Last updated January 13, 2022

Head and Neck Cancer Survivorship Care

ACS key recommendations for HNC survivorship care

Surveillance for HNC recurrence

History and physical

It is recommended that primary care clinicians:
a. should individualize clinical follow-up care provided to HNC survivors based on age, specific diagnosis, and treatment protocol as recommended by the treating oncology team. (2A)
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b. should conduct a detailed cancer-related history and physical examination every 1–3 mo for the first y after primary treatment, every 2–6 mo in the second y, every 4–8 mo in y 3–5, and annually after 5y. (2A)
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c. should confirm continued follow-up with otolaryngologist or HNC specialist for HN-focused examination. (2A)
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It is recommended that primary care clinicians:

Surveillance education

a. should educate and counsel all HNC survivors about the signs and symptoms of local recurrence. (0)
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b. should refer HNC survivors to an HNC specialist if signs and symptoms of local recurrence are present. (0)
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Screening and early detection of second primary cancers (SPCs)

It is recommended that primary care clinicians:
a. should screen HNC survivors for other cancers as they would for patients in the general population by adhering to the ACS Early Detection Recommendations (cancer.org/professionals). (0)
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b. should screen HNC survivors for lung cancer according to ASCO or NCCN recommendations for annual lung cancer screening with LDCT for high-risk patients based on smoking history. (2A)
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c. should screen HNC survivors for another HN and esophageal cancer as they would for patients of increased risk. ()
(LOE = 0, IIA)
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Assessment and management of physical and psychosocial long-term and late effects of HNC and its treatment

It is recommended that primary care clinicians should assess for long-term and late effects of HNC and its treatment at each follow-up visit.
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Spinal accessory nerve (SAN) palsy

It is recommended that primary care clinicians should refer HNC survivors with SAN palsy occurring postradical neck dissection to a rehabilitation specialist to improve range of motion and ability to perform daily tasks. (IA)
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Cervical dystonia/muscle spasms/neuropathies

It is recommended that primary care clinicians:
a. should assess HNC survivors for cervical dystonia, which is characterized by painful dystonic spasms of the cervical muscles and can be caused by neck dissection, radiation, or both. (0)
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b. should refer HNC survivors to a rehabilitation specialist for comprehensive neuromusculoskeletal management if cervical dystonia or neuropathy is found. (0)
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c. should prescribe nerve-stabilizing agents, such as pregabalin, gabapentin, and duloxetine, or refer to a specialist for botulinum toxin type A injections into the affected muscles for pain management and spasm control as indicated. ()
(LOE = 0, IIA)
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Shoulder dysfunction

It is recommended that primary care clinicians:
a. should conduct baseline assessment of HNC survivor shoulder function posttreatment for strength, range of motion, and impingement signs, and continue to assess as follow-up for ongoing complications or worsening condition. (IIA)
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b. should refer HNC survivors to a rehabilitation specialist for improvement to pain, disability, and range of motion where shoulder morbidity exists. (IA)
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Trismus

It is recommended that primary care clinicians:
a. should refer HNC survivors to rehabilitation specialists and dental professionals to prevent trismus and to treat trismus as soon as it is diagnosed. (0)
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b. should prescribe nerve-stabilizing agents to combat pain and spasms, which may also ease physical therapy and stretching devices. (IIA)
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Dysphagia/aspiration/stricture

It is recommended that primary care clinicians:
a. should refer HNC survivors presenting with complaints of dysphagia, postprandial cough, unexplained weight loss, and/or pneumonia to an experienced speech-language pathologist for instrumental evaluation of swallowing function to assess and manage dysphagia and possible aspiration. (IIA)
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b. should recognize potential for psychosocial barriers to swallowing recovery and refer HNC survivors to an appropriate clinician if barriers are present. (IIA)
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c. should refer to a speech-language pathologist for videofluoroscopy as the first-line test for HNC survivors with suspected stricture due to the high degree of coexisting physiologic dysphagia. (IIA)
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d. should refer HNC survivors with stricture to a gastroenterologist or HN surgeon for esophageal dilation. (IIA)
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Gastroesophageal reflux disease (GERD)

It is recommended that primary care clinicians:
a. should monitor HNC survivors for developing or worsening GERD, as it prevents healing of irradiated tissues and is associated with increased risk of HNC recurrence or SPCs. (IIA)
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b. should counsel HNC survivors on an increased risk of esophageal cancer and the associated symptoms. (IIA)
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c. should recommend PPIs or antacids, sleeping with a wedge pillow or 3-inch blocks under the head of the bed, not eating or drinking fluids for 3 h before bedtime, tobacco cessation, and avoidance of alcohol. (IIA)
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d. should refer HNC survivors to a gastroenterologist if symptoms are not relieved by treatments listed above. (IIA)
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Lymphedema

It is recommended that primary care clinicians:
a. should assess HNC survivors for lymphedema using the NCI CTCAE v.4.03, or referral for endoscopic evaluation of mucosal edema of the oropharynx and larynx, tape measurements, sonography, or external photographs. (IIA)
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b. should refer HNC survivors to a rehabilitation specialist for treatment consisting of MLD and, if tolerated, compressive bandaging. (IIA)
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Fatigue

It is recommended that primary care clinicians:
a. should assess for fatigue and treat any causative factors for fatigue, including anemia, thyroid dysfunction, and cardiac dysfunction. (0)
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b. should offer treatment or referral for factors that may impact fatigue (eg, mood disorders, sleep disturbance, pain, etc.) for those who do not have an otherwise identifiable cause of fatigue. (I)
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c. should counsel HNC survivors to engage in regular physical activity and refer for CBT as appropriate. (I)
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Altered or loss of taste

It is recommended that primary care clinicians should refer HNC survivors with altered or loss of taste to a registered dietitian for dietary counseling and assistance in additional seasoning of food, avoiding unpleasant food, and expanding dietary options. (IIA)
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Hearing loss, vertigo, vestibular neuropathy

It is recommended that primary care clinicians should refer HNC survivors to appropriate specialists (ie, audiologists) for loss of hearing, vertigo, or vestibular neuropathy related to treatment. (IIA)
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Sleep disturbance/sleep apnea

It is recommended that primary care clinicians:
a. should screen HNC survivors for sleep disturbance by asking HNC survivors and partners about snoring and symptoms of sleep apnea. (0)
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b. should refer HNC survivors to a sleep specialist for a sleep study (polysomnogram) if sleep apnea is suspected. (0)
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c. should manage sleep disturbance similar to patients in the general population. (0)
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d. should recommend nasal decongestants, nasal strips, and sleeping in the propped-up position to reduce snoring and mouth-breathing; room cool-mist humidifiers can aid sleep as well by keeping the airway moist. (0)
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e. should refer to a dental professional to test the fit of dentures to ensure proper fit and counsel HNC survivors to remove dentures at night to avoid irritation. (0)
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Speech/voice

It is recommended that primary care clinicians:
a. should assess HNC survivors for speech disturbance. (0)
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b. should refer HNC survivors to an experienced speech-language pathologist if communication disorder exists. ()
(LOE = IA, IIA)
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Hypothyroidism

It is recommended that primary care clinicians should evaluate HNC survivor thyroid function by measuring TSH every 6–12 mo. (III)
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Oral and dental surveillance

It is recommended that primary care clinicians:
a. should counsel HNC survivors to maintain close follow-up with the dental professional and reiterate that proper preventive care can help reduce caries and gingival disease. (IA)
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b. should counsel HNC survivors to avoid tobacco, alcohol (including mouthwash containing alcohol), spicy or abrasive foods, extreme temperature liquids, sugar-containing chewing gum or sugary soft drinks, and acidic or citric liquids. (0)
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c. should refer HNC survivors to a dental professional specializing in the care of oncology patients. (0)
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Caries

It is recommended that primary care clinicians:
a. should counsel HNC survivors to seek regular professional dental care for routine examination and cleaning and immediate attention to any intraoral changes that may occur. (0)
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b. should counsel HNC survivors to minimize intake of sticky and/or sugar-containing food and drink to minimize risk of caries. (0)
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c. should counsel HNC survivors on dental prophylaxis, including brushing with remineralizing toothpaste, the use of dental floss, and fluoride use (prescription 1.1% sodium fluoride toothpaste as a dentifrice or in customized delivery trays). ()
(LOE = IA, 0)
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Periodontitis

It is recommended that primary care clinicians:
a. should refer HNC survivors to a dentist or periodontist for thorough evaluation. (0)
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b. should counsel HNC survivors to seek regular treatment from and follow recommendations of a qualified dental professional and reinforce that proper examination of the gingival attachment is a normal part of ongoing dental care. (0)
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Xerostomia

It is recommended that primary care clinicians:
a. should encourage use of alcohol-free rinses if an HNC survivor requires mouth rinses. (0)
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b. should counsel HNC survivors to consume a low-sucrose diet and to avoid caffeine, spicy and highly acidic foods, and tobacco. (0)
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c. should encourage HNC survivors to avoid dehydration by drinking fluoridated tap water, but explain that consumption of water will not eliminate xerostomia (0)
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Osteonecrosis

It is recommended that primary care clinicians:
a. should monitor HNC survivors for swelling of the jaw and/or jaw pain, indicating possible osteonecrosis. ()
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b. should administer conservative treatment protocols, such as broad-spectrum antibiotics and daily saline or aqueous chlorhexidine gluconate irrigations, for early stage lesions. ()
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c. should refer to an HN surgeon for consideration of hyperbaric oxygen therapy for early and intermediate lesions, for debridement of necrotic bone while undergoing conservative management, or for external mandible bony exposure through the skin. (0)
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Oral infections/candidiasis

It is recommended that primary care clinicians:
a. should refer HNC survivors to a qualified dental professional for treatment and management of complicated oral conditions and infections. (0)
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b. should consider systemic fluconazole and/or localized therapy of clotrimazole troches to treat oral fungal infections. (0)
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Body and self-image

It is recommended that primary care clinicians:
a. should assess HNC survivors for body and self-image concerns. (IIA)
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b. should refer for psychosocial care as indicated. (IA)
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Distress/depression/anxiety

It is recommended that primary care clinicians:
a. should assess HNC survivors for distress/depression and/or anxiety periodically (3 mo posttreatment and at least annually), ideally using a validated screening tool. (I)
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b. should offer in-office counseling and/or pharmacotherapy and/or refer to appropriate psycho-oncology and mental health resources as clinically indicated if signs of distress, depression, or anxiety are present. (I)
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c. should refer HNC survivors to mental health specialists for specific QoL concerns, such as to social workers for issues like financial and employment challenges or to addiction specialists for substance abuse. (I)
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Health promotion

Information

It is recommended that primary care clinicians:
a. should assess the information needs of the HNC survivor related to HNC and its treatment, side effects, other health concerns, and available support services. (0)
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b. should provide or refer HNC survivors to appropriate resources to meet identified needs. (0)
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Healthy weight

It is recommended that primary care clinicians:
a. should counsel HNC survivors to achieve and maintain a healthy weight. (III)
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b. should counsel HNC survivors on nutrition strategies to maintain a healthy weight for those at risk for cachexia. (0)
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c. should counsel HNC survivors if overweight or obese to limit consumption of high‐calorie foods and beverages and increase physical activity to promote and maintain weight loss. (IA)
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Physical activity

It is recommended that primary care clinicians should counsel HNC survivors to engage in regular physical activity consistent with the ACS guideline, and specifically:
a. should avoid inactivity and return to normal daily activities as soon as possible after diagnosis. (III)
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b. should aim for at least 150 min of moderate or 75 min of vigorous aerobic exercise per week. ()
(LOE = I, IA)
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c. should include strength training exercises at least 2 d/wk. (IA)
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Nutrition

It is recommended that primary care clinicians:
a. should counsel HNC survivors to achieve a dietary pattern that is high in vegetables, fruits, and whole grains, low in saturated fats, sufficient in dietary fiber, and avoids alcohol consumption. ()
(LOE = IA, III)
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b. should refer HNC survivors with nutrition-related challenges (eg, swallowing problems that impact nutrient intake) to a registered dietician or other specialist. (0)
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Tobacco cessation

It is recommended that primary care clinicians should counsel HNC survivors to avoid tobacco products and offer or refer patients to cessation counseling and resources. (I)
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Personal oral health

It is recommended that primary care clinicians:
a. should counsel HNC survivors to maintain regular dental care, including frequent visits to dental professionals, early interventions for dental complications, and meticulous oral hygiene. (0)
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b. should test fit dentures to ensure proper fit and counsel HNC survivors to remove them at night to avoid irritation. (0)
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c. should counsel HNC survivors that nasal strips can reduce snoring and mouth-breathing and that room humidifiers and nasal saline sprays can aid sleep as well. (0)
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d. should train HNC survivors to do at-home HN self-evaluations and be instructed to report any suspicions or concerns immediately. ()
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Care coordination and practice implications

Survivorship care plan

It is recommended that primary care clinicians should consult with the oncology team and obtain a treatment summary and survivorship care plan. ()
(LOE = 0, III)
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Communication with other providers

It is recommended that primary care clinicians:
a. should maintain communication with the oncology team throughout diagnosis, treatment, and posttreatment care to ensure that care is evidence‐based and well coordinated. (0)
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b. should refer HNC survivors to a dentist to provide diagnosis and treatment of dental caries, periodontal disease, and other intraoral conditions, including mucositis and oral infections, and communicate with the dentist on follow-up recommendations and patient education. (0)
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c. should maintain communication with specialists referred to for management of comorbidities, symptoms, and long-term and late effects. (0)
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Inclusion of caregivers

It is recommended that primary care clinicians should encourage the inclusion of caregivers, spouses, or partners in usual HNC survivorship care and support. (0)
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More resources

More resources to support guideline implementation are available at cancer.org/professionals. ()
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Recommendation Grading

Overview

Title

Head and Neck Cancer Survivorship Care

Authoring Organization

Publication Month/Year

March 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long‐term and late effects, health promotion, and care coordination.

Target Patient Population

Head and neck cancer survivors

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Long term care, Outpatient

Scope

Counseling, Assessment and screening, Rehabilitation, Management

Diseases/Conditions (MeSH)

D000073116 - Cancer Survivors, D000073859 - Survivorship, D006258 - Head and Neck Neoplasms

Keywords

head and neck cancer, head and neck squamous cell carcinoma (HNSCC), cancer survivors