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Diagnosis and Management of Head and Neck Cancer 90 a National Clinical Guideline

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Diagnosis and Management of Head and Neck Cancer 90 a National Clinical Guideline 90 SIGN Scottish Intercollegiate Guidelines Network Diagnosis and management of head and neck cancer 90 A national clinical guideline 1 Introduction 1 2 Presentation, screening and risk factors 3 3 Referral and diagnosis 6 4 Histopathology reporting 10 5 Overview of treatment of the primary tumour and neck 12 6 Treatment: radiotherapy as the major treatment modality 17 7 Treatment: surgery as the major treatment modality 22 8 Treatment: chemotherapy in combination with surgery or radiotherapy 25 9 Treatment: management of locoregional recurrence 28 10 Treatment: palliation of incurable disease 30 11 Laryngeal cancer 32 12 Hypopharyngeal cancer 36 13 Oropharyngeal cancer 39 14 Oral cavity cancer 43 15 Follow up, rehabilitation and patient support 47 16 Information for discussion with patients and carers 53 17 Implementation, resource implications, audit and further research 63 18 Development of the guideline 65 Abbreviations 68 Annexes 70 References 78 October 2006 COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE ONLINE AT WWW.SIGN.AC.UK KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias 1 - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias 2++ High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS Recommended best practice based on the clinical experience of the guideline development group Supplementary material available on our website www.sign.ac.uk This document is produced from elemental chlorine-free material and is sourced from sustainable forests Scottish Intercollegiate Guidelines Network Diagnosis and management of head and neck cancer A national clinical guideline October 2006 © Scottish Intercollegiate Guidelines Network ISBN (10) 1 905813 007 ISBN (13) 978 1 905813 00 1 First published 2006 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network 28 Thistle Street, Edinburgh EH2 1EN www.sign.ac.uk 1 INTRODUCTION 1 Introduction 1.1 thE NEED FOR A GUIDELINE Approximately 1,000 patients with new cancers of the head and neck are registered in Scotland each year. The incidence of disease has tended to increase with age and in the UK 85% of cases are in people aged over 50. There is now evidence that the incidence of head and neck cancers is increasing amongst young people of both sexes.1, 2 The disease tends to be a disease of deprivation, with the risk of developing the disease four times greater for men living in the most deprived areas. The current overall five-year survival rates vary by tumour site.3 In general, patients with early disease stand a better chance of cure or increased survival. Many patients with head and neck cancer present at a late stage, and improved survival for patients may be achieved with rapid detection and treatment. Clear guidelines for management of tumours of all stages arising at all sites are lacking and there is a lack of good quality evidence from randomised controlled trials (RCTs). Improved awareness and the implementation of a national guideline should improve patient outcomes. 1.2 rEMIT OF THE GUIDELINE The guideline follows the patient’s journey of care from prevention and awareness through treatment to follow up and rehabilitation, making generic recommendations which hold for all head and neck cancers. The treatment sections focus specifically on cancers of the larynx, oral cavity, oropharynx and hypopharynx, as these are the tumour sites with the highest incidences. The guideline does not cover tumours of the nasopharynx, sinuses, salivary glands or thyroid. This guideline will be of interest to all healthcare professionals working with patients with head and neck cancers, including ear, nose and throat specialists, oral and maxillofacial surgeons, plastic surgeons, general surgeons, clinical oncologists, nurses and allied health professionals. 1.3 dEFINITIONS 1.3.1 LARYNGEAL CANCER Laryngeal cancer includes tumours of the:4 . supraglottis . glottis . subglottis. 1.3.2 hYPOPHARYNGEAL CANCER Hypopharyngeal cancer includes tumours of the:4 . postcricoid area . pyriform sinus . posterior pharyngeal wall. 1.3.3 oroPHARYNGEAL CANCER Oropharyngeal cancer includes tumours of the:4 . base of tongue . tonsil . soft palate. 1 DIAGNOSIS AND MANAGEMENT OF HEAD AND NECK CANCER 1.3.4 oraL CAVITY CANCER Oral cavity cancer includes tumours of the:4 . buccal mucosa . retromolar triangle . alveolus . hard palate . anterior two-thirds of tongue . floor of mouth . mucosal surface of the lip. 1.4 tUMOUR STAGING For the purposes of the guideline each tumour subsite is divided into “early disease” – equivalent to stages 1 and 2 following the Union Internationale Contre le Cancer (UICC)/ TNM Classification of Malignant Tumours – and “locally advanced disease” – UICC/TNM stages 3 and 4. (See Annex 1.)4 1.5 StatEMENT OF INTENT This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken. 1.6 rEVIEW AND UPDATING This guideline was issued in 2006 and will be considered for review in three years. Any updates to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk. 2 2 PRESENTATION, SCREENING AND RISK FACTORS 2 Presentation, screening and risk factors 2.1 changing EPIDEMIOLOGY Head and neck cancers are traditionally associated with older men who smoke and consume alcohol. A percentage of patients will not have the traditional risk factors, but the absence of these risk factors does not preclude the diagnosis. Evidence suggests that the incidence in the younger population of both sexes is rising. This coincides with an increase in the incidence of oral cancer.1 No evidence to explain these changes was identified. 2.2 riSK FACTORS Healthcare professionals should be aware of the possible risk factors for head and neck cancer and that patients with a combination of risk factors may be at greater risk. A detailed case history should be taken for patients with suspected head and neck cancer. 2.2.1 smoking AND TOBACCO USE 5-12 Smoking is a risk factor for all tumour sites covered by this guideline. Leaving a cigarette on 2+ the lip is predictive of lip cancer risk irrespective of cumulative tobacco consumption.13 Chewing tobacco is a risk factor for cancer of the oral cavity.14 1++ B The population of Scotland should be discouraged from smoking or chewing tobacco. The Smoking Cessation Guidelines for Scotland: 2004 Update,15 commissioned by NHSScotland and ASH Scotland makes recommendations for the organisation and implementation of clinical 4 interventions to promote smoking cessation in Scotland. D Healthcare professionals should put people in contact with the appropriate smoking cessation services. A small cohort study comparing smokers, ex-smokers and non-smokers showed that smoking alters gene expression in bronchial epithelium cells. Two years after discontinuation of smoking 2++ all but 13 of the 97 genes reverted to normal expression levels.16 C Patients with precancerous oral lesions who use tobacco should be advised to give up. 2.2.2 aLCOHOL CONSUMPTION Alcohol consumption strongly increases the risk of developing cancers of the oral cavity, pharynx 17,18 and larynx. There is a strong relationship between the quantity of alcohol consumption and 2++ the level of risk.
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