Pan-Asian adaptation of the EHNS-ESMO-ESTRO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with squamous cell carcinoma of the head and neck

Key guideline recommendations

1. Rigid endoscopy of the head and neck, contrast-enhanced CT and/or MRI of the head and neck, and chest imaging (with CT and/or FDG-PET) are strongly recommended.

   IV, A

2. In oropharyngeal cancer, p16 immunohistochemical staining is strongly recommended.

   I, A

3. For recurrent and/or metastatic disease, tumour PD-L1 expression should be assessed.

   II, B

4. When radiotherapy is given, all patients should be treated with IMRT or VMAT.

   I, A

5. The treatment strategy for HPV-positive SCCHN should be the same as for HPV-negative SCCHN.

   I, A

6. Standard options for locally advanced disease are surgery with adjuvant (chemo)radiotherapy or primary concurrent chemoradiotherapy.

   I, A

7. Standard chemotherapy is cisplatin 100 mg/m² on days 1, 22 and 43 of concurrent radiotherapy; weekly cisplatin 40 mg/m² is an alternative in the postoperative setting [II, A].

   II, A

8. In patients unable to receive cisplatin, carboplatin plus 5-FU or cetuximab concurrent with radiotherapy, or hyperfractionated or accelerated radiotherapy without chemotherapy, are treatment alternatives.

   II, A

9. For larynx preservation, induction chemotherapy with docetaxel, cisplatin and 5-FU (TPF; up to three cycles depending on response) followed by radiotherapy alone is a valid treatment option (I, A). Other than for larynx preservation, induction chemotherapy is not routinely recommended (no level of evidence in the text).

   I, A

10. With a negative FDG-PET and normal-sized lymph nodes 12 weeks after chemoradiotherapy, neck dissection is not recommended.

    I, A

11. Postoperative radiotherapy is recommended for patients with pT3-4 tumours, surgical margins with macroscopic (R2) or microscopic (R1) residual disease, perineural invasion, lymphatic invasion, involvement of more than one lymph node and extracapsular extension (II, A); postoperative chemoradiotherapy is recommended for patients with R1 resection and extranodal extension (I, A).

    II, A / I, A

12. Every effort should be made to start postoperative radiotherapy or chemoradiotherapy within 6 weeks of surgery.

    II, A

13. Pembrolizumab plus platinum/5-FU and pembrolizumab monotherapy are two approved regimens for patients with recurrent or metastatic SCCHN expressing PD-L1 (CPS ≥1) (I, A; ESMO-MCBS v1.1: score 4). The choice between pembrolizumab monotherapy and chemotherapy plus pembrolizumab can be based on CPS, tumour burden and symptoms (V, B in the text; V, C in the summary table).

    I, A; ESMO-MCBS 4

14. Platinum/5-FU/cetuximab remains the standard treatment for patients with recurrent or metastatic SCCHN without PD-L1 expression (I, A; ESMO-MCBS v1.1: score 3); pembrolizumab plus chemotherapy (II, C), TPEx (II, B) and PCE (II, B) are also treatment options in this population.

    I, A; ESMO-MCBS 3

15. Nivolumab is FDA-‎ and EMA-approved for patients with recurrent or metastatic disease progressing within 6 months of platinum-based therapy.

    I, A; ESMO-MCBS 4

16. Given the specific genetic profile of Asian populations, DPD genotyping or phenotyping before starting fluoropyrimidine-based treatment can be considered.

    III, C

17. Clinical follow-up including head and neck examination with flexible endoscopy: every 2 to 3 months in the first 2 years, every 6 months in years 3 to 5 and annually thereafter; FDG PET/CT three months after chemoradiotherapy is recommended in patients with nodal involvement to determine the need for neck dissection (I, A).

    III, A / I, A

Study population

Clinical significance and place in guidelines

Limitations