North of Scotland Cancer Network Clinical Management Guideline for Oropharyngeal Cancer

Transcription

1 Nth of Scotland Cancer Netwk Clinical Management Guideline f Oropharyngeal Cancer UNCONTROLLED WHEN PRINTED Based on NHST CMG with further extensive consultation within NOSCAN DOCUMENT CONTROL Original Prepared by NMcL March 2016 (using NHST documents as base) Approved by STILL TO BE FORMALLY APPROVED Issue date Review date September 2016 Version 1.0 ( ) NMcL Version 1.0 ( ) Page 1 of 5

2 General Guidance Notes: Initial diagnosis and Assessment It is imptant to establish a definitive diagnosis earliest and an indication of clinical staging (see page 8) in advance of patient being discussed at the specialist weekly Head & Neck Cancer MDT Confirm Diagnosis Full Histy & Clinical Examination Full blood profile (ie FBC, U&E, Biochem) Fibreoptic Endoscopy FNA neck nodes +/- US Pharyngo-laryngoscopy + Biopsy MRI/CT neck & chest FDG-PET (as per national guidance) Histology Site Type Grade Infiltration pattern Depth of Invasion Cytology Register with MDT Due to the nature of their presenting disease and likely treatment, in addition to above, all patients should be referred earliest to the appropriate relevant multidisciplinary specialities as detailed below: (Note: others may also be clinically required depending on individual patient circumstances) Clinical Nurse Specialist (CNS) - f assessment and ongoing specialist advice, education, suppt and co-dination of care f patient and their relatives throughout the treatment pathway Speech and Language Therapist (SLT) f routine assessment soonest after diagnosis and thereafter at suitable intervals befe, during and after treatment completion Dietetic & Nutrition all patients assessed as at risk by screening tool should be fmally referred f me fmal assessment and nutritional car planning/suppt Dental - f initial assessment and completion of any treatment intervention identified necessary pri to commencement of any cancer treatment In line with best principles, at all stages throughout the treatment pathway: Any treatment plans should be discussed with patient and relatives during their preparation Patients and their relatives should be provided with written infmation Primary Care should be notified of patients pathway progress Baseline measurement of functional outcome HPV Testing recommended in all cases Screening Tools MUST WHO Perfmance Status If available, clinical trials should always be considered the preferred option f eligible patients Version 1.0 ( ) Page 2 of 8

3 Primary Treatment Initial Evaluation Clinical stage (see page 8 f details) Primary Treatment Follow-up Confirmed Diagnosis of Orapharyngeal Cancer (see page 2 f guidance on tests and investigations required) Discussion at specialist MDT Curative Intent Non-Curative Intent Early: Superficial (<2mm depth) T1 + T2 T1 + T2 (>4mm depth) N0 Resectable T3, T4 any TN+ve M0 Unresectable Stage III, IVa,b Unresectable M0 Cure felt unlikely but prolonged local control, fit patient, consider Surgery: Per-al Local Excision Radical radiotherapy Surgery: Wide Local Excision + Elective Lymphadenectomy. Assess procedure and reconstruction as indicated. Radical radiotherapy to primary site + Level II,III,IV retropharyngeal lymph nodes. Consider ipsilateral only if well lateralised primary Surgery: Neck+ primary + adjuvant radiotherapy (+ chemotherapy if pathology indicates) Definitive Chemadiation Definitive chemadiation Refer to Palliative Care. Best Supptive Care +/- palliative oncological treatment as clinically dictated. Careful assessment of anticipated toxicity and potential benefit. Post-operative pathology and/ treatment review (see page 4) and discussion at specialist MDT All patients should be offered follow-up as per local guidelines appropriate (see page 4 f details) Note: HPV+ve Tumours are usually managed by Primary Radiotherapy (+/- chemotherapy) The role of neo-adjuvant chemotherapy has not yet been clarified. However, in bulky Locally Advanced disease, it can be used as: induction therapy to relive symptoms pri to definitive therapy, in an attempt to improve tumour control If available clinical trials should always be considered the preferred option f eligible patients Version 1.1 ( ) Page 3 of 8

4 Adjuvant Therapy and Follow-up General Guidance Notes: Where any multimodal therapy is being considered (ie such as Radiotherapy after surgery), consideration should always be given as to the compromise between improved tumour control and increased risk of functional mbidity Response to non-surgical treatment can be investigated at 8-12 weeks from completion (either by CT PET-CT), when surgical salvage f persistent disease can also be considered Follow-up Excepting where patients are participating in a Clinical Trial (when separate guidance exists), all other patients should attend Outpatient Clinic and Nurse-led Suppt Clinic(s) f follow-up and symptom management accding to local guidelines, at which they should have ongoing review of their Nutritional status as well as any methods of nutritional suppt monited by a Dietitian any repts of pain investigated access to instrumental investigation f dysphagia Patients with dysphagia should thereafter also receive Speech & Language Therapy (SLT) to optimise residual swallow function reduce aspiration risk maximise speech outcomes following treatment Follow-up imaging should be considered f patients not undergoing fmal surgical neck staging If available clinical trials should always be considered the preferred option f eligible patients Version 1.1 ( ) Page 4 of 8

5 Concomitant Chemotherapy Applications As primary therapy f Patients aged <70; ECOG* PS 0/1; Stage III/IV disease. Systemic Anti-Cancer Therapy Curative Intent Note: If available clinical trials should always be considered As adjuvant therapy f the preferred option f eligible patients Patients aged <70; ECOG* PS 0/1; Note: definite indications are ECS (extra-capsular spread) and close/positive margins - other high risk pathological features (e.g. multiple nodes/t4 stage) are relative indications only. Single Agent Cisplatin: Cisplatin 30-40mg/m² IV infusion on Day 1 Repeat weekly f duration of Radiotherapy Note: In renal impairment (GFR <60), hearing impairment, peripheral neuropathy, po cardiac function (significant risk with Cisplatin fluid challenge) in other cases where clinician has concerns over Cisplatin toxicity, consider Carboplatin Cetuximab as long as treatment intent remains curative and fitness otherwise appropriate f combined modality therapy (in general WHO PS 0,1; age <70, good renal and cardiac function). Single Agent Carboplatin: Carboplatin [AUC 5] IV infusion on Day 1 Repeat on Day 28 whilst on radiotherapy. Single Agent Cisplatin: Cisplatin 100mg/m² IV infusion on Day 1 Repeat every 3 weeks/21days f duration of radiotherapy. Single Agent Cetuximab: Cetuximab 400mg/m² IV infusion on Day 1 (up to 1 week pri to radiotherapy start date) and then Cetuximab 250mg/m² IV infusion every week/7 days f duration of radiotherapy. Note: Cetuximab is only suitable f primary treatment. There is presently no evidence f post-operative adjuvant use. Neo-Adjuvant Chemotherapy Currently limited evidence to suppt this. Nevertheless, it is accepted that it may be used in locally advanced SCC, especially where symptoms are distressing, disease particularly bulky, and there is thus a clinical suspicion that neo-adjuvant chemotherapy may provide either rapid symptom control, improved chance of disease control. Such patients must be intended f curative intent. The role of neo-adjuvant chemotherapy pri to surgery is even less well established, and is best considered in the context of a clinical trial. The regimen recommended f neo-adjuvant use in the NoS is Cisplatin / 5FU (regimen details as per above), when Carboplatin can occasionally be substituted (also see above f reasons ) Version 1.1 ( ) Page 5 of 8

6 Palliative Chemotherapy Systemic Anti-Cancer Therapy Palliative Intent There are two regimens approved by the Nth of Scotland Regional Head & Neck Cancer Group f routine use, with patient choice and characteristics determining which is most appropriate f an individual: Cisplatin + 5FU Cisplatin 100mg/m² IV infusion on Day 1 5 Fluuacil 1000mg/m² IV infusion (via PICC Line and ambulaty device) on Days 1-4 Repeat every 3 weeks/21 days Continue f up to 6 cycles Note: In cases of concern over renal/cardiac function: substitute Carboplatin AUC5 f Cisplatin Paclitaxel + Carboplatin Paclitaxel 175mg/m² IV infusion on Day 1 Carboplatin [AUC 5] IV infusion on Day 1 Repeat every 3 weeks/21 days Continuef up to 6 cycles Note: There is presently no established second-line chemotherapy regimen. Re-challenge with Cisplatin/Carboplatin regimen may be possible where a good earlier response has been achieved. [AUC 5] Area Under the Curve (as per Cockcroft-Gault equation) PICC Peripherally Inserted Central Catheter If available clinical trials should always be considered the preferred option f eligible patients Version 1.1 ( ) Page 6 of 8