Does Pharma Fund the Pipers? – Scottish Intercollegiate Guidelines Network (SIGN) Guidelines 90 — Diagnosis and Management of Head and Neck Cancer, October 2006

Abstract

Clinicians involved in the diagnosis and treatment of head and neck cancer have greatly welcomed the appearance of the Scottish Intercollegiate Guidelines Network (SIGN) guidelines. The typical, thorough exploration of the evidence, carefully weighted evaluation and clear, accessible layout carry the quality hallmark of the SIGN series. As a UK-generated document, the latest SIGN guidance also represents a considerable step forward from the only comparable predecessor, the British Association of Otolaryngologists’ Consensus documents, which it was my privilege to edit [1]. It is also forward looking, towards, for example, the future role of human papillomavirus subtyping as a potential stratifier of treatment modalities d such as prediction of chemoradiosensitivity, for which evidence has since begun to appear [2]. The SIGN guidelines’ stated remit is to follow the patient’s journey of care, and a case is made for one stop clinic assessment, on the evidence base of management of the undiagnosed neck lump. Neck lumps are, however, less common than hoarseness among otolaryngological presentations of head and neck cancer, and only 7% of patients with hoarseness in one UK ‘cancer wait’ clinic in fact had cancer [3]. A one stop dysphonia service requires other expertise than that of a cancer diagnosis clinic. Many patients with head and neck cancer will develop a second primary tumour. The SIGN guidance on the initial assessment of the chest is somewhat contradictory. A statement that all patients with head and neck cancer should have direct laryngoscopy and pharyngoscopy with a chest X-ray is followed on the next page by advice that all patients should have thoracic computed tomography. Inevitably, no such ambitious a document could be totally comprehensive and all contributors have had the unenviable task of selecting the most vital work to include. However, the case for routine follow-up after therapy is complex and perhaps demanded more than one 15-year-old reference. In 2004, Morton et al. [4] concluded that it was unclear whether surveillance provides any survival advantage. More recent work has used mathematical modelling to compare review with ‘no follow-up’ there is