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Guideline Updates

NCCN Updates Clinical Practice Guideline for Head and Neck Cancers

February 14, 2020

The National Comprehensive Cancer Network (NCCN) updated its clinical practice guideline for head and neck cancers.

The workup has been modified for each disease site to include nutrition evaluation, speech and swallowing evaluation, smoking cessation counseling, and fertility or reproductive counseling.

In the section for cancer of the oropharynx, adjuvant radiotherapy is now listed as a category 2A option for patients with a positive margin following resection of HPV-positive T1-2, N0 disease. Concurrent systemic therapy/radiotherapy is also now included as a category 2B primary treatment options for patients with HPV-positive T1, N1 disease.

An additional definitive radiotherapy dose option has been added for TI, N0 cancer of the glottic larynx: 50 Gy (3.12 Gy/fraction) to 52 Gy (3.28 Gy/fraction).

For patients with a resectable, locoregional recurrence without prior radiotherapy, “combination systemic therapy (category 3) followed by radiotherapy or systemic therapy/radiotherapy” is now listed.

Follow-up recommendations have been significantly modified for post-systemic therapy/radiotherapy or radiotherapy alone. Additionally, a new section has been added for principles of imaging.

In the section for postoperative systemic therapy/radiotherapy for non-nasopharyngeal cancer, a new option is listed: docetaxel/cetuximab (category 2B) as useful in certain circumstances if the patient is cisplatin ineligible and has positive margins or extranodal extension.

The section for systemic therapy for recurrent, unresectable or metastatic non-nasopharyngeal cancer features a variety of changes. For lip, oral cavity, oropharynx, hypopharynx, glottic larynx, supraglottic larynx, ethmoid sinus, maxillary sinus, and occult primary disease sites, “pembrolizumab/platinum (cisplatin or carboplatin)/5-FU” has been changed to a category 1 preferred option. A new section has been added for salivary gland tumors with the following new regimens: cisplatin/vinorelbine (other recommended regimen), cisplatin/doxorubicin/cyclophosphamide (category 2B, other recommended regimen), and lenvatinib (category 2B for adenoid cystic carcinoma, useful in certain circumstances).

In the section for systemic therapy for nasopharyngeal cancer, gemcitabine/cisplatin has been added as a category 1, preferred primary induction/sequential therapy option. Additionally, gemcitabine/carboplatin has been added as a category 2A other recommended first-line therapy option for recurrent, unresectable or metastatic disease.

For oral mucositis pain, diphenhydramine/lidocaine/antacid mouthwash has been added as an option.—Zachary Bessette

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