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 » Methodology
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  Table of Contents  
Year : 2020  |  Volume : 57  |  Issue : 5  |  Page : 1-5

Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck

1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
3 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Department of Surgical Oncology, Cochin Cancer Research Centre, Cochin, Kerala, India
5 Department of Oral Medicine and Radiology, KLE Society's Institute of Dental Sciences (KLESIDS), Bangalore, Karnataka, India
6 Department of Radiation Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
7 Department of Medical Oncology, HCG Cancer Centre, Ahmedabad, Gujarat, India
8 Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
9 Department of Radiation Oncology, Civil Hospital, Shillong, Meghalaya, India
10 Department of Medical Oncology, Indraprastha Apollo Hospital, New Delhi, India
11 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
12 Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Centre, Bangalore, Karnataka, India
13 Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
14 Department of Radiotherapy, Christian Medical College, Vellore, Tamil Nadu, India
15 Department of Surgical Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
16 Department of Surgical Oncology, HCG Cancer Centre, Bangalore, Karnataka, India
17 Department of Radiation Oncology, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Jammu, Jammu and Kashmir, India
18 Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, Delhi, India

Date of Submission25-Jul-2019
Date of Decision13-Nov-2019
Date of Acceptance29-Dec-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.278971

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 » Abstract 

Head and neck cancers (HNCs) are malignant tumors of the upper aerodigestive tract and are the sixth most common cancer worldwide. In India, around 30–40% of all cancers are HNCs. Even though there are global guidelines or recommendations for the management of HNCs, these may not be appropriate for Indian scenarios. In an effort to discuss current practices, latest developments and to come to a consensus to recommend management strategies for different anatomical subsites of HNCs for Indian patients, a group of experts (medical, surgical and radiation oncologists and dentists) was formed. A review of literature from medical databases was conducted to provide the best possible evidence base, which was reviewed by experts during a consensus group meeting (January, 2019) to provide recommendations.

Keywords: Chemoradiation, consensus, head and neck cancer, Indian guidelines, recommendations

How to cite this article:
Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck. Indian J Cancer 2020;57, Suppl S1:1-5

How to cite this URL:
Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck. Indian J Cancer [serial online] 2020 [cited 2022 Jul 2];57, Suppl S1:1-5. Available from:

 » Introduction Top

Head and neck cancers (HNCs) are malignant tumors of the upper aerodigestive tract including oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.[1],[2] Squamous cell carcinoma (SCC) constitutes for >90% of HNCs. Among all etiologic factors, smoking and chewing of tobacco are considered important for the development of HNCs. In India, there is a significant increase in the incidence of HNCs and there is variability in the management of these patients.

According to GLOBOCAN 2018 report, worldwide HNC statistics indicate that there are 834,860 cases of HNC per year, resulting in approximately 431,131 deaths per year. High incidence rates have been reported from developing countries including India, Pakistan, Bangladesh, Taiwan, and Sri Lanka.[3] HNCs account for approximately 30–40% of all cancer sites, in India.[4],[5] The Cancer Atlas project by the Indian Council for Medical Research (ICMR) reports incidences of different cancers across India. The incidence in Assam, Manipur, Mizoram, Tripura, and Nagaland has been reported to be higher (54%). The world's highest incidence of cancers in men, which was of the lower pharynx (11.5/100,000 people) and the tongue (7.6/100,000 people), was reported from Mizoram. Pondicherry has also reported the incidence of mouth cancer in males (7.8–8.9/100,000); however, the highest incidence of nasopharyngeal cancer has been reported from Nagaland.[6–11] The possible reasons for the higher incidence of HNCs in India include extensive use of tobacco, pan masala (which include betel quid, areca nuts, and slaked lime), and gutkha. [Table 1] summarizes the HNC statistics of India (GLOBOCAN 2018).
Table 1: GLOBOCAN 2018 report showing HNC statistics of India

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Even though there are global guidelines or recommendations for the management of HNCs (NCCN 2018; ESMO; SEOM 2017), these recommendations may not be appropriate for Indian scenarios.[1],[12],[13],[14] While the existing international guidelines provide recommendations on the management of HNC universally, the objective of these guidelines is to bring consensus on the management of HNC in the Indian context. It is intended to give a comprehensive and simpler overview of treatment recommendations in the form of algorithms, which cover all aspects of disease stages along with resectability criteria, positive margins criteria, and various modalities of the treatment. Recommendations are made considering Indian evidence-based available treatment options. It also provides tabular summaries of all anatomical site-wise evidence considered for recommendations.

Genetically and etiologically, our patient profiles are different showing more unfavorable outcomes. Compared to the western world, these patients require an aggressive treatment and optimal use of chemoradiation.[15] Prevalence of usage of smokeless tobacco and per capita consumption of alcohol is different in different countries, with India showing 25.9% and 5.7 liters versus 3.6% and 9.8 liters in United States of America, respectively.[16],[17] In India, among patients diagnosed with HNC, 86.5% were reported as tobacco users and 23.2% were reported as alcohol users.[18] Habits of chewing tobacco, areca nuts, slaked lime, gutkha, betel quid, and alcohol consumption add to further adverse prognosis. Tobacco allows long exposure and causes discoloration because of which early changes are masked resulting in an advanced presentation. In oral cancer patients, tobacco users have shown lower survival than nontobacco users (median overall survival [OS] at 5 years: 43% vs. 72%, respectively). Tobacco and alcohol frequently coexist and lead to adverse prognosis. Five-year OS in patients who consumed both alcohol and tobacco was 29%.[19] There is a delayed diagnosis with most commonly reported sites being oropharynx, hypopharynx, oral cavity, and presence of predominantly human papillomavirus (HPV)-negative tumors.[20],[21] Delayed diagnosis leads to poor prognosis with 5-year median OS varying from 100% at stage 1 to 42% at stage 4.[19] According to a study conducted by Tata Memorial Hospital, India, about 57% of the HNC patients present with comorbidities, the majority being hypertension, cardiac, and respiratory. One-fifth of these patients had moderate-to-severe comorbidities that were predictors of deviation from an ideal treatment plan of guideline-concordant therapy, leading to poor survival outcomes.[21] Patients with comorbidities show lower survival rate than patients with no comorbidities (median OS at 5 years: 16% vs. 84%, respectively).[19] About 25–50% of these patients are found nutritionally compromised prior to commencement of treatment. Poor nutritional status affects their physical function, quality of life, and OS.[22] Around 30% of HNC patients in India and Southeast Asia present with genetic abnormalities like preponderance of Ha-ras mutations, loss of heterozygosity of Ha-ras, N-ras amplification, and N-myc amplification. These ras oncogenes mutations are uncommon in the western world.[23] Michmerhuizen et al. noted distinct differences in genomic aberrations in Indian patients compared to other regions in terms of EGFR, MYC, PIK3CA, CDKN2A, TRMP3, USP9X, FAT1, FAT3, FAT4, TP53, FAT1, CASP8, HRAS, and NOTCH1. The HPV prevalence also varies between regions (7.1% in India vs. 21.4% in Eastern Europe). Divergence in sexual activity in different populations can be one of the reasons for this difference.[24] RTOG0522 trial conducted in United States of America showed an HPV-positive rate of 73%, whereas an Indian study showed an HPV-positive rate of 7.4–10.5% of total oropharyngeal carcinoma.[18] These various factors make a compelling reason to bring a common consensus for managing this predominant cancer type in our country. Additionally, available Indian guidelines for the management of HNC are not updated regularly.[25],[26],[27],[28]

There are various patient-related factors, which affect overall prognosis and influence the treatment decisions. These factors include the age of the patient, performance status, nutritional status, associated comorbidities, active smoking, HPV-associated oropharyngeal cancers, and tumor programmed death-ligand 1 expression status, which is a predictive marker for response to anti-programmed cell death protein 1 therapy. Management of SCC of head and neck includes radiotherapy as an integral part of treatment along with chemotherapy, targeted therapy, and immunotherapy. In India, most of the government institutes still use conventional radiotherapy 2D/3D conformal therapy by cobalt 60 for external beam radiotherapy. Evidence showing improved treatment outcomes using conventional radiotherapy not only helps in wide accessibility of treatment for a greater number of patients but also will encourage health insurance systems to support health care in India. The India-specific guidelines will be of help in decisions of universal health insurance coverage and that ultimately will reduce overall financial toxicity of patients and the nation.

 » Methodology Top

A review of literature from medical databases as mentioned in annexure was conducted to provide the best possible evidence base for the recommendations. Current guidelines, meta-analyses, cross-sectional studies, systematic reviews, and key cited articles related to HNCs were reviewed by the group of experts (medical, surgical and radiation oncologists and dentists) and recommendations relevant to Indian scenarios were developed. The consensus group meeting was convened on January 19, 2019, with the goal of discussing current practices and to come to a consensus to recommend management strategies for different anatomical subsites of HNCs. Recommendations for each section of the consensus document and overall recommendations were agreed by all the participants. In the case where there was no or little evidence, the consensus group discussed the expert's experience and judgment, and recommendations were provided.

The initial draft was developed by an independent medical writing agency under the guidance of consensus group experts, which was subsequently discussed during the consensus group meeting. The draft was then revised and circulated for comments to group members and other experts across the country for their inputs, and the revisions were done until all the participants agreed to the content.

Recommendations are organized by topic and assigned evidence level ratings on the basis of the quality of supporting evidence, all of which have also been rated for strength. Recommendations are graded as A (strongly recommend), B (intermediate), C (weak), and D (not recommended). The evidence levels are grouped in four levels (I–IV) as shown in [Table 2]. HNCs should be staged according to the eighth edition of AJCC classification, which is based on grouping of T, N, and M categories [Table 3].[27]Recommendations of early and locally advanced disease for each sub-site are covered in site specific articles and the very advanced disease for all sub-sites is presented towards the end in a separate article.

Table 2: Evidence levels

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Table 3: TNM categories for different anatomical subsites of head and neck cancer (TNM eighth edition, 2017)

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In summary, these recommendations are based on available literature as mentioned in annexure, particularly from India, and consensus of meeting participants. Further, the group intends to update these recommendations on a regular basis. The choice of treatment should be decided by the multidisciplinary team. Rehabilitation, counseling, and nutritional therapy are important to improve patient's adherence to the treatment and patient survival.


We acknowledge the significant contribution of J Balawardana, C Vithanage, S Resnayaka from Sri Lanka during the meeting and S Ghosh Laskar, S Ranjan, P Chavan, R Halkud and C Ramachandra for their involvement and insights. We also acknowledge the medical writing support provided by an independent medical writing agency, IQVIA. We are fully responsible for the content of this manuscript and the recommendations described in the review reflect the views and opinions of the authors only.

Financial Support and Sponsorship

Oral Cancer Task Force (OCTF) with a multidisciplinary expert panel, has a long standing commitment to work for early detection and management of oral cancer in underserved populations. The task force members have taken this educational initiative of developing India specific consensus guidelines for management of head and neck cancer under its ambit. The meeting and supplement were supported by an unrestricted grant by Biocon Foundation.

Conflicts of interest

Oral Cancer Task Force (OCTF) members and authors do not have any conflicts of interest.

 » References Top

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  [Table 1], [Table 2], [Table 3]

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