Cancer of the upper aerodigestive tract: assessment and management in people aged 16 or over

  • NICE guideline
  • NG36
  • Published: 
  • Last updated: 
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Recommendations

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.

Health and social care professionals should follow our general guidelines for people delivering care:

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.

1.1 Information and support

Information needs

1.1.1

Offer information about human papillomavirus (HPV) to people with HPV‑related cancer of the upper aerodigestive tract. [2016]

Smoking cessation

1.1.2

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]

1.2 Investigation

Assessment of neck lumps

1.2.1

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]

1.2.2

Consider having a cytopathologist or biomedical scientist assess the cytology sample adequacy when the procedure is carried out. [2016]

Identifying the occult primary

1.2.3

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]

1.2.4

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]

1.2.5

Offer a biopsy to confirm a possible primary site. [2016]

1.2.6

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]

1.2.7

Consider an MRI or CT scan before diagnostic surgery to help with planning radiotherapy treatment. [2016]

Clinical staging – who and how?

1.2.8

Offer systemic staging (see recommendations 1.2.9 to 1.2.11) to all people with cancer of the upper aerodigestive tract except those with T1N0 or T2N0 disease. [2016]

1.2.9

Offer FDG PET‑CT to people with T4 cancer of the hypopharynx or nasopharynx. [2016]

1.2.10

Offer FDG PET‑CT to people with N3 cancer of the upper aerodigestive tract. [2016]

1.2.11

Offer conventional imaging (for example, chest CT) to people with cancer of the upper aerodigestive tract if they need systemic staging (see recommendation 1.2.8) and FDG PET‑CT is not indicated for them. [2016]

1.3 Treatment of early-stage disease

Squamous cell carcinoma of the larynx

1.3.1

Offer transoral laser microsurgery to people with newly diagnosed T1a squamous cell carcinoma of the glottic larynx. [2016]

1.3.2

Offer a choice of transoral laser microsurgery or radiotherapy to people with newly diagnosed squamous cell carcinoma of the glottic larynx (grade T1b to T2). [2016]

1.3.3

Offer a choice of transoral surgery or radiotherapy to people with newly diagnosed squamous cell carcinoma of the supraglottic larynx (grade T1b to T2). [2016]

Management of the N0 neck in grade T1 to T2 squamous cell carcinoma of the oral cavity

1.3.4

Offer surgical management of the neck to all people with early oral cavity cancer (grade T1 to T2, N0). [2016]

1.3.5

Offer sentinel lymph node biopsy instead of elective neck dissection to people with early oral cavity cancer (grade T1 to T2, N0), unless they need cervical access at the same time (for example, free‑flap reconstruction). [2016]

Squamous cell carcinoma of the oropharynx (grade T1 to T2, N0)

1.3.6

Offer people the choice of transoral surgical resection or primary radiotherapy for tumours of the oropharynx (grade T1 to T2, N0). [2016]

1.3.7

Consider postoperative radiotherapy, with or without concomitant chemotherapy, for tumours of the oropharynx (grade T1 to T2, N0) if pathologically adverse risk factors have been identified. [2016]

1.4 Response assessment after chemoradiotherapy

1.4.1

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. [2018]

1.4.2

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 in the neck that is larger than 6 cm across or

  • a hypopharyngeal or laryngeal primary site with 1 or more positive nodes in the neck. [2018]

1.4.3

For people having an FDG PET-CT scan after chemoradiotherapy, perform the scan 3 to 6 months after chemoradiotherapy has finished. [2018]

1.4.4

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: treatment of advanced disease.

1.5 Treatment of advanced disease

Squamous cell carcinoma of the larynx

1.5.1

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]

1.5.2

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]

1.5.3

For people with T4a squamous cell carcinoma of the larynx consider surgery with adjuvant radiotherapy, with or without concomitant chemotherapy. [2016]

Squamous cell carcinoma of the hypopharynx

1.5.4

Offer larynx‑preserving treatment to people with locally advanced squamous cell carcinoma of the hypopharynx if:

  • radiation with neo‑adjuvant chemotherapy, with concomitant chemotherapy, or with both, would be suitable for them and

  • they do not have:

    • tumour‑related dysphagia needing a feeding tube

    • a compromised airway

    • recurrent aspiration pneumonias. [2016]

1.5.5

Offer radiotherapy with neo‑adjuvant chemotherapy, with concomitant chemotherapy, or with both, if larynx‑preserving treatment is suitable for the person. [2016]

1.5.6

Offer primary surgery followed by adjuvant radiotherapy to people if chemotherapy is not a suitable treatment for them. [2016]

1.5.7

Offer adjuvant radiotherapy to people having surgery as their primary treatment. Add concomitant chemotherapy if appropriate. [2016]

Systemic anticancer therapy for squamous cell carcinoma of the head and neck (oropharynx, hypopharynx, larynx or oral cavity)

Locally advanced
1.5.8

Cetuximab in combination with radiotherapy is recommended as an option in NICE technology appraisal guidance for treating people with locally advanced squamous cell cancer of the head and neck whose Karnofsky performance-status score is 90% or greater and in whom platinum-based chemoradiotherapy treatment is contraindicated. For full details, see the guidance on cetuximab (TA145, 2008).

Recurrent or metastatic
1.5.9

Pembrolizumab monotherapy is recommended as an option in NICE technology appraisal guidance for untreated metastatic or unresectable recurrent head and neck squamous cell carcinoma in adults whose tumours express PD‑L1 with a combined positive score of 1 or more. It should be stopped at 2 years of uninterrupted treatment, or earlier if disease progresses. For full details, see the guidance on pembrolizumab (TA661, 2020).

1.5.10

Nivolumab monotherapy is recommended as an option in NICE technology appraisal guidance for treating recurrent or metastatic squamous cell carcinoma of the head and neck in adults, only if the disease has progressed within 6 months of platinum‑based chemotherapy. For full details, see the guidance on nivolumab (TA736, 2021).

1.5.11

Cetuximab in combination with platinum-based chemotherapy is recommended as an option in NICE technology appraisal guidance for treating recurrent or metastatic squamous cell cancer of the head and neck in adults, only if the cancer started in the oral cavity. For full details, see the guidance on cetuximab (TA473, 2017).

Palliation of breathing difficulties

1.5.12

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]

1.5.13

Consider endoluminal debulking in preference to tracheostomy. [2016]

1.5.14

Establish a management plan if surgical intervention is not appropriate, in conjunction with the person, carers and clinical staff. [2016]

1.5.15

Assess and treat other causes of breathlessness in people with incurable upper aerodigestive tract cancer. [2016]

Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours

1.5.16

For NTRK inhibitors recommended as options in NICE technology appraisal guidance through the Cancer Drugs Fund for treating locally advanced or metastatic NTRK fusion-positive solid tumours when there are no other satisfactory treatment options, see the guidance on:

1.6 HPV‑related disease

HPV testing

1.6.1

Test all squamous cell carcinomas of the oropharynx using p16 immunohistochemistry. Regard the p16 test result as positive only if there is strong nuclear and cytoplasmic staining in more than 70% of tumour cells. [2016]

1.6.2

Consider high‑risk HPV DNA or RNA in‑situ hybridisation in all p16‑positive cancers of the oropharynx to confirm HPV status. [2016]

De‑intensification of treatment

1.6.3

Do not offer de‑intensification of curative treatment to people with HPV‑positive cancer of the oropharynx, unless it is part of a clinical trial. [2016]

1.7 Less common upper aerodigestive tract cancers

Carcinoma of the nasopharynx

1.7.1

Offer intensity‑modulated radiation therapy with concomitant chemotherapy to people with locally‑advanced (stage 2 and above) nasopharyngeal cancer. [2016]

1.7.2

Consider adjuvant or neo‑adjuvant chemotherapy for people with locally‑advanced (stage 2 and above) nasopharyngeal cancer. [2016]

Carcinoma of the paranasal sinuses

1.7.3

Offer surgery as the first treatment for carcinoma of the paranasal sinuses if complete resection is possible. [2016]

1.7.4

Consider radiotherapy with or without concomitant chemotherapy before planned surgical resection of the paranasal sinuses if complete resection is not initially possible. [2016]

Unknown primary of presumed upper aerodigestive tract origin

1.7.5

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]

1.7.6

Consider no further treatment as an option in people with pN1 disease without extracapsular spread after neck dissection. [2016]

1.7.7

Consider including potential primary tumour sites when selecting the volume to be treated with radiotherapy. [2016]

Mucosal melanoma

1.7.8

Consider surgery and adjuvant radiotherapy for people with newly‑diagnosed upper aerodigestive tract mucosal melanoma without systemic metastases. [2016]

Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours

1.7.9

For NTRK inhibitors recommended as options in NICE technology appraisal guidance through the Cancer Drugs Fund for treating locally advanced or metastatic NTRK fusion-positive solid tumours when there are no other satisfactory treatment options, see the guidance on:

1.8 Optimising rehabilitation and function

Enteral nutrition support

1.8.1

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]

Speech and language therapy interventions

1.8.3

Consider swallowing‑exercise programmes for people having radiotherapy. [2016]

1.8.4

Consider mouth‑opening exercises for people having radiotherapy who are at risk of reduced mouth opening. [2016]

1.8.5

Consider voice therapy for people whose voice has changed because of their treatment. [2016]

Shoulder rehabilitation

1.8.6

Consider progressive resistance training for people with impaired shoulder function, as soon as possible after neck dissection. [2016]

1.9 Follow‑up for people with cancer of the upper aerodigestive tract

1.9.1

Give people with cancer of the upper aerodigestive tract and their carers tailored information about the symptoms of recurrence and late effects of treatment at the end of curative therapy. [2016]

1.9.2

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]

1.10 Management of osteoradionecrosis

1.10.1

Consider surgery to remove necrotic bone and to establish soft tissue coverage in people with osteoradionecrosis. [2016]

1.10.2

Only consider hyperbaric oxygen therapy or medical management for treating osteoradionecrosis as part of a clinical trial. [2016]

Terms used in this guideline

Radical chemotherapy

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.