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Head and Neck Cancer

Last updated 31 May 2026 · Oncology clinical guideline

📋 Key Information Summary

📋
  • Head and neck squamous cell carcinoma (HNSCC) accounts for ~90 % of head and neck malignancies in Australia, with approximately 5 100 new diagnoses annually (AIHW 2024).
  • HPV-16–driven oropharyngeal SCC is the fastest-growing subtype; these patients are younger (median age 55–60) and carry a significantly better prognosis (5-year OS 75–85 % vs 40–50 % for HPV-negative).
  • Tobacco and alcohol remain the dominant risk factors for non-oropharyngeal sites; risk rises multiplicatively with combined exposure.
  • TNM staging follows AJCC 8th edition; HPV-mediated oropharyngeal cancers use a separate staging system.
  • All newly diagnosed patients should be discussed at a multidisciplinary team (MDT) meeting before treatment.
  • Early-stage (I–II) disease is treated with single-modality therapy — surgery or definitive radiotherapy (RT) — both yielding equivalent outcomes for most subsites.
  • Locally advanced disease (III–IVB) requires combined-modality treatment: surgery + post-operative (chemo)RT, or definitive concurrent chemoradiation.
  • Standard concurrent radiosensitiser is cisplatin 100 mg/m² IV every 3 weeks × 3 cycles; cetuximab is an alternative for cisplatin-ineligible patients.
  • Recurrent/metastatic (R/M) disease: first-line platinum-based chemotherapy ± pembrolizumab; nivolumab or pembrolizumab monotherapy for platinum-refractory disease (PBS-listed).
  • Transoral robotic surgery (TORS) and de-escalated RT protocols are increasingly used for low-risk HPV-positive oropharyngeal SCC in select centres.
  • Survivorship care must address dysphagia, xerostomia, trismus, hypothyroidism, lymphoedema, and psychosocial impact.
  • Aboriginal and Torres Strait Islander peoples experience higher incidence and later-stage presentation with worse outcomes — targeted screening and culturally safe care are essential.

Introduction & Australian Epidemiology

Head and neck cancer (HNC) encompasses a heterogeneous group of malignancies arising from the mucosal epithelium of the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, paranasal sinuses, and salivary glands. The vast majority — approximately 90 % — are squamous cell carcinomas (SCC). The anatomical complexity of this region means that tumours can profoundly affect speech, swallowing, respiration, and cosmesis, making functional outcomes central to treatment planning.

In Australia, head and neck cancers collectively represent the fifth most common cancer group. The Australian Institute of Health and Welfare (AIHW) estimated approximately 5 100 new cases in 2024, with a male-to-female ratio of roughly 2.5:1. Age-standardised incidence has been rising, driven almost entirely by HPV-associated oropharyngeal SCC, which has increased 2–3 % per annum over the past two decades.

Statistic Australia (2024 est.) Trend
New cases / year ~5 100 ↑ (HPV-driven)
Deaths / year ~1 100 ↓ overall; ↑ non-oropharyngeal
5-year survival (all sites) ~66 % ↑ (HPV cohort effect)
Median age at diagnosis 65 years (non-OP); 58 years (OP) ↓ for OP cancers
Male : Female ratio 2.5 : 1 Narrowing

Prognosis varies substantially by subsite and HPV status. HPV-positive oropharyngeal SCC carries a 5-year overall survival of 75–85 %, compared with 40–50 % for HPV-negative disease. This divergence has prompted international efforts toward treatment de-escalation in favourable-risk HPV-positive tumours, though mature randomised data are still awaited.

Epidemiology & Risk Factors (HPV, Tobacco & Alcohol)

Human Papillomavirus (HPV)

HPV-16 accounts for >90 % of HPV-driven oropharyngeal SCC. Transmission is predominantly sexual (oral–genital contact), with the incidence peak in the 40–60 age cohort. In Australia, HPV vaccination (National HPV Vaccination Programme, Gardasil® 9) covers HPV-16 and 18; modelling suggests a potential 40–60 % reduction in oropharyngeal cancer incidence over coming decades, though herd-immunity effects require 15–20 years to manifest in cancer endpoints.

✅
HPV testing: p16 immunohistochemistry is the recommended surrogate marker; if p16-positive, HPV DNA ISH or PCR confirmation is not routinely required in the Australian setting (per RCPA guidelines). All oropharyngeal SCCs must be tested for p16 status.

Tobacco

Cigarette smoking remains the strongest modifiable risk factor for non-oropharyngeal HNSCC. The relative risk increases linearly with pack-years: >20 pack-years confers a 5–10× increased risk. Smoking also worsens prognosis in HPV-positive cancers and is independently associated with higher rates of recurrence and second primary tumours. Alcohol acts synergistically — combined heavy use (>40 standard drinks/week + >20 pack-years) produces a multiplicative risk exceeding 30×.

Other Risk Factors

  • Betel nut (areca nut): Important risk factor in Aboriginal and Torres Strait Islander communities and among Pacific Islander and South-East Asian populations in Australia.
  • Epstein–Barr virus (EBV): Causally linked to nasopharyngeal carcinoma, particularly non-keratinising subtype.
  • Occupational exposures: Wood dust (sinonasal), formaldehyde, nickel compounds.
  • Immunosuppression: Post-transplant and HIV-associated HNSCC present at younger ages with more aggressive disease.
  • Poor oral hygiene and dental status: Independent risk factor, particularly for oral cavity SCC.
  • Plummer–Vinson syndrome: Iron deficiency anaemia + oesophageal web → postcricoid carcinoma (rare).
⚠️
Smoking cessation after diagnosis: Continued smoking during treatment reduces RT efficacy by ~50 % and increases acute toxicity. All patients should be offered pharmacotherapy (varenicline, NRT) and behavioural support at diagnosis.

Pathology & Sites of Origin

Histological Subtypes

Squamous cell carcinoma (including variants: basaloid, verrucous, spindle cell) constitutes ~90 % of all HNSCC. Non-SCC histologies include:

  • Salivary gland tumours: Mucoepidermoid, adenoid cystic, acinic cell, adenocarcinoma NOS.
  • Mucosal melanoma: Nasal cavity / sinonosal; poor prognosis.
  • Sinonasal undifferentiated carcinoma (SNUC): Aggressive, EBV-related.
  • Sarcomas: Osteosarcoma, chondrosarcoma, rhabdomyosarcoma (paediatric).
  • Thyroid carcinoma: When arising in the cervical region (managed under separate guidelines).

Anatomical Subsites

Subsite % of HNSCC Key Features
Oral cavity ~30 % Tongue (lateral border most common), floor of mouth, alveolus, buccal mucosa, hard palate, retromolar trigone. HPV-independent.
Oropharynx ~35 % Tonsil, base of tongue, soft palate, posterior pharyngeal wall. 60–70 % HPV-positive (Australia). Rising incidence.
Larynx ~20 % Supraglottic, glottic, subglottic. Glottic SCC often presents early (hoarseness). Smoking-related.
Hypopharynx ~5 % Pyriform sinus, postcricoid, posterior wall. Late presentation, poor prognosis.
Nasopharynx ~4 % EBV-driven (non-keratinising). Higher incidence in SE Asian / Cantonese populations. Distinct staging and treatment.
Nasal cavity / paranasal sinuses ~3 % Maxillary sinus most common. Mixed histologies (SCC, adenocarcinoma, SNUC). Late presentation.
Salivary glands ~3 % Parotid (majority), submandibular, minor glands. Wide histological variety.

Molecular Pathology

Key molecular alterations in HNSCC include TP53 mutations (85 % in HPV-negative), CDKN2A loss, PIK3CA activating mutations, and EGFR overexpression (90 % of HNSCCs). HPV-positive tumours are characterised by p53 wild-type status, p16 overexpression (via Rb pathway inactivation by HPV E7), and intact p16/CDKN2A. Tumour mutational burden (TMB) and PD-L1 expression (CPS ≥ 1) predict response to checkpoint inhibitors in the recurrent/metastatic setting.

Staging & Investigations

Staging System

TNM staging follows the AJCC/UICC 8th edition (2017). A critical change from the 7th edition is the introduction of separate staging for HPV-mediated (p16-positive) oropharyngeal SCC, reflecting its distinct biology and prognosis.

⚠️
HPV staging applies only to oropharyngeal SCC that is p16-positive. Non-oropharyngeal and p16-negative oropharyngeal tumours use the conventional staging system. Do not apply HPV staging to oral cavity, larynx, or hypopharynx primaries.

Diagnostic Workup

ESSENTIAL
Clinical examination including flexible nasolaryngoscopy
All patients. Direct visualisation of primary tumour, assessment of mucosal subsites (panendoscopy if required).
ESSENTIAL
Incisional / punch biopsy with histopathology + p16 IHC
All patients. p16 immunohistochemistry mandatory for oropharyngeal SCC (RCPA protocol).
ESSENTIAL
CT head/neck with contrast + CT chest
All patients. MBS Item 5600. Assess primary extent, nodal disease, lung metastases.
RECOMMENDED
MRI head/neck with gadolinium
Preferred for oral cavity, nasopharynx, sinonasal. Superior soft-tissue contrast for perineural spread, skull base, and bone marrow invasion.
RECOMMENDED
PET-CT (18F-FDG)
Locally advanced disease (T3–4, N2–3). MBS Item 61425 (restricted). Detects occult distant metastases (5–10 % upstaging rate) and unknown primary.
RECOMMENDED
EU examination under anaesthesia + biopsy
Most patients. Tissue confirmation, assess resectability, exclude synchronous primaries.
SPECIALIST
EBV DNA serology / circulating EBV DNA
Nasopharyngeal carcinoma only. Prognostic and surveillance marker.
RECOMMENDED
Baseline bloods: FBC, LFT, renal function, TFT, dental review
All patients prior to MDT discussion. Dental assessment mandatory before RT.

AJCC 8th Edition — HPV-Mediated Oropharyngeal Staging (Simplified)

Stage T N M
I T0–T2 N0–N1 M0
II T0–T2 N2 M0
III T3–T4 N0–N2 M0
IV Any T Any N M1
ℹ️
Multidisciplinary Team (MDT): All head and neck cancer patients must be discussed at a recognised MDT meeting involving head and neck surgeon, radiation oncologist, medical oncologist, radiologist, pathologist, speech pathologist, dietitian, and allied health. MDT discussion is a NSQHS Standard 1 requirement and is reportable under Cancer Australia clinical indicators.

Management: Surgery, Radiotherapy & Chemotherapy

Treatment Principles

Treatment selection is guided by primary site, stage, HPV status, patient fitness (performance status, comorbidities), and patient preference. The overarching goal is oncologic cure with maximal organ preservation and functional outcome. All treatment plans must be established through MDT consensus.

1
MDT Discussion
All cases reviewed at head and neck MDT with full imaging and pathology.
2
Staging & Workup
Complete AJCC staging, PET-CT if locally advanced, dental clearance.
3
Primary Treatment
Single-modality (early) or combined-modality (advanced) with curative intent.
4
Adjuvant / Rehab
Post-operative (chemo)RT if indicated. Swallowing rehabilitation, nutritional support.
5
Surveillance
Structured follow-up with clinical examination and imaging as per protocol.

Surgery

Surgical approaches have evolved from open radical resection toward minimally invasive techniques where oncologically appropriate.

Approach Indications Key Considerations
Transoral robotic surgery (TORS) T1–T2 oropharyngeal SCC, selected T3. HPV-positive favourable-risk tumours. Lower morbidity vs open surgery. Available at major centres (RMH, RPAH, PAH, Peter Mac). Pathological staging enables risk-stratified adjuvant RT de-escalation.
Transoral laser microsurgery (TLM) Early glottic (T1–T2), supraglottic larynx, select oropharynx. Excellent voice preservation for early glottic. Requires CO₂ laser and direct laryngoscopy expertise.
Wide local excision + reconstruction Oral cavity SCC (all stages). Primary treatment for oral cavity. Free-flap reconstruction (radial forearm, anterolateral thigh, fibula) is standard. ≥1 cm clinical margins recommended.
Total laryngectomy Advanced laryngeal/hypopharyngeal SCC, salvage after failed RT/CRT. Tracheoesophageal puncture (TEP) for voice restoration. Organ-preservation CRT preferred when equivalent survival.
Neck dissection Clinically/radiologically positive nodes. Selective dissection for high-risk occult disease. Sentinel lymph node biopsy (SLNB) validated for early oral cavity SCC (cN0). Modified radical or selective neck dissection for clinically positive nodes.
⚠️
Surgical margins: Positive margins (<1 mm tumour at ink) mandate adjuvant treatment and worsen survival. Intraoperative frozen section is recommended for close margins. Final pathology should report margin status in millimetres.

Radiotherapy

Radiotherapy (RT) is a cornerstone of head and neck cancer management, used as definitive treatment, adjuvant post-operative therapy, or palliation. Intensity-modulated radiotherapy (IMRT) is the standard of care, enabling conformal dose delivery and reduced toxicity to salivary glands, swallowing structures, and cochleae.

Early Stage
Definitive RT Alone
T1–T2 N0 larynx, oropharynx. 66–70 Gy / 33–35 fractions (conventional) or 55 Gy / 20 fractions (hypofractionated for early glottic).
Setting: Outpatient, 6–7 weeks
Locally Advanced
Concurrent Chemoradiation
66–70 Gy / 33–35 fractions + cisplatin 100 mg/m² q3w × 3. Alternative: weekly cisplatin 40 mg/m². Organ preservation for larynx/hypopharynx.
Setting: Outpatient, 7 weeks + chemo
Post-Operative
Adjuvant (Chemo)RT
60–66 Gy / 30–33 fractions. + cisplatin if high-risk features (positive/ close margins, ECE). Begin within 6 weeks of surgery.
Setting: Outpatient, 6 weeks

Key RT techniques and considerations:

  • IMRT/VMAT: Standard of care. Reduces xerostomia by ≥20 % compared with 3D-conformal RT. Mandated in Australia (RANZCR TROG guidelines).
  • Proton beam therapy: Increasingly available (Adelaide Proton Therapy Centre). May reduce late toxicity for skull base, sinonasal, and paediatric tumours. MBS item pending for select indications.
  • Altered fractionation: Accelerated fractionation (e.g., CHART) improves locoregional control in HPV-negative tumours. Hyperfractionation (1.15–1.2 Gy BID) also evidence-based.
  • Supportive care during RT: Intensity-modulated swallowing therapy (IMST), amifostine (limited PBS access), oral cryotherapy, regular dietician input.

Systemic Therapy

Concurrent with Radiotherapy (Curative Intent)

💊
Cisplatin
DBL Cisplatin® · Platinum agent
Adult dose 100 mg/m² IV over 1–2 h, day 1 every 21 days × 3 cycles (concurrent with RT). Alternative: 40 mg/m² IV weekly × 6–7 weeks.
Paediatric dose Not applicable for HNSCC
Route IV with aggressive hydration (≥2 L NS pre/post)
Renal adjustment Contraindicated if CrCl < 60 mL/min (q3w regimen). Weekly regimen with caution if CrCl 40–60.
Hepatic adjustment No formal dose reduction; monitor LFTs
Key toxicities Nephrotoxicity, ototoxicity, severe nausea/vomiting, myelosuppression, peripheral neuropathy
PBS status ✔ PBS General Benefit
💊
Cetuximab
Erbitux® · Anti-EGFR monoclonal antibody
Adult dose Loading 400 mg/m² IV, then 250 mg/m² IV weekly throughout RT course.
Paediatric dose Not applicable
Route IV infusion (premedicate with antihistamine)
Renal adjustment None required
Key toxicities Acneiform rash (grade ≥3 in ~17 %), hypomagnesaemia, infusion reactions, diarrhoea
PBS status ⬤ PBS Restricted Benefit Head and neck SCC
🔴
Cisplatin vs cetuximab: The RTOG 1016 trial demonstrated that cetuximab + RT is inferior to cisplatin + RT for HPV-positive oropharyngeal SCC (5-year OS 77.9 % vs 84.6 %). Cetuximab + RT should NOT be used as a radiosensitiser for HPV-positive oropharyngeal cancers. Reserve cetuximab for patients truly cisplatin-ineligible (renal impairment, hearing loss, neuropathy).

Induction Chemotherapy

Induction (neoadjuvant) chemotherapy is not standard for most HNSCC. It may be considered for organ preservation in laryngeal/hypopharyngeal cancers or borderline-resectable disease, though concurrent chemoradiation remains preferred. The TPF regimen has been largely replaced by concurrent strategies in routine practice.

💊
Docetaxel + Cisplatin + 5-FU (TPF)
Induction regimen
Adult dose Docetaxel 75 mg/m² IV d1 + Cisplatin 75 mg/m² IV d1 + 5-FU 750 mg/m²/day CIV d1–5, q3w × 3 cycles.
Key toxicities Febrile neutropenia (15–20 %), mucositis, diarrhoea. Requires G-CSF support.
PBS status ✔ PBS General Benefit (individual agents)

Recurrent / Metastatic Disease

Patients with recurrent or metastatic (R/M) HNSCC not amenable to curative salvage therapy receive systemic treatment with palliative intent.

💊
Pembrolizumab
Keytruda® · Anti-PD-1 checkpoint inhibitor
Adult dose (1st-line R/M) 200 mg IV q3w (fixed dose) + platinum + 5-FU × up to 6 cycles, then pembrolizumab monotherapy maintenance.
Adult dose (2nd-line) 200 mg IV q3w as monotherapy until progression or 24 months.
Key biomarker PD-L1 CPS ≥ 1 for monotherapy; CPS ≥ 20 for best benefit.
Key toxicities Immune-related AEs: thyroiditis, hepatitis, pneumonitis, colitis, adrenal insufficiency. Dermatological.
PBS status AUTH PBS Authority Required R/M HNSCC post-platinum (2nd line); 1st line with chemo as per Authority criteria.
💊
Nivolumab
Opdivo® · Anti-PD-1 checkpoint inhibitor
Adult dose 3 mg/kg IV q2w (or 240 mg flat dose q2w) until progression or unacceptable toxicity.
Key evidence CheckMate 141: OS 7.5 vs 5.1 months vs investigator's choice in platinum-refractory R/M HNSCC.
Key toxicities Immute-related AEs as per pembrolizumab. Fatigue common.
PBS status AUTH PBS Authority Required R/M HNSCC after platinum-based therapy.

Treatment by Stage — Quick Reference

I–II (Early)
Single modality: Surgery (oral cavity) or RT (larynx/oropharynx). TORS for favourable OP.
—
Equivalent outcomes for both approaches.
III–IVB (Locally Advanced)
Surgery + adjuvant (chemo)RT, OR definitive CRT (cisplatin 100 mg/m² q3w × 3).
ChemoRT: 7 weeks
Adjuvant cisplatin if ECE or positive margins.
Recurrent (Salvageable)
Salvage surgery ± re-irradiation. Re-RT with IMRT, dose ~60 Gy if prior interval >6 months.
Case-by-case
Mandatory MDT review. Consider clinical trial.
R/M (Incurable)
1L: Pembrolizumab + platinum + 5-FU → pembro maintenance. 2L: Nivolumab or pembrolizumab mono.
Continuous
PD-L1 CPS guides monotherapy. Best supportive care if PS >2.

Monitoring & Surveillance

Structured follow-up is essential for early detection of recurrence (80–90 % occur within 2 years), management of treatment sequelae, and screening for second primary tumours (risk 3–5 % per year, predominantly aerodigestive tract).

Months 1–12
Clinical examination every 1–3 months. Flexible nasolaryngoscopy at each visit. Neck ultrasound or CT if high-risk features. Speech pathology and dietitian review.
Months 12–24
Clinical examination every 3–4 months. CT neck/chest at 12 months (or as clinically indicated). Thyroid function tests (if neck irradiated) every 6 months.
Months 24–60
Clinical examination every 6 months. Annual CT chest. Smoking cessation support ongoing. Dental review every 6 months (post-RT).
Year 5+
Annual clinical examination. Lifelong surveillance. Second primary cancer screening. Ongoing management of late effects (xerostomia, dysphagia, osteoradionecrosis, hypothyroidism).
ℹ️
Post-RT thyroid monitoring: Hypothyroidism occurs in 20–40 % of patients receiving neck irradiation. Check TSH at 6, 12, and 24 months, then annually. Treat if symptomatic (levothyroxine 1.6 mcg/kg/day, PBS General Benefit).

Late Toxicity Management

  • Xerostomia: Pilocarpine 5 mg TDS (PBS authority), salivary substitutes, acupuncture (evidence for benefit).
  • Dysphagia: Regular swallowing exercises during and after RT (IMST programme). Barium swallow / FEES assessment if progressive.
  • Osteoradionecrosis (ORN): Prevention via pre-RT dental clearance. Treatment: hyperbaric oxygen, pentoxifylline + tocopherol, surgical debridement.
  • Lymphoedema: Cervicofacial lymphoedema management with specialist physiotherapy.
  • Trismus: Therabite jaw stretching, passive ROM exercises. Start within 1 week of surgery/RT.

Special Populations

🤰 Pregnancy
Diagnosis
MRI (no radiation) preferred for staging. Limited ultrasound of neck acceptable. CT chest deferred if possible. Biopsy under local anaesthesia is safe.
Treatment
Surgery is feasible in all trimesters (avoid 1st trimester if deferrable). RT: can treat with appropriate shielding in 2nd/3rd trimester but fetal dose must be <100 mGy. Chemotherapy is contraindicated in 1st trimester; platinum agents may be used in 2nd/3rd trimester with neonatology involvement. Multidisciplinary obstetric–oncology input mandatory.
👶 Paediatrics
Incidence
Very rare. Nasopharyngeal carcinoma in adolescents (EBV-related). Rhabdomyosarcoma is the most common paediatric head and neck sarcoma.
Treatment
Nasopharyngeal carcinoma: cisplatin + 5-FU induction → cisplatin concurrent RT (adult protocols, dose-adjusted). Proton therapy strongly considered to minimise late effects on developing tissues. Rhabdomyosarcoma: per Children's Oncology Group (COG) protocols — VAC chemotherapy ± RT.
RT considerations
Minimise long-term effects: growth disturbance, hypothyroidism, secondary malignancy. Proton therapy preferred. Anaesthesia often required for RT delivery in young children.
👴 Elderly (≥70 years)
Risk assessment
Comprehensive geriatric assessment (CGA) prior to treatment planning. Frailty index, nutritional status, cognitive function, social supports.
Treatment modification
Cisplatin 100 mg/m² q3w associated with high toxicity in elderly — weekly cisplatin 40 mg/m² or carboplatin AUC 5 may be preferred. RT alone (accelerated or conventional) if cisplatin contraindicated. Cetuximab + RT an alternative (but inferior for HPV-positive). De-escalation for favourable-risk HPV-positive OP SCC.
🫘 Renal Impairment
Cisplatin
Contraindicated if CrCl < 60 mL/min (q3w). Weekly cisplatin 40 mg/m² possible if CrCl 40–60 with close monitoring and aggressive hydration. Consider carboplatin AUC 5 as substitute.
Carboplatin dose
Calvert formula: Dose (mg) = AUC × (GFR + 25). Cap GFR at 125 mL/min. Monitor FBC weekly.
🫁 Hepatic Impairment
General
No formal dose adjustments for cisplatin. Docetaxel requires dose reduction for bilirubin >1.5× ULN. Cetuximab: no adjustment. Pembrolizumab/nivolumab: no adjustment (but monitor for immune hepatitis).
🛡️ Immunocompromised
HIV
HNSCC in HIV-positive patients treated with standard protocols when CD4 > 200 and viral load suppressed. Consult with HIV specialist. Monitor drug interactions with ART (e.g., renal toxicity with tenofovir + cisplatin).
Post-transplant
Post-transplant lymphoproliferative disorder (PTLD) must be excluded. EBV-positive SCC behaves more aggressively. Consider immunosuppression reduction where possible.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health
Incidence & burden
Aboriginal and Torres Strait Islander peoples experience higher age-standardised incidence of oral cavity and oropharyngeal SCC compared with non-Indigenous Australians (AIHW 2023). Oral cavity cancer — particularly of the lip, tongue, and buccal mucosa — is disproportionately prevalent, reflecting higher rates of tobacco use and betel nut chewing in some communities.
Stage at diagnosis
Later-stage presentation is more common, driven by barriers to accessing oral health services, limited awareness of early signs, and longer travel distances to specialist centres. Five-year survival is significantly lower than for non-Indigenous Australians across all subsites.
Betel nut (areca nut)
Betel nut chewing is a cultural practice in some Aboriginal and Torres Strait Islander communities, as well as among Pacific Islander and South-East Asian populations. Areca nut is a Group 1 carcinogen (IARC) strongly associated with oral submucous fibrosis and oral SCC. Culturally appropriate education and cessation support are essential.
Remote & rural access
Definitive treatment (surgery, RT, CRT) requires metropolitan centre referral. Aboriginal Health Workers and Liaison Officers should facilitate navigation, accommodation, and transport (Patient Assisted Travel Scheme — PATS). Telehealth follow-up for surveillance is supported by Medicare items.
Cultural safety
Employ Aboriginal and Torres Strait Islander Health Workers as part of the care team. Provide culturally safe environments, gender-sensitive care, yarning-based communication. Involve family and community in care planning. Acknowledge connection to Country during treatment planning.
Smoking & cessation
Tobacco smoking prevalence in Aboriginal and Torres Strait Islander adults remains approximately 2× the non-Indigenous rate (~37 % vs ~11 %). Tackling Indigenous Smoking programme provides community-level support. Pharmacotherapy (varenicline, NRT) is PBS-subsidised.
Oral health
Poor oral health and dental disease are independent risk factors for oral SCC. Aboriginal Community Controlled Health Organisations (ACHCOs) should integrate oral health screening and dental referral into primary care visits. Dental clearance prior to RT must be prioritised.
Key resources
RHDAustralia (www.rhdaustralia.org.au) · Cancer Council Australia Aboriginal & Torres Strait Islander resources · National Aboriginal Community Controlled Health Organisation (NACCHO) · Australian Indigenous HealthInfoNet.

📚 References

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  4. 4. Mehanna H, Robinson M, Hartley A, et al. Radiotherapy plus cisplatin or cetuximab in low-risk human papillomavirus-positive oropharyngeal cancer (De-ESCALaTE HPV): an open-label randomised controlled phase 3 trial. Lancet. 2019;393(10166):51–60.
  5. 5. Burtness B, Harrington KJ, Greil R, et al. Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck (KEYNOTE-048): a randomised, open-label, phase 3 study. Lancet. 2019;394(10212):1915–1928.
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for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

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  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).