Service Provision for Head and Neck Cancer Patients in New Zealand- Provisional
National Head and Neck Cancer Tumour Standards Working Group
Citation: National Head and Neck Cancer Tumour Standards Working Group. 2013.
Standards of Service Provision for Head and Neck Cancer Patients in New Zealand - Provisional.
Wellington: Ministry of Health.
Revised January 2014
Published in December 2013 by the
Ministry of Health
PO Box 5013, Wellington 6145, New Zealand
ISBN 978-0-478-41543-8 (online)
This document is available through the Ministry of Health website: www.health.govt.nz
or from the regional cancer network websites:
How the head and neck cancer service standards were developed 3
Equity and Whānau Ora 4
Summary of the clinical standards for the management of head and neck cancer services 6
Standards of service provision pathway 6
Summary of standards 7
1 Prevention and Early Identification 10
Good practice points 10
2 Timely Access to Services 12
Good practice points 13
3 Referral and Communication 14
Good practice points 14
Good practice points 15
4 Investigation, Diagnosis and Staging 16
Good practice points 16
Good practice points 17
Good practice points 18
Good practice points 18
Good practice points 20
Good practice points 21
5 Multidisciplinary Care 22
Good practice points 22
Good practice points 24
Good practice points 25
Good practice points 26
6 Supportive Care 27
Good practice points 27
7 Care Coordination 29
Good practice points 29
8 Treatment 30
Good practice points 30
Good practice points 32
Good practice points 33
9 Follow-up and Surveillance 35
Good practice points 35
Good practice points 37
10 Clinical Performance Monitoring and Research 39
Good practice points 39
Good practice points 40
National Head and Neck Cancer Tumour Standards Working Group Membership 41
For this purposes of this document, the term ‘head and neck cancer’ applies to the following sites in adults:
mucosa of the head and neck (oral cavity and lip, pharynx, larynx and cervical oesophagus)
nasal cavity and paranasal sinuses
skin of the head and neck, in the context of high-risk and advanced non-melanoma skin cancer.
Nationally, there are approximately 520 new cases of cancer of head and neck mucosal surfaces registered each year (Ministry of Health 2013). In addition, there are an estimated 200 cases of metastatic non-melanoma skin cancer of the head and neck registered annually, as well as a smaller number of salivary malignancies – these are currently not captured separately in the Cancer Registry.
Incidence of head and neck cancer by gender varies with primary cancer site; incidence rates in men are double the rates in women for oral cavity/pharyngeal cancers, and triple the rates in women for laryngeal cancer (National Cancer Institute 2003). The five-year survival rate for patients with head and neck cancer is approximately 60 percent (Jemal et al 2002; Ries et al 2006; Saman 2012). While these cancers (excluding skin) represent only 2.5 percent of all cancers (NCCN 2012), they require sophisticated and complex health care services, and the individual, social, family and economic burden is large.
Traditionally, major aetiological factors in head and neck cancer have been smoking and alcohol. Cigarette smoking is considered the most important risk factor for head and neck cancer (Saman 2012). A significant dose–response relationship exists between alcohol consumption and risk of head and neck cancer (Agudo et al 2006). Users of both tobacco and alcohol have a 50-fold (or greater) increased risk of developing head and neck cancer (Maier et al 1992; Rodriguez et al 2004).
While incidence of head and neck cancer is greatest in those over 50, incidence in young adults is on the rise, most likely attributable to human papillomavirus (HPV) exposure (Curado and Hashibe 2009; Marur and Forastiere 2008). Viral aetiologies are also implicated in cancers more common in certain ethnic groups. Nasopharyngeal cancer is associated with the Epstein-Barr Virus (EBV) as well as genetic and environmental factors, and is the commonest cancer of any site in Southern China (Wei and Sham 2005).
With each stage of human migration from Southern Asia into Polynesia in the last 5000 years there has been a graduated dilution of aetiological factors and cancer incidence. Thus the risk of nasopharyngeal carcinoma in New Zealand for Asians, Pacific Islanders and Māori compared to those of European descent is respectively eight times, five times and three times (Morton and Benjamin 1989). Pacific Islanders in New Zealand are also more likely to have smaller primary cancers and larger nodal metastases than their Asian counterparts (Ianovski et al 2009). As Asian and Pacific ethnic groups grow at faster rates than any other,1 an increasing burden of patients with nasopharyngeal carcinoma is expected.
Human papillomavirus has been implicated in the rapid rise in the incidence of oropharyngeal (tonsil and base of tongue) cancer throughout the western world (Snijders et al 1992; Mellin et al 2000). This virus is also linked with cervical cancer; it is postulated that the increase in oropharyngeal cancer is associated with the sexual revolution and oral sex in western society. These cancers appear in an earlier age group, and incidence is usually not associated with the traditional risk factors of smoking and alcohol. Early data indicate that HPV-related tumours are more responsive to treatment and have a better prognosis than HPV-negative cancers (Hong et al 2010).
Current unpublished data from the Auckland regional Head and Neck Service indicate that, excluding cutaneous lesions, oropharyngeal cancer is now the most common head and neck malignancy; over 75 percent of cases are HPV-positive. New Zealand currently offers free immunisation for HPV to girls aged 13 and over, but not to boys. Canada and Australia offer vaccination to girls and boys, in an effort to gain herd immunity. Expected benefits include a reduction in the incidence of both cervical cancer in women and oropharyngeal cancer in both sexes.
The head and neck is a common site for non-melanoma skin cancer due to ultraviolet (UV) skin exposure. Squamous cell carcinoma presents the greatest challenge, and is largely dealt with in primary care. However, there is a subset of more aggressive tumours that can be identified histologically and which carry an increased risk of recurrence and nodal metastases; these require treatment by a multidisciplinary team (MDT) (Peat et al 2012). In the context of an aging population and global warming, the incidence of such lesions is rising.
Studies in New Zealand and overseas have shown that patients with head and neck cancer generally experience a measurable improvement in quality of life in the first two to three years following treatment (Morton 2003). Long-term survival has also been shown to be significantly associated with early quality of life scores in these patients (Mehanna et al 2005). More recent Auckland research has shown that patients with head and neck cancer have substantial unmet needs, and that there is great potential for enhanced quality of life and other benefits for individuals if they receive adequate support (Cavell et al (in press)).
Head and neck cancer and its treatment may impinge on a patient’s facial appearance, voice and speech, oral continence, chewing and swallowing, breathing, hearing and sight. It may also impact on shoulder function. For this reason a multidisciplinary meeting (MDM) forms the basis of clinical care for head and neck cancer. The MDM involves specialists in ablative and reconstructive surgery; dental, oral and maxillofacial surgery; speech-language therapy; dietetics; and psychology, alongside a nurse specialist. These practitioners confer and interact with patients to determine optimal individual treatment pathways (BAHNO 2009; NHS Wales 2005).
A recent (unpublished) review of patients requiring major head and neck surgery in Auckland over a two-year period found that the average patient required two admissions, and spent a total 30 days in hospital. Because of the relatively low number of disparate cancers of the head and neck nationally, the requirement for multidisciplinary care and the large workload associated with inpatient care, a case can be made for a concentration of services, to consistently achieve optimal treatment outcomes and cost-effective care.