New ASCO Guideline on Head and Neck Cancer Clarifies Lymph Node Management

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A NEW ASCO guideline, “Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline,” aims to clarify issues in lymph node management.1

F. Christopher Holsinger, MD

F. Christopher Holsinger, MD

“This guideline represents a true multidisciplinary synthesis of some important new information about oral and pharyngeal cancers,” said guideline Co-Chair F. Christopher Holsinger, MD, of Stanford University, Stanford, California.

The guideline’s release is timely, Dr. Holsinger noted, because of a rise in the number of oropharyngeal cancer cases due to human papillomavirus (HPV) infection. “Because of this precipitous rise, I believe this guideline will be helpful for the broad community of oncologists—not just those who focus on patients with head and neck cancer. Specifically, those in the community might greatly benefit from the updated approach to managing these diseases as presented in the guideline,” he said.

Co-Chair Shlomo A. Koyfman, MD, of the Cleveland Clinic, agreed. “HPV infection has become overwhelmingly the most common cause of oropharynx cancer, accounting for approximately 70% to 80% of oropharynx cancers in the United States. The cure rates are high and these patients often do well without surgery. Because it’s so common and so many clinicians are seeing it, there is danger in conflating how we manage cancer of the oropharynx with how we manage oral cavity cancer,” he said. “The biology is completely different and the management is, too. Whereas in oropharynx cancer, nonoperative therapy is often the primary treatment modality, in oral cavity cancer, and specifically managing the neck, surgery is very important. So we must understand the differences.”

Shlomo A. Koyfman, MD

Shlomo A. Koyfman, MD

Management of the Neck

THE DOCUMENT specifically focuses on management of the neck in squamous cell carcinoma of the oral cavity and oropharynx. The Expert Panel began developing the guideline by performing a review of literature from 1990 to 2018. They focused on outcomes of interest including survival, regional disease control, neck recurrence, and quality of life. The panel—which included medical oncology, surgery, radiation oncology, and advocacy experts—then used the available evidence and informal consensus to develop guideline recommendations.

“The benefit of this guideline is not so much that it contains tons of new data,” Dr. Koyfman said. “Rather, the value lies in our collecting and collating of the data in a systematic way to inform specifically neck management in head and neck cancer. One of the great things about this guideline is that we focused on practical clinical questions that come up every week during tumor boards. We stayed true to the evidence base and shed light on important factors such as surgical quality.”

As the guideline authors said, “For decades, neck dissection and radiotherapy have served as the mainstays of treatment for cervical metastasis from both oral and oropharyngeal squamous cell carcinoma. As our scientific understanding of the biology of these tumors has evolved, and data have emerged clarifying the role of novel imaging, surgical, radiotherapeutic, and systemic therapies in these diseases, a need to articulate guiding principles in managing the neck in these diseases was identified.”1

Using the Guideline

THE GUIDELINE presents a list of recommendations for the treatment of squamous cell carcinoma of the oral cavity and oropharynx, including a three-page bulleted list titled “The Bottom Line,” which should be helpful for busy clinicians, Dr. Koyfman noted.

“The best way to use the guideline, especially after it first comes out, is to have it in your clinic, hanging up by your computer,” he said. “Print off the recommendations and leave them hanging there until you become familiar with them.”

The guideline aims to highlight relevant clinical questions about indications, quality measures, comparative efficacy of neck dissection and radiotherapy, and when and how to incorporate systemic therapy in oral cavity and oropharyngeal squamous cell carcinoma based on nodal characteristics.

“One of the great things about this guideline is that we focused on practical clinical questions that come up every week during tumor boards.”
— Shlomo A. Koyfman, MD

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In crafting the guideline, the Expert Panel devised and discussed six clinical scenarios—three for oral cavity cancer and three for oropharyngeal cancer. For oral cavity cancers, the clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is a sufficient elective treatment of an undissected neck compared with a high-quality neck dissection. For oropharynx cancers, the scenarios discussed include the hallmarks of a high-quality neck dissection, factors that would favor operative vs nonoperative primary management, and clarifying criteria for an incomplete response to definitive radiation or chemoradiation for which salvage neck dissection would be recommended. The Expert Panel reached consensus and generated recommendations for each scenario.

Recent additions to the surgical armamentarium are addressed in the document, Dr. Holsinger noted. “The guideline clarifies how to optimally manage the neck in patients following treatment with minimally invasive and robotic surgery,” he said. The guideline also discusses when surgery might be preferred vs when radiation or chemoradiation is preferred, and it underlines the continuing role of surgery in oral cavity cancer, Dr. Koyfman said.

Primary Goals

“IT WAS VERY important that we clarify the distinction in management between oropharyngeal and oral cavity cancers,” he said. “We were careful to reemphasize the importance of surgery in oral cavity cancer because the outcomes are not as good, and we have to be careful about managing it properly.”

The main goal of the guideline is to standardize practice. “There is a lot of variability out there in how these diseases are managed, and we were trying to set a reasonable standard,” Dr. Koyfman continued. “It’s not perfect, and it’s not always the right answer, but we believe it’s the closest thing to the best way to practice, day to day, consistently, across the country. Of course, there will be modifications on a patient-to-patient basis.”

As a final thought, Dr. Koyfman noted that both diseases are “very curable.”

“With both of these cancers, your first shot is your best shot. Sometimes, if we are undervigilant with management upfront and then [the cancer] comes back and we have to be more aggressive, we don’t always cure patients with the same success rates,” he said.

DISCLOSURE: For full disclosures of the panel authors, visit


1. Koyfman SA, Ismaila N, Crook D, et al: Management of the neck in squamous cell carcinoma of the oral cavity and oropharynx: ASCO Clinical Practice Guideline. J Clin Oncol. February 27, 2019 (early release online).

Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, February 27, 2019. All rights reserved.