NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Head and Neck Cancers. These NCCN Guidelines® are currently available as Version 1.2017.

·         Cancer of the Oral Cavity

o    For clinical stage T1-2, N0, re-resection has been made the preferred adjuvant therapy option for those with positive margins. (OR-2 and ORPH-2)

o    Clinical stage of T3, N0; T1-3, N1-3; or T4a, any N

§  Re-resection has been removed from the adjuvant therapy options for those with extracapsular spread +/- positive margins. (OR-3)

§  Adjuvant therapy options have been added for those with positive margins. Adjuvant options include: systemic therapy/RT (category 1), or re-resection and consider RT if negative margins, or RT alone. (OR-3)

·         Cancer of the Nasopharynx

o    A footnote has been added for EBV/DNA testing: “For nonkeratinizing or undifferentiated histology, consider testing for EBV in tumor and blood. Common means for detecting EBV in pathologic specimens include in situ hybridization for EBV-encoded RNA (EBER) or immunohistochemical staining for latent membrane protein (LMP). The EBV DNA load within the serum or plasma may be quantified using polymerase chain reaction (PCR) targeting genomic sequences of the EBV DNA such as BamHI-W, EBNA, or LMP; these tests vary in their sensitivity. The EBV DNA load may reflect prognosis and change in response to therapy.” (NASO-1)

·         Salivary Gland Tumors

o    Dental evaluation, nutritional evaluation, preanesthesia studies, and multidisciplinary consultation have been added to the workup, as clinically indicated. (SALI-1)

·         Mucosal Melanoma

o    A footnote has been added: “Recent studies suggest that increased toxicity may occur when RT is used in combination with BRAF inhibitors. (Anker CJ, Grossmann KF, Atkins MB, et al. Avoiding severe toxicity from combined BRAF inhibitor and radiation treatment: Consensus guidelines from the Eastern Cooperative Oncology Group (ECOG). Int J Radiat Oncol Biol Phys 2016;95:632-646.)” (MM-A)

·         Follow-Up Recommendations

o    “Consider EBV DNA monitoring for nasopharyngeal cancer” has been changed to a category 2B recommendation. (FOLL-A, 1 of 2)

o    The following bullet and reference have been added:

§  “Integration of survivorship care and care plan within 1 year, complementary to ongoing involvement from a head and neck oncologist. See NCCN Guidelines for Survivorship.” (FOLL-A, 1 of 2)

§  Cohen EE, LaMonte SJ, Erb NL, et al. American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA Cancer J Clin 2016;66:203-239. (FOLL-A, 1 of 2)

·         Radiation Techniques

o    Proton beam therapy has been incorporated into the recommended RT techniques and references have been added.

o    The second, third, and fourth paragraphs of text have been added. (RAD-A, 1 of 5)

o    The following bullets have been added under reirradiation:

§  “Radiation volumes should include known disease only. There is no need to treat prophylactic regions.” (RAD-A, 3 of 5)

§  “When using SBRT techniques, selection of patients who do not have circumferential carotid involvement is advised.” (RAD-A, 3 of 5)

§  “Current SBRT schedules being used or investigated are in the range of 30–44 Gy using 5 fractions.” (RAD-A, 3 of 5)

·         Principles of Systemic Therapy

o    The category of evidence has been revised for the following primary systemic therapy + concurrent RT option: “Cetuximab (category 1 for oropharynx, hypopharynx, or larynx; category 2B for lip, oral cavity, ethmoid sinus, maxillary sinus, occult primary)”. (CHEM-A, 1 of 5)

o    A footnote has been added to clarify when postoperative chemoradiation with cisplatin is a category 1 recommendation: “Adverse features: extracapsular nodal spread and/or positive margins.” (CHEM-A, 1 of 5)

o    The following options have been added for the treatment of recurrent, unresectable, or metastatic head and neck cancer (non-nasopharyngeal) with no surgery or RT option (CHEM-A, 2 of 5):

§  Carboplatin/docetaxel/cetuximab

§  Carboplatin/paclitaxel/cetuximab

o    Vinorelbine has been removed from the single-agent options for recurrent, unresectable, or metastatic head and neck cancer. (CHEM-A, 2 of 5)

o    Clarified that afatinib (category 2B) is recommendation for non-nasopharyngeal cancer as a second line option if disease progression on or after platinum-containing chemotherapy. (CHEM-A, 2 of 5)

o    Clarified that the single-agent options of pembrolizumab and nivolumab apply to non-nasopharyngeal cancers. (CHEM-A, 2 of 5)

·         Principles of Nutrition (NUTRA-A, 1 of 2)

o    The first paragraph has been revised: “Most head and neck cancer patients lose weight and are nutritionally compromised as a result of their disease, health behaviors, and treatment-related toxicities. Nutritional management is very important in head and neck cancer patients to improve outcomes and to minimize significant temporary or permanent treatment-related complications (eg, severe weight loss). A registered dietitian and a speech language/swallowing therapist should be part of the multidisciplinary team for treating patients with head and neck cancer throughout the continuum of care. .”

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Compendium^®, the NCCN Biomarkers Compendium^®, the NCCN Chemotherapy Order Templates (NCCN Templates^®), and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To view the NCCN Guidelines for Patients^®, please visit NCCN.org/patients.

Free NCCN Guidelines apps for iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.

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