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Upper aerodigestive tract cancer

About

What is covered

This interactive flowchart covers the assessment and management of cancers of the upper aerodigestive tract in young people (aged 16 and over) and adults. It aims to reduce variation in practice and improve survival.
Who is it for?
  • People aged 16 and over with cancer of the upper aerodigestive tract, and their families and carers.
  • Healthcare professionals working in secondary and tertiary care.

Updates

Updates to this interactive flowchart

5 June 2018 New recommendations added to oropharynx, hypopharynx and larynx in line with the update of cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over (NICE guideline 36) and low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy (NICE interventional procedure guidance 615) added to squamous cell cancer and less common cancers.
21 November 2017 Nivolumab for treating squamous cell carcinoma of the head and neck after platinum-based chemotherapy (NICE technology appraisal guidance 490) added to squamous cell cancer.
31 August 2017 Added cetuximab for treating recurrent or metastatic squamous cell cancer of the head and neck (NICE technology appraisal guidance 473) to oral cavity.
2 March 2017 Head and neck cancer (NICE quality standard 146) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on assessing and managing upper aerodigestive tract cancer in young people and adults in an interactive flowchart

What is covered

This interactive flowchart covers the assessment and management of cancers of the upper aerodigestive tract in young people (aged 16 and over) and adults. It aims to reduce variation in practice and improve survival.
Who is it for?
  • People aged 16 and over with cancer of the upper aerodigestive tract, and their families and carers.
  • Healthcare professionals working in secondary and tertiary care.

Updates

Updates to this interactive flowchart

5 June 2018 New recommendations added to oropharynx, hypopharynx and larynx in line with the update of cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over (NICE guideline 36) and low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy (NICE interventional procedure guidance 615) added to squamous cell cancer and less common cancers.
21 November 2017 Nivolumab for treating squamous cell carcinoma of the head and neck after platinum-based chemotherapy (NICE technology appraisal guidance 490) added to squamous cell cancer.
31 August 2017 Added cetuximab for treating recurrent or metastatic squamous cell cancer of the head and neck (NICE technology appraisal guidance 473) to oral cavity.
2 March 2017 Head and neck cancer (NICE quality standard 146) added.

Quality standards

Head and neck cancer

These quality statements are taken from the head and neck cancer quality standard. The quality standard defines clinical best practice for head and neck cancer and should be read in full.

Quality statements

Nutritional status

This quality statement is taken from the head and neck cancer quality standard. The quality standard defines clinical best practice for head and neck cancer and should be read in full.

Quality statement

People with cancer of the upper aerodigestive tract have their nutritional status, including the need for a prophylactic tube, assessed at diagnosis.

Rationale

Many people with cancer of the upper aerodigestive tract lose a lot of weight as a result of the disease and its treatment; they often have difficulty eating. Assessing their nutritional status, including their need for a prophylactic tube, at the time of diagnosis will help to ensure adequate nutrition before, during and after treatment. This in turn will maximise the chances of people with cancer of the upper aerodigestive tract completing curative treatment.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with cancer of the upper aerodigestive tract have their nutritional status, including the need for a prophylactic tube, assessed at diagnosis.
Data source: Local data collection and HANA (Head and Neck Cancer National Audit), Saving Faces.
Process
Proportion of people with cancer of the upper aerodigestive tract who have their nutritional status, including the need for a prophylactic tube, assessed at diagnosis.
Numerator – the number in the denominator who have their nutritional status, including the need for a prophylactic tube, assessed at diagnosis.
Denominator – the number of people diagnosed with cancer of the upper aerodigestive tract.
Data source: Local data collection and HANA (Head and Neck Cancer National Audit), Saving Faces.
Outcome
Nutritional status of people with cancer of the upper aerodigestive tract.
Data source: Local data collection, for example, body mass index (BMI) levels and percentage weight loss, and HANA (Head and Neck Cancer National Audit), Saving Faces.

What the quality statement means for different audiences

Service providers (head and neck cancer secondary and tertiary care services) have systems in place to ensure that their teams assess nutritional status, including the need for a prophylactic tube, when cancer of the upper aerodigestive tract is diagnosed.
Healthcare professionals (members of head and neck cancer multidisciplinary teams) assess nutritional status, including the need for a prophylactic tube, when they diagnose cancer of the upper aerodigestive tract.
Commissioners (NHS England) ensure that they commission services which have systems in place to assess nutritional status, including the need for a prophylactic tube, when cancer of the upper aerodigestive tract is diagnosed.
People with cancer of the upper aerodigestive tract (the mouth, throat, voice box or sinuses) have an assessment when their condition is diagnosed to check their levels of nutrition and decide whether they need or might need feeding through a tube. Tube feeding can ensure that people who are finding it difficult to eat or drink get enough nutrients.

Source guidance

Definitions of terms used in this quality statement

Cancer of the upper aerodigestive tract
This encompasses cancers arising at different sites in the airways of the head and neck. These include cancers of the oral cavity, oropharynx, nasopharynx, hypopharynx, larynx and nasal sinuses.
[NICE’s guideline on cancer of the upper aerodigestive tract, full guideline glossary, appendix E]
Nutritional status
This is a person’s level of nutrition and includes weight loss, high or low BMI and their ability to meet estimated nutritional needs.
[NICE’s guideline on cancer of the upper aerodigestive tract, recommendation 1.8.1]

Clinical staging

This quality statement is taken from the head and neck cancer quality standard. The quality standard defines clinical best practice for head and neck cancer and should be read in full.

Quality statement

People with specific advanced stage cancers of the upper aerodigestive tract are offered systemic staging using fluorodeoxyglucose positron emission tomography (FDG PET)-CT.

Rationale

FDG PET-CT is more accurate for systemic staging than CT alone and shows if the cancer has spread beyond the primary site. More accurate staging will mean more appropriate treatment for specific advanced stage cancers. This will mean that people needing palliative treatment for disease spread will not have to undergo treatments with curative intent from which they will not benefit.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that people with N3 upper aerodigestive tract cancer are offered systemic staging using FDG PET-CT.
Data source: Local data collection.
b) Evidence of local arrangements and written clinical protocols to ensure that people with T4 cancers of the hypopharynx and nasopharynx are offered systemic staging using FDG PET-CT.
Data source: Local data collection.
Process
a) Proportion of people with N3 upper aerodigestive tract cancer who have systemic staging using FDG PET-CT.
Numerator – the number in the denominator who have systemic staging using FDG PET-CT.
Denominator – the number of people with N3 upper aerodigestive tract cancer.
Data source: Local data collection.
b) Proportion of people with T4 cancers of the hypopharynx and nasopharynx who have systemic staging using FDG PET-CT.
Numerator – the number in the denominator who have systemic staging using FDG PET-CT.
Denominator – the number of people with T4 cancers of the hypopharynx and nasopharynx.
Data source: Local data collection.
Outcome
Rates of surgery or radiotherapy in people with advanced stage cancer of the upper aerodigestive tract.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (head and neck cancer secondary and tertiary care services) have systems in place for people with N3 upper aerodigestive tract cancer or T4 cancers of the hypopharynx and nasopharynx to have systemic staging using FDG PET-CT.
Healthcare professionals (members of head and neck cancer multidisciplinary teams) offer systemic staging using FDG PET-CT to people with N3 upper aerodigestive tract cancer or T4 cancers of the hypopharynx and nasopharynx.
Commissioners (NHS England) ensure that they commission services which offer people with N3 upper aerodigestive tract cancer or T4 cancers of the hypopharynx and nasopharynx systemic staging using FDG PET-CT.
People with some cancers of the upper aerodigestive tract (the mouth, throat, voice box or sinuses) that are at an advanced stage are offered a scan to show where the cancer is and how far it has spread. This will mean that they can be offered the best treatment for them.

Source guidance

Definitions of terms used in this quality statement

Specific advanced stage cancers of the upper aerodigestive tract
These are cancers of the upper aerodigestive tract with significant involvement of the lymph nodes by cancer cells (N3) and cancers of the hypopharynx (the area of the throat where the oesophagus and voice box meet) and nasopharynx (the air cavity lying at the back of the nose and above the roof of the mouth) where the primary tumour is significant in size (T4).
[Adapted from NICE’s guideline on cancer of the upper aerodigestive tract, recommendations 1.2.9 and 1.2.10 and expert opinion]

Equality and diversity considerations

Due to the availability of FDG PET-CT scanning, a few people with specific advanced stage cancers of the upper aerodigestive tract may need to travel a significant distance to undergo the scan. People needing this type of scan should be offered it irrespective of the distance they need to travel and should be supported to make the journey if necessary.

Sentinel lymph node biopsy (developmental)

This quality statement is taken from the head and neck cancer quality standard. The quality standard defines clinical best practice for head and neck cancer and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

People with early stage oral cavity cancer who do not need cervical access as part of surgical management are offered sentinel lymph node biopsy as an alternative to elective neck dissection.

Rationale

Sentinel lymph node biopsy for early stage oral cavity cancer can mean that elective neck dissection is avoided in those people who do not need it. This means a quicker recovery time, less time in hospital and avoiding the significant morbidity (neuropathic pain and reduced shoulder movement) associated with elective neck dissection.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that people with early stage oral cavity cancer who do not need cervical access as part of surgical management are offered sentinel lymph node biopsy as an alternative to elective neck dissection.
Data source: Local data collection and HANA (Head and Neck Cancer National Audit), Saving Faces.
Process
Proportion of people with early stage oral cavity cancer who do not need cervical access as part of surgical management who have sentinel lymph node biopsy as an alternative to elective neck dissection.
Numerator – the number in the denominator who do not need cervical access as part of surgical management who have sentinel lymph node biopsy as an alternative to elective neck dissection.
Denominator – the number of people with early stage oral cavity cancer.
Data source: Local data collection and HANA (Head and Neck Cancer National Audit), Saving Faces.
Outcome
a) Surgery-related morbidity for people with early stage oral cavity cancer.
Data source: Local data collection.
b) Length of hospital stay for people with early stage oral cavity cancer.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (head and neck cancer secondary and tertiary care services) have systems in place for people with early stage oral cavity cancer who do not need cervical access as part of surgical management to have sentinel lymph node biopsy as an alternative to elective neck dissection.
Healthcare professionals (members of head and neck cancer multidisciplinary teams) offer sentinel lymph node biopsy as an alternative to elective neck dissection to people with early stage oral cavity cancer who do not need cervical access as part of surgical management.
Commissioners (NHS England) ensure that they commission services which provide sentinel lymph node biopsy as an alternative to elective neck dissection for people with early stage oral cavity cancer who do not need cervical access as part of surgical management.
People with early stage mouth cancer have a minor diagnostic procedure to remove the main lymph gland linked to the cancer unless they need more extensive surgery at the same time. This will show whether the cancer has spread and if more surgery is needed.

Source guidance

Definitions of terms used in this quality statement

Early stage oral cavity cancer
Cancer of the mouth which is staged as T1-T2, N-0, meaning that the size of the cancer is still relatively small and no lymph nodes contain cancer cells.
[Adapted from NICE’s guideline on cancer of the upper aerodigestive tract, information for the public]
Cervical access
This is surgical access into the neck, for example, to carry out free flap reconstruction.
[Adapted from NICE’s guideline on cancer of the upper aerodigestive tract, recommendation 1.3.5 and expert opinion]
Sentinel lymph node biopsy
This is a diagnostic procedure which involves surgical removal of the first lymph node or group of nodes (the sentinel node) which drain directly from the primary cancer site. This is a minor surgical procedure which requires an overnight stay in hospital and has no significant morbidity attached to it.
[Adapted from NICE’s guideline on cancer of the upper aerodigestive tract, full guideline glossary, appendix E]
Elective neck dissection
This is the planned removal of cervical lymph nodes in the neck. It is a significant surgical procedure requiring a stay in hospital of approximately 5 nights and has potentially significant morbidity risks such as neuropathic pain and reduced shoulder movement.
[Adapted from NICE’s guideline on cancer of the upper aerodigestive tract, full guideline glossary, appendix E and expert opinion]

Equality and diversity considerations

Sentinel lymph node biopsy is a relatively new procedure for assessing early stage oral cavity cancer. It is not widely available and so people with early stage oral cavity cancer may need to travel a significant distance to undergo the procedure. People needing this procedure should be offered it irrespective of the distance they need to travel and should be supported to make the journey if necessary.

Choice of treatment

This quality statement is taken from the head and neck cancer quality standard. The quality standard defines clinical best practice for head and neck cancer and should be read in full.

Quality statement

People with cancer of the upper aerodigestive tract are given the choice of either radiotherapy or surgery if both are suitable options for their type of cancer.

Rationale

People with cancers of the upper aerodigestive tract that have similar outcomes from radiotherapy and surgery should be told that both of these treatments are available and what they involve. This should include details of the potential side effects (including late effects). Clear explanation and support from healthcare professionals should help people with cancers of the upper aerodigestive tract to make a fully informed choice of treatment based on their preference and should increase patient satisfaction.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with cancer of the upper aerodigestive tract are given a choice of either radiotherapy or surgery if both are suitable options for their type of cancer.
Data source: Local data collection, National Peer Review: Head and neck cancer services, National Peer Review Programme and HANA (Head and Neck Cancer National Audit), Saving Faces.
Process
a) Proportion of people with newly diagnosed T1b–T2 squamous cell carcinoma of the glottic larynx who are given a choice of surgery or radiotherapy.
Numerator – the number in the denominator who are given a choice of surgery or radiotherapy.
Denominator – the number of people with newly diagnosed T1b–T2 squamous cell carcinoma of the glottic larynx.
Data source: Local data collection, National Peer Review: Head and neck cancer services, National Peer Review Programme and HANA (Head and Neck Cancer National Audit), Saving Faces.
b) Proportion of people with newly diagnosed T1–T2 squamous cell carcinoma of the supraglottic larynx who are given a choice of surgery or radiotherapy.
Numerator – the number in the denominator who are given a choice of surgery or radiotherapy.
Denominator – the number of people with newly diagnosed T1–T2 squamous cell carcinoma of the supraglottic larynx.
Data source: Local data collection, National Peer Review: Head and neck cancer services, National Peer Review Programme and HANA (Head and Neck Cancer National Audit), Saving Faces.
c) Proportion of people with T1–2 N0 tumours of the oropharynx who are given a choice of surgery or radiotherapy.
Numerator – the number in the denominator who are given a choice of surgery or radiotherapy.
Denominator – the number of people with T1–2 N0 tumours of the oropharynx.
Data source: Local data collection, National Peer Review: Head and neck cancer services, National Peer Review Programme and HANA (Head and Neck Cancer National Audit), Saving Faces.
d) Proportion of people with T3 squamous cell carcinoma of the larynx who are given a choice of either radiotherapy with concomitant chemotherapy or surgery with adjuvant radiotherapy, with or without concomitant chemotherapy.
Numerator – the number in the denominator who are given a choice of either radiotherapy with concomitant chemotherapy or surgery with adjuvant radiotherapy, with or without concomitant chemotherapy.
Denominator – the number of people with T3 squamous cell carcinoma of the larynx.
Data source: Local data collection, National Peer Review: Head and neck cancer services, National Peer Review Programme and HANA (Head and Neck Cancer National Audit), Saving Faces.
Outcome
Satisfaction with treatment for people with cancers of the upper aerodigestive tract that have similar outcomes from radiotherapy and surgery.
Data source: Local data collection and the National Cancer Patient Experience Survey, Quality Health.

What the quality statement means for different audiences

Service providers (head and neck cancer secondary and tertiary care services) ensure that people with cancer of the upper aerodigestive tract are told about both radiotherapy and surgery if they are both suitable options for their type of cancer. Discussion should include the potential side effects, and people should be given a choice based on their preference. If the service does not provide both treatment options, it should refer people to a local centre which provides the treatment they wish to have.
Healthcare professionals (members of head and neck cancer multidisciplinary teams) clearly explain radiotherapy and surgery to people with cancer of the upper aerodigestive tract if they are both suitable options for their type of cancer. This discussion should include the potential side effects, so that people can decide which they would prefer.
Commissioners (NHS England) ensure that they commission services which clearly explain radiotherapy and surgery to people with cancer of the upper aerodigestive tract if both are suitable options for the type of cancer. Discussion should include the potential side effects, and people should be given a choice based on their preference. Commissioners should ensure that the services commissioned either offer both radiotherapy and surgery or refer people to a local centre which provides the treatment a person wishes to have.
People with some cancers of the vocal cords are told what the different treatment options involve, including any side effects. This will help them to choose which treatment is best for them. If they choose a treatment that is not available at their local service, they should be referred to another local centre that can provide the treatment.

Source guidance

Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over (2016) NICE guideline NG36, recommendations 1.3.2, 1.3.3, 1.3.6 and 1.4.1

Definitions of terms used in this quality statement

Cancer of the upper aerodigestive tract for which radiotherapy or surgery are suitable options
These are:
  • newly diagnosed T1b–T2 squamous cell carcinoma of the glottic larynx
  • newly diagnosed T1–T2 squamous cell carcinoma of the supraglottic larynx
  • T1–2 N0 tumours of the oropharynx
  • T3 squamous cell carcinoma of the larynx.
[Adapted from NICE’s guideline on cancer of the upper aerodigestive tract, recommendations 1.3.2, 1.3.3, 1.3.6 and 1.4.1]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Why we made the recommendations on nivolumab

There are limited treatment options for squamous cell carcinoma of the head and neck that has progressed on platinum-based chemotherapy. The population in the clinical trial for nivolumab had disease that had progressed within 6 months of platinum-based chemotherapy (early recurrence). This is a clinically distinct population who have a poor prognosis and whose disease will not be retreated with a platinum drug. In England, these people are usually offered docetaxel.
Clinical trial evidence shows that nivolumab improves overall survival by 2.6 months compared with docetaxel, methotrexate or cetuximab, but longer-term survival benefit, after 2 years, is uncertain. There is also uncertainty about its benefit for tumours expressing less than 1% PD-L1 protein.
Nivolumab meets NICE's criteria to be considered a life-extending end-of-life treatment. However, it cannot be recommended for routine use because the most likely cost-effectiveness estimate would fall between £45,000 and £73,600 per quality-adjusted life year gained.
Nivolumab has the potential to be cost effective, but more evidence is needed to address the clinical uncertainties. It can therefore be recommended for use within the Cancer Drugs Fund while further data are collected as part of a managed access agreement. Collecting further data from people having nivolumab should address the uncertainties about its benefits for longer-term survival and for tumours expressing less than 1% PD-L1 protein.
For more information see the committee discussion in the NICE technology appraisal on nivolumab for treating squamous cell carcinoma of the head and neck after platinum-based chemotherapy.

Response assessment after chemoradiotherapy

Overall, the evidence showed that recurrence rates and overall mortality for FDG PET-CT-guided management after radical chemoradiotherapy were similar to those for neck dissection. In addition, the evidence showed that FDG PET-CT was cost-saving compared with neck dissection, and would prevent unnecessary surgeries, surgical complications, and adverse events.
The committee agreed to make recommendations only for people with oropharyngeal, laryngeal and hypopharyngeal primary sites, because these were the main focus of the evidence. Most of the people in the study had an oropharyngeal primary site and more than 1 positive node under 6 cm across in the neck, and the evidence was strongest for this population. Therefore, the committee agreed that they should be offered an FDG PET-CT scan.
The evidence was weaker for people with an oropharyngeal primary site and higher 'N' stage disease (1 or more positive node larger than 6 cm across in the neck) and for people with laryngeal or hypopharyngeal primary sites. To reflect this, FDG PET-CT scanning could be considered for these groups.
The evidence did not include people with an oropharyngeal primary site and 'N1' stage disease (only 1 positive node of less than 3 cm across). However, the committee agreed that it is particularly important that FDG PET-CT scans are considered for this population to avoid unnecessary surgery. These people are likely to be at a lower risk of recurrence and so the benefits of neck dissection are lower.
The committee noted that new classifications for head and neck cancer (TNM classification of malignant tumours, 8th edition) have been introduced, which are different to those used in the evidence. They decided to describe the stage of cancer for these recommendations in terms of the number and size of positive nodes to avoid confusion.
The timing of FDG PET-CT scans (3 to 6 months after completion of radical chemoradiotherapy) is in line with current Royal College of Radiologists guidelines. Scans earlier than 3 months are more likely to give a false-positive result, due to the residual effects of treatment.
The committee decided to be specific that neck dissection should not be offered to people with no abnormal FDG uptake or residual soft tissue mass, to give clear advice about how to interpret a 'negative' FDG PET-CT result.
The committee noted several areas in which future research would be helpful, such as management for people with indeterminate test results (see research recommendation 1 and research recommendation 2), the role of FDG PET-CT for people with nasopharyngeal cancer (see research recommendation 3) and the effectiveness of FDG PET-CT to guide follow-up (see research recommendation 4).

How the recommendations might affect practice

There may an increase in the number of FDG PET-CT scans performed and a reduction in surgical procedures. However, the evidence showed that the amount of money saved from unnecessary surgery is likely to be considerably higher than the cost of the additional scans.

Glossary

fluorodeoxyglucose positron emission tomography
human papillomavirus
refers to treatment aiming to cure cancer rather than to relieve symptoms (palliative treatment) and used here to reflect the evidence these recommendations are based on

Paths in this pathway

Pathway created: February 2016 Last updated: June 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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