Laryngoscope Investig Oto - 2021 - Goyal - Head and Neck Cancer Survivorship Consensus Statement From The American Head and

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Received: 21 September 2020 Revised: 15 October 2021 Accepted: 10 November 2021
DOI: 10.1002/lio2.702
REVIEW
Head and neck cancer survivorship consensus statement from

the American Head and Neck Society
Neerav Goyal MD, MPH FACS1 | Andrew Day MD2 |

3,4
Joel Epstein DMD, MSD, FRCD(C) |Joseph Goodman MD5 |
Evan Graboyes MD, MPH, FACS6 | Scharukh Jalisi MD7 | Ana P. Kiess MD, PhD8 |
9 10 11
Jamie A. Ku MD | Matthew C. Miller MD | Aru Panwar MD |
12 13
Vijay A. Patel MD | Assuntina Sacco MD | Vlad Sandulache MD, PhD14 |
15 16
Amy M. Williams PhD | Daniel Deschler MD, FACS |
17
D. Gregory Farwell MD, FACS | Cherie-Ann Nathan MD, FACS18 |
19 20
Carole Fakhry MD, MPH | Nishant Agrawal MD
1
Department of Otolaryngology—Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
2
Department of Otolaryngology—Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
3
Department of Surgery, Cedars Sinai, Los Angeles, California, USA
4
City of Hope, California, Duarte, USA
5
Ear, Nose and Throat Center, George Washington University, Washington, District of Columbia, USA
6
Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
7
Department of Otolaryngology, Beth Israel Deaconess, Boston, Massachusetts, USA
8
Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, Maryland, USA
9
Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
10
Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, USA
11
Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
12
Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
13
Department of Medical Oncology, University of California San Diego, La Jolla, California, USA
14
Department of Otolaryngology—Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
15
Department of Otolaryngology—Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
16
Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
17
Department of Otolaryngology—Head and Neck Surgery, University of California Davis, Davis, California, USA
18
Department of Otolaryngology—Head and Neck Surgery, Louisiana State University, Shreveport, Louisiana, USA
19
Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
20
Department of Surgery, Section of Otolaryngology—Head and Neck Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
This manuscript represents a consensus statement from the Survivorship, Supportive Care & Rehabilitation Service of the American Head and Neck Society.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
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© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.
70 wileyonlinelibrary.com/journal/lio2 Laryngoscope Investigative Otolaryngology. 2022;7:70–92.

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GOYAL ET AL. 71
Correspondence
Neerav Goyal, Department of Abstract
Otolaryngology—Head and Neck Surgery, The Objectives: To provide a consensus statement describing best practices and evi-
Pennsylvania State University, College of
Medicine, 500 University Drive, H091, dence regarding head and neck cancer survivorship.
Hershey, PA 17033-0850, USA. Methods: Key topics regarding head and neck cancer survivorship were identified
Email: [email protected]
by the multidisciplinary membership of the American Head and Neck Society Survi-
Nishant Agrawal, Section of Otolaryngology—
Head and Neck Surgery, University of Chicago, vorship, Supportive Care & Rehabilitation Service. Guidelines were generated by
Pritzker School of Medicine, 5841 S. Maryland
combining expert opinion and a review of the literature and categorized by level of
Avenue, MC 1035, Chicago, IL 60637, USA.
Email: [email protected] evidence.
Results: Several areas regarding survivorship including dysphonia, dysphagia,
fatigue, chronic pain, intimacy, the ability to return to work, financial toxicity,
lymphedema, psycho-oncology, physical activity, and substance abuse were identi-
fied and discussed. Additionally, the group identified and described the role of key
clinicians in survivorship including surgical, medical and radiation oncologists; den-
tists; primary care physicians; psychotherapists; as well as physical, occupational,
speech, and respiratory therapists.
Conclusion: Head and neck cancer survivorship is complex and requires a multi-
disciplinary approach centered around patients and their caregivers. As survival
related to head and neck cancer treatment improves, addressing post-treatment
concerns appropriately is critically important to our patient's quality of life. There
continues to be a need to define effective and efficient programs that can coordi-
nate this multidisciplinary effort toward survivorship.
KEYWORDS
consensus statement, head and neck cancer, survivorship
1 | I N T RO DU CT I O N While cure rates for advanced-stage HNC remain low, with the
increased incidence of HPV associated tumors, there is a rise in overall
In the modern era, cancer remains a major public health problem HNC survivors in the United States.4
worldwide and remains the second leading cause of death in the In 1985, Dr. Fitzhugh Mullan first described his own personal bat-
United States. In 2020, it is estimated 65,630 new cases of head and tle with cancer and fundamentally changed the concept of survivor-
neck cancer (HNC) will occur, which accounts for 3.6% of new onco- ship. He delineated three key phases of survival: “acute survival,” a
logic cases nationwide.1 period that encompasses diagnosis and treatment; “extended sur-
Well-described risk factors in the development of squamous cell vival,” a period that begins at treatment completion and includes sur-
carcinoma (SCC) include tobacco use and alcohol consumption, which veillance; and “permanent survival,” a period vaguely defined as cure.5
2
traditionally accounted for 90% of HNC cases. In recent years, During this journey, survivors may encounter substantial medical,
human papillomavirus (HPV)-associated oropharyngeal SCC, a biologi- psychosocial, interpersonal, financial, and functional consequences.6
cally unique and clinically distinct disease process, has been shown to As a unique discipline, cancer survivorship has garnered much atten-
encompass as much as 70% of new oropharyngeal carcinoma diagno- tion in recent years, with a renewed focus on continuing care for
ses.3 patients beyond their defined surgery, radiation therapy, and/or che-
After completion of an appropriate diagnostic work-up, which motherapy. Recognizing these changes, the American Head and Neck
includes a complete head and neck physical examination, radiographic Society (AHNS) has convened the AHNS Survivorship, Supportive
imaging, and surgical biopsy, management of HNC is largely driven by Care & Rehabilitation Service, a committee on HNC survivorship. In
the primary anatomic site, TNM (tumor, lymph node, and metastasis) this article, the concept of survivorship is reviewed to identify current
classification, and patient medical comorbidities. Single-treatment practice patterns for HNC patients and gaps in survivor care providing
modalities such as surgery or radiation are typically reserved for the a roadmap for future initiatives in HNC survivorship. We expand upon
30%–40% HNC patients who present with early-stage (I or II) disease. the guidelines set forth by the American Cancer Society (ACS) and the
Multi-modality treatment is reserved for the approximately 60% of American Society of Clinical Oncology (ASCO) with special emphasis
HNC patients presenting with locally or regionally advanced disease.2 placed on the importance of the multidisciplinary model.7,8 The goal
72 GOYAL ET AL.
TABLE 1 Head and neck cancer survivorship: AHNS Committee Guidelines
Level of evidence Topic Recommendation

a
2A Surgical oncology evaluation Evaluate every 1–3 months in the 1st year after treatment; every 2–6 months in the 2nd
year after treatment; every 4–8 months in the 3rd–5th year after treatment; and every
12 months thereafter
2Aa Follow closely for a complete head and neck examination, indirect mirror and/or flexible
fiberoptic laryngoscopy, and nasal endoscopy for patients with sinonasal malignancies
2Ba Monitor with EBV DNA in the setting of nasopharyngeal carcinoma surveillance
2Aa Radiation oncology evaluation Evaluate for thyroid dysfunction (TSH/T4) every 6–12 months, particularly with prior
neck irradiation
2Aa Refer for regular dental examinations, especially if the patient received intraoral or
salivary gland irradiation
2Aa Follow in close, alternating intervals with surgical and medical oncology
2Aa Medical oncology evaluation Follow in close, alternating intervals with surgical and radiation oncology with attention to
adverse effects related to chemotherapy and immunotherapy
2Aa Radiographic imaging Follow with radiographic imaging (CT, MRI, and/or PET/CT) based on worrisome signs or
symptoms and areas inaccessible to clinical examination (i.e., salivary glands,
nasopharynx, and skull base)
2Aa Consider chest CT with or without contrast as clinically indicated for those with a
smoking history
2Aa Survivorship clinic Incorporate a multidisciplinary team including nurses, advanced practice providers,
oncologists (medical, radiation, surgical) in close coordination with the patient's primary
care provider on at least an annual basis
2Aa Dysphonia and dysphagia Incorporate speech-language pathology evaluation and management for at risk patients
5b Fatigue Evaluate for underlying etiologies of fatigue
b
2A Sexual dysfunction and intimacy Screen for sexual and intimacy dysfunction
2Ab Offer supportive care services for sexual function and intimacy issues
b
2A Consider pituitary dysfunction if patients have received skull base irradiation
2Ab Counsel regarding the risk of HPV transmission after treatment for HPV-related OPSCC
a
2A Chronic pain Screen for chronic pain at routine intervals
2Aa Assess for the quality and severity of their pain using pain assessment tools
a
2A Evaluate for depressive symptoms in the presence of chronic pain
3Bb Consider ruling out recurrent disease as a cause of pain
a
2A Screen for opioid abuse
2Cb, 2Aa, 1Ab Offer non-opioid analgesics including nonsteroidal anti-inflammatory agents,
acetaminophen, neuromodulators, and acupuncture
5b Refer to palliative and/or pain management specialists for refractory or opioid-dependent
pain
5b Physical therapy Screen for physical rehabilitation needs early in the post-treatment phase with objective
assessments of upper limb dysfunction at regular intervals
2Aa Assess for objective measures of trismus at regular intervals prior to and following
therapy
5b Refer to exercise and physiotherapy professionals for structured rehabilitation after HNC
treatment
1Bb Incorporate shoulder physiotherapy after completion of neck dissection
2Aa Lymphedema Evaluate for lymphedema after HNC treatment
2Aa Refer to certified lymphedema therapists for CDT
2Aa Psycho-oncology Screen for BID concerns
2Aa Refer to psychology or psychiatry for the management of BID as indicated
1Ab Assess for distress, depression, and/or anxiety at regular intervals using a validated
questionnaire
1Bb Consider referral to psychology or psychiatry if distress, depression, and/or anxiety is
present
GOYAL ET AL. 73
TABLE 1 (Continued)
Level of evidence Topic Recommendation

a
2A Hearing loss Evaluate yearly, for first 2 years, for hearing loss via pure tone audiometry in at risk
patients
5b Respiratory therapy Multidisciplinary team should be aware and versed in tracheostomy and laryngectomy
stoma care
5b Caregivers Include caregivers in all aspects of HNC care provided by the oncology team and PCP
b
5 Social support groups Educate on social support groups and their impact on understanding the wide-ranging
sequelae of oncologic treatment
5b Return to work Counsel on medical disability rights and protections afforded by federal law
5b Financial burden Refer to social workers and financial navigators to understand health care costs
associated with HNC care
2Ab Primary care physician Include PCP involvement for age-appropriate and gender-appropriate screening of other
neoplasms and general health as well as well-being
1Bb Dental care Counsel to maintain close follow-up with the dental professional
5b Encourage to avoid tobacco and alcohol to minimize the risk of dental disease
b
1A Substance abuse Refer for tobacco and alcohol cessation counseling and abstinence resources as needed
1Bb Physical activity/exercise Encourage regular physical activity and exercise
5b HPV counseling Counsel on the sequelae of HPV related oncologic disease and the potential value of
vaccination
Abbreviations: BID, body image disturbance; CDT, complete decongestive therapy; CT, computed tomography; EBV DNA, Epstein–Barr virus
deoxyribonucleic acid; HNC, head and neck cancer; HPV, human papillomavirus; OPSCC, oropharyngeal squamous cell carcinoma; PCP, primary care
physician; TSH, thyroid-stimulating hormone.
a
NCCN categories of evidence and consensus.
b
Oxford level of evidence.
of this document is to serve as a guide for head and neck oncologists, transition beyond 5 years after treatment completion to focusing less
primary care clinicians, and allied health care providers treating HNC on cancer surveillance and more on other aspects of survivorship care.
survivors. This clinical advice (summarized in Table 1) has been anno- This section will outline the integration of surveillance and survivor-
tated throughout this article with key recommendations categorized ship concepts during the first 5 years after treatment. During this
by level of evidence, as defined by the University of Oxford Center time, the oncologic treatment team provides close clinical surveillance,
for Evidence-based Medicine (Table 2).9 Recommendations supported augmented by appropriate radiographic imaging and other ancillary
by the National Comprehensive Cancer Network (NCCN) are catego- testing designed to detect disease recurrence while also managing
2
rized differently to incorporate expert consensus (Table 3). treatment-related side effects and other aspects of survivorship. The
use of a formal document to outline the details of the treatment and
outline a survivorship care plan can be helpful and several documents
2 | C A NC E R S U R V E I LL A N C E published by AHNS and ASCO can help accomplish this.6,7 Figure 1
illustrates a timeline of a proposed survivorship care plan based on
A person is considered a cancer survivor from the time of diagnosis the recommendations from this document.
through the balance of his or her life. Although cancer surveillance
and cancer survivorship are often described in an intermingled fash-
ion, they represent distinct concepts.7 Cancer surveillance generally 2.1 | Surgical oncology
refers to surveillance for disease recurrence, progression, or second
primary cancers, often during the first 5 years after treatment comple- During the cancer surveillance period, it is recommended that patients
tion. Cancer survivorship is a broader concept of life-long care that follow-up with their head and neck surgeon at regular, established
also includes intervention for consequences of cancer and treatment intervals after treatment completion. The head and neck surgeon may
including physical and psychosocial effects, coordination of care remain a part of the surveillance team even in those settings where
between primary care providers and specialists, prevention of new the patient received non-surgical treatment. The NCCN has
cancers and late effects, and survivorship care planning.2 For HNC established guidelines for surveillance, entitled “Follow-up Recom-
patients, the relationship between cancer surveillance and cancer sur- mendations” (FOLL-A) under the current Treatment Guideline for
vivorship is an area of active research and will be discussed in Sec- Head and Neck Cancers, which are updated periodically (current
tion 2.5. However, most of the existing medical literature supports a v2.2020—June 2020) and summarized below:
74 GOYAL ET AL.
TABLE 2 Oxford levels of evidence 2.1.1 | Recommendation

Level Study design
Patients who have undergone treatment for HNC should be:
1A Systematic review of randomized controlled trials
1B Individual randomized controlled trial
a. Evaluated every 1–3 months in the 1st year after treatment; every
1C All or none case-series
2–6 months in the 2nd year after treatment; every 4–8 months in
2A Systematic review of cohort studies
the 3rd–5th year after treatment; and every 12 months thereafter
2B Individual cohort study
(NCCN Category 2A).
2C Outcomes research b. Followed by a surgical oncologist for a complete head and neck
3A Systematic review of case–control studies examination, indirect mirror and/or flexible fiberoptic laryngos-
3B Individual case–control study copy, and nasal endoscopy in the setting of sinonasal malignancy
4 Case-series (NCCN Category 2A).
5 Expert opinion c. Monitored with EBV DNA for nasopharyngeal carcinoma surveil-
lance (NCCN Category 2B).
• Patients should be evaluated every 1–3 months in the 1st year 2.2 | Radiation oncology
after treatment; every 2–6 months in the 2nd year after treatment;
every 4–8 months in the 3rd–5th year after treatment; and every Patients are recommended to follow-up with their radiation oncolo-
12 months thereafter (NCCN Category 2A). gists, if they received radiation treatment, throughout the cancer sur-
• Clinic visits should include a complete head and neck examination, veillance period. Timely evaluation of possible persistent or recurrent
indirect mirror and/or flexible fiberoptic laryngoscopy, and nasal locoregional disease after completion of radiation is crucial, as well as
endoscopy for patients with sinonasal malignancies (NCCN Cate- close communication with medical and surgical oncologists. In some
gory 2A). cases, it can be quite challenging to distinguish radiation treatment
• In some cases, initial follow-up after surgical treatment may be effects from disease persistence or recurrence, which may require fur-
more frequent based on symptoms, risk factors, treatment ther evaluation. In addition to performing cancer surveillance, the
sequelae, or physician preference (Oxford Category 5). radiation oncologist will manage acute, subacute, and chronic toxic-
• Consider EBV DNA monitoring for nasopharyngeal carcinoma sur- ities of radiation and evaluate QOL measures as well as health mainte-
veillance (NCCN Category 2B). nance. Many head and neck radiation toxicities are discussed in
• Cancer surveillance visits should also include screening and evalua- Sections 3 and 4, and comprehensive reviews regarding these topics
tion for toxicities, quality of life (QOL) measures, and health main- have recently been published.13,14 These toxicities may be complex
tenance (see Sections 3 and 4). and interrelated; for example, xerostomia may cause secondary dental
• Establishment of survivorship care within 1 year of definitive HNC complications, dysphagia, dietary changes, and depression. A multi-
treatment (NCCN Guidelines: Survivorship). disciplinary team approach to manage these manifestations is critical;
the radiation oncologist should coordinate care with speech-language
Currently, no randomized clinical trials have compared outcomes pathologists, dieticians, dentists, physical therapists, and other special-
in patients following recommended cancer surveillance to those not ists as clinically indicated. At each visit, the radiation oncologist should
adhering to practice guidelines. A recent analysis of 3975 HNC provide patient education and emphasize the importance of routine
patients in Ontario revealed that less than 50% met recommended neck and swallowing exercises.
follow-up guidelines after 2 years of treatment.10 Another study of
esophageal cancer surveillance demonstrated a 9% rate of second pri-
mary with early detection made possible with periodic 2.2.1 | Recommendation
11
nasopharyngolaryngoscopy. Detection of early lesions may also be
aided by advanced optical technology such as high definition fiber Patients who have undergone radiation for HNC should be:
optic imaging, video archiving, and narrow-band imaging.12 Education
and training resources for flexible fiberoptic laryngoscopy can be a. Evaluated for thyroid dysfunction (TSH/T4) every 6–12 months,
found through the American Academy of Otolaryngology and particularly in the setting of neck irradiation (NCCN Category 2A).
OTOSOURCE. While “cure” has traditionally been defined as 5 years b. Referred for regular dental examinations, especially if the patient
of disease-free interval, most patients require at least annual follow- received intraoral or salivary gland irradiation (NCCN Cate-
up beyond 5 years for treatment-related concerns (see Section 2.5). gory 2A).
Similarly, screening for second primaries should also be considered c. Followed in close, alternating intervals, in conjunction with surgical
based on risk factors, including the continuation of tobacco and alco- oncology and medical oncology as outlined in Section 2.1 (NCCN
hol use. Category 2A).
GOYAL ET AL. 75
2.3 | Medical oncology induced peripheral neurotoxicity (CIPN). Although poorly understood,
CIPN typically carries a dose-dependent and cumulative relationship,
Medical oncologists are recommended to perform detailed cancer- though patients with pre-existing neuropathy or those receiving dou-
related histories and physical examinations at routine, established blet therapy may develop CIPN at lower doses. CIPN presents as a
intervals throughout the care continuum, including post-treatment “glove and stocking” and its incidence decreases as one is further
surveillance, if the patient received systemic therapy (e.g., chemother- from treatment.15,16 Treatment interventions can include duloxetine,
apy, immunotherapy). Specifically, recognizing and managing the side topical menthol, topical 8% capsaicin, and physical therapy.17–20
effects of commonly utilized chemotherapy agents such as platinum There are no well-defined guidelines and limited medical litera-
agents (i.e., cisplatin, carboplatin, and oxaliplatin), taxanes (paclitaxel ture regarding the timing or frequency of evaluation by medical oncol-
and docetaxel), and vinca alkaloids (vincristine and vinblastine) remain ogy.21 Nonetheless, these assessments should be incorporated into a
challenging, including when patients are afflicted with chemotherapy- shared responsibility surveillance plan with surgical and radiation
oncologists that take into account NCCN guidelines. Establishment of
clinical care pathways that incorporate evidence-based guidelines,
TABLE 3 NCCN categories of evidence and consensus clinical expertise, and program infrastructure/feasibility to integrate
Category 1: Based upon high-level evidence, there is uniform NCCN multidisciplinary care, cancer surveillance, and care transitions should
consensus that the intervention is appropriate. also be considered.21 A shared surveillance plan may also serve to
Category 2A: Based upon lower-level evidence, there is uniform reduce patient burden on individual specialties, thus permitting
NCCN consensus that the intervention is appropriate. improved patient access. In addition to cancer surveillance and toxic-
Category 2B: Based upon lower-level evidence, there is NCCN ity monitoring, the role of medical oncology evaluations could also be
consensus that the intervention is appropriate.
viewed as a potential facilitator of improved health promotion and
Category 3: Based upon any level of evidence, there is major NCCN care coordination with primary care physicians (PCPs) and survivor-
disagreement that the intervention is appropriate.
ship clinics to potentially minimize health care fragmentation.22
FIGURE 1 A proposed timeline depicting the timing of the different assessments suggested by these guidelines
76 GOYAL ET AL.
2.3.1 | Recommendation a. Post-treatment baseline radiographic imaging of primary (and neck

if treated) within 3–4 months (NCCN Category 2A).
Patients who have undergone treatment for HNC should be: b. For those patients in which PET/CT is used for follow-up, PET/CT
should be performed within 3–6 months after definitive treatment
a. Followed in close, alternating intervals, in conjunction with surgical (NCCN Category 2A).
and radiation oncology as outlined in Section 2.1 (NCCN Cate- c. Further radiographic imaging based on worrisome signs or symp-
gory 2A). toms, smoking history, and areas inaccessible to clinical examina-
tion (i.e., salivary glands, nasopharynx, and skull base) (NCCN
Category 2A).
2.4 | Radiographic imaging d. Chest CT with or without contrast as clinically indicated for
patients with a smoking history (NCCN Guidelines for Lung Cancer
Recommendations for post-treatment imaging for HNC include the Screening) (NCCN Category 2A).
following (adapted from NCCN Guidelines for Head and Neck Cancers
v2.2020):
2.5 | Survivorship clinic
• For patients with locoregionally advanced disease:
If there is clinical concern for residual disease or progression, CT The relationship between cancer surveillance and survivorship
of primary site and neck with contrast and/or MRI with contrast remains poorly defined for HNC patients. However, as noted above,
may be considered at 4–8 weeks after treatment. most of the existing medical literature supports a transition toward
If there is no concern for residual disease, post-treatment imag- non-surveillance aspects of survivorship care at 5 years after treat-
ing may be performed with CT or MRI with contrast at 3– ment completion. This transition point is supported by a decreased
4 months after completion of treatment. risk of recurrence and an increase in the ratio of non-cancer-related
For those patients in which PET/CT is used for follow-up, PET/ mortality to cancer-related mortality.24 Increased non-cancer-related
CT should be performed within 3–6 months after definitive mortality in >5-year survivors is multifactorial but appears to be
treatment. largely driven by cardiovascular disease (i.e., exacerbation of hyper-
• Post-treatment, consider obtaining radiographic imaging of primary tension, increased risk of stroke, and myocardial infarction).25 A Sur-
site (and neck, if treated) within 3–4 months to establish a new veillance, Epidemiology and End Results (SEER) population-based
baseline for surveillance following surgery, definitive radiation, or study demonstrated a high comorbidity burden in HNC patients at the
chemoradiation (NCCN Category 2A). time of diagnosis which increased significantly at 5 years post-diagno-
• Further radiographic imaging may be indicated based on worrisome sis; this trend was measured in both HPV-related and HPV-unrelated
signs or symptoms, smoking history, and areas inaccessible to clini- disease variants.26 In addition to a higher rate of medical problems,
cal examination (i.e., salivary glands, nasopharynx, and skull base) HNC survivors have also been shown to demonstrate a nearly twofold
(NCCN Category 2A). risk (adjusted rate ratio, 1.97) of suicide over time compared to
• Routine annual radiographic imaging is often employed for HNC patients with other types of cancers.27
difficult to visualize including salivary glands, nasopharynx, or skull HNC survivorship care is extraordinarily complex and requires a
base (NCCN Category 2A). robust understanding of the underlying cancer pathophysiology, the
• Chest CT with or without contrast as clinically indicated for chronic sequelae of relevant treatment modalities, and the interaction
patients with a smoking history (NCCN Guidelines for Lung Cancer between cancer, oncologic treatment, and patient comorbidities. This
Screening) (NCCN Category 2A). naturally raises the question of who should provide survivorship care.
• Carotid ultrasound screening may also be considered every 2– The majority of existing data supports a simple unitary answer: a mul-
5 years for patients who received neck irradiation. tidisciplinary team. Existing data support an approach which generates
algorithms designed to maximize care delivered while minimizing the
Of note, a recent study at MD Anderson Cancer Center of 1508 burden placed on patients for multiple clinic visits and extensive trav-
HNC patients (62% T0–T2) treated with definitive radiation revealed eling.28 Multiple studies have demonstrated a role for registered
a low yield and high cost for routine radiographic imaging beyond nurses in survivorship care. A recent meta-analysis demonstrated sig-
2 years after treatment without clinically suspicious findings; a 12.6% nificant gains in some QOL domains for patients enrolled in nurse-led
rate of disease recurrence was appreciated, with 70% of recurrences survivorship care.29 Data from other tumor types also support the
23
occurring within the first 2 years. involvement of advanced practice providers in survivorship care.30 In
part due to these findings, survivorship care is often transitioned to
nurses or advanced practice providers at multiple centers throughout
2.4.1 | Recommendation the United States. In lieu of organized survivorship care plans, primary
care providers sometimes become de facto survivorship care pro-
Patients who have undergone treatment for HNC should undergo: viders. However, there is significant data that indicates that patients
GOYAL ET AL. 77
prefer specialist-led care.31,32 This represents a recognition on the assessment of baseline function may help identify patients at risk of
part of patients that oncologists familiar with the survivor, cancer chronic dysfunction and those who may require additional assistance
type, and treatment regimen are better equipped to understand late for nutritional needs (i.e., gastrostomy tube) or for phonatory rehabili-
sequelae of disease and associated treatment. Ideally, survivorship tation (i.e., alaryngeal speech). In patients receiving radiotherapy or
care would be provided by a team consisting of nurses, advanced chemoradiation therapy, SLP providers may teach and encourage pro-
practice providers, oral health care providers, medical oncologists, phylactic swallowing exercises that may improve post-treatment func-
radiation oncologists, and/or surgical oncologists working in close tional outcomes.43,44 In such patients, swallowing exercises that help
33
coordination with the patient's primary care provider. maintain oral intake through the treatment phase are associated with
better long-term swallowing outcomes and reduced gastrostomy tube
dependence.45
2.5.1 | Recommendation Patients with HNC also experience difficulties with speech and
voice production that may include a spectrum of presentations:
Patients who are beyond 5 years of HNC treatment and are desig- impaired intelligibility to poor quality of voice or loss of natural
nated as survivors may be: speech. Speech therapy may certainly improve speech quality and
intelligibility.46 SLP providers may also help identify optimal strategies
a. Followed by a multidisciplinary team consisting of nurses, for speech rehabilitation and restoration in alaryngeal patients via an
advanced practice providers, oral health care providers, medical electrolarynx, tracheoesophageal puncture, or esophageal speech.
oncologists, and/or radiation oncologists, in conjunction with the As a result, early referral to SLP providers should be considered
annual follow-up with surgical oncologists, working in close coordi- for patients with HNC as part of their evaluation and treatment plan-
nation with the patient's primary care provider on at least an ning. SLP professionals may play a role in ongoing survivorship care
annual basis (NCCN Category 2A). for patients through surveillance of functional outcomes related to
speech and swallowing. Symptom driven assessment tools including
modified barium swallow study, fiberoptic endoscopic evaluation of
3 | Q U A LI T Y O F L I F E swallowing, and videostroboscopy provide insights into developing
targeted interventions including the teaching of compensatory
3.1 | Dysphonia and dysphagia maneuvers and swallowing exercises when needed.41 Given the
potential for development of late toxicities in patients receiving radia-
Patients affected by HNC commonly experience symptoms related to tion therapy, long-term evaluation of cranial nerve function, speech,
compromised speech, voice, and swallowing function and thus experi- and swallowing are indicated.
ence diminished QOL. Speech and swallowing impairments may arise
from the intrinsic neoplastic process or resultant sequelae of therapy
including surgery, radiation, and/or chemoradiation therapy.34 Factors 3.1.1 | Recommendation
such as anatomic alterations, dentition loss, xerostomia, trismus,
mucositis, post-treatment lymphedema, fibrosis, and neuropathy may Patients who have been diagnosed with HNC, particularly of the
detrimentally influence a person's ability for mastication, deglutition, aerodigestive tract, should be:
and nutritional maintenance.35,36
Symptoms of swallowing disturbance are common among a. Referred to SLP providers for evaluation and management of
patients with HNC. In one SEER based study, the prevalence of dys- speech, voice, and swallowing symptoms (NCCN Category 2A).
phagia, stricture, and aspiration pneumonia was 45.3%, 10.2%, and b. Referred to SLP, if possible, prior to the initiation of therapy to
8.7%, respectively. The prevalence of these signs and symptoms was optimize post-treatment communication and swallowing outcomes
modified by site (lower in oral cavity), stage (higher with more (NCCN Category 2A).
advanced cancers), and by treatment modality (higher in patients
receiving non-surgical or multiple treatment modalities).37 Other stud-
ies suggest that nearly one in two patients experience poor QOL due 3.2 | Fatigue
to dysphagia and that up to 84% of patients may experience aspira-
tion.38,39 The addition of chemotherapy as a radiosensitizer may fur- Cancer-related fatigue is a distressing, persistent, and subjective sense
40
ther exacerbate these symptoms. of physical, emotional, and/or cognitive tiredness or exhaustion
Collaborative multidisciplinary efforts centered on the patient's related to cancer or oncologic treatment that is not proportional to
ability to preserve and recoup functional speech and swallowing may recent activity and interferes with normal function.47 Typically, can-
produce improvements in QOL.41 SLP providers may help identify cer-related fatigue is not relieved by rest or sleep. Most patients diag-
baseline speech and swallowing disturbances and provide education nosed with HNC experience cancer-related fatigue, particularly when
and counseling that may help patients understand the implications of treatment includes radiation or chemoradiation.48,49 Symptoms
42
their disease and its impact on speech and swallowing. This related to fatigue peak early (i.e., within 8 weeks) after initiation of
78 GOYAL ET AL.
radiation, with persistent or worsening of symptoms over the first head and neck-specific intimacy questionnaire is created. Referral for
2 years following therapy and contribute to a significant loss of psychosexual therapy may be beneficial in some circumstances.57
48
QOL. Individuals treated with irradiation to the skull base are at risk of
Fatigue may arise from a variety of underlying medical conditions hypothalamic–pituitary axis disorders.58 Specifically, up to 20% of
that may coexist with the diagnosis of HNC. This includes baseline patients treated with radiotherapy for nasopharyngeal carcinoma may
frailty, anemia, anxiety, depression, poor cardiopulmonary reserve, experience hypogonadism.59 As this can have profound effects on sex-
malnutrition, psychological distress, sleep disturbances, thyroid dys- ual function, it is encouraged that these patients undergo regular assess-
function, pain related to cancer and/or its therapy, pro-inflammatory ment of hypothalamic–pituitary function (e.g., screening for symptoms,
or catabolic state, and substance abuse.50 Patients with a history of laboratory testing) with referral to endocrinology as indicated.
HNC can be counseled and screened for fatigue upon initial evalua-
tion and then periodically through their survivorship.47 Patients identi-
fied with symptoms of fatigue should be assessed for underlying 3.3.1 | Recommendation
medical conditions through a comprehensive review of history, physi-
cal examination, appropriate hematology and biochemical testing (i.e., Patients who have undergone treatment for HNC should be:
complete blood count, comprehensive metabolic panel, thyroid func-
tion testing, and nutritional markers), use of screening tools for psy- a. Screened for sexual and intimacy dysfunction, possibly using ques-
chologic distress and depression, and referral to specialists when tionnaires (Oxford Category 2A).
appropriate. b. Offered referrals for therapy for sexual function and intimacy
In addition to counseling and treatment of comorbid medical con- issues (Oxford Category 2A).
ditions contributing to fatigue, patients should be encouraged to par- c. Assessed for pituitary dysfunction if they have received skull base
ticipate in a regular exercise regimen.50,51 Physical therapists irradiation (Oxford Category 2A).
specializing in oncology care can provide treatment to address cancer-
related fatigue. Additionally, clinicians and patients may consider the
use of cognitive-behavioral therapy, yoga, massage therapy, and 3.4 | Chronic pain
others to mitigate cancer-related fatigue.47,52
Chronic pain may be present in up to 45% of patients treated for
HNC.60,61 This can have profound effects on function and QOL
3.2.1 | Recommendation among HNC survivors. There is no clear universally accepted or stan-
dardized tool for assessing chronic pain in patients with HNC. Likert
For patients who have undergone treatment for HNC: scales or validated QOL instruments may be utilized as adjuncts to
better assess the degree of disability experienced by the patient as a
a. Consider evaluating for underlying etiologies of fatigue by the mul- result of pain.62 Over 20% of patients with chronic pain meet criteria
tidisciplinary care team (Oxford Category 5). for a major depressive episode.60 Patients should be evaluated for
depressive symptoms and referred accordingly in this context.
While pain is most often associated with treatment sequelae, it
3.3 | Sexual dysfunction and intimacy can also be a harbinger of recurrent disease. Up to 70% of patients
with recurrent carcinoma will present with pain as the first symp-
HNC and its associated treatment can have significant physical, psy- tom.63 A comprehensive examination of the upper aerodigestive tract
chosocial, and emotional consequences which may adversely affect is imperative in the context of chronic post-treatment pain—particu-
sexual function and intimacy. Patients and partners report a signifi- larly in the setting of lancinating focal pain that radiates to the unilat-
cantly reduced frequency of vaginal and oral sex practices after treat- eral auricle or mandible.
ment for head and neck carcinoma regardless of HPV status.53 Up to Though definitions vary in the literature, a generally accepted def-
44% of patients treated for upper aerodigestive malignancies report inition of chronic pain is pain that extends beyond 3 months beyond
at least some difficulty with sexual function and/or intimacy following the acute phase of treatment—provided that the acute effects of ther-
treatment.54 Furthermore, patients perceive that their questions and apy have resolved.64 Thirteen to fifty percent of patients undergoing
concerns regarding intimacy and sexuality are not being addressed by HNC-directed therapy with curative intent will utilize opioids chroni-
their oncology team. This is most significant among those treated for cally. Chronic use and abuse following treatment are associated with
tumors that do not have a direct effect on fertility and urogenital pre-treatment opioid use, alcohol disorders, and nicotine dependence,
function.55 At the same time, no validated tool exists to address sex- as well as the employment of induction chemotherapy or tri-modal
ual function and intimacy among individuals specifically treated for therapy. Furthermore, depression and anxiety are associated with
56
HNC. At this time, several oncologic and HNC-related quality of life chronic opioid use after cancer treatment.60,65–67 Chronic opioid use
instruments do include items that pertain to sex and intimacy (e.g., has also been associated with decreased disease-free survival among
FACT-HN)56; these may be utilized as screening tools until a validated patients with oral cavity carcinoma.68
GOYAL ET AL. 79
Given the opioid crisis that currently exists, patients (particularly commonly encountered post-treatment. Baseline assessment of
those in high-risk groups) should be screened for chronic opioid use shoulder, temporomandibular joint, and neck mobility should be com-
and abuse at 3 months after completion of treatment. Opioid alterna- pleted before therapy and at routine post-treatment visits as a com-
tives with demonstrated success in managing chronic pain include ponent of a comprehensive physical examination by HNC providers.
nonsteroidal anti-inflammatory drugs and acetaminophen. The prevalence of shoulder dysfunction after neck dissection has
Neuromodulators, such as gabapentin, have also demonstrated effi- been variably reported and is associated with the extent of surgery.
cacy in the management of acute treatment-related pain during HNC One meta-analysis demonstrated impaired abduction is observed in
therapy.69,70 and in managing chronic cancer-related pain.71 greater than 90% of patients undergoing radical neck dissection and
For those patients whose chronic opioid use or pain refractory to 23% of patients undergoing modified radical neck dissection.77 Objec-
non-opioid therapy remains a concern, referral to a palliative care or tive assessment of shoulder strength and range of motion may be per-
multidisciplinary pain management team is recommended. These spe- formed using the standard Medical Research Council “0–5” scale and
cialized teams typically take a more holistic approach toward chronic a handheld goniometer, but may not be practical to execute in a surgi-
pain and can provide integration of pharmacotherapy, physiotherapy, cal clinic.78,79 Several patient-directed questionnaires regarding shoul-
psychotherapy, and non-traditional resources. These wide-ranging der function after neck dissection have been developed to quantify
treatment modalities may be beneficial in reducing opioid depen- disability and assess rehabilitation needs.80 One review noted that the
72,73
dence, cost, and pain-related morbidity in certain contexts. Neck Dissection Impairment Index is the only patient-reported out-
come scale to specifically address shoulder function in patients who
have undergone neck dissection.80
3.4.1 | Recommendation When subjective or objective shoulder dysfunction is identified,
the efficacy of physiotherapy is somewhat equivocal based upon the
Patients who have undergone treatment for HNC should be: existing medical literature. McGarvey and colleagues noted in a 2011
review that while well-tolerated by patients, there is little evidence to
a. Screened by the survivorship team for chronic pain at routine suggest that physical therapy is effective in ameliorating shoulder dys-
intervals (NCCN Category 2A). function after neck dissection.81 This same group published a follow-
b. Assessed for the quality and severity of their pain using pain up study in which patients were prospectively randomized to either a
assessment tools by the team (NCCN Category 2A). 12-week shoulder strength program or a control group after neck dis-
c. Evaluated for depressive symptoms in the presence of chronic pain section. They found that the group enrolled in physical therapy had
by the team (NCCN Category 2A). significant improvements in active abduction of the shoulder at
d. Undergo comprehensive evaluation to rule out recurrent disease 3 months postoperatively.82
as a cause of their pain by the team (Category 3B). With advancements in radiation therapy, transverse myelitis fol-
e. Screened for opioid abuse by the team (NCCN Category 2A). lowing HNC treatment is very uncommon (<1% at 54 Gy with con-
f. Offered non-opioid analgesics including nonsteroidal anti- ventional fractionation).83 However, mild spinal cord toxicity can
inflammatory agents, acetaminophen (Oxford Category 2C), occur in the form of L'Hermitte's sign, which is characterized as elec-
neuromodulators (NCCN Category 2A), and acupuncture (Oxford tric-shock sensations down the spinal cord and into the extremities
Category 1A) through palliative and/or pain management consulta- upon neck flexion.84 With historical conformal, field-based radiation
tions by the team. therapy for HNC, rates between 3% and 13% are reported.85 Interest-
g. Referred to palliative and/or pain management specialists for ingly, recent work focusing on intensity-modulated radiation therapy
refractory or opioid-dependent pain (Oxford Category 5) by for thoracic and head and neck malignancy describes an increased
their team. incidence of L'Hermitte's sign between 15% and 29%. Typically,
L'Hermitte's sign develops in the first few months following radiation
therapy and seldom lasts more than 6 months.86 Treatment for
3.5 | Physical therapy patients suffering from this condition remains conservative in nature,
including a soft neck collar, corticosteroids, and hyperbaric oxygen.87
Functional musculoskeletal limitations after HNC-directed therapy are Trismus is variably defined but has been most compellingly vali-
relatively common, though often under-reported and under-treated. dated at a 35 mm inter-incisor distance.88 Among patients with oral
The subsequent disability can result in significant reductions in QOL cavity or oropharyngeal primary tumors, studies estimate that 25%–
and livelihood of HNC survivors. Indeed, a minority of HNC multi- 40% of patients will develop trismus post-therapy with risk factors
disciplinary teams refer patients for physical therapy on a routine including the initial tumor stage, need for reconstruction, receipt of
basis.74 The most common musculoskeletal issues include shoulder chemotherapy, and the receipt of radiation.89,90 Three recent system-
dysfunction, seen in up to 70% of patients undergoing neck dissec- atic reviews note that trismus is improved by exercise therapy and that
tion, and trismus, which may be observed in up to one-half of patients early initiation and compliance resulted in more favorable outcomes. In
undergoing radiotherapy to the pterygoid musculature/temporoman- one review the TheraBite device increased mouth opening significantly
dibular joint region.75,76 Diminished neck range of motion is also with an effect size of 2.6 compared to tongue blades (1.5), forced
80 GOYAL ET AL.
opening (1.1.), or microcurrent therapy (0.3). However, a return to nor- Treatment of lymphedema involves improving lymphatic drainage
mal (i.e., >35 mm) levels was not feasible in most cases.91–93 through manual massage and compressive bandages. Manual lym-
phatic drainage (MLD) employs gentle circular massage to improve
lymphatic flow. Complete decongestive therapy (CDT) represents the
3.5.1 | Recommendation “gold standard” for management; it combines MLD, exercise, skincare,
and compressive bandages and is performed by certified lymphedema
Patients who have undergone treatment for HNC may need to be: therapists. This therapy often involves intense, near-daily outpatient
therapy for the first 2–4 weeks followed by a transition to home ther-
a. Screened for physical rehabilitation needs early in the post-treat- apy; however, a motivated patient or caregiver may be able to provide
ment phase and at regular intervals by their survivorship team appropriate and effective home care if frequent clinic visits are not
(Oxford Category 5). feasible.101 Exercises include range of motion exercises of the face,
b. Assessed for trismus, depending on the site of their cancer, before neck, shoulders, and arms as well as swallowing exercises. The com-
and at regular intervals following therapy by their survivorship pressive bandages are often applied after MLD, though some institu-
team (NCCN Category 2A). tions support applying the bandages before and after MLD.94 These
c. Referred to exercise and physiotherapy professionals for struc- therapies are effective in managing lymphedema in HNC patients.102
tured rehabilitation after HNC treatment by their survivorship
team (Oxford Category 5).
d. Undergoing shoulder physiotherapy after completion of neck dis- 3.6.1 | Recommendation
section as early as feasible by their survivorship team (Oxford Cat-
egory 1B). Patients who have undergone treatment for HNC should be:
a. Evaluated for lymphedema after treatment for HNC by their survi-

3.6 | Lymphedema vorship team (NCCN Category 2A).
b. Referred for certified lymphedema therapists for management of
Lymphedema results from an increase in lymphatic load and the lymphedema via CDT by their survivorship team (NCCN Cate-
need for drainage exceeding the capacity of the lymphatic system gory 2A).
to transport. In HNC, lymphedema occurs secondarily after disrup-
tion of lymphatics due to either tumor burden or cancer treatment
(surgery, radiation, and/or chemotherapy).94,95 The lack of adequate 3.7 | Psycho-oncology
drainage results in the accumulation of lymphatic fluid within soft
tissues and interstitial spaces, which in turn can lead to inflamma- The diagnosis and treatment of HNC can have a devastating impact
tion and fibrosis. This will manifest as significant dense soft tissue on psychosocial function. As HNC arises in cosmetically and function-
edema with either external edema (face and neck) or internal edema ally critical areas, highly visible and socially significant changes are
(tongue, pharynx, and larynx). Symptoms can include cosmetic common following treatment.103,104 The visible disfigurement,
deformity, neck and shoulder dysfunction, visual disturbance, dys- impaired smile, dysphagia, dysphonia, and fear of recurrence can
phonia, dysphagia, and difficulty breathing.7 Rarely, lymphedema result in substantial psychosocial morbidity, including body image con-
can be significant enough to require tracheotomy. The reported cerns, depression, and anxiety.104–108
incidence of lymphedema varies and is likely related to cancer site,
stage, and severity/combination of treatment, with published rates
ranging between 12% and 90%.95,96 3.7.1 | Body image disturbance
Several studies have demonstrated the impact lymphedema has
on QOL in HNC survivors.97–100 Given its functional and psychoso- Body image disturbance (BID) is a multidimensional phenomenon
cial impact, early diagnosis and management are important. Identifi- characterized by a displeasing self-perceived change in appearance
cation of head and neck lymphedema can be objectively determined and/or function.109–111 Body image concerns are expressed in up to
by physical exam with discrete measurements and flexible fiberoptic 75% of patients with HNC; an increase in prevalence and severity
laryngoscopy to identify internal lymphedema.94 The Foldi lymph- early in the survivorship period is associated with social isolation, stig-
edema rating scale allows for a qualitative rating system although its matization, depression, and decreased QOL.103,104,110 As a result,
94
original design was intended for extremity lymphedema. To HNC survivors should be periodically assessed for BID.7 Unfortu-
address this limitation, the University of Texas M. D. Anderson Can- nately, there is a lack of psychometrically sound, patient-centered
cer Center Head and Neck Lymphedema Rating Scale was adapted tools to measure BID in HNC survivors. Improved measurement strat-
from the Foldi lymphedema rating scale, which allows for the cap- egies represent an area of clinical and scientific need.112 Management
ture of subtle presentations of HNC lymphedema with a simple 5 of BID remains a critical component of HNC survivorship care.7
94
point rating scale. Affected patients should be referred for psycho-oncologic
GOYAL ET AL. 81
management, although further work is needed to develop effective 3.7.3 | Recommendation

interventions that specifically target BID in HNC survivors.7,113–115
3.7.2 | Distress, depression, and anxiety a. Screened for BID concerns by their survivorship team (NCCN Cat-
egory 2A).
Distress, depression, and anxiety are prevalent in HNC survivors, who b. Referred to psychology or psychiatry for the management of BID
are at higher risk for developing psychological sequelae than survivors as indicated by their team (NCCN Category 2A).
with other types of cancer.116 As a result, HNC survivors should be c. Assessed for distress, depression, and/or anxiety at regular inter-
assessed periodically for distress, depression, and anxiety using vali- vals with a validated questionnaire by their team (Oxford Cate-
dated screening tools (e.g., NCCN Distress Thermometer, Hospital gory 1A).
Anxiety and Depression Scale, Beck Depression or Anxiety Invento- d. Referred to psychology or psychiatry if distress, depression, and/or
ries, Generalized Anxiety Disorder-7, and Patient Health Question- anxiety are present (Oxford Category 1B).
naire-9).7,117–119 For survivors with clinical findings of distress,
depression, or anxiety, recommended treatments include psychother-
apy, pharmacotherapy, and referral to psycho-oncology. Unfortu- 3.8 | Hearing loss
nately, mental health support is frequently underutilized.7,120 There is
evidence that preventative interventions, before initiation of HNC HNC treatment can have a profound impact on auditory function. For
treatment, may decrease the risk of depression in HNC survivors. A cancers involving the ear, nasopharynx, skull base, and paranasal
landmark trial found that prophylactic escitalopram given to HNC sinuses, both surgery and radiation can have a significant effect on
patients at treatment initiation reduced the risk of depression by more the auditory pathway. Surgical resection of the external auditory canal
than 50%, with beneficial effects seen primarily in those treated with (EAC), tympanic membrane, and/or middle ear space will result in con-
121
definitive radiation-based approaches. Other multidisciplinary HNC ductive hearing loss (CHL). Similarly, surgery of the paranasal sinuses,
programs have integrated health psychologists in the multidisciplinary nasopharynx, and/or skull base can lead to trauma, edema, or dysfunc-
treatment team to aid in pre-treatment evaluation and identification tion of the Eustachian tube leading to CHL from serous otitis media.
of psychosocial risk factors, with close follow-up with intervention as Radiation therapy to the head and neck may also lead to both
indicated. This integration has been well received by patients, care- CHL and sensorineural hearing loss (SNHL). CHL may result via radia-
givers, and medical professionals.122 tion changes to the Eustachian tube apparatus, additionally, external
Although the body of literature remains small for HNC, there is evi- toxicity to the auricle or EAC may lead to otitis externa, EAC stenosis,
dence to suggest support group participation in patients with breast, or ossicular necrosis.129,130 Radiation to the inner ear can also lead to
lung, and colon cancer has been found to decrease anxiety and depres- SNHL anywhere along the auditory pathway from the brainstem to
sion.123 Furthermore, with the advent of internet technology, virtual the cochlea. Studies have identified that the incidence of ototoxicity
support groups have been associated with reductions in physiological is associated with radiation dose and technique, patient age, and the
and psychological stress.124 Online gatherings can promote social sup- combination of radiation with chemotherapy. Studies suggest a radia-
port by increasing functional status, personal empowerment, and self- tion dose greater than 40–45 Gy to the cochlea may be associated
esteem as well as decrease feelings of depression, emotional distress, with a higher incidence of irreversible ototoxicity, though some have
helplessness, and social isolation.125 In a study of 199 patients with described SNHL with radiation doses as low as 20–25 Gy.130–134
HNC, better health-related QOL was associated with being a member Reports of ototoxicity also range from 0% to 43% including a variety
of an online support group for a longer period (B = 0.07, p < .05). With of radiation techniques.131,132,135
these notable benefits, health care professionals should certainly Chemotherapy, particularly platinum-based agents (primarily cis-
encourage and refer patients to seek out regional and support groups platin but also carboplatin and oxaliplatin), can have strong effects on
and information related to their clinical condition. the inner ear and may result in high-frequency SNHL and tinnitus.129
Given the tremendous psychosocial burden of HNC for survivors, These drugs have a cumulative dose-dependent effect; a total dose of
suicide is a critically important issue.126 Up to 16% of HNC survivors more than 100 mg/m2 of cisplatin places patients at risk for develop-
report suicidal ideation within the first year, with the highest risk ing high-frequency SNHL.7 Ototoxic effects related to chemotherapy
being in those with substance abuse and prior psychiatric disor- can be characterized by cochlear dysfunction (hearing loss, tinnitus, or
127
ders. The adjusted suicide risk in HNC survivors ranges from 38 to hyperacusis), vestibular dysfunction (vertigo, dizziness, or imbalance),
60/100,000 person-years; HNC survivors are 2-fold more likely to die or a combination of phenomena.136 Tinnitus, defined as a subjective
from suicide than patients with other types of cancer and 3-fold more perception of sound without an external source can lead to a signifi-
likely than the general US population.27,128 Even more concerning, the cant negative impact on psychological status and QOL; it has been
27
risk of suicide in HNC survivors is increasing over time. There is thus estimated that 40% of patients receiving chemotherapy develop tinni-
an urgent need to develop novel strategies to prevent suicide in HNC tus.137 Vestibular symptoms can trigger a deterioration of QOL includ-
127
survivors and integrate them into routine clinical care. ing interference with driving, riding a bicycle, and other activities as
82 GOYAL ET AL.
well as psychological symptoms.138 Hearing loss related to caregiver unmet needs, which often differ from and are put aside for
cochleotoxicity may present immediately or in a delayed fashion and those of the survivor.154,155 These unmet needs include balancing com-
can be progressive, affecting as many as 18% of patients who under- peting roles/responsibilities, making time for self-care, finding effective
went cisplatin therapy.139 The presence of hearing loss in the middle strategies for encouraging patient self-care, changes in intimacy and
of treatment may lead to consideration for an alternative chemother- social/leisure activities, fears/anxiety regarding cancer recurrence, and
apy regimen. the lack of coping strategies for others not acknowledging “the impact
Chemoprotective agents have been studied, though none are that having a partner experience cancer has had on my own life.” These
standard of care.129 Treating and managing ototoxicity are dependent findings suggest the need for information, counseling, and reassurance
on the cause and location. CHL secondary to edema will often resolve that partners and caregivers may require through education, interven-
over time, while losses secondary to scarring/fibrosis or Eustachian tions, and sharing of assessment and management plan by the clinicians.
tube dysfunction may require surgical approaches to relieve the focal It is important to encourage caregivers to pause and take the time to
obstruction. Serous otitis media may also resolve over time but those take care of themselves, as this will allow them to continue taking care
patients with persistent CHL for 3–6 months may benefit from either of HNC survivors. Caregivers should be encouraged to seek help from
simple myringotomy or tympanostomy tube placement.129 Unfortu- others, recognize the limits of their abilities and endurance, and take
nately, there is no established treatment for SNHL with mixed results pride in the care they provide for HNC survivors. For physical health
associated with high-dose steroid administration or hyperbaric oxygen maintenance, they should similarly see their PCP regularly, adopt a
therapy. As outlined by the American Academy of Audiology, patients healthy active lifestyle, and undergo routine age-appropriate and gender-
undergoing platinum-based chemotherapy should undergo pure tone appropriate cancer screening. For mental health concerns, care-
audiometry a few months following completion of chemotherapy givers should be counseled on a wide variety of emotions, such as
followed by monitoring for at least 2 years in the setting of concomi- guilt, anger, depression, and anxiety, particularly around the fear of
tant radiation therapy as hearing loss may progress over time (https:// cancer recurrence. Caregivers should also be encouraged to speak
www.audiology.org/publications-resources/document-library/ openly to their loved ones or talk with a counselor, the oncology
ototoxicity-monitoring). In addition, post-treatment SNHL rehabilita- team, PCP, close friends, or support groups. There remains an
tion relies on the use of hearing amplification (hearing aids).131 For important clinical need for additional research to develop effective
patients with profound bilateral SNHL, cochlear implantation is effec- supportive interventions targeting the unique concerns of HNC
tive with no difference in outcomes as compared to those who did caregiver–survivor dyads.156–159
129,131
not previously receive chemotherapy or radiation.
3.9.1 | Recommendation
Care of patients who have undergone treatment for HNC should be:
Patients who have undergone platinum-based chemotherapy and/or
radiation therapy for HNC should be: a. Inclusive of partners and caregivers in all aspects of HNC care pro-
vided by the oncology team (Oxford Category 5).
a. Evaluated yearly for hearing loss via pure tone audiometry for at
least 2 years (NCCN Category 2A).
3.10 | Social support groups
3.9 | Caregivers The Commission on Cancer of the American College of Surgeons

2020 Standard 5.2 necessitates policies and procedures that are in
Caregivers of patients with HNC face a unique burden in their role caring place to ensure patient access to psychosocial services either on-site
for HNC survivors.140–142 Caregivers are tasked with coordinating com- or by referral.160 Cancer support groups provide an environment for
plicated and demanding treatment regimens, survivorship care schedules, patients, families, and caregivers to share their experiences and be
performing medical and nursing tasks to manage treatment toxicities in able to cope with all aspects of cancer care. Peer support can also help
the setting of nutritional, speech, and addiction challenges, assisting patients, families, and caregivers feel supported by a community or
patients with time-consuming self-management interventions to mitigate navigate the complex process of managing a life-altering illness such
long-term treatment effects, and managing ongoing psychosocial, emo- as cancer.161
6,140,143–152
tional, and financial concerns. Despite this impressive array of There is a dearth of research examining support groups for HNC.
supportive tasks, caregivers typically receive little or no formal train- However, as mentioned previously, online support groups often pro-
ing.151 It is thus not surprising that HNC caregiver distress is quite high, vide low-threshold advice for acute problems to patients with high
equaling or exceeding the distress levels of HNC patients for whom they distress.162 Patient support groups play an important role in the short-
151,153
care. Caregiver psychological distress is related to task burden (fre- term and long-term management of HNC and should be offered in all
quency and complexity) of caring for the HNC survivors as well as programs offering HNC care.
GOYAL ET AL. 83
3.10.1 | Recommendation 3.12 | Financial burden
Patients who have undergone treatment for HNC should be: As a result of the convergence between improved oncologic out-
comes, increased cost of cancer care, and continued shifting of cost
a. Educated by their survivorship team on social support groups and burden to the patient, there has been a growing awareness of the
their impact on understanding the wide-ranging sequelae of onco- devastating financial toxicity that can burden HNC survivors and their
logic treatment (Oxford Category 5). caregivers.165,166 Financial toxicity is a multidimensional construct: (1)
material hardship that results from increased out-of-pocket costs and
lower-income, (2) psychological distress resulting from material hard-
3.11 | Return to work ship, and (3) compensatory coping strategies that families develop in
response to the financial cost of cancer and its treatment.167,168
Returning to work after cancer treatment can be a daunting task for Patients with HNC are disproportionately burdened by the destruc-
patients. For HNC patients, simple tasks such as eating in public, tive consequences of financial toxicity relative to other types of cancer165
fatigue, radiation dermatitis, and oral ulcers can make functioning in a HNC-related financial toxicity is especially common, with cumulative inci-
public work environment difficult and at times, embarrassing. Due to dence estimates ranging from 40% to 69%.169,170 Patients with HNC
the impact on the patient's speech and voice, communication may be who are particularly high-risk include those with Medicaid, decreased
difficult with coworkers and performing daily work-related duties. It is wealth, higher perceived social isolation, and higher total out-of-pocket
imperative for employers to support the employees' successful return treatment costs.165,170 Financial toxicity is thus yet another aspect of the
to work and provide them engagement opportunities or accommoda- cancer care continuum in which significant and disturbing disparities in
tions to change the nature of their job. Cancelliere and colleagues outcomes exist.166 Financial toxicity can be assessed using quantitative
demonstrated common factors associated with positive return to measures (e.g., financial burden, ratio of out-of-pocket health-related
work outcomes include higher education and socioeconomic status, spending to household income) or patient-reported measures such as the
higher self-efficacy and optimistic expectations for recovery and Comprehensive Score for financial Toxicity questionnaire.171,172 The
return to work, lower severity of injury/illness, return to work coordi- downstream impact of financial toxicity on patients with cancer is signifi-
nation, and multidisciplinary interventions that include the workplace cant, as increased levels of financial toxicity are associated with decreased
and stakeholders. On the other hand, factors associated with negative adherence to cancer treatment, increased symptom burden, decreased
return-to-work outcomes were advanced age, female gender, higher QOL, higher unmet needs for HNC survivors, and decreased survival.173–
177
pain or disability, depression, higher physical work demands, previous Financial toxicity is also a common problem for HNC caregivers and
sick leave and unemployment, and activity limitations.163 one that can have a devastating impact.152,155
It is important for physicians caring for HNC patients to understand Although many sociodemographic determinants of financial toxic-
medical disability and the protections afforded by the United States law. ity are beyond the control of the multidisciplinary HNC team, pro-
When employees are injured or disabled or become ill on the job, they viders can help by increasing awareness that financial toxicity is
may be entitled to medical and/or disability-related leave under two fed- common following treatment for HNC, identifying at-risk patients,
eral laws: the Americans with Disabilities Act (ADA) and the Family and alerting patients and caregiver to resources for its management, and
Medical Leave Act (FMLA). An individual with a disability is defined as a making referrals to social workers and financial navigators who may
person who: (1) has physical or mental impairment that substantially further facilitate engagement with social welfare systems to help
limits one or more major life activities; (2) has a record of such an impair- assess and manage HNC-related financial toxicity.152,166
ment; or (3) is regarded as having such an impairment.164 The ADA does
not specifically require employers to provide medical or disability-related
leave. However, it does require employers to make reasonable accom- 3.12.1 | Recommendation
modations for qualified employees with disabilities if necessary to per-
form essential job functions or to benefit from the same opportunities Patients who have undergone treatment for HNC:
164
and rights afforded employees without disabilities. Accommodations
can include modifications to work schedules (e.g., 8-h shifts instead of a. Can be referred to social workers and financial navigators by their
12-h shifts or 5-day work week, no overtime), restricted duties (i.e., limi- survivorship team to navigate health care costs associated with
tations on lifting), or medical leave.164 HNC care (Oxford Category 5).
3.11.1 | Recommendation 4 | HE AL TH MAIN T E N A NC E
Patients who have undergone treatment for HNC should be: 4.1 | Primary care physician
a. Counseled by their survivorship team on medical disability rights PCPs have a critical and continuing role in the management of acute
and protections afforded by federal law (Oxford Category 5). and chronic care of HNC survivors, supporting the diagnosis and
84 GOYAL ET AL.
management of HNC, and promoting good health behaviors. It is criti- demineralization/caries, periodontal status, oral hygiene, changes due
cal that the oncology team communicate regularly with the PCP. A to tissue fibrosis (tongue mobility, presence of trismus, oral aperture),
treatment summary, risk of recurrence, short-term and long-term local infection, and exposed bone. Diet and nutritional status should
effects of treatment, and an individualized surveillance/survivorship also be assessed. Dental prophylaxis should include brushing with
plan should be available to PCP and HNC providers. Several docu- remineralizing toothpaste, dental floss utilization, and fluoride supple-
ments exist to help communicate this information including those mentation. Consultation with the oncology team and review of the
6,7
published by AHNS and ASCO. Of note, the use of a standardized radiation fields are indicated prior to any invasive dental treatment is
survivorship care plan has been integrated into the 2020 Commission performed. Although there is limited evidence, consideration may be
on Cancer Standards for member organizations (Standard 4.8).160 given to hyperbaric oxygen therapy in HNC patients with a prior his-
PCPs should be aware of the signs, symptoms, and physical find- tory of radiotherapy who require dental extractions.187 Following this,
ings of cancer recurrence or second malignancy and promptly refer patient management and referral for oral and dental care can be per-
patients back to the oncology team for further investigation of any formed as deemed appropriate. A recent study reported only 50% of
suspicious findings. The PCP should engage in discussion and counsel- HNC survivors received recommended post-treatment oral/dental
ing regarding cardiovascular health, smoking cessation, alcohol con- care, which further highlights the need for a more coordinated and
sumption, diet/nutrition/weight, regular physical activity, dental enhanced multidisciplinary approach in educating and helping patients
hygiene, and mental/psychosocial health. General well-being and utilize oral/dental supportive care.188
QOL should be assessed including weight, energy/fatigue, mood
(depression), sleep, activity (work, avocation). As HNC survivors are at
an increased risk of developing second primary malignancies, both in 4.2.1 | Recommendation
head and neck and non-head and neck sites, the PCP should also per-
form age-appropriate and gender-appropriate screening of HNC survi- Patients who have undergone treatment for HNC:
vors for other neoplasms, as they would for patients in the general
population.178–181 The multidisciplinary cancer team and/or PCP a. Should be counseled by their survivorship team to maintain close
should also routinely evaluate thyroid function by measuring TSH/T4 follow-up with a dental professional (Oxford Category 1B).
every 6–12 months in patients with a surgically compromised thyroid b. Can be encouraged by their survivorship team to avoid tobacco
gland or history of neck irradiation.182–184 and alcohol to minimize the risk of dental disease (Oxford
Category 5).
4.3 | Substance abuse
According to pooled analyses of United States HNC cohorts
a. Followed by their PCP for age-appropriate and gender-appropriate (n = 7570, 1981–2006), 58% of HNC survivors were current smokers
screening of other neoplasms, general health, and well-being at diagnosis and 37% reported consuming >3 alcoholic beverages per
(Oxford Category 2A). day.189 Over 50% of HNC survivors continue smoking after diagnosis
and persistent tobacco or alcohol dependence has been associated
with an increased risk of perioperative complications, recurrence, sec-
4.2 | Dental care ond primary cancers, and mortality in HNC survivors.190–196 An esti-
mated 10% of HNC survivors report ever using marijuana.197 While
HNC survivors experience a wide range of changes that increase their studies have not identified a clear association between marijuana and
risk of oral and dental diseases.185,186 Dental providers have a role in HNC, some have reported an association with oropharyngeal squa-
oral and dental care from diagnosis to survivorship of HNC patients, mous cell carcinoma (OPSCC).196,197 Approximately 10% of HNC sur-
establishing oral health and preventive programs, and manage HNC vivors exhibit new opioid dependence 6 months after treatment. In
treatment complications. A comprehensive history and physical exam- the general population, opioid use disorder, defined as a problematic
ination, including issues related to primary cancer treatment and pattern of utilizing opioids that leads to significant distress or impair-
potential survivorship symptoms, should be addressed at each dental ment over 12 months, is associated with increased mortality from
visit. An understanding of prior cancer therapy, especially radiation accidental overdose, trauma, suicide, or infectious disease.65,67,198
dose and treatment fields, is required. The frequency of dental visits Evidence demonstrating that directed tobacco or alcohol treatment in
should be individualized, often requiring more frequent visits. At each HNC patients yields improved abstinence rates compared to usual
visit, the history should address head and neck, oral/dental symptoms, care is limited and underpowered.199–201 Hence, guideline recommen-
tobacco/alcohol cessation, and surveillance for potential recurrence dations for HNC and other cancer patients are inferred from data con-
or second primary cancers. Symptoms include sensory changes (pain, firming the efficacy of treatment in adults generally.202,203 Timely
taste), xerostomia, and dysphagia. Oral and dental evaluation should management of tobacco or alcohol dependence before oncologic
focus on mucosal and gingival integrity, oral hydration, dental treatment is preferred and may associate most strongly with reduced
GOYAL ET AL. 85
complications, recurrence, and mortality.191–196 In addition to manag- 4.5 | Respiratory therapy

ing tobacco dependence, clinicians should assess and treat or refer
HNC survivors with alcohol or opioid abuse. Additional studies evalu- HNC survivors may have significant needs for respiratory therapy sec-
ating (1) interventions to improve abstinence among tobacco or alco- ondary to their disease process. Following treatment, surgical changes
hol-dependent HNC survivors and (2) management of opioid abuse in to native anatomy as well as mucositis, edema, or fibrosis secondary
HNC survivors are needed. to chemotherapy and radiation can impact a patient's ability to protect
their airway. Comparing patients that aspirate post-therapy to those
that do not, there is evidence that expiratory pressure and cough is
4.3.1 | Recommendation depressed in patients that aspirate.214 Expiratory muscle strength
training (EMST) has been shown to improve swallowing function and
Patients who have undergone treatment for HNC should be: airway protection in patients with neurodegenerative disorders and
several case series demonstrated improvement in swallowing parame-
a. Referred by their survivorship team for tobacco cessation counsel- ters in HNC patients after treatment.215–217 EMST involves expiration
ing and alcohol abstinence resources (Oxford Category 1A). against a spring-loaded relief valve that can provide a variable amount
b. Encouraged by their survivorship team to avoid tobacco and alco- of resistance. Over time, the resistance can be increased as the
hol consumption (Oxford Category 5). patient's expiratory muscles strengthen, and an increased maximal
expiratory pressure can be generated.
4.4 | Physical activity/exercise

4.5.1 | Tracheostomy care
HNC survivor participation in physical activity, exercise, and
strength training is poorly understood. Early studies describe vari- Patients who are tracheostomy-dependent in the post-surgical or
able findings: 19%–63% of patients reported any vigorous or moder- post-treatment period require specific care. Humidification can reduce
ate levels of physical activity and 9%–40% were compliant with the thickness and quantity of secretions. Heat and moisture exchange
national physical activity guidelines.204,205 Several small cohort and (HME) filters can also provide humidification while allowing the
randomized-controlled studies have evaluated physical activity or patient to be active and mobile. Additionally, suction equipment may
resistance training interventions in HNC survivors during or after be necessary to clear secretions. The inner cannula should be replaced
oncologic treatment. Most have reported significant improvements or cleaned on a routine basis to clear any crusting or retained mucus
in at least some symptoms, health-related QOL domains, or objec- along the tube's path. The degree and frequency of suctioning or inner
tive measures of weight, muscle mass, physical function (i.e., 6-min cannula maintenance will be dependent on several patient factors
206–210
walk test), and range of motion. While physical activity may including mucus quality, amount produced, and aspiration status.218
associate with improved overall, disease-free, or disease-specific As HNC patients recover function after treatment, consideration can
survival among patients with other types of cancer (i.e., breast and be given to decannulation or removal of the tracheostomy tube if the
colorectal cancer), these outcomes have not been evaluated in HNC patient is able to breathe comfortably with the tracheostomy tube
211–213
patients. Therefore, the authors support the ACS and ASCO occluded and demonstrate a lack of overt aspiration. One-way speak-
survivorship guidelines on physical activity in HNC survivors: (a) ing valves such as the Passy Muir Valve may provide an interim stage
avoid inactivity and return to normal daily activities as soon as possi- between tracheostomy dependence and decannulation as well as
ble following diagnosis, (b) aim for at least 150 min of moderate or facilitation of verbal communication and cough.
75 min of vigorous aerobic exercise per week, (c) include strength
training exercises at least 2 days/week.7,8,51 Further evaluation of
the implementation of increased physical activity into routine clinical 4.5.2 | Laryngectomy care
care and the optimal timing, intensity, and duration of exercise inter-
ventions in relation to oncologic treatment will be necessary. Patients who are status post-laryngectomy permanently bypass oral
Assessment of associations between exercise and HNC recurrence and nasal humidification as well as filtration mechanisms of inspired
or survival is also warranted. air with a permanent stoma between the tracheal wall and anterior
cervical skin. As such, patients with a laryngectomy stoma will require
a suction apparatus or evidence of strong cough reflex as well as a
4.4.1 | Recommendation method of humidification. In the setting of patient self-care, a hand-
held mirror can be helpful with cleaning and suctioning. Additionally,
Patients who have undergone treatment for HNC should be: humidification can be provided either via an external humidified air
(delivered via a mist collar) or by wearing an HME device which can fit
a. Encouraged by their survivorship team to engage in regular physi- over the stoma and can reduce the reliance on pulmonary toilet and
cal activity and exercise (Oxford Category 1B). suctioning.219,220 Patients with a tracheoesophageal puncture for
86 GOYAL ET AL.
phonation will also need to keep the prosthesis clean of crusting and a. Counseled by their survivorship team on the sequelae of HPV-
debris with a bristle brush. Should the tracheoesophageal prosthesis related oncologic disease as well as the clinical evidence relating to
become incompetent, it will start leaking esophageal contents into the the benefits of HPV vaccine (Oxford Category 5).
airway, resulting in frank aspiration and mandating replacement. Some
patients may require routine use of a “laryngectomy tube” to maintain
stoma patency and minimize stomal stenosis; these stents should also 5 | CONC LU SION
219
be removed and cleaned of crusting and debris regularly.
Cancer survivorship necessarily incorporates a multidisciplinary
approach centered around the patient and the caregiver, led by oncol-
4.5.3 | Recommendation ogists (surgical, medical, and radiation) and primary care providers and
managed by a wide variety of allied health providers including but not
Patients who have undergone treatment for HNC should be: limited to therapists (speech, physical, occupational, and respiratory),
dieticians, social workers, dentists, and psycho-oncologists. With
a. Educated in the tracheostomy and laryngectomy stoma care if increasing survival related to HNC treatment, addressing post-treat-
either is present by their survivorship team (Oxford Category 5). ment concerns will have a profound impact on patient quality of life
and survival. There continues to be a need to define effective and effi-
cient programs that can coordinate this multidisciplinary effort toward
4.6 | HPV counseling survivorship.
The incidence of HPV-associated OPSCC is rising; the disease now ACKNOWLEDG MENTS
comprises 70% of OPSCC in the United States. Despite this, there is a The authors would like to acknowledge Jenna Loewus and Isabella
significant gap in knowledge and awareness about HPV and HPV- Yeung for administrative support.
associated OPSCC among both general adults and HPV OPSCC survi-
vors.221–225 HPV OPSCC survivors report reduced sexual activity,53 CONFLIC T OF INT ER E ST
informational, emotional, and psychosocial needs related to their diag- None of the authors have any conflicts of interest.
nosis including self-blame, guilt, anxiety, distress, and concern about
transmitting HPV to others.224–226 Broad patient information needs OR CID
may include knowledge regarding: the prevalence, nature, and trans- Neerav Goyal https://orcid.org/0000-0001-7783-1097
mission of HPV infection, risk to current and future partners, and util- Andrew Day https://orcid.org/0000-0001-7187-4125
ity of preventative vaccination. Recent publications have provided Evan Graboyes https://orcid.org/0000-0003-3766-468X
227,228
helpful resources for both clinicians and patients. To better Vlad Sandulache https://orcid.org/0000-0002-9205-385X
understand general knowledge and advocacy intent, a cross-sectional Amy M. Williams https://orcid.org/0000-0001-9643-3684
study (n = 200) of HPV-related cancer survivors (i.e., cervical, vaginal, Cherie-Ann Nathan https://orcid.org/0000-0001-7386-318X
vulvar, penile, anal, or oropharyngeal) revealed only 33% of respon-
dents were aware that their cancer was HPV-associated and 57% RE FE RE NCE S
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23788038, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/lio2.702 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [03/01/2023].

Head and neck cancer survivorship consensus statement from

Neerav Goyal MD, MPH FACS1 | Andrew Day MD2 |

70 wileyonlinelibrary.com/journal/lio2 Laryngoscope Investigative Otolaryngology. 2022;7:70–92.

TABLE 1 Head and neck cancer survivorship: AHNS Committee Guidelines

Level of evidence Topic Recommendation

Level of evidence Topic Recommendation

TABLE 2 Oxford levels of evidence 2.1.1 | Recommendation

2.3.1 | Recommendation a. Post-treatment baseline radiographic imaging of primary (and neck

a. Evaluated for lymphedema after treatment for HNC by their survi-

management, although further work is needed to develop effective 3.7.3 | Recommendation

3.9 | Caregivers The Commission on Cancer of the American College of Surgeons

3.10.1 | Recommendation 3.12 | Financial burden

3.11.1 | Recommendation 4 | HE AL TH MAIN T E N A NC E

complications, recurrence, and mortality.191–196 In addition to manag- 4.5 | Respiratory therapy

4.4 | Physical activity/exercise

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