

• • Plan ahead for anticipated symptoms or events (G)

• • Recognition that a person might be in the last days of life is critical to providing good end-of-life care (G)

Advance care planning in head and neck cancer patients can be challenging (Table 18).^{Reference Rietjens, Sudore, Connolly, van Delden, Drickamer and Droger584} Communication about illness trajectories and outcomes is critical to the initiation of advance care planning discussions. Studies of head and neck cancer patients demonstrate differences in the understanding and interpretation of information between healthcare professionals, patients and carers, alongside differences in preferences regarding openness to prognostic discussions.^{Reference Vukkadala, Fardeen, Ramchandran and Divi585} Whilst acknowledging that there will be differences in the desire to discuss the future, the opportunity for such a discussion may affect patients’ access to palliative care and hospice care at the end of life.^{Reference Paladino, Koritsanszky, Nisotel, Neville, Miller and Sanders586}

Table 18. European Association of Palliative Care definition of advance care planning

ACP = advance care planning

There are many different models that support discussions relating to advance care planning; these can be helpful frameworks to support clinicians when initiating conversations. Models such as the Serious Illness Conversation Guide^{Reference Paladino, Koritsanszky, Nisotel, Neville, Miller and Sanders586} and mnemonic frameworks (e.g. ‘REMAP’, which stands for Reframe, Expect emotion, Map out patient goals, Align with goals, and Propose a plan^{Reference Childers, Back, Tulsky and Arnold587}) focus on eliciting patients’ values and preferences for care, alongside their goals of care. Advance care planning should be considered to support options for care, including the continuation of further lines of therapy, alongside less interventional approaches and end-of-life care planning.^{Reference Vukkadala, Fardeen, Ramchandran and Divi585} Importantly, advance care planning may not reduce hospital attendance for patients with head and neck cancer, as has been anticipated in patients with other conditions; rather, the difficulty of managing symptoms such as bleeding, airway obstruction and complex wounds in the home setting frequently necessitates hospital-based care. Crucial to introducing advance care planning into practice is the recognition of key ‘triggers’ that prompt the clinician to consider and raise conversations regarding such planning (Table 19).

Table 19. Examples of triggers for introducing conversations about advance care planning

End-of-life care

It can be difficult to be certain that a person is in the last days of life (Table 20). Anticipating this, however, is critical to allow a person to communicate with loved ones, have the potential to be in a place of their choosing, complete any important rituals or attend to spiritual care needs. Care in the last days of life should follow National Institute for Health and Care Excellence (NICE) recommendations (Table 21).⁵⁹⁰

Table 20. Indicators that an individual is entering last days of life

Table 21. Care in last days of life

MDT = multidisciplinary team

For those approaching the last days of life with established artificial nutrition (enteral or parenteral), similar challenges to those with clinically assisted hydration can arise. It is important for patients and/or those individuals close to them to understand that there is a change in the goal of the nutritional support, from maintaining a good nutritional status, to providing comfort and symptom control. The manner in which this happens should be tailored to the individual, and their preferences and needs. For many, stopping the feed when in the last days of life allows the best balance between the burden of the feeding and the clinical benefit (which is minimal at this stage of life).^{Reference Orrevall591} Given the emotional and sometimes spiritual importance of feeding, however, it might be important to discuss a gradual reduction in feeding rather than an abrupt stopping, depending on the person's wishes.

Medication at end of life

‘Anticipatory’ medications should be prescribed to ensure there is no delay in the administration of a required drug, especially for a symptom or situation that can be anticipated (Table 22).⁵⁹⁰

Table 22. Summary of first-line options for anticipated symptoms at end of life*

* Refer also to previous relevant sections about symptom control

‘One Chance to Get it Right’ details the principles for caring for dying people, and highlights five key priorities for care (Table 23).⁵⁹² This advocates the use of an individualised care plan in the last days of life and supports all members of the patient's care team to adopt an appropriate focus of care for the patient, alongside attention to supporting carers. Detailed plans, such as those described above, for anticipated emergencies, are considered essential.

Table 23. The five priorities for caring for a dying person

Current and future research

Over the last decade, many trials have been conducted assessing the merits of palliative care.^{Reference Haun, Estel, Rucker, Friederich, Villalobos and Thomas593,Reference Davis, Temel, Balboni and Glare594} Generally, it is advocated that palliative care be integrated into standard oncological care early in the illness trajectory, often alongside active anti-cancer treatments.^{Reference Ferrell, Temel, Temin, Alesi, Balboni and Basch547} Within an Indian healthcare context, early routine specialist palliative care input for those with head and neck cancer did not improve quality of life at three months.^{Reference Patil, Singhai, Noronha, Bhattacharjee, Deodhar and Salins595} Models of care, however, need to be targeted to individual populations. Questions therefore remain about the optimum model of care needed to improve outcomes for this complex population. Addressing variability in terms of clinical outcomes is essential. Geographical and socio-economic inequalities persist, and ultimately affect place of death.⁵⁹⁶

The limited evidence base for symptom control highlights the need for further work and dedicated funding. Within cancer research, less than 0.3 per cent of the £500 million is allocated to palliative care.^{Reference Higginson597} Clinical trials need to extend inclusion beyond those patients with good performance status, and be combined with novel methodologies to help overcome practical and ethical challenges.

Improving the general palliative care skills and knowledge of the head and neck cancer MDT, and integrating a needs-driven mechanism for access to specialist palliative care services, seem essential.^{Reference Mayland and Payne598} Models of integrated care, which include community providers, are pertinent to avoid ‘silo’ working,^{Reference Ullgren, Kirkpatrick, Kilpelainen and Sharp548} and to enhance decision-making and advance care planning, encourage mutual learning, and optimise quality of life for patients and their family carers.

Chyle leak following head and neck cancer surgery

Recommendations

• • Surgery to the supraclavicular region on both sides of the neck should necessitate careful inspection for a potential chyle leak at completion (evidence-based recommendation (R))

• • If an intra-operative chyle leak is identified, every effort should be made to repair or close the damaged thoracic duct at the time of surgery (R)

• • Biochemical testing to be undertaken to confirm a clinically suspected post-operative chyle leak (good practice point (G))

• • Monitor fluid balance, electrolytes, protein levels and white cell count (R)

• • Consider non-operative measures that can be implemented to reduce chyle flow (R)

• • Operative interventions will be influenced by local experience and available resources (G)

• • Consideration should be given to involving interventional radiology and thoracic teams, even if not available locally for persistent leaks (G)

Intra-operative diagnosis and treatment

Surgery to the supraclavicular region on both sides of the neck should necessitate careful inspection for a potential chyle leak at completion. Identifying a chyle leak can be aided by manoeuvres that increase the intrabdominal and/or intrathoracic pressure. These include Trendelenburg positioning, a Valsalva manoeuvre or abdominal compression. Meticulous haemostasis, careful drying and observation of the area can aid the detection of even small chyle leaks.

If an intra-operative chyle leak is identified, every effort should be made to repair or close the damaged thoracic duct at the time of surgery. If clearly visible, ligation of the thoracic duct can be readily achieved with clips or by over-sewing the duct. Additionally, the use of locoregional muscle flaps to cover the area should be considered. A number of these flaps have been proposed, including the clavicular head of the sternocleidomastoid, the scalenus medius and the omohyoid; one or more of these can be raised and rotated into the space (usually posteriorly to the IJV). Alternatively, a regional pedicled flap such as a pectoralis major flap can be used to fill the space. A number of glues, such as fibrin- or cyanoacrylate-based products, have been proposed to help.^{Reference Delaney, Shi, Shokrani and Sinha599,Reference Brennan, Blythe, Herd, Habib and Anand600} If using such products, care should be taken to isolate nerves (such as the vagus) traversing the region. Figure 1 shows a flow chart summarising the identification and management of a chyle leak following surgery for head and neck cancer.

Figure 1. Flow chart summarising the identification and management of chyle leak following surgery for head and neck cancer.

Post-operative diagnosis and treatment

Table 1 summarises the clinical and biochemical features of a chyle leak. Whilst the classical creamy or milky appearance of the drain fluid is highly indicative of a chyle leak, this may not be evident for a few days, especially if there is serosanguinous discharge or a delay in enteral feeding.^{Reference Erisen, Coskun and Basut602,Reference Rodgers, Johnson, Petruzzelli, Warty and Wagner603}

Table 1. Clinical and biochemical diagnosis of chyle leak

The volume of chyle produced in a 24-hour period is one of the main determinants of treatment. Low output chyle leaks (less than 500 ml/day) are initially managed with conservative non-operative treatment, whilst persistent high output chyle leaks (more than 500 ml/day) will usually require operative treatment. However, volume alone is not the only determinant of treatment. Management will also be influenced by patient factors, the duration of the chyle leak and the impact of losing a large volume of electrolyte-rich fluid. Further factors to consider include the response of the drain output to treatment measures, individual surgeon preference and the range of local services available.^{Reference Delaney, Shi, Shokrani and Sinha599,Reference Brennan, Blythe, Herd, Habib and Anand600,Reference Campisi, Boccardo, Piazza and Campisi604} It is important to note that large fluid shifts can occur, so fluid balance and electrolytes should be monitored regularly, along with white cell counts, blood glucose and albumin levels.

Osteoradionecrosis following head and neck cancer treatment

Recommendations

• • For early osteoradionecrosis, pragmatic conservative and symptomatic management involves debridement of sharp and exposed necrotic bone, analgesia, antiseptic mouthwash, and antibiotics (good practice point (G))

• • Minor bone spicules may heal with entirely conservative management (evidence-based recommendation (R))

• • The role of rim resection and saucerisation, i.e. resection of all necrotic bone in cases of Notani stage 1 and 2 osteoradionecrosis, remains uncertain (G)

• • The use of hyperbaric oxygen in the management or prevention of osteoradionecrosis is not supported by recent randomised, controlled clinical trials (R)

• • The efficacy of the pharmacological therapy with pentoxifylline, vitamin E and clodronate (‘PENTOCLO’) protocol requires further evaluation in controlled trials (R)

• • In patients with Notani stage 3 (advanced) osteoradionecrosis or in those with disease refractory to medical or conservative management, definitive surgical resection and reconstruction is likely to be necessary. This may result in acceptable healing outcomes, but with significant complications and compromised function (R)

Trismus following head and neck cancer treatment

Recommendations

• • The primary focus should be directed towards prevention by identifying high-risk patients before treatment of head and neck cancer (evidence-based recommendation (R))

• • The mainstay of treatment is physiotherapy; jaw-stretching exercises with a trismus device should be commenced as soon as feasible following surgery and/or radiotherapy (RT) (R)/(good practice point (G))

• • Every effort should be made to establish the cause of trismus for targeted investigations and treatment (G)

• • Mouth-opening distance should be measured and recorded at each follow-up consultation, and a realistic goal for mouth opening agreed with the patient (G)

Introduction

Trismus is a common but often overlooked sequelae of head and neck cancer treatment involving surgery and/or RT that involves the masticatory system. It can have a significant impact on the physical, psychological and social well-being of patients, and is generally defined as a reduced jaw opening of 35 mm or less.^{Reference Dijkstra, Huisman and Roodenburg620,Reference Scott, Butterworth, Lowe and Rogers621}

Trismus is associated with several potential complications that lead to a poor overall quality of life for patients. It may result in poor nutrition due to difficulty chewing and poor dentition, and periodontal disease as a result of limited access for both oral hygiene and dental treatment. Chewing and speech difficulties may cause patients to avoid eating in public, leading to social isolation, and even anxiety and depression. Restricted mouth opening may compromise cancer surveillance, and may complicate airway management during general anaesthesia for procedures that may be required down the line. Impaired clearance of oropharyngeal secretions may also lead to a risk of aspiration.^{Reference Scott, Butterworth, Lowe and Rogers621–Reference Kamstra, van Leeuwen, Roodenburg and Dijkstra623} It is therefore important that trismus is actively addressed and dealt with by clinicians as soon as possible (Table 2).

Table 2. Summary of management of trismus post head and neck cancer treatment

CT = computed tomography; MRI = magnetic resonance imaging; PET = positron emission tomography

Aspiration and dysphagia following head and neck cancer treatment

Recommendations

• • Functional and radiological swallowing assessment should be considered in all patients with post-treatment dysphagia and aspiration (evidence-based recommendation (R))

• • Endoscopic dilatation should be offered to patients with a symptomatic pharyngeal stricture (R)

• • Multidisciplinary team (MDT) input and shared decision-making with the patient must support consideration of a functional laryngectomy (R)

• • Gastrostomy and tracheostomy insertion are reasonable interventions to manage laryngeal and pharyngeal dysfunction following head and neck cancer treatment (good practice point (G))

• • Cross-sectional imaging should be performed prior to major surgical intervention, to exclude recurrent disease (G)

Radiotherapy-induced xerostomia

Recommendations

• • All patients should be asked about dry mouth symptoms (xerostomia) as part of their post-treatment clinical reviews (evidence-based recommendation (R))

• • Salivary substitutes and oral lubricants in a variety of forms (sprays, gel, mouthwash, slow-release adhesive discs) may be recommended for the pragmatic temporary reduction of dry mouth symptoms. When residual saliva gland function is present, tactile stimulation of the salivary reflex with topical sialagogues (sugar-free gums, pastilles and lozenges) may temporarily increase natural salivation and reduce dry mouth symptoms. Evidence behind both interventions is not robust, and the perceived benefits can vary widely (good practice point (G))

• • When residual salivary gland function is present, and topical sialagogues do not offer satisfactory relief from persistent xerostomia, systemic sialagogues (e.g. the parasympathomimetic cholinergic agonist pilocarpine hydrochloride) should be considered if there are no absolute contraindications in the patient's medical history. The efficacy of pilocarpine in increasing salivary flow and reducing xerostomia is supported by robust evidence. Adverse effects are common but usually mild, and should be discussed with the patient (R)

• • If the above strategies are not effective, clinicians may consider acupuncture or neuro-electrostimulation (intra-oral or extra-oral devices). The evidence supporting these strategies is not robust, and availability may vary widely (G)

Introduction

Xerostomia is defined as the subjective sensation of oral dryness, whereas hyposalivation reflects an objective, measurable decrease in salivary flow.^{Reference Epstein, Thariat, Bensadoun, Barasch, Murphy and Kolnick634}

Radiation exposure of salivary glands located within the treatment portal results in a dramatic loss of gland function within the first week of treatment, with a subsequent permanent decrease in salivary flow rate in the vast majority of patients.^{Reference Burlage, Coppes, Meertens, Stokman and Vissink635,Reference Nagler636} The critical dose limit for parotid and submandibular salivary gland tissue is less than 30 Gy; exceeding this limit typically leads to the acute and eventually progressive, irreversible loss of saliva-producing acinar cells, impaired parasympathetic innervation, and injury to glandular vascular structures.^{Reference Konings, Coppes and Vissink637} Hyposalivation and xerostomia can also be associated with chemotherapy, although function loss and associated symptoms tend to be less severe and often transient.^{Reference Jensen, Mouridsen, Reibel, Brünner and Nauntofte638}

More than 60 per cent of individuals with head and neck cancer receiving radiation as a monotherapy or in combination with chemotherapy develop irreversible hyposalivation and experience permanent xerostomia.^{Reference Wijers, Levendag, Braaksma, Boonzaaijer, Visch and Schmitz639} Intra-oral discomfort, difficulties with speech, chewing and swallowing, as well as increased risks of secondary oral infection (e.g. candidiasis and suppurative sialadenitis) and dental disease are commonly seen as consequences of hyposalivation in head and neck cancer survivors.^{Reference Porter, Fedele and Habbab640} Dental disease in turn may increase the risk of jawbone osteoradionecrosis. Ultimately, a restriction in daily activities, reduced quality of life, poorer general health, social disability and malnutrition may be observed.^{Reference van der Laan, Van den Bosch, Schuit, Steenbakkers, van der Schaaf and Langendijk641,Reference Langendijk, Doornaert, Verdonck-de Leeuw, Leemans, Aaronson and Slotman247}

This chapter proposes a working management plan for hyposalivation and xerostomia (Figure 2).

Figure 2. Flow chart summarising a working management plan for hyposalivation and xerostomia.

Unilateral vocal fold paralysis following treatment for head and neck cancer

Recommendations

• • All patients with a unilateral vocal fold palsy should be assessed by a speech and language therapist (evidence-based recommendation (R))

• • Transection of the recurrent laryngeal nerve at the time of surgery should be followed by primary repair where skills allow for this (good practice point (G))

• • Early medialisation should be considered in all patients (G)

Introduction and presentation

Unilateral vocal fold paralysis is not uncommon in patients undergoing treatment for head and neck cancer, particularly following surgery for thyroid cancer. Symptoms of unilateral vocal fold paralysis include a breathy and quiet voice. Many patients will also instinctively tension the vocal folds, resulting in a high-pitched voice.

The loss of adequate glottic closure affects swallow function, with aspiration of solids and liquids, but also saliva. Spontaneous coughing on the patient's own secretions is not uncommon. The loss of glottic competence also means that the strength of the cough is diminished (characteristically described as ‘bovine’). It is now recognised that silent aspiration results in excess morbidity and mortality.^{Reference Nouraei, Allen, Kaddour, Middleton, Aylin and Darzi654} Figure 3 shows a suggested algorithm for the management of unilateral vocal fold paralysis.

Figure 3. Suggested algorithm for the management of unilateral vocal fold (VF) paralysis. EMG = electromyography

Features of unilateral vocal fold paralysis:

• • Breathy, weak voice

• • Altered pitch (often high-pitched)

• • Vocal fatigue

• • Hyperventilation

• • Ineffective cough

• • Aspiration (particularly liquids)

• • Pneumonia

The degree of breathy dysphonia is variable and depends on the position of the paralysed vocal fold; a vocal fold sitting in a median or paramedian position results in better glottic closure, and hence a stronger voice. Conversely, a vocal fold in a lateral position will result in a very breathy voice. Most treatments for unilateral vocal fold paralysis are aimed at pushing the paralysed vocal fold into a more medial position (vocal fold augmentation or medialisation). Some patients will still aspirate despite good compensation, and this may be related to sensory deficits from the injury.

Thyroid testing and dysfunction following head and neck cancer treatment