People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Stages of upper aerodigestive tract cancer
The stages of upper aerodigestive tract cancer referred to in this guideline are based on the TNM classification 7th Edition:
T0: this means there is no primary tumour, but there may be abnormal cells that are precancerous.
T1 to T4: this refers to the increasing size and/or extent of the primary tumour, with 1 being smallest and 4 largest.
N0: no lymph nodes contain cancer cells.
N1 and upwards: increasing involvement of lymph nodes by cancer cells.
For people with cancer of the upper aerodigestive tract and their carers:
provide consistent information and support at diagnosis
review their needs throughout the care pathway including at the end of treatment
tailor information and support to the person's needs (including the benefits and side effects of treatment, psychosocial and long‑term functional issues). [2016]
Give people contact details for their allocated key worker, in line with NICE's cancer service guidance on improving outcomes in head and neck cancer and recommendations of the National Peer Review Programme. [2016]
Give people details of peer support services that can help them throughout their care pathway. [2016]
Offer information about human papillomavirus (HPV) to people with HPV‑related cancer of the upper aerodigestive tract. [2016]
Inform patients and carers at the point of diagnosis about how continuing to smoke adversely affects outcomes such as:
treatment‑related side effects
risk of recurrence
risk of second primary cancers. [2016]
Offer help to people to stop smoking, in line with NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence. [2016]
Consider adding ultrasound‑guidance to fine‑needle aspiration cytology or core biopsy for people with a neck lump that is suspected of being cancer of the upper aerodigestive tract. [2016]
Consider having a cytopathologist or biomedical scientist assess the cytology sample adequacy when the procedure is carried out. [2016]
Consider a fluorodeoxyglucose positron emission tomography (FDG PET)‑CT scan as the first investigation to detect the primary site in people with metastatic nodal squamous cell carcinoma of unknown origin that is thought to arise from the upper aerodigestive tract. [2016]
Consider using narrow‑band imaging endoscopy to identify a possible primary site when it has not been possible to do so using FDG PET‑CT. [2016]
Offer a biopsy to confirm a possible primary site. [2016]
Offer surgical diagnostic assessment if FDG PET‑CT does not identify a possible primary site. This may include:
guided biopsies
tonsillectomy
tongue base mucosectomy. [2016]
Consider an MRI or CT scan before diagnostic surgery to help with radiotherapy treatment planning. [2016]
Offer systemic staging (see recommendations 1.2.9–1.2.11) to all people with cancer of the upper aerodigestive tract except those with T1N0 or T2N0 disease. [2016]
Offer FDG PET‑CT to people with T4 cancer of the hypopharynx or nasopharynx. [2016]
Offer FDG PET‑CT to people with N3 cancer of the upper aerodigestive tract. [2016]
Offer conventional imaging (for example, chest CT) to people with cancer of the upper aerodigestive tract who require systemic staging (see recommendation 1.2.8) but FDG PET‑CT is not indicated for them. [2016]
Offer transoral laser microsurgery to people with newly‑diagnosed T1a squamous cell carcinoma of the glottic larynx. [2016]
Offer a choice of transoral laser microsurgery or radiotherapy to people with newly‑diagnosed T1b–T2 squamous cell carcinoma of the glottic larynx. [2016]
Offer a choice of transoral surgery or radiotherapy to people with newly‑diagnosed T1–T2 squamous cell carcinoma of the supraglottic larynx. [2016]
Offer surgical management of the neck to all people with early oral cavity cancer (T1–T2, N0). [2016]
Offer sentinel lymph node biopsy instead of elective neck dissection to people with early oral cavity cancer (T1–T2, N0), unless they need cervical access at the same time (for example, free‑flap reconstruction). [2016]
Offer people the choice of transoral surgical resection or primary radiotherapy for T1–2 N0 tumours of the oropharynx. [2016]
Consider postoperative radiotherapy, with or without concomitant chemotherapy, for T1–2 N0 tumours of the oropharynx if pathologically adverse risk factors have been identified. [2016]
Offer people with T3 squamous cell carcinoma of the larynx a choice of:
radiotherapy with concomitant chemotherapy or
surgery with adjuvant radiotherapy, with or without concomitant chemotherapy. [2016]
Discuss the following with people with T3 squamous cell carcinoma of the larynx and their carers, to inform their choice of treatment:
the potential advantages of laryngeal preservation
the risk of needing salvage laryngectomy (and its associated complications)
the benefits of primary surgery in people with existing compromised swallowing and airway function
likely voice and swallowing function after treatment (including the need for a long‑term feeding tube). [2016]
For people with T4a squamous cell carcinoma of the larynx consider surgery with adjuvant radiotherapy, with or without concomitant chemotherapy. [2016]
Offer larynx‑preserving treatment to people with locally‑advanced squamous cell carcinoma of the hypopharynx if radiation and neo‑adjuvant and/or concomitant chemotherapy would be suitable for them and they do not have:
tumour‑related dysphagia needing a feeding tube
a compromised airway
recurrent aspiration pneumonias. [2016]
Offer radiotherapy with neo‑adjuvant and/or concomitant chemotherapy if larynx‑preserving treatment is suitable for the person. [2016]
Offer primary surgery followed by adjuvant radiotherapy to people if chemotherapy is not a suitable treatment for them. [2016]
Offer adjuvant radiotherapy to people having surgery as their primary treatment. Add concomitant chemotherapy if appropriate. [2016]
Identify people at risk of airways obstruction for whom intervention is appropriate. Think about:
their performance status
treatment side effects and length of hospital stay
involving the palliative care team and other specialists when appropriate. [2016]
Consider endoluminal debulking in preference to tracheostomy. [2016]
Establish a management plan if surgical intervention is not appropriate, in conjunction with the person, carers and clinical staff. [2016]
Assess and treat other causes of breathlessness in people with incurable upper aerodigestive tract cancer. [2016]
The point at which to use genomic biomarker-based therapy in solid tumour treatment pathways is uncertain. See the NICE topic page on genomic biomarker-based therapy.
Offer FDG PET-CT to guide management for people treated with radical chemoradiotherapy who have:
an oropharyngeal primary cancer site and
2 or more positive nodes in the neck, all of which are less than 6 cm across.
The term 'radical chemoradiotherapy' refers to treatment aiming to cure cancer rather than to relieve symptoms (palliative treatment). It is used here to reflect the evidence that these recommendations are based on. [2018]
Consider FDG PET-CT to guide management for people treated with radical chemoradiotherapy who have:
an oropharyngeal primary site with 1 positive node in the neck that is less than 6 cm across or
an oropharyngeal primary site with 1 or more positive nodes larger than 6 cm across in the neck or
a hypopharyngeal or laryngeal primary site with 1 or more positive nodes in the neck. [2018]
For people having an FDG PET-CT scan after chemoradiotherapy, perform the scan 3 to 6 months after chemoradiotherapy has finished. [2018]
Do not offer neck dissection to people with no abnormal FDG uptake or residual soft tissue mass on an FDG PET-CT scan. [2018]
For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on response assessment after chemoradiotherapy.
Full details of the evidence and the committee's discussion are in evidence review A: evidence reviews for treatment of advanced disease
Offer intensity‑modulated radiation therapy with concomitant chemotherapy to people with locally‑advanced (stage II and above) nasopharyngeal cancer. [2016]
Consider adjuvant or neo‑adjuvant chemotherapy for people with locally‑advanced (stage II and above) nasopharyngeal cancer. [2016]
Offer surgery as the first treatment for carcinoma of the paranasal sinuses if complete resection is possible. [2016]
Consider radiotherapy with or without concomitant chemotherapy before planned surgical resection of the paranasal sinuses if complete resection is not initially possible. [2016]
Offer people with squamous cell carcinoma in the cervical lymph nodes with an unknown primary the choice of:
neck dissection and adjuvant radiation with or without chemotherapy or
primary radiation with or without chemotherapy, with surgery for persistent disease. [2016]
Consider no further treatment as an option in people with pN1 disease without extracapsular spread after neck dissection. [2016]
Consider including potential primary tumour sites when selecting the volume to be treated with radiotherapy. [2016]
Consider surgery and adjuvant radiotherapy for people with newly‑diagnosed upper aerodigestive tract mucosal melanoma without systemic metastases. [2016]
The point at which to use genomic biomarker-based therapy in solid tumour treatment pathways is uncertain. See the NICE topic page on genomic biomarker-based therapy.
Assess people's need for enteral nutrition at diagnosis, including prophylactic tube placement. The multidisciplinary team should take into account:
performance status and social factors
nutritional status (weight loss, high or low BMI, ability to meet estimated nutritional needs)
tumour stage
tumour site
pre‑existing dysphagia
impact of planned treatment (such as radiation treatment volume and dose‑fractionation, concomitant chemotherapy, and extent and site of surgery). [2016]
Follow the recommendations in NICE's guideline on nutrition support for adults for people aged 18 years and over. [2016]
Consider swallowing‑exercise programmes for people having radiotherapy. [2016]
Consider mouth‑opening exercises for people having radiotherapy who are at risk of reduced mouth opening. [2016]
Consider voice therapy for people whose voice has changed because of their treatment. [2016]
Consider progressive resistance training for people with impaired shoulder function, as soon as possible after neck dissection. [2016]
Ensure people with cancer of the upper aerodigestive tract and their carers have tailored information about the symptoms of recurrence and late effects of treatment at the end of curative therapy. [2016]
Consider structured, risk‑adapted follow‑up using locally‑agreed protocols for people who have had curative treatment for cancer of the upper aerodigestive tract. Use the follow‑up protocols to:
help improve quality of life, including discussing psychosocial issues
detect disease recurrence or second primary cancer, possibly including narrow‑band imaging to improve detection. [2016]
Consider surgery to remove necrotic bone and to establish soft tissue coverage in people with osteoradionecrosis. [2016]
Only consider hyperbaric oxygen therapy or medical management for treating osteoradionecrosis as part of a clinical trial. [2016]