Head and neck cancer - guidance

Head and Neck Cancer and its treatment

The term ‘head and neck cancer’ includes tumours of the oral cavity, oropharynx, lip, nasopharynx, hypopharynx, larynx, mandible, maxilla, nasal cavity, paranasal sinuses and of the salivary glands (Baijens et al, 2021). Incidence of each sub-site varies depending on geographic region, population and levels of exposure to risk factors (Pezzuto et al, 2015). More than 90% of these tumours are squamous cell carcinomas (Baijens et al, 2021).

Head and neck cancer occurs mainly in adults, with 12,422 cases diagnosed on average per year in the UK and an increase of 37% in cases since the early 1990’s (CRUK, 2021). Head and neck cancer accounted for over 700,000 new cases (3.9% of all cancer cases) and over 350,000 deaths (3.8% of all cancer cases) worldwide in 2018 (Bravi et al, 2021). Head and neck cancer, although relatively uncommon, carries a high level of morbidity and mortality; the tenth most common cancer worldwide but the seventh most common cause of cancer mortality (WHO, 2004). It is the 15th most common cause of cancer death in the UK (CRUK, 2021).

The five-year survival rate in 2007 was 44% for oropharyngeal cancer (Orlandi et al, 2019). Based on 2009-2013 data, 19-59% of people in the UK diagnosed with head and neck cancer survive for more than 10 years (CRUK, 2021a).  However, human papilloma virus-related oropharyngeal squamous cell carcinoma five-year survival rates can be as high as 70-80% (Huang et al, 2015).

Surgery and/or (chemo)radiotherapy are the most common head and neck cancer treatments (Mehenna et al, 2010). Patients with advanced disease may be offered multimodality treatment e.g. surgery and adjuvant (chemo) radiotherapy.

Surgery may include:

• transoral surgery
• open surgery, which may be combined with reconstructive techniques such as microvascular free-flaps.

Oncological treatments may include:

• radiotherapy
• chemotherapy
• chemoradiotherapy

Types of radiotherapy include intensity-modulated radiotherapy (IMRT) which can reduce the dose to the pharyngeal constrictors, parotid glands and oral cavity (Price et al, 2019) or proton beam therapy which improves precision and targeting of radiation dose to the tumour volume, sparing healthy tissue.

Choice of treatment is a result of multidisciplinary team discussion, and depends on tumour site, stage, histopathology, patient preference and individual factors as well as treatment intent (curative or palliative). Treatment also depends on what standard treatments and clinical trials are currently available at each individual cancer centre. Treatment decisions should take into account the likely effects on voice, speech and swallowing, as well as survival (Clarke et al, 2016).

Functional impact

Impairment

Dysphagia and persistent hoarseness are red flag symptoms of head and neck cancer (Mehenna et al, 2010; Tikka 2016). Up to 75% of head and neck cancer patients have difficulty or alteration to their swallowing at diagnosis (Patterson et al, 2013, Russi et al, 2012).  Each treatment modality has the potential to negatively affect speech, voice and swallowing function. 60-75% of patients have dysphagia post-head and neck cancer treatment (Malagelada et al, 2015). Minimally invasive surgery will often result in early post-operative dysfunction, depending on baseline function, tumour stage and volume (Stephen, 2022). The severity of voice, speech and swallowing impairment following open surgery depends on factors such as tumour site, volume resected, and nature of the reconstruction. Radiotherapy often results in fibrotic and oedematous tissues, significantly affecting their movement and coordination. Function may gradually or suddenly deteriorate in the long-term, with a continuation of the fibrotic process, neuropathy, intractable oedema, and atrophy (Hutcheson, 2015, Hutcheson, 2012).

Psychosocial effects

Functional changes after head and neck cancer treatment are strongly associated with low mood and distress (Goff et al, awaiting publication). Nayak et al (2002)’s systematic review found that head and neck cancer patients are psychosocially distressed during radiotherapy, and the distress steadily increases during the therapy. Eating and drinking problems may  result in substantial embarrassment, heightened anxiety and avoidance of eating with others  (Lang, 2013) and poorer overall wellbeing (Bressan et al, 2017). Head and neck cancer treatment can result in persistent and complex dysphagia and poorer self-reported quality of life outcomes, with people reporting swallowing as one of their highest concerns following treatment (Clunie et al, 2023, Rathod et al, 2015).

An acquired communication impairment post-treatment affects the way a person interacts and engages with others. It can reduce the breadth and frequency of social contacts, increasing the likelihood of withdrawal and loneliness (Palmer, 2019). Furthermore, people are less likely to return to work if they have voice, speech or eating issues (Zecena, 2022). In head and neck cancer, restricted social eating and social contact has a strong relationship with depression and poor quality of life overall (Patterson, 2022).

Risk factors

The aetiology of head and neck cancer is complex with the evidence base in this area continuing to evolve. A person’s risk of developing cancer may be influenced by many elements including age, genetics, and exposure to environmental factors.

Risk factors with sufficient evidence to increase the chance of developing head and neck cancer may include:

• alcohol
• tobacco
• betel quid
• smokeless tobacco
• Human Papillomavirus (HPV)
• Epstein Barr Virus (EPV)
• formaldehyde
• radiation
• asbestos
• salted fish (Chinese style)
• wood dust.

The adoption of a healthy lifestyle is associated with a reduction in cancer morbidity and mortality (Zhang et al 2020, Nicoletti et al 2011, Bravi et al 2021). Health professionals can play an important role in supporting healthy lifestyle choices.

Download the risk factors for head and neck cancer (PDF)

Role of Speech and Language Therapy

Multi-disciplinary team working

Speech and language therapists (SLTs) are an integral part of a multi-disciplinary team (MDT) working with patients with head and neck cancer. These collaborative multi-disciplinary teams (MDTs) are essential for optimal patient outcomes and responsible for assessment, intervention planning and management of every individual, with their involvement in decision-making. SLTs will also be part of coordinated local support teams to provide long-term support and rehabilitation for individuals in the community. These teams will work closely with every level of the service from primary care teams to the specialist MDT.

SLTs working, as part of an integrated MDT, are involved in all stages of the patient care pathway:

• pre-diagnosis
• diagnosis and care planning
• treatment
• post-treatment
• monitoring and survivorship
• late effects of treatment
• palliative care
• end of life.

The SLT at each of these stages aims to contribute to the assessment, treatment, maximising and maintenance of abilities relating to: speech, voice, swallowing and communication; cognitive and psychological factors; and nutrition.

This will involve information provision (including on likely treatment effects, local support groups, charitable organisations such as cancer support centres or online resources), support to patients and carers, referral to other teams (such as the lymphoedema service or clinical psychology) and liaison with other members of the MDT (such as head and neck clinical nurse specialists, dietitians, radiographers, surgeons or oncologists).

SLTs make a unique contribution to the MDT through completing technical assessments that may include clinical dysphagia assessments e.g. 100 ml water swallow test (Patterson, 2009) or instrumental assessments such as FEES or videofluoroscopy. In addition, SLTs working with laryngectomy patients may have additional competencies in tracheal manometry, selection and fitting of voice prosthesis for SVR post-laryngectomy, teaching patients to self-change voice prostheses, videofluoroscopy for laryngectomy patients and air insufflation testing (RCSLT, 2023, Patterson 2009, Carding et al, 2008, RCSLT 2008, RCSLT 1999).

SLTs can work in different multidisciplinary teams according to the needs of the individual. For example, SLTs may work with intensive care nurses to help to optimise the safety of swallow in patients, engender safe swallow and facilitate communication. They are involved in MDT tracheostomy weaning decisions post-surgery following SLT assessment of voice and swallowing.  SLTs may also work with dietitians and oncologists to assess people’s need for enteral feeding support and put in place prehabilitation swallowing exercises prior to commencing radiotherapy. SLTs work closely with the ENT surgeon and head and neck clinical nurse specialists to explain to the patient what laryngectomy surgery will involve, including changes in speaking, breathing, swallowing, olfaction, explaining care of the stoma and voice prosthesis. The SLT can advise on and can fit one-way valves to both aid communication and reduce the risk of aspiration in those with a long-term tracheostomy or intubation (Baumgartner, 2008).

The role of  SLTs

Working as part of an MDT, SLTs can be involved in all stages of the patient care pathway providing a mixture of clinical expertise and practical support.

SLTs:

• have expertise in assessing, diagnosing, and managing disorders of communication, speech, voice and swallowing
• provide information and support to people with head and neck cancer regarding how head and neck cancer treatment may affect swallowing and communication
• provide pre-head and neck cancer treatment prehabilitation to maximise swallowing and communication outcomes
• may facilitate pre-treatment voice banking for patients where head and neck cancer treatment will significantly affect their voice e.g. total glossectomy or total laryngectomy
• have a unique and positive role to play in alaryngeal voice restoration post laryngectomy.
• have the lead responsibility within the MDT for the decision-making process of selection of voice prosthesis, care and management in Surgical Voice Restoration service (SVR) post- laryngectomy.
• develop and support the communication skills of both the patient and communicative partners
• support and facilitate patient involvement in decision-making regarding methods of communication (e.g. post-laryngectomy) or dysphagia management (e.g. helping patients make informed decisions about safest options for eating/ drinking with acknowledged risks and minimised choking risks)
• intervention for swallowing problems associated with head and neck cancer requires a thorough assessment that may include both clinical and instrumental assessment e.g. videofluoroscopy and/or FEES (fibreoptic endoscopic evaluation of swallowing).
• contribute to better health outcomes through their unique role in assessing, diagnosing and managing oropharyngeal dysphagia for patients at all stages of head and neck cancer treatment and those who are post-treatment.
• are actively involved in service evaluations, audits, collection of outcome measure data, high-quality research and clinical trials which contribute to improved outcomes and evidence-based treatment and service improvements for head and neck patients
• monitor and review patients progress over the long term, as the long-term risk and/or presence of transient, intermittent, or persistent dysphagia and late effects of treatment puts patients at risk of the complications that are associated with dysphagia, requiring a specialist SLT’s intervention as required
• take into account the changing needs and pathways of care for persons with speech, voice or swallowing disorders associated with head and neck cancer and focus interventions as the condition alters or declines
• support head and neck cancer patients in survivorship and accessing support networks or organisations, enabling them to live fulfilling lives with improved quality of life outcomes
• contribute to palliative and end-of-life care, maximising and facilitating communication and managing dysphagia throughout the end stages, promoting quality of life.

Resources required

Specific resources required for SLT head and neck cancer services include:

• Surgical voice restoration equipment, pulmonary rehabilitation equipment e.g. baseplates/ HME systems and stoma accessories plus inflation related budget
• Voice recording equipment including microphone suitable for voice banking recording or FEES
• Acoustic analysis equipment
• Fibreoptic endoscopy facilities for voice and FEES and access to disinfection facilities for scope, suitable room and personal protective equipment for aerosol-generating procedure.
• Electrolarynxes, batteries and oral adaptors
• Voice amplifiers, communication aids
• Access to specialised services and equipment if not available on site, e.g. VF FEES, stroboscopy
• Equipment for tracheal manometry and air insufflation testing if undertaking these assessments
• Diagrams, models and web-based resources for explaining dysphagia, exercises and effects of surgery and local and national information on support groups/places where information, financial advice, details of complementary intervention can be accessed
• Equipment used for communication and dysphagia rehabilitation and assessment e.g. biofeedback devices, therapy spoons, specialist dysphagia equipment, measuring cup and syringes, mouth opening rehabilitative devices

The nature of speech and language therapy intervention with the head and neck cancer caseload requires SLTs to have specialist training and competencies in assessment and management of communication and swallowing, including specific skills in working with tracheostomy and laryngectomy. SLTs assess, rehabilitate and advise on: communication, safety of swallowing, swallowing rehabilitation, secretion management, tracheostomy weaning, laryngectomy voice and pulmonary rehabilitation. SLT rehabilitation, assessment, information and support enables psycho-social adjustment to communication and swallowing changes throughout the cancer pathway, including pre-treatment information and prehabilitation e.g pre-radiotherapy swallowing exercises.

Aims of intervention

The specific aims of intervention vary with the location of the cancer and the nature and extent of treatment, and the SLTs will work with an individual and their family as required, including determining their goals for SLT input. This period may be from the individual’s referral to end of life; the SLT role includes palliative care such as providing support with quality of life decisions regarding eating and drinking whilst accepting risk of aspiration.

The SLT aims to complete a full assessment of communication, including an assessment of body structure/function and use of communication. SLTs assess the oro-motor and laryngeal motor function, language abilities (both receptive and expressive), sensory abilities (both auditory and visual), speech fluency, voice, cognition including insight and awareness, and para-linguistic abilities (NACT, 2009). SLT swallowing exercise programmes including mouth opening exercises are recommended for people having radiotherapy (NICE, 2016). Effective post-treatment swallowing interventions may be optimised with behavioural change strategies such as practical social support, behavioural practice, self-monitoring of behaviour and a skilled clinician delivering the intervention (Govender et al, 2017). Voice therapy should be considered for those whose voice has changed because of treatment (NICE, 2016). SLTs facilitate different methods of communication post-laryngectomy including mouthing, pseudo voice, gesture, facial expression, oesophageal voice, use of electrolarynx and surgical voice restoration (RCSLT, 2023).

See also Voice, Dysphagia.

Resources for SLTs

Outcome measures

Patient-reported outcome measures (PROMS) and clinician-reported outcomes measures for speech, voice and swallow should be collected at regular time intervals (e.g. at baseline, 3-6 months post-treatment and 6-12 months post-treatment) and stored in an appropriate system in line with information governance standards (Goff et al, to be published).  PROMS inform treatment consequences e.g. swallowing related quality of life measures, that cannot be captured by objective clinician measures alone (Manduchi et al, 2022).

Please note, this list of SLT head and neck outcome measures is not exhaustive, not specifically for head and neck cancer patients and it is up to the clinician to weigh up the validity and clinical utility of these for their own practice:

• Voice – GRBAS (Hirano et al, 1991), Voice Handicap Index (Jacobson et al, 1997)
• Communication – Speech Handicap Index (Rinkel et al, 2008), PSS (Understandability of Speech, List et al, 1996)
• Dysphagia – Functional Oral Intake Scale (Crary et al, 2005), PSS (Normalcy of Diet, Eating in Public, List et al, 1996), 100ml Water Swallow Test (Patterson et al, 2011), MDADI (Chen et al, 2001), Swallowing Quality-of-Life Questionnaire (McHorney et al, 2002), EAT-10 (Belafsky et al, 2008, Sinn et al, 2020)
• Instrumental assessment – DIGEST (Hutcheson, 2017), Patterson Oedema Scale (Starmer et al, 2021), Penetration Aspiration Scale (Rosenbek, 1996), New Zealand Secretion Scale (Miles et al, 2019, Miles et al, 2018), Yale Residue Scale (Neubauer, 2015), Modified Barium Swallow Impairment Profile (MBSImP, Martin-Harris et al, 2008)
• Laryngectomy – Self-Evaluation of Communication Experiences after Laryngeal Cancer (Blood et al, 1993), Sunderland Tracheoesophageal Voice Perceptual Scale (Hurren et al, 2019), Swallowing Outcomes after Laryngectomy (Govender et al, 2016, Govender et al, 2012), Voice Prosthesis Questionnaire (Kazi et al, 2005 and 2006) and Robillard Schultz-Harrison Tracheoesophageal Puncture Rating Scale (Shultz and Harrison, 1992).
• Mouth opening – Maximum Interincisor Opening (mm).

In addition, a number of the TOMS rating scales (Enderby et al, 2013) will be relevant to SLT head and neck cancer outcomes (Crouch, 2014).

Please contact the multicentre Head and Neck Outcome Measures project group via the Head and Neck CEN basecamp if you are interested in participating in national data collection projects.

Service development

The main threats to UK head and neck SLT clinical services include increased patient complexity, delayed diagnosis and reduced access to instrumental procedures and inequitable care provision as a result of disruption to services during the COVID-19 pandemic (Patterson et al, 2020). 63% of patients are now diagnosed with T3 or T4 advanced disease (Cancer Research UK, 2022) which makes treatment more likely to be more extensive or multi-modality and result in poorer functional outcomes for swallowing and communication, requiring more SLT resources and input. However, opportunities include potential for new models of delivery (such as telehealth if suitable), SLT-led community care models, developing patient-led care, collaborative research and broader MDT working, service innovation and extended practice roles for SLTs. A pilot study of an extended SLT role of practice in an ENT SLT-led Two Week Wait clinic for suspected head and neck cancer demonstrated excellent records for cancer screening (Slade and McGlashan, 2019).

Head and neck SLT services work collaboratively with other members of the head and neck MDT. Reid et al (2019)’s project on implementing coordinated care for head and neck patients to receive both dietetic and speech and language therapy intervention during radiotherapy demonstrated benefits to the individual and service in terms of reduced length of stay, recovery from treatment and reduced weight loss. There should be clear pathways for access and re-referral to SLT with excellent communication between central and locality-based services with a robust training and supervision programme for specialist knowledge and skill development and maintenance (Goff et al, to be published, Hancock et al, 2020).

McLachlan et al (2021)’s three-year service evaluation of laryngectomy valve usage in a UK regional head and neck cancer unit is a useful resource for service planning, outlining costing, staff resources and a model of service delivery. Wilson et al (2022) discuss implementation of an MDT enhanced recovery programme for patients undergoing laryngectomy to improve consistency of patient care. The RCSLT resources on service planning and improvement are recommended, including the Resource Manual for Commissioning and Planning Services for SLCN (RCSLT, 2009). Macmillan have developed a Cancer Rehabilitation Service Improvement Tool (Macmillan, 2018).

Research

There are multiple ways for SLTs working in head & neck to participate in research activities. Currently, there are a number of SLTs who are chief or co-investigators on NIHR portfolio studies, including multidisciplinary, multi centre and single centre clinical trials.  Examples of these include: PATHOS (Odawally et al, 2015); DARS (Petkar et al, 2016); and SIP SMART (Govender et al, 2020b).  More information about these and other studies can be found online at: www.isrctn.com, https://public-odp.nihr.ac.uk.

Several SLTs have also been recipients of individual fellowships available from funders such as NIHR, Wellcome Trust and other charities. These fellowships allow for individuals to progress from research internship level to post-doctoral awards.  It is also possible for individuals to participate in others’ studies by delivering interventions or collecting outcomes.  Involvement of SLTs in clinical research drives improvements in patient care and should be a core part of our services.  Dedicated time for research is therefore encouraged and seeking funding may facilitate this. See RCSLT research pages.

Innovations

The Covid-19 pandemic has highlighted the rapid changes that can be made in progressing patient care through service innovation.  Examples of these include: delivery of care via telehealth, domiciliary care for people after laryngectomy, and the use of non-aerosol generating procedures such as ultrasound in the assessment of swallowing and voice.  Post-pandemic, the challenges facing the NHS have also called for innovations in practice, for example use of SLT-led ENT clinics in the two weeks wait cancer pathway.

Alongside innovations, methods for developing new services include the use of co-production (e.g. Point of Care Foundation), Quality Improvement (e.g. Institute for Healthcare Improvement), and audit. These methods may expedite implementation of innovations at site level.  SLTs are encouraged to use reliable data and process-mapping to inform and evaluate the development of local innovations.

Developments in head and neck cancer SLT interventions

Patterson and Lawton (2023) is recommended for a review of dysphagia advances in head and neck cancer. The following is a list of some recent developments within SLT interventions for

• Expiratory Muscle Strength Training (EMST, Hutcheson et al, 2018).
• Biofeedback devices g. surface electromyography (sEMG) with mobile app (Constantinescu et al, 2021), sEMG feedback (Cuicci et al, 2016), Iowa Oral Performance Instrument (IOPI, Lazarus et al, 2014).
• Cognitive-behavioural therapy combined with swallowing therapy (Patterson et al, 2018).
• The McNeil Dysphagia Program (bolus driven therapy, Crary et al, 2012).
• Manual therapy (Hutcheson et al, 2021, Krisciunas et al, 2019, Krisciunas, et al 2016).
• MD Anderson’s ‘Swallow Boot camp’ approach (Malandraki and Hutcheson, 2018).
• Pharyngocise (Carnaby-Mann et al, 2012).
• Prehabilitation (Govender et al, 2020b, Baudelet et al, 2020, Guillen-Sola, 2019, Hajdú, 2019) including virtual coaching (Starmer et al, 2022) and use of apps (Baudelet, 2022, Constantinescu, 2021).
• Respiratory-swallow training (Martin Harris et al, 2015).
• Voice banking – pretreatment voice banking is becoming increasingly available and should be considered where the person’s voice may be affected by treatment (such as for total laryngectomy or glossectomy patients). The Mouth Cancer Foundation is funding voice banking for people in the UK at risk of losing their voice through head and neck through their Saving Voices

In addition, there may be future changes to head and neck cancer treatments (with implications for effects on swallowing and communication) as the outcomes of current national and international research trials are analysed. These include Intensity Modulated Radiotherapy (IMRT) or dysphagia optimised IMRT, including the Dysphagia-Aspiration Related Structures (DARS) trial, Intensity Modulated Proton Therapy (IMPT) or de-escalation of post-operative adjuvant chemoradiotherapy for oropharyngeal cancer (Goff et al, to be published).

RCSLT Laryngectomy resources

Laryngectomy position paper

The laryngectomy position paper sets out the role of SLTs working in this clinical area and encompasses the following: background and evidence base, training and competencies, procedure and interpretation, health and safety, types of clinics, medico-legal aspects, patient populations and documentation.

Download the Laryngectomy Position Paper (2023) (PDF)

Laryngectomy competency framework

The laryngectomy competency framework reflects guiding principles in laryngectomy care, to ensure safe and best practice for SLTs working in the UK. The competency framework is for practising SLTs. It has been commissioned and written by the RCSLT and is for the use of the SLT profession only. This document does not address training or competency requirements for non-SLT professionals. It is aimed at qualified SLTs adhering to the HCPC guidelines, working with people with laryngectomy within a head and neck cancer caseload and with access to suitable clinical supervision.

Download the Laryngectomy Competency Framework (PDF)

Download the Laryngectomy Competency Framework (Word)

References

• Allen, J., Greene, M., Sabido, I., Stretton, M. and Miles, A. (2020). Economic costs of dysphagia among hospitalised patients. Laryngoscope, 130 (4), 974-979.
• Baijens, L., Walshe, M., Aalonen, L., Arens, C., Cordier, R., Cras, P., Crevier-Buchman, L., Curtis, C., Golusinski, W., Govender R., Eiksen,J., Hansen, K., Heathcote, K., Hess, M., Hosal, S., Klussman, J., Leemans, C., MacCarthy, D., Manduchi, B., Marie, J-P., Nouraei, R., Parkes, C., Pflug, C., Pilz, W., Regan, J., Rommel, N., Schindler, A., Schols, A., Speyer, R., Succo, G., Wessel, I., Willemsen, A., Yilmas, T. and Clave P. (2020). European White Paper: Oropharyngeal dysphagia in head and neck cancer. European Archives of Oto-Rhino-Laryngology, 278, 577-616.
• Baudelet, M., Van den Steen, L. Duprez, F., De Bodt, M., Deschuymer, S., Goeleven, A., Hutsebaut, I., Mariën, S., Meersschout, S., Nevens, D., Nuyts, S., Peeters, M., Specenier, P., Van den Brekel, M., van der Molen, L., Vandenbruaene, C., Vanderveken, O., Van Dinther, J., Van Laer, C., Vauterin, T., Verstraete, H., Van Nuffelen, G. and Member of the Belgian PRESTO Group (2020). Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head and neck cancer patients treated with (chemo) radiotherapy (PRESTO) trial. Trials 21 (1), 237.
• Baudelet M, Duprez F, Van den Steen L, Nuyts S, Nevens D, Goeleven A, Vandenbruaene C, Massonet H, Vergauwen A, Bollen H, Deschuymer S. (2022). Increasing adherence to prophylactic swallowing exercises during head and neck radiotherapy: the multicenter, randomized controlled PRESTO-Trial. Dysphagia, 19:1–10
• Baumgartner, C., Bewyer, E. and Bruner, D. (2008). Management of communication and swallowing in intensive care: the role of the speech pathologist. AACN Advanced Critical Care, 19(4), 433-443.
• Belafsky, P., Mouadeb, D., Rees, C., Pryor, J., Postma, G., Allen, J., Leonard, R. (2008). Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol., 117(12):919-24.
• Bergman M, Fountoukidis G, Smith D, Ahlgren J, Lambe M, Valachis A (2022) Effect of Smoking on Treatment Efficacy and Toxicity in Patients with Cancer: A Systematic Review and Meta-Analysis. Cancers. 14(17):4117.
• Bhabra, M. and Sparks, F. (2022). Exploring research impact; why it matters? Current Opinion in Otolaryngology and Head and Neck Surgery, 30 (3), 188.
• Blood, G (1993). Development and assessment of a scale addressing communication needs of patients with laryngectomies. American Journal of Speech and Language Pathology, 2(3), 82-90.
• Bravi, F., Lee, Y., Hashibe, M., Boffetta, P., Conway, D., Ferraroni, M., La Vecchia, C. and Edefonti, V. (2021). INHANCE Consortium investigators. Lessons learned from the INHANCE consortium: An overview of recent results on head and neck cancer. Oral Dis. 27(1), 73-93.
• British Association of Head and Neck Oncologists (2020). BAHNO Standards 2020.
• Caini, S., Del Riccio, M., Vettori, V., D’Ecclesiis, O., Bonomo, P., Locatello, L., Salvestrini, V., Gallo, O., Tagliabue, M., Raimondi, S., Saieva, C., Cozzolino, F., Bendinelli, B. and Gandini, S. (2022). Post-diagnosis smoking cessation and survival of patients with head and neck cancer: a systematic review and meta-analysis. Br J Cancer 127, 1907–1915.
• Cancer Research UK (2015). Achieving World Class Cancer Outcomes: A strategy for England 2015-2020.
• Cancer Research UK (2020). Cancer in the UK 2020: Socioeconomic deprivation.
• Cancer Research UK (). Head and Neck Cancers Incidence Statistics.
• Cancer Research UK (2021b). Creating time for Research.
• Cancer Research UK (2022) Early Diagnosis Data Hub.
• Carding, P., Jones, S., Morton, V., Robinson, F., Slade, S. and Wells, C. (2008). Speech and language therapy endoscopy for voice disordered patients. RCSLT Position Paper. London: Royal College of Speech and Language Therapists.
• Crouch, H. (2014). Tangible feedback using therapy outcome measures. RCSLT Bulletin, October, issue 750, pp 16-17.
• Carnaby-Mann, G., Crary, M., Schmalfuss, I. and Andur, R. (2012). “Pharyngocise”: randomised controlled trial of preventative exercises to maintain muscle structure and swallowing function during head and neck chemoradiotherapy. Int J Radiat Oncol Biol Phys, 83, 210-219.
• Chen, A., Frankowski, R., Bishop-Leone, J., Hebert, T., Leyk, S., Lewin, J and Goepfert, H. (2001). The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia inventory. Arch Otolaryngol Head Neck Surg, 127(7), 870-6.
• Clarke, P., Radford, K., Coffey, M. and Stewart, M. (2016). Speech and swallow rehabilitation in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. Journal of Laryngology and Otology, 130 (52), 176-180.
• Cocks, H. Ah-See, K., Capel, M. and Taylor, P. (2016). Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. Journal of Laryngology and Otology, 130 (S2), 198-207.
• Conway, D., Hashibe, M., Boffetta, P., Wunsch-Filho, V., Muscat, J., La Vecchia, C. et al (2009) Enhancing epidemiological research on head and neck cancer: INHANCE- the International Head and Neck Cancer Epidemiology Consortium. Oral Oncology, 45, 743-746.
• Constantinescu, G., Rieger, J., Seikaly, H., Eurich, D. (2021). Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors. Am J Speech Lang Pathol., 30(6), 2465-2475.
• Crary, M., Mann, G., and Groher, M. (2005). Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil, 86(8), 1516-20.
• Crary, M. Carnaby, G., Lagorio, L., Carvajal, P. (2012) Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill dysphagia therapy program. Arch Phys Med Rehabil, 93, 1173-1178.
• Cuicci, M., Jones, C., Malandraki, G. and Hutcheson, K. (2016). Dysphagia practice in 2035: beyond fluorography, thickener and electrical stimulation. Semin Speech Lang, 37 (3), 201-18.
• Dai, Y, Li, C., Xie, Y., Liu, X., Zhang, J., Zhou, J., Pan, X. and Zang, S. (2014). Interventions for dysphagia in oesophageal cancer. Cochrane Database of Systematic Reviews, Issue 10. CD005048.
• Dal Maso L, Torelli N, Biancotto E, Di Maso M, Gini A, Franchin G, Levi F, La Vecchia C, Serraino D, Polesel J. (2015) Combined effect of tobacco smoking and alcohol drinking in the risk of head and neck cancers: a re-analysis of case-control studies using bi-dimensional spline models. Eur J Epidemiol., 31(4):385-93.
• Department of Health (2011). Improving Outcomes: A Strategy for Cancer.
• Department of Health (2011). Cancer prevention, treatment and care – service framework documents. 
• Department of Health (2014). Improving Outcomes: A Strategy for Cancer Fourth Annual Report.
• Department of Health (2022). A Cancer Strategy for Northern Ireland 2022-2032. 
• Dhull, A., Atri, R., Dhankhar, A., Chauhan, A. and Kaushal, V. (2018). Major risk factors in head and neck cancer: a retrospective analysis of 12-year experiences. World Journal of Oncology, 9 (3), 80-84.
• Elhalawani, H., Abdallah, S., Elgohari, B., Lin, T., Sikora, A., Lai, S., Abusaif, A., Phan, J., Morrison, W., Brandon Gunn, G., Rosenthal, D., Garden, A., Fuller, C. and Sandulache, V. (2020). Tobacco exposure as a major modifier of oncologic outcomes in human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma. BMC Cancer, 20, 912-924.
• Enderby, P., John, A. and Petheram, B. (2013). Therapy Outcome Measures for Rehabilitation Professionals: Speech and Language Therapy, Physiotherapy, Occupational Therapy, 2^nd Edition. Oxford: Wiley.
• European Society for Clinical Nutrition and Metabolism (2021). ESPEN guideline on hospital nutrition. Clinical Nutrition, 40 (12).
• Fedele, S., Barber, J., Roe, J., Mercadente, V., Hagan, D., Kalavrezos, N., Kanabus, A., Lee, M., Shah, B., Brew-Graves, C., Williams, N., Shaw, R., Porter, S. and Jones, T.  (2017). Pentoxlfylline and Tocopherol for the treatment of poST radiotherapy fibrosis in head and neck cancer Patients: a feasibility study (PIT-STOP).
• Fox, L. & Rau, M. (2001). Augmentative and alternative communication for adults following glossectomy and laryngeal surgery. Augmentative and Alternative Communication, 17(3), 161-165.
• Furness, S., Bryan, G., McMillan, R. and Worthington, H. (2013). Interventions for the management of dry mouth: non-pharmacological interventions. Cochrane Database of Systematic Reviews, Issue 9. CD009603.
• Gamondi, C., Larkin, P. and Payne, A. (2013). Core competencies in palliative care: An EACP white paper on palliative care education – Part 1 Palliative and End of Life Care. Competency Assessment Tool. European Journal of Palliative Care, 20 (2), pp. 86-91.
• Goff, D., Coffey, M., Govender, R., Thornton, J., Roe, J., Brady, G., Clunie, G., Watson, L-J and Patterson, J. (awaiting publication). Speech, Voice and Swallowing Rehabilitation for Head and Neck Cancer, ENT UK guidelines.
• Govender, R., Lee, M., Davies, T., Twinn, C.,  Katsoulis, K., Payten, C., Stephens, R. and Drinnan, M. (2012). Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire). Clinical Otolaryngology, 37(6), 452-9.
• Govender, R., Lee, M., Drinnan, M., Davies, T., Twinn, C. and Hilari, K. (2016). Psychometric evaluation of the Swallowing Outcomes After Laryngectomy (SOAL) patient-reported outcome measure. Head Neck, 38 Suppl 1, E1639-45.
• Govender, R., Smith, C., Taylor, S., Barratt, H. and Gardner, B. (2017). Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises. BMC Cancer, 17(1), 43.
• Govender, R. (2020a). Pre-habilitation of swallowing difficulties in people with head and neck cancer: A pilot cluster randomized trial.
• Govender, R., Smith, C., Barratt, H., Gardner, B., Taylor, S. (2020b). SIP SMART: a parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer. BMC Cancer, 20 (1), 360.
• Government of Ireland (2017). National Cancer Strategy 2017-2026. Government of Ireland.
• Gupta, S., Gupta, R., Sinha, D. and Mehrota, R. (2018) Relationship between type of smokeless tobacco and risk of cancer: A systematic review. Indian Journal of Medical Research, 148, 56-76.
• Guillen-Sola, A. (2019). Effects of prophylactic swallowing exercises on dysphagia and quality of life in patients with head and neck cancer receiving (chemo) radiotherapy: the Redyor study, a protocol for a randomized clinical trial. Trials 20 (1-7), 503.
• Hajdú, S., Christensen, M., Kristensen, M., Wessel, I., Johansen, C. and Dalton, S. (2019). Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment. Acta Oncol., 58(5):658-664
• Hardman, J., Holsinger, F., Brady, G., Beharry, A., Bonifer, A., D’Andréa, G., Dabas, S., de Almeida, J., Duvvuri, U., Floros, P., Ghanem, T., Gorphe, P., Gross, N., Hamilton, D., Kurukulasuriya, C., Hjordt Holm Larsen, M., Lin, D., Scott Magnuson, Meulemans, J., Miles, B., Moore, E., Pantvaidya, G., Roof, S., Rubek, N., Simon, C., Subash, A., Topf, M., Van Abel, K., Vander Poorten, V. Walgama, E., Greenlay, E., Potts, L., Balaji, A., Starmer, H., Stephen, S., Roe, J., Harrington, K  and  Paleri, V.  (2022). Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An international Cohort Study. J Natl Cancer Inst, 114 (10), 1400-1409.
• Hartmann‐Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. (2016). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, Issue 9. CD010216.
• Hashibe, M., Brennan, P., Benhamou,  S., Castellsague, X., Chen, C., Curado, M., Dal Maso, L., Daudt, A., Fabianova, E., Fernandez, L., Wünsch-Filho, V., Franceschi, S., Hayes, R., Herrero, R., Koifman, S., La Vecchia, C., Lazarus, P., Levi, F., Mates, D., Matos, E., Menezes, A., Muscat, J., Eluf-Neto, J., Olshan, A., Rudnai, P., Schwartz, S., Smith, E., Sturgis, E., Szeszenia-Dabrowska, N., Talamini, R., Wei, Q., Winn, D., Zaridze, D., Zatonski, W., Zhang, Z., Berthiller, J. and Boffetta, P (2007)  Alcohol drinking in never users of tobacco, cigarette smoking in never drinkers, and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. J Natl Cancer Inst. 16;99(10), 777-89.
• Hashibe, M., Brennan, P., Chuang, S., Boccia, S., Castellsague, X., Chen, C., Curado, M., Dal Maso, L., Daudt, A., Fabianova, E., Fernandez, L., Wünsch-Filho, V., Franceschi, S., Hayes, R., Herrero, R., Kelsey, K., Koifman, S., La Vecchia, C., Lazarus, P., Levi, F., Lence, J., Mates, D., Matos, E., Menezes, A., McClean, M., Muscat, J., Eluf-Neto, J., Olshan, A., Purdue, M., Rudnai, P., Schwartz, S., Smith, E., Sturgis, E., Szeszenia-Dabrowska, N., Talamini, R., Wei, Q., Winn, D., Shangina, O., Pilarska, A., Zhang, Z., Ferro, G., Berthiller, J. and Boffetta, P.  (2009) Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiological Biomarkers Prev., 18(2), 541-550.
• Hashim, D., Sartori, S., Brennan, P., Curado, M., Wunsch-Filho, V., Divaris, K., … Boffetta, P. (2016). The role of oral hygiene in head and neck cancer: results from International Head and Neck Cancer Epidemiology (INHANCE) consortium. Ann Oncol, 27(8), 1619–1625.
• Hashim D, Genden E, Posner M, Hashibe M, Boffetta P. (2019). Head and neck cancer prevention: from primary prevention to impact of clinicians on reducing burden. Ann Oncol. 2019 May 1;30(5), 744-756.
• Hall, A., Krombout, H., Schuz, J., Peters, S. et al (2020) Laryngeal cancer risks in workers exposed to lung carcinogens: exposure-effect analysis using a quantitative job exposure matrix. 31 (1), 145-154.
• Hancock, K., Ward, E. and Hill, A. (2020). Factors contributing to clinician training and development in the clinical area of laryngectomy and tracheoesophageal voice. International journal of language and communication disorders, 55 (5), 690-701
• Health Education England (HEE) (2017). The NHS Cancer Workforce Plan.
• Health Education England (2017). Multi-professional framework for advanced clinical practice in England.
• Healthcare Improvement Scotland (2021). Head and Neck Cancer Clinical Quality Performance Indicators.
• Hirano, M. (1991) Clinical Examination of Voice. New York, Springer Verlag.
• Huang, S., Xu, W., Waldron, J., Siu, L., Shen, X., Tong, L., Ringash, J., Bayley, A., Kim, J., Hope, A., Cho, J., Giuliani, M., Hansen, A., Irish, J., Gilbert, R., Gullane, P., Perez-Ordonez, B., Weinreb, I., Liu, F., O’Sullivan, B. (2015). Refining American joint committee on cancer/ union for international cancer control TNM stage and prognostic groups for human papillomavirus-related oropharyngeal carcinomas. Journal of Clinical Oncology, 33, 836-845.
• Hurren, A., Miller, N. and Carding, P. (2019). Perceptual Assessment of Tracheoesophageal Voice Quality With the SToPS: The Development of a Reliable and Valid Tool. J Voice, 33(4), 465-472.
• Hutcheson, K., Lewin, J., Barringer, D., Lisec, A, Gunn, G., Moore, M. and Holsinger, F. (2012). Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer, 118 (23), 5793-5799.
• Hutcheson, K., Yuk, M., Holsinger, Brandon Gunn, F. and Lewin, S. (2015) Late radiation-associated dysphagia with lower cranial neuropathy in long-term oropharyngeal dysphagia cancer survivors: video case reports. Head Neck, 37 (4), E56-62.
• Hutcheson, K., Barrow, M., Barringer, D., Knott, J., Lin, H., Weber, R., Fuller, C., Lai, S., Alvarez, C., Raut, J., Lazarus, C., May, A., Patterson, J., Roe, J., Starmer, H. and Lewin, L. (2017). Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Scale development and validation. Cancer, 123(1), 62-70.
• Hutcheson, K., Barrow, M., Plowman, E., Lai, S., David Fuller, Barringer, D., Eapen, G., Wang, Y., Hubbard, R., Jimenez, S., Little, L. and Lewin, J. (2018). Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: a case series. Laryngoscope, 128, 1044-1051.
• Hutcheson, K., McMillan, H., Warneke, C., Porsche, C., Savage, K., Buoy, S., Wang, J., Woodman, K., Lai, S. and Fuller C. (2021). Manual therapy for fibrosis-related late effect dysphagia in head and neck cancer survivors: the pilot MANTLE trial. BMJ Open, 11(8):1–13.
• Intensive Care Society (2018). Allied Health Professionals: Critical Care Professional Development Framework. London: The Faculty of Intensive Care Medicine.
• Intensive Care Society (2021). The Speech and Language Therapy Pillar: A supplementary resource of the Allied Health Professionals (AHP) Critical Care Professional Development Framework (CCPDF). London: The Faculty of Intensive Care Medicine.
• Jacobson, B., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, G., Benninger, M. and Newman, C. (1997). The Voice Handicap Index (VHI). American Journal of Speech-Language Pathology, 6(3), 66-70.
• Jefford, M., Howell, D., Li, Q., Lisy, K., Maher, J., Alfano, C., Rynderman, M. and Emery, J. (2022). Improved models of care for cancer survivors. Lancet, 399, 1551-60.
• Kazi R, Singh A, De Cordova J, Clarke P, Harrington K, Rhys-Evans P. (2005) A new self-administered questionnaire to determine patient experience with voice prostheses. J Postgrad Med, 51, 253-8.
• Kazi, R., Singh, A., De Cordova, J., Al-Mutairy, A., Clarke, P., Nutting, C., Rhys-Evans, P. and Harrington, K. (2006). Validation of a voice prosthesis questionnaire to assess valved speech and its related issues in patients following total laryngectomy. Clinical Otolaryngology, 31 (5), 404-410.
• Koo, H., Kyungdo, H., Shin, D., Yoo, J., Cho, M., Jeon, K., Kim, D., Hong, S. and Jun, J. (2021) Alcohol drinking pattern and risk of head and neck cancer: a nationwide cohort study. International Journal of Environmental Research and Public Health, 18 (21), 11204.
• Krisciunas, G., Golan, H., Marinko, L., Pearson, W., Jalisi, S. and Langmore S. (2016). A novel manual therapy programme during radiation therapy for head and neck cancer–our clinical experience with five patients. Clin Otolaryngol, 4, 425–31.
• Krisciunas, G., Vakharia, A., Lazarus, C., Taborda, S., Martino, R., Hutcheson, K., McCulloch, T. and Langmore, S. (2019). Application of manual therapy for dysphagia in head and neck cancer patients: a preliminary national survey of treatment trends and adverse events. Global advances in health and medicine, 11, 1–13.
• Lazarus, C., Husaini, H., Falciglia, D., DeLacure, M., Branski, R., Kraus, D., Lee, N., Ho, M., Ganz, C., Smith, B., Sanfilippo, N. (2014). Effects of exercise on swallowing and tongue strength in patients with oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. Int J Oral Maxillofac Surg, 43, 523-530.
• Lee, R, Salesky, M., Benjamin, T., El-Sayed I., George, J., Ha, P., Ryan, W. and Heaton, C. (2022) Impact of Smoking and Primary Tumor Subsite on Recurrence in HPV-Associated Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg., 166(4):704-711.
• List, M., D’Antonio, L., Cella, D., Siston, A., Mumby, P., Haraf, D. and Vokes, E. (1996). The Performance Status Scale for Head and Neck Cancer Patients and the Functional Assessment of Cancer Therapy-Head and Neck Scale. A study of utility and validity. Cancer, 77(11), 2294-301.
• Logemann, J., Pauloski, B., Rademaker, A. and Colangelo, L.  (1997). Speech and swallowing rehabilitation for head and neck cancer patients, Oncology, 11(5), 651.
• Maasland, D., van den Brandt, P., Kremer, B., Goldbohm, R. and Schouten, L. (2014). Alcohol consumption, cigarette smoking and the risk of subtypes of head-neck cancer – results from the Netherlands cohort study. BMC Cancer, 14, 187.
• Macmillan (2017, updated Dec 2020) Macmillan Allied Health Professions Competency Framework.
• Macmillan (2017). The Rich Picture: People living with head and neck cancer. Understanding the numbers, needs and experiences of people affected by cancer.
• Macmillan Cancer Support (2018). Cancer Rehabilitation Service Improvement Tool: Service Provider version.
• Macmillan Cancer Support (2019). Prehabilitation principles and guidance for people with cancer’.
• Macmillan (2020). Cancer Rehabilitation Pathways Guidance.
• Malagelada, J., Bazzoli, F., Boeckxstaens, G., De Looze, D., Fried, M., Kahrilas, P., Lindberg, G., Malfertheiner, P., Salis, G., Sharma, P., Sifrim, D., Vakil, N. and Le Mair, A. (2015). World gastroenterology organisation global guidelines: dysphagia-global guidelines and cascades update September 2014. J Clin Gastroenterol. 49(5), 370-8.
• Malandraki, G. and Hutcheson, K. (2018). Intensive Therapies for Dysphagia: Implementation of the Intensive Dysphagia Rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3 (3), 133-145.
• Marmot, M., Allen. J., Goldblatt, P., Herd, E. and Morrison, J. (2020) Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London, Institute of Health Equity.
• Marron, M., Boffetta, P., Zhang, Z., Zaridze, A. Wunsch-Filho, V. Winn, D., Wei, Q., Talamini, R., Szeszenia-Dabrowska, N., Sturgis, E., Smith, E., Schwartz, S., Rudnai, P., Purdue, M., Olshan, A., Eluf-Neto, J., Muscat, J., Morgenstern, H., Menezes, A., McClean, M., Matos, E., Mates, N., Lissowska, J., Levi, F., Lazarus, P., La Vecchia, C., Koifman, S., Kelsey, K., Herrero, R., Hayes, R., Franceschi, S., Fernandez, L., Fabianova, E., Daudt, A., Dal Maso, L., Curado, M., Cadoni, G., Chen, C., Castellsague, X., Boccia, S., Benhamou, S., Ferro, G., Berthiller, J., Brennan, P., Møller, H. and Hashibe M. (2010) Cessation of alcohol drinking, tobacco smoking and the reversal of head and neck cancer risk. International Journal of Epidemiology, 39, 182-196.
• Martin-Harris, B., Brodsky, M., Michel, Y., Castell, D., Schleicher, M., Sandidge, J., Maxwell, R., Blair, J. (2008). MBS measurement tool for swallow impairment–MBSImP: establishing a standard. Dysphagia, 23(4):392-405.
• Martin-Harris B, McFarland D, Hill EG, Strange CB, Focht KL, Wan Z, Blair J, McGrattan K. (2015). Respiratory-swallow training in patients with head and neck cancer. Arch Phys Med Rehabil., 96(5):885–93.
• Martino, R., Ringash, J., Durkin, L., Greco, E., Huang, S., Xu, W. and Longo, C. (2017). Feasibility of assessing patient health benefits and incurred costs resulting from early dysphagia intervention during and immediately after chemoradiotherapy for head-and-neck cancer. Curr Oncol. 24(6), 466-476.
• Martino, R., Fitch, M., Fuller, C., Hope, A., Krisciunas, G., Langmore, S., Lazarus, C., Macdonald, C., McCulloch, T., Mills, G., Palma, D., Pytynia, K., Ringash, J., Sultanem, K., Theurer, J., Thorpe, K. and Hutcheson K. (2021). The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer. BMC Cancer, 21, 1100.
• McHorney, C., Robbins, J., Lomax, K., Rosenbek, J., Chignell, K., Kramer, A., Bricker, D. (2002). The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity. Dysphagia, 17(2), 97-114.
• McLachlan, K., Hurren, A., Owen, S. and Miller, N. (2021). Informing patient choice and service planning in surgical voice restoration: valve usage over three years in a UK head and neck cancer unit. Journal of Laryngology and Otology, 136, 158-166.
• Mehanna, H., Rattay, T., Smith, J. and McConkey, C. (2009) Treatment and follow-up of oral dysplasia – a systematic review and meta-analysis. Head Neck, 31, 1600–9.
• Mehanna, H., Paleri, V., West, C and Nutting, C. (2010a). Head and neck cancer- Part 1: epidemiology, presentation, and prevention. BMJ, 341, 663-666.
• Mehanna, H., West, C., Nutting, C. and Paleri, V. (2010b). Head and neck cancer- Part 2: Treatment and Prognostic Factors. BMJ, 341, c4690.
• Mehanna, H., Beech, T., Nicholsohn, T, El-Hariry, I, McConkey, C., Paleri, V. et al (2013) Prevalence of human papillomavirus in oropharyngeal and non-oropharyngeal head and neck cancer – systematic review and meta- analysis of trends by time and region. Head Neck, 35, 747-755.
• Mehenna, H., Evans, M., Beasley, N., Chatterjee, S., Dilkes, M., Homer, J., O’Hara, J., Robinson, M., Shaw, R. and Sloan, P. (2016). Oropharyngeal cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol., 130(S2): S90-S96.
• Miles, A., Hunting, A., McFarlane, M., Caddy, D. and Scott, S. (2018). Predictive Value of the New Zealand Secretion Scale (NZSS) for Pneumonia. Dysphagia, 33(1), 115-122.
• Miles, A. and A. Hunting (2019). Development, intra- and inter-rater reliability of the New Zealand Secretion Scale (NZSS). Int J Speech Lang Pathol, 21(4), 377-384.
• National Cancer Action Team (2009a). Supporting and Improving Commissioning of Cancer Rehabilitation Services. London, NCAT.
• National Cancer Action Team (2009b). Cancer and Palliative Care Rehabilitation Workforce Project: A Review of the Evidence. London, NCAT.
• National Cancer Peer Review (2008). National Cancer Action Team. Programme Manual for Cancer Services 2008: Head and Neck Measures (1-15). London, NCAT.
• National Cancer Registry Ireland (2019a). Cancer in Ireland 1994-2017 with estimates for 2017-2019: Annual report of the National Cancer Registry 2019 Annual Report.
• National Cancer Registry Ireland (2019b). National Cancer Survivorship Needs Assessment: The Unmet Needs of Cancer Survivors in Ireland: A Scoping Review 2019.
• National Cancer Survivorship Initiative (2013) Living with and beyond cancer: taking action to improve outcomes.
• National Comprehensive Cancer Network (2022). Head and Neck Cancer Guidelines.
• Nayak, S., Sharan, K., Chakrabarty, J., Devi, E., Ravishankar, N. and George, A. (2022). Psychosocial Distress of Head Neck Cancer (HNC) Patients Receiving Radiotherapy: A Systematic Review. Asian Pac J Cancer Prev. 23(6), 1827-1835
• NHS England (2013). 2013/14 NHS Standard Contract for Cancer: Head and Neck (Adult).
• NHS England (2014). Five Year Forward View.
• NHS England (2016). Achieving World-Class Cancer Outcomes: Taking the strategy forward.
• NHS England (2017). Delivering World-Class Cancer Outcomes: Guidance for Cancer Alliances and the National Cancer Vanguard.
• NHS England (2018). Quick guide: The role of allied health professionals in supporting people to live well with and beyond cancer.
• NHS Wales Health Collaborative (2019). National Optimal Pathway for Head and Neck Mucosal: Point of suspicion to First Definitive Treatment in Adults (aged 16 and over).
• NHS Wales Health Collaborative (2021). NHS Wales Health Collaborative Annual Report 2020/21.
• National Institute for Health and Care Excellence (2021). Tobacco: preventing uptake, promoting quitting and treating dependence. NICE guideline [NG209].
• National Institute for Health and Care Excellence (2011). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. Clinical guideline [CG115].
• National Palliative and End of Life Care Partnership (2021). Ambitions for Palliative and End of Life Care: A national framework for local action 2021-2026.
• Neubauer, P., Rademaker, A., and Leder, S. (2015). The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool. Dysphagia, 30(5), 521-8.
• NHS England (2016a). Commissioning Guidance for Rehabilitation.
• NHS England (2016b). Achieving world-class cancer outcomes: a strategy for England 2015-2020.
• NHS England (2019). The NHS Long Term Plan.
• Northern Ireland Assembly (2017). Cancer: Northern Ireland.
• Nugent, B., Lewis, S. and O’Sullivan, J. (2013). Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Cochrane Database of Systematic Reviews, Issue 1. CD007904.
• Owadally, W., Hurt, C., Timmins, H., Parsons, E., Townsend, S., Patterson, J., Hutcheson, K., Powell, N., Beasley, M., Palaniappan, N., Robinson, M., Jones, T., Evans, M. (2015). PATHOS: a phase II/III trial of risk-stratified, reduced intensity adjuvant treatment in patients undergoing transoral surgery for Human papillomavirus (HPV) positive oropharyngeal cancer. BMC Cancer, 15 (10), 602.
• Oral Health Foundation (2022). State of Mouth Cancer UK Report 2022.
• Orlandi, E., Alfieri, S., Simon, C., Trama, A., Licitra, L. and RARECAREnet Working Group (2019). Treatment challenges in and outside a network setting: head and neck cancers. European Journal of Surgical Oncology, 45, 40-45.
• Paleri, V. and Roland, N. (2016). Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines. Journal of Laryngology and Otology, 130 (Suppl S2).
• Paleri, V. (2019). The MOSES study: Evaluation of the role of tongue base MucOsectomy and Step sErial Sectioning in the management of the unknown primary squamous cell carcinoma in the head and neck’.
• Paleri, V., Patterson, J., Kellar, I., Kavanagh, K., Rousseau, N., Bradley, P., Tikka, T., Elkington, C., Hardman, J., Kapoor, K., Emery, L., Mihaylova, B., Kerawala, C., Van der Meulen, J., Randell, R. and Hooper, R. (2022) Evolution of a patient-Reported symptom-based risk stratification system to redesign the suspected Head and Neck cancer referral pathway (EVEREST-HN).
• Parakh, M., Ulaganambi, S. Ashifa, N., Premkumar, R and Jain, A. (2020) Oral potentially malignant disorders: clinical diagnosis and current screening aids: a narrative review. Eur J Cancer Prev 29. 65-72.
• Patterson, J., McColl, E., Carding, P., Kelly, C. and Wilson, J. (2009). Swallowing performance in patients with head and neck cancer: a simple clinical test. Oral Oncology. 45, 10, 904-907.
• Patterson, J., Hildreth, A., McColl, E., Carding, P., Hamilton, D and Wilson, J. (2011). The clinical application of the 100ml water swallow test in head and neck cancer. Oral Oncology, 47 (3), 180-184.
• Patterson, J., McColl, E., Carding, P., Hildreth, A., Kelly, C. and Wilson, J. (2013) Swallowing in the first year after chemotherapy for head and neck cancer: Clinician- and patient-reported measures. Head Neck, 36 (3), 352-358.
• Patterson, J., Fay, M., Exley, C., McColl, E., Breckons, M. and Deary, V. (2018). Feasibility and acceptability of combining cognitive behavioural therapy techniques with swallowing therapy in head and neck cancer dysphagia. BMC Cancer, 18(1), 1–1.
• Patterson, J., Govender, R., Roe, J., Clunie, G., Murphy, J., Brady, G., Haines, J., White, A. and Carding, P. (2020). COVID-19 and ENT SLT services, workforce and research in the UK: A discussion paper. International Journal of Language and Communication Disorders, 55 (5), 806-817.
• Patterson, J. and Lawton, M. (2023). Dysphagia Advances in Head and Neck Cancer. Current Otolaryngology Reports, Laryngology: Update on Dysphagia
• Penfold, C., Thomas, S., Waylen, A. and Ness, A. (2018) Change in alcohol and tobacco consumption after a diagnosis of head and neck cancer: findings from Head and Neck 5000. Head Neck. 40 (7), 1389-1399.
• Petkar, I., Rooney, K., Roe, J., Patterson, J., Bernstein, D., Tyler, J., Emson, M., Morden, J., Miles, E., Beasley, M., Roques, T., Bhide, S., Newbold, K., Harrington, K., Hall, E. and Nutting, C. (2016). DARS: a phase III randomised multicentre study of dysphagia -optimised intensity-modulated radiotherapy (Do-IMRT) versus standard intensity – modulated radiotherapy (S-IMRT) in head and neck cancer. BMC Cancer, 16, 770-780.
• Pezzuto, F., Buonaguro, L., Caponigro, F., Ionna, F., Starita, N., Annunziata, C., Buonaguro, F. and Tornesello, M. (2015). Update on head and neck cancer: current knowledge on epidemiology, risk factors, molecular features and novel therapies. Oncology, 89, 125-136.
• Price, J., Hall, E., West, C. and Thomson, D. (2020). TORPEdO – A Phase III Trial of Intensity-Modulated Proton Beam Therapy Versus Intensity-Modulated Radiotherapy for Multi-toxicity Reduction in Oropharyngeal Cancer. Clinical Oncology, 32 (2), 84-88.
• Public Health England (2016). National Cancer Registration and Analysis Service. Deprivation and cancer: in search of a common measure across England, Wales, Scotland, Northern Ireland and Ireland. Public Health England.
• Radford, K., Woods H, Lowe D. and Rogers, S. (2004). A UK multi-centre pilot study of speech and swallowing outcomes following head and neck cancer. Clinical Otolaryngology and Allied Sciences, 29, (4) 376-381.
• Reich, M., Leemans, C., Vermoken, J., Bernier, J., Licitra, L., Parmar, S., Golusinski, W. and Lefebvre, J. (2014). Best practices in the management of the psychooncologic aspects of head and neck cancer patients: recommendations from the European head and neck cancer society make sense campaign. Ann Oncol, 25, 2115-2124.
• Reid, K, Price, S., Dawson, C. and Duff, S. (2019). Improving the care of head and neck cancer patients with collaborative dietetics and speech and language therapy intervention NICE Shared Learning Database.
• Rinkel, R., Leemans, C., Vermorken, J., Bernier, J., Licitra, L., Parmar, S., Golusinski, W. and Lefebvre, J. (2008). Speech Handicap Index in patients with oral and pharyngeal cancer: better understanding of patients’ complaints. Head Neck, 30(7), 868-74.
• Rinkel, R. N., Verdonck-de Leeuw, I. M., Doornaert, P., Butler, J., de Bree, R., Langendijk, J. A., Aaronson, N. K. & Leemans, C. R. (2016). Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI. European Archives of Oto-Rhino-Laryngology, 273 (7), 1849-1855.
• Roe, J., Carding, P., Dwivedi, R., Kazi, R., Rhys-Evans, P., Harrington, K. and Nutting, C. (2010). Swallowing outcomes following intensity modulated radiation therapy (IMRT) for head & neck cancer: a systematic review. Oral Oncology, 46(10), 727-733.
• Rosenbek, J., Robbins, J., Roecker, E., Coyle, J. and Wood, J. (1996). A penetration-aspiration scale. Dysphagia, 11(2), 93-8.
• Royal College of Speech & Language Therapists (RCSLT) (1999). Guidelines for Endoscopic Evaluation of the Vocal Tract. London: Royal College of Speech and Language Therapists.
• Royal College of Speech & Language Therapists (RCSLT) (2006). Communicating Quality 3. London: Royal College of Speech and Language Therapists.
• Royal College of Speech and Language Therapists (2009). Resource Manual for Commissioning and Planning Services for SLCN. London: Royal College of Speech and Language Therapists.
• RCSLT (2020). RCSLT Clinical Guidance for the Management of Total Laryngectomy in the Context of the COVID-19 pandemic.
• Royal College of Speech and Language Therapists (2023). Laryngectomy Competency Framework. London: Royal College of Speech and Language Therapists.
• Russi, E., Corvò, R., Merlotti, A., Alterio, D., Franco, P., Pergolizzi, S., De Sanctis, V., Ruo Redda, M., Ricardi, U., Paiar, F., Bonomo, P., Merlano, M., Zurlo, V., Chiesa, F., Sanguineti, G. and Bernier, J. (2012). Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology. Cancer Treat Rev, 38(8), 1033-1049.
• Scottish Government (2008). Better Cancer, An Action Plan.
• Scottish Government (2016). Beating Cancer: Ambition and Action.
• Scottish Government (2021). Effective Cancer management: framework.
• Scottish Government (2021). National cancer plan: progress report – August 2022.
• Scottish Government (2021). Collaborative and Compassionate Cancer Care: cancer strategy for children and young people 2021-2026.
• Scottish Government (2022). Cancer workforce: clinical leadership guidance.
• Scottish Government (2022). National radiotherapy plan
• Scottish Government (2022). National cancer plan: progress report – August 2022.
• Semple, C., Sullivan, K., Dunwoody, L. and Kernohan, W. (2013). Psychosocial interventions for patients with head and neck cancer. Cochrane Database of Systematic Reviews, Issue 7. CD009441.
• Shaw, R. and Beasley, N. (2016) Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines. Journal of Laryngology and Otology, 130 (Suppl. S2), S9-S12.
• Shultz, J. and Harrison, J. (1992) Defining and predicting tracheoesophageal puncture success. Arch Otolaryngol Head Neck Surg 118, 811–816.
• Sinn, F., Charters, E., Stone, D., Janabi, M. and Bogaardt, H. (2020). Responsiveness of the EAT-10 to Clinical Change in Head and Neck Cancer Patients with Dysphagia. Int J Speech Lang Pathol. 22(1):78-85.
• Slade, S. and McGlashan, J. (2018). Can Speech and Language Therapists manage hoarse voice patients on the Two Week Wait Head and neck cancer referral pathway? [Poster] exhibited at European Laryngology Society meeting London.
• Stafford, N. (2016). Clinical research, national studies and grant applications: United Kingdom National Multidisciplinary Guidelines. Journal of Laryngology and Otology, 130, S216-S217.
• Starmer, H., Drinnan, M., Bhabra, M., Watson, L.J. and Patterson J. (2021). Development and reliability of the revised Patterson Edema Scale. Clinical Otolaryngology, 46(4), 752-757.
• Starmer, H., Klein, D., Montgomery, A., Goldsmith, T., McCarroll, L., Richmon, J., Christopher Holsinger, F., Beadle, B. and Jain, P. (2022). Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation. Dysphagia. 2022 Aug 12. doi: 10.1007/s00455-022-10506-5. Epub ahead of print.
• van der Molen, L., van Rossum, M., Burkhead, L., Smeele, L., Rasch, C. and Hilgers, F. (2011). A randomized preventive rehabilitation trial in advanced head and neck cancer patients treated with chemoradiotherapy: feasibility, compliance, and short-term effects. Dysphagia, 26 (2), 155-170.
• Verdonck-de Leeuw, I., Dawson, C., Licitra, L., Eriksen, J., Hosal, S., Singer, S., Laverty, D., Golusinski, W., Machczynski, P., Varges Gomes, A., Girvalaki, C., Simon, C. and Leemans CR (2022). European Head and Neck Society recommendations for head and neck cancer survivorship care. Oral Oncology, 133, 106047.
• von Kroge, P., Bokemeyer, F., Ghandili, S., Bokemeyer, C. and Seidel C. (2020). The Impact of Smoking Cessation and Continuation on Recurrence and Survival in Patients with Head and Neck Cancer: A Systematic Review of the Literature. Oncol Res Treat, 43(10), 549-558.
• Wagner, S., Wittekindt, C. Sharma, S., Wuerdemann, N., Juttner, T., Reuschenbach, M., Prigge, E-S., von Knebel Doeberitz, M., Gattenlohner, S., Burkardt, E., Pons-Kunemann, J and Klussman, J.  (2017). Human papillomavirus association is the most important predictor for surgically treated patients with oropharyngeal cancer. British Journal of Cancer, 116, 1604-1611.
• Weller, M., Nankivell, P., McConkey, C., Paleri, V. and Mehanna, H. (2010). The risk and interval to malignancy of patients with laryngeal dysplasia; a systematic review of case series and meta-analysis. Clin Otolaryngol, 35, 364–72.
• Welsh Assembly Government (2010). National Standards for Rehabilitation of Adult Cancer Patients.
• Welsh Government (2016). Cancer delivery plan for Wales 2016-2020.
• Welsh Government (2021). The quality standard for cancer.
• Welsh Government and Macmillan Cancer Support (2017). Wales Cancer Patient Experience Survey.
• Wilson, C., Tellez Freitas, C.M., Awan, K.H., Ajdaharian, J., Geiler, J., Thirucenthilvelan, P. (2022) Adverse effects of E-cigarettes on head, neck, and oral cells: A systematic review. J Oral Pathol Med, 51(2):113-125.
• Wilson, G., Nistor, M. and Beasley, N. (2022). The formulation of an enhanced recovery programme for patients undergoing laryngectomy. Journal of Laryngology and Otology, 136, 848-860.
• World Health Organisation (2004). The global burden of disease.
• World Health Organisation (2017). Artificial tanning devices: public health interventions to manage sunbeds.
• World Health Organisation (2020). WHO report on cancer: setting priorities, investing widely and providing care for all.
• Zhang, YB., Pan, XF., Chen, J., Cao, A., Zhang, Y., Xia, L., Wang, J., Li, H., Liu, G. and Pan, A. (2020). Combined lifestyle factors, incident cancer, and cancer mortality: a systematic review and meta-analysis of prospective cohort studies. Br J Cancer 122, 1085–1093.