• • Recent evidence synthesis from National Institute for Health and Care Excellence suggests that the following brief interventions for smoking cessation work should be used:

  • ○ Ask smokers how interested they are in quitting (R)

  • ○ If they want to stop, refer them to an intensive support service such as National Health Service Stop Smoking Services (R)

  • ○ If they are unwilling or unable to accept a referral, offer a stop smoking aid, e.g. pharmacotherapy. (R)

• • Brief interventions are effective for hazardous and harmful drinking. (R)

• • Specialist interventions are effective in people with alcohol dependence. (R)

• • Most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment. (R)

• • Management of leukoplakia is not informed by high-level evidence but consensus supports targeted use of biopsy and histopathological assessment. (R)

• • The management of biopsy proven dysplastic lesions favours:

  • ○ advice to reduce known environmental carcinogens such as tobacco and alcohol (R)

  • ○ surgical excision when the size of the lesions and the patient's function allows (R)

  • ○ long-term surveillance. (R)

• • Fanconi anaemia patients should:

  • ○ be followed up in a multidisciplinary specialist Fanconi anaemia clinic (G)

  • ○ have quarterly screening for head and neck squamous cell carcinoma and an aggressive biopsy policy (G)

  • ○ receive prophylactic vaccination against high risk human papilloma virus (G)

  • ○ receive treatment for head and neck squamous cell carcinoma with surgery alone where possible. (G)

• Comorbidity data should be collected as it is important in the analysis of survival, quality of life and functional outcomes after treatment as well as for comparing results of different treatment regimens and different centres. (R)

• Patients with hypertension of over 180/110 or associated target organ damage, should have antihypertensive medication started pre-operatively as per British Hypertension Society guidelines. (R)

• Rapidly correcting pre-operative hypertension with beta blockade appears to cause higher mortality due to stroke and hypotension and should not be used. (R)

• Patients with poorly controlled or unstable ischaemic heart disease should be referred for cardiology assessment pre-operatively. (G)

• Patients within one year of drug eluting stents should be discussed with the cardiologist who was responsible for their percutaneous coronary intervention pre-operatively with regard to cessation of antiplatelet medication due to risk of stent thrombosis. (G)

• Patients with multiple recent stents should be managed in a centre with access to interventional cardiology. (G)

• Surgery after myocardial infarction should be delayed if possible to reduce mortality risk. (R)

• Patients with critical aortic stenosis (AS) should be considered for pre-operative intervention. (G)

• Clopidogrel should be discontinued 7 days pre-operatively; warfarin should be discontinued 5 days pre-operatively. (R)

• Patients with thromboembolic disease or artificial heart valves require heparin therapy to bridge peri-operative warfarin cessation, this should start 2 days after last warfarin dose. (R)

• Cardiac drugs other than angotensin-converting enzyme inhibitors and angiotensin II antagonists should be continued including on the day of surgery. (R)

• Angotensin-converting enzyme inhibitors and angiotensin II antagonists should be withheld on the day of surgery unless they are for the treatment of heart failure. (R)

• Post-operative care in a critical care area should be considered for patients with heart failure or significant diastolic dysfunction. (R)

• Patients with respiratory disease should have their peri-operative respiratory failure risk assessed and critical care booked accordingly. (G)

• Patients with severe lung disease should be assessed for right heart disease pre-operatively. (G)

• Patients with pulmonary hypertension and right heart failure will be at extraordinarily high risk and should have the need for surgery re-evaluated. (G)

• Perioperative glucose readings should be kept within 4–12 mmol/l. (R)

• Patients with a high HbA1C facing urgent surgery should have their diabetes management assessed by a diabetes specialist. (G)

• Insulin-dependent diabetic patients must not omit insulin for more than one missed meal and will therefore require an insulin replacement regime. (R)

• Patients taking more than 5 mg of prednisolone daily should have steroid replacement in the peri-operative period. (R)

• Consider proton pump therapy for patients taking steroids in the peri-operative phase if they fit higher risk criteria. (R)

• Surgery within three months of stroke carries high risk of further stroke and should be delayed if possible. (R)

• Patients with rheumatoid arthritis should have flexion/extension views assessed by a senior radiologist pre-operatively. (R)

• Patients at risk of post-operative cognitive dysfunction and delirium should be highlighted at pre-operative assessment. (G)

• Patients with Parkinson's disease (PD) must have enteral access so drugs can be given intra-operatively. Liaison with a specialist in PD is essential. (R)

• Intravenous iron should be considered for anaemia in the urgent head and neck cancer patient. (G)

• Preoperative blood transfusion should be avoided where possible. (R)

• Where pre-operative transfusion is essential it should be completed 24–48 hours pre-operatively. (R)

• An accurate alcohol intake assessment should be completed for all patients. (G)

• Patients considered to have a high level of alcohol dependency should be considered for active in-patient withdrawal at least 48 hours pre-operatively in liaison with relevant specialists. (R)

• Parenteral B vitamins should be given routinely on admission to alcohol-dependent patients. (R)

• Smoking cessation, commenced preferably six weeks before surgery, decreases the incidence of post-operative complications. (R)

• Antibiotics are necessary for clean-contaminated head and neck surgery, but unnecessary for clean surgery. (R)

• Antibiotics should be administered up to 60 minutes before skin incision, as close to the time of incision as possible. (R)

• Antibiotic regimes longer than 24 hours have no additional benefit in clean-contaminated head and neck surgery. (R)

• Repeat intra-operative antibiotic dosing should be considered for longer surgeries or where there is major blood loss. (R)

• Local antibiotic policies should be developed and adhered to due to local resistance patterns. (G)

• Individual assessment for venous thromboembolism (VTE) risk and bleeding risk should occur on admission and be reassessed throughout the patients' stay. (G)

• Mechanical prophylaxis for VTE is recommended for all patients with one or more risk factors for VTE. (R)

• Patients with additional risk factors of VTE and low bleeding risk should have low molecular weight heparin at prophylactic dose or unfractionated heparin if they have severe renal impairment. (R)

• All theatre staff should participate in the World Health Organization checklist process. (R)

• Post-operative airway management should be guided by local protocols. (R)

• Patients admitted to post-operative care units with tracheal tubes in place should be monitored with continuous capnography. Removal for tracheal tubes is the responsibility of the anaesthetist. (R)

• Anaesthetists should formally hand over care to an appropriately trained practitioner in the post-operative or intensive care unit. (G)

• Intensive care unit staff looking after post-operative tracheostomies must be clear about which patients are not suitable for bag-mask ventilation and/or oral intubation in the event of emergencies. (R)

• Offer appropriate radiological imaging, based on tumour extent, site and local expertise, to stage tumours and plan treatment for patients diagnosed with head and neck cancer. (G)

• Consider positron emission tomography combined with computed tomography (PET–CT) imaging if conventional cross-sectional imaging identifies no primary site. (R)

• Offer PET–CT imaging 12 weeks after non-surgical treatment to detect residual disease. (R)

• A specialist dietitian should be part of the multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes. (R)

• Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment. (R)

• Patients at high risk should be referred to the dietitian for early intervention. (R)

• Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R)

• Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R)

• Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition. (G)

• Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway. (G)

• Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R)

• Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R)

• Perform nutritional assessment of cancer patients frequently. (G)

• Initiate nutritional intervention early when deficits are detected. (G)

• Integrate measures to modulate cancer cachexia changes into the nutritional management. (G)

• Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R)

• Use standard polymeric feed. (G)

• Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R)

• Monitor nutritional parameters regularly throughout the patient's cancer journey. (G)

• Pre-operative:

○ Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. (R)

○ Consider carbohydrate loading in patients undergoing head and neck surgery. (R)

• Post-operative:

○ Initiate tube feeding within 24 hours of surgery. (R)

○ Consider early oral feeding after primary laryngectomy. (R)

• Chyle Leak:

○ Confirm chyle leak by analysis of drainage fluid for triglycerides and chylomicrons. (R)

○ Commence nutritional intervention with fat free or medium chain triglyceride nutritional supplements either orally or via a feeding tube. (R)

○ Consider parenteral nutrition in severe cases when drainage volume is consistently high. (G)

• Weekly dietetic intervention is offered for all patients undergoing radiotherapy treatment to prevent weight loss, increase intake and reduce treatments interruptions. (R)

• Offer prophylactic tube feeding as part of locally agreed guidelines, where oral nutrition is inadequate. (R)

• Offer nutritional intervention (dietary counselling and/or supplements) for up to three months after treatment. (R)

• Patients who have completed their rehabilitation and are disease free should be offered healthy eating advice as part of a health and wellbeing clinic. (G)

• Quality of life parameters including nutritional and swallowing, should be measured at diagnosis and at regular intervals post-treatment. (G)

• Preventative oral care must be delivered to patients whose cancer treatment will affect the oral cavity, jaws, salivary glands and oral accessibility. (G)

• Close working and communication between the surgeons, oncologists and restorative dental specialists is important in ensuring optimal oral health outcomes. (G)

• Intensity-modulated radiotherapy has been shown to reduce long-term xerostomia and should be offered to all appropriate patients. (R)

• If patients are deemed at risk of trismus they should be warned and its progressive and potentially irreversible nature explained. (G)

• Where it is known that adjuvant radiotherapy will be given, extractions should take place at primary surgery to maximise the time for healing and minimise the number of surgical events for patients. (G)

• Osseointegrated implants should be considered for all patients having resection for head and neck cancer. (G)

• Audit of information supplied to patients and carers should be conducted on an annual basis to update and review content and media presentation. (G)

• Patients and carers should be invited to discuss treatment options and relate possible outcomes to functional retention or loss to provide a patient-centred approach. (G)

• Clinical staff should inspect their systems of assessment to make them sensitive enough to identify patients with psychological difficulties. (G)

• Flexibility, rather than rigid formulation is required to assess patients frequently, and to allow for change in circumstances to be noted. (G)

• Multidisciplinary teams should determine the supportive care services available and commission extra assistance to provide patients and carers with timely information, education or brief supportive advice. (G)

• Multidisciplinary teams need to inspect specialist services for mental health interventions at structured and complex levels for the small proportion of patients with more serious, but rarer, psychological difficulties. (G)

• Clinical staff at all levels should receive communication skills training to raise and maintain consultation expertise with difficult patient and/or carer interactions. (G)

• Health-related quality of life is integral to treatment planning, refining treatment protocols, and more personalised follow-up support. (G)

• Health-related quality of life and patient concerns should be regularly assessed during patient care. (G)

• Health-related quality of life assessment and patient concerns on an individual patient basis can be helpful to trigger multi-professional support and interventions. (G)

• All patients with head and neck cancer (HNC) should undergo tumour classification and staging prior to treatment. (R)

• Pre-therapeutic clinical staging of HNCs should be based on at least a C2 factor (evidence obtained by special diagnostic means, e.g. radiographic imaging (e.g. computed tomography, magnetic resonance imaging or ultrasound scan), endoscopy, biopsy and cytology). (R)

• Imaging to evaluate the primary site should be performed prior to biopsy to avoid the effect of upstaging from the oedema caused by biopsy trauma. (G)

• Panendoscopy is only recommended for symptomatic patients or patients with primary tumours known to have a significant risk of a second (synchronous) primary tumour. (G)

• Accurate diagnosis of the type of malignancy is a key component of effective management. (R)

• Surgeons and oncologists should understand the scope and limitations of cellular pathology in order to inform multidisciplinary discussions. (R)

• A clinically suspected diagnosis of malignancy should be confirmed by biopsy or cytology before operation. (R)

• Cytopathological diagnoses should be discussed with surgeons and radiologists to maximise the information gained from each modality of investigation. (R)

• Pathological investigations are the basis for accurate cancer staging and stratification of clinical outcomes. (R)

• Radiotherapy (RT) and transoral laser microsurgery (TLM) are accepted treatment options for T1a–T2a glottic carcinoma. (R)

• Open partial surgery may have a role in the management of selected tumours. (R)

• Radiotherapy, TLM and transoral robotic surgery are reasonable treatment options for T1–T2 supraglottic carcinoma. (R)

• Supraglottic laryngectomy may have a role in the management of selected tumours. (R)

• Most patients with T2b–T3 glottic cancers are suitable for non-surgical larynx preservation therapies. (R)

• Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R)

• Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may be also be appropriate in selected cases. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, it is recommended that lymph node levels II–V should be treated on the involved side. If level II nodes are involved, then elective irradiation of ipsilateral level Ib nodes may be considered. (R)

• Most patients with T3 supraglottic cancers are suitable for non-surgical larynx preservation therapies. (R)

• Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R)

• Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may also be appropriate in selected cases. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, lymph node levels II–V should be treated on the involved side. (R)

• As per the PET-Neck clinical trial, patients with N2 or N3 neck disease who undergo treatment with chemoradiotherapy to their laryngeal primary and experience a complete response with a subsequent negative post-treatment positron emission tomography combined with computed tomography (PET–CT) scan do not require an elective neck dissection. In contrast, patients who have a partial response to treatment or have increased uptake on a post-treatment PET–CT scan should have a neck dissection. (R)

• Larynx preservation with concurrent chemoradiotherapy should be considered for T4 tumours, unless there is tumour invasion through cartilage into the soft tissues of the neck, in which case total laryngectomy yields better outcomes. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to bilateral lymph node levels II, III, IV, V and VI. (R)

• Surgery remains the mainstay of management for oral cavity tumours. (R)

• Tumour resection should be performed with a clinical clearance of 1 cm vital structures permitting. (R)

• Elective neck treatment should be offered for all oral cavity tumours. (R)

• Adjuvant radiochemotherapy in the presence of advanced neck disease or positive margins improves control rates. (R)

• Early stage lip cancer can be treated equally well by surgery or radiation therapy. (R)

• Cross-sectional imaging is required in all cases to complete assessment and staging. (R)

• Magnetic resonance imaging is recommended for primary site and computed tomography scan for neck and chest. (R)

• Positron emission tomography combined with computed tomography scanning is recommended for the assessment of response after chemoradiotherapy, and has a role in assessing recurrence. (R)

• Examination under anaesthetic is strongly recommended, but not mandatory. (R)

• Histological diagnosis is mandatory in most cases, especially for patients receiving treatment with curative intent. (R)

• Oropharyngeal carcinoma histopathology reports should be prepared according to The Royal College of Pathologists Guidelines. (G)

• Human papilloma virus (HPV) testing should be carried out for all oropharyngeal squamous cell carcinomas as recommended in The Royal College of Pathologists Guidelines. (R)

• Human papilloma virus testing for oropharyngeal cancer should be performed within a diagnostic service where the laboratory procedures and reporting standards are quality assured. (G)

• Treatment options for T1–T2 N0 oropharyngeal squamous cell carcinoma include radical radiotherapy or transoral surgery and neck dissection (with post-operative (chemo)radiotherapy if there are adverse pathological features on histological examination). (R)

• Transoral surgery is preferable to open techniques and is associated with good functional outcomes in retrospective series. (R)

• If treated surgically, neck dissection should include levels II–IV and possibly level I. Level IIb can be omitted if there is no disease in level IIa. (R)

• If treated with radiotherapy, levels II–IV should be included, and possibly level Ib in selected cases. (R)

• Altering the modalities of treatment according to HPV status is currently controversial and should be undertaken only in clinical trials. (R)

• Where possible, patients should be offered the opportunity to enrol in clinical trials in the field. (G)

• Patients with nasopharyngeal carcinoma (NPC) should be assessed with rigid and fibre-optic nasendoscopy. (R)

• Nasopharyngeal biopsies should be preferably carried out endoscopically. (R)

• Multislice computed tomographic (CT) scan of head, neck and chest should be carried out in all patients and magnetic resonance imaging (MRI) where appropriate to optimise staging. (R)

• Radiotherapy (RT) is the mainstay for the radical treatment for NPC. (R)

• Concurrent chemoradiotherapy offers significant improvement in overall survival in stage III and IV diseases. (R)

• Surgery should only be used to obtain tissue for diagnosis and to deal with otitis media with effusion. (R)

• Radiation therapy is the treatment of choice for stage I and II disease. (R)

• Intensity modulated radiation therapy techniques should be employed. (R)

• Concurrent chemotherapy with radiation therapy is the treatment of choice for stage III and IV disease. (R)

• Patients with NPC should be followed-up and assessed with rigid and/or fibre-optic nasendoscopy. (G)

• Positron emission tomography–computed tomography (PET–CT), CT or MRI scan should be carried out at three months from completion of treatment to assess response. (R)

• Multislice CT scan of head, neck and chest should be carried out in all patients and MRI scan whenever possible and specially in advanced cases with suspected recurrence. (R)

• Surgery in form of nasopharyngectomy should be considered as a first line treatment of residual or recurrent disease at the primary site. (R)

• Neck dissection remains the treatment of choice for residual or metastatic neck disease whenever possible. (R)

• Re-irradiation should be considered as a second line of treatment in recurrent disease. (R)