Head & Neck incl Thyroid - 2WW

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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance 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, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

Top Tips for GPs holding a 2WW Conversation 

Macmillan 2WW guidance

Scope:

• the assessment, diagnosis, and management of cancers of the:
  • larynx
  • oral cavity
  • oropharynx
  • hypopharynx
  • nasopharynx
  • nose and sinuses
  • salivary glands
• care in primary and specialist services for all patient groups

Out of scope:

• cancers of the thyroid

Definitions:

• laryngeal cancer includes tumours of the:
  • supraglottis
  • glottis
  • subglottis
• oral cavity cancer includes tumours of the:
  • buccal mucosa
  • retromolar triangle
  • alveolus
  • hard palate
  • anterior two-thirds of tongue
  • floor of mouth
  • mucosal surface of the lip
• oropharyngeal cancer includes tumours of the:
  • base of tongue

  • tonsil

  • soft palate
  • oropharynx posterior pharyngeal wall [10]
• hypopharyngeal cancer includes tumours of the:
  • postcricoid area
  • pyriform sinus
  • posterior pharyngeal wall
• salivary gland cancer includes tumours of the [2]:
  • parotid, submandibular, or minor salivary glands
• nasopharyngeal cancer includes tumours of the [12]:
  • mucosal surface of the nasopharynx
  • fossa of Rosenmuller
• nose and sinus cancer includes tumours of the [12]:
  • nasal cavity
  • paranasal sinuses
  • lateral wall
  • ethmoids
  • maxillary sinus
  • frontal and sphenoid sinuses (rare)

Incidence:

• there were an estimated total of 7354 cases of head and neck cancer in England and Wales in 2011 [18]

Risk factors:

• tobacco smoking and alcohol consumption are the major risk factors for head and neck cancers in the UK [12]
• also consider chewing:
  • tobacco
  • betel nut
  • paan
  • gutka
• poor diet
• genetic factors
• gastro-oesophageal reflux disease (GORD) – laryngeal and pharyngeal tumours
• human papillomavirus 16 (HPV 16) seropositivity – oral and pharyngeal tumours
• Epstein-Barr virus (EBV) - nasopharyngeal tumours
• exposure to environmental factors – the following are very rare, with poor supporting evidence, but should be considered:
  • hardwood dust
  • asbestos
  • formaldehyde
  • nickel
  • isopropyl alcohol
  • sulphuric acid mist
  • diesel fumes

Prognosis:

• the 5-year age-standardised relative survival rates for patients with head and neck cancers range from 40-70% [3].
• the 2-year survival rate depends on the stage at diagnosis [3]:
  • stage I – 89.7%
  • stage II – 71.8%
  • stage III – 57.6%
  • stage IV – 48.6%

References:

[2] National Comprehensive Cancer Network (NCCN). Head and neck cancers. NCCN clinical practice guidelines in oncology. Fort Washington, PA: NCCN; 2012.

[3] National Institute for Health and Clinical Excellence (NICE). Guidance on cancer services – improving outcomes in head and neck cancers – the manual. London: NICE; 2004.

[4] Contributors representing the National Cancer Action Team; 2010.

[5] Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of head and neck cancer. A national clinical guideline. SIGN Publication no. 90. Edinburgh: SIGN; 2006.

[12] ENT UK. Head and Neck Cancer: Multidisciplinary Management Guidelines 4th Edition. ENT UK: London; 2011.

[18] DAHNO project team. National Head and Neck Cancer Audit. 7th Annual Report (DAHNO). Health and Social Care Information Centre: Leeds; 2011. 

UHB Patient Information Leaflet

NBT Patient Information Leaflet

• 'Head and neck cancer' (URL) from Cancer Research UK at www.cancerhelp.org.uk
• 'Head and neck cancers' (URL) from Macmillan Cancer Support at www.macmillan.org.uk
• 'Mouth (Oral) Cancer' (PDF) from Patient UK at www.patient.co.uk
• 'Cancer of the Larynx (Throat Cancer)' (PDF) from Patient UK at www.patient.co.uk

The following resources have been written or recommended by national policy bodies or guideline producers whose content has informed this care map:

• 'Mouth Cancer' (URL) from the British Dental Health Foundation at www.dentalhealth.org.uk

NSCCG Sign off form 2017

Updated in line with NICE Guideline NG12: Suspected cancer: recognition and referral to coincide with updated  BNSSG 2WW Referral forms

This care map has been updated with recommendations provided by:

• [10] Contributors representing the National Cancer Action Team (NCAT); 2013.

Please see the care map’s Provenance for additional information on references, accreditations from national clinical bodies, contributors, and the editorial methodology.

Date of publication: 31-Jan-2013

This care map has been updated with the following evidence:

• [1] Chan ATC, Gregoire V, Lefebvre et al. Nasopharyngeal cancer: EHNS–ESMO–ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of oncology 2010; 21: 187-9.
• [2] National Comprehensive Cancer Network (NCCN). Head and neck cancers. NCCN clinical practice guidelines in oncology. Fort Washington, PA: NCCN; 2012.
• [11] Department of Health (DH). Guidelines for urgent referral of patients with suspected cancer. London: DH; 2000.
• [12] ENT UK. Head and Neck Cancer: Multidisciplinary Management Guidelines 4th Edition. ENT UK, London; 2011.
• [13] Gregoire V, Lefebvre, Licitra L et al. Squamous cell carcinoma of the head and neck: EHNS-ESMO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of oncology 2010; 21:184-6.
• [14] Clinical Oncological Society of Australia (COSA). Evidence based practice guidelines for the nutritional management of adult patients with head and neck cancer. Sydney: COSA; 2011.
• [15] Pfister DG, Laurie SA, Weinstein GS et al. American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer. J Clin Oncol 2006; 24: 3693-704.
• [16] National Institute for Health and Clinical Excellence (NICE). Cetuximab for the treatment of locally advanced squamous cell cancer of the head and neck. Technology appraisal 145. London: NICE; 2008.
• [17] Scullion F, Rudge J, Davies N. National. Health and Well-Being Clinics: Transition from Patient to Survivor. London: Macmillan; 2010.
• [18] DAHNO project team. National Head and Neck Cancer Audit. 7th Annual Report (DAHNO). Leeds: Health and Social Care Information Centre; 2011.

• [3] National Institute for Health and Clinical Excellence (NICE). Guidance on cancer services – improving outcomes in head and neck cancers – the manual. London: NICE; 2006.
• [5] Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of head and neck cancer. A national clinical guideline. SIGN Publication no. 90. Edinburgh: SIGN; 2006.

• [9] National Institute for Health and Clinical Excellence (NICE). Cetuximab for the treatment of recurrent and/or metastatic squamous cell cancer of the head and neck. NICE technology appraisal guidance 172. London: NICE; 2006.

Suspected Head and Neck Cancer - General:

• An unexplained palpable lump in the neck i.e. of recent onset or a previously undiagnosed lump that has changed over a period of 3 – 6 weeks.
• An unexplained persistent swelling in the parotid or submandibular gland

Suspected Thyroid Cancer:

• unexplained thyroid lump (consider)

Please perform thyroid function test in parallel with referral.

Suspected Head and Neck Cancer – Ear, Nose and Throat Origin:

• Persistent unexplained hoarseness i.e. >3 weeks, with negative chest X-ray (consider)
• An unexplained persistent sore throat especially if associated with dysphagia, hoarseness or otalgia
• Persistent unilateral nasal obstruction with bloody discharge
• Unexplained unilateral serous otitis media/ effusion in a patient aged over 18  

Suspected Head and Neck Cancer – Oral Maxillo-Facial Origin

• Unexplained ulceration of the oral cavity or mass persisting for more than 3 weeks (consider)
• Unexplained red and white patches (including suspected lichen planus) of the oral cavity particularly if painful, bleeding or swollen (consider).
• Oral cavity and lip lesions or persistent symptoms of the oral cavity followed up for six weeks where definitive diagnosis of a benign lesion cannot be made
• Non-healing extraction sockets (>4 weeks duration) or suspicious loosening of teeth, where malignancy is suspected (particularly if associated with numbness of the lip)

The following are alarm features that require immediate telephone referral [12]:

• stridor [10]
• noisy breathing [10]

References:

[10] Contributors representing the National Cancer Action Team (NCAT); 2013.

[12] ENT UK. Head and Neck Cancer: Multidisciplinary Management Guidelines 4th Edition. ENT UK, London; 2011.

 2WW Referral forms are available as EMIS templates

Enquire about the following symptoms:

• the nature and history of any mass, including details regarding:
  • pain
  • ulceration
  • itching
  • changes in size
• presence and duration of dental symptoms
• constitutional symptoms, such as:
  • anorexia
  • weight loss

 Enquire about associated factors, including:

• smoking is the single most important factor for head and neck cancers
• also consider chewing:
  • tobacco
  • betel nut
  • paan
  • gutka
• alcohol consumption
• diet
• gastro-oesophageal reflux disease (GORD)
• family history of head and neck cancer
• exposure to environmental factors – the following are very rare, with poor supporting evidence, but should be considered: 
  • hardwood dust
  • asbestos
  • formaldehyde
  • nickel
  • isopropyl alcohol
  • sulphuric acid mist
  • diesel fumes

References:

[3] National Institute for Health and Clinical Excellence (NICE). Guidance on cancer services – improving outcomes in head and neck cancers – the manual. London: NICE; 2004.

[4] Contributors representing the National Cancer Action Team; 2010.

[6] Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2010.

Examine the patient for [3]:

• neck masses
• ulceration of oral mucosa
• oral swellings
• red, or red and white, patches

Reference:

[3] National Institute for Health and Clinical Excellence (NICE). Guidance on cancer services – improving outcomes in head and neck cancers – the manual. London: NICE; 2004.

Differential diagnoses include:

• lung cancer – all patients with persistent hoarseness should have a chest X-ray [10]
• other causes of oral lesions, such as [4,6]:
  • oral lichen planus − if diagnosed, the patient should be monitored for oral cancer as part of routine dental examination
  • dental or oral infection
  • aphthous ulceration
• acute viral infections [10]
• other laryngeal disorders, including [4,6]:
  • vocal cord palsy [10]
  • laryngeal polyps
  • laryngeal nodules
  • Reinke's oedema
  • laryngopharyngeal reflux
• other causes of vocal hoarseness and speech changes, including neurological causes [4,6]

References:

[4] Contributors representing the National Cancer Action Team; 2010.

[6] Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2010.

[10] Contributors representing the National Cancer Action Team (NCAT); 2013.

2WW Head & Neck Services are provided by UHBristol only

Criteria

Suspected Head and Neck Cancer - General:

• An unexplained palpable lump in the neck i.e. of recent onset or a previously undiagnosed lump that has changed over a period of 3 – 6 weeks.
• An unexplained persistent swelling in the parotid or submandibular gland

Suspected Thyroid Cancer:

• unexplained thyroid lump

Please perform thyroid function test in parallel with referral.

Suspected Head and Neck Cancer – Ear, Nose and Throat Origin:

• Persistent unexplained hoarseness i.e. >3 weeks, with negative chest X-ray
• An unexplained persistent sore throat especially if associated with dysphagia, hoarseness or otalgia
• Persistent unilateral nasal obstruction with bloody discharge
• Unexplained unilateral serous otitis media/ effusion in a patient aged over 18  

Suspected Head and Neck Cancer – Oral Maxillo-Facial Origin

• Unexplained ulceration of the oral cavity or mass persisting for more than 3 weeks
• Unexplained red and white patches (including suspected lichen planus) of the oral cavity particularly if painful, bleeding or swollen
• Oral cavity and lip lesions or persistent symptoms of the oral cavity followed up for six weeks where definitive diagnosis of a benign lesion cannot be made
• Non-healing extraction sockets (>4 weeks duration) or suspicious loosening of teeth, where malignancy is suspected (particularly if associated with numbness of the lip)

 2WW Referral forms are available as EMIS templates