NICE NG36 and NG12: assessment, management and referral criteria in upper aerodigestive tract cancer

Key points

• NG36 was published on 10 February 2016 and updated in June 2018 with recommendations on response assessment after chemoradiotherapy; later changes have been minor, such as links to technology appraisals.
• p16 immunohistochemistry is recommended for all oropharyngeal squamous cell carcinomas; de-intensification of treatment for HPV-positive oropharyngeal cancer should only be offered within a clinical trial.
• In early (T1–T2, N0) oral cavity cancer, surgical management of the neck is recommended and—unless cervical access is needed at the same time—sentinel lymph node biopsy instead of elective neck dissection.
• Under NG12, persistent unexplained hoarseness or an unexplained neck lump in people aged 45 and over should prompt consideration of a suspected cancer referral for laryngeal cancer.

Scope and wording of recommendations

NG36 ("Cancer of the upper aerodigestive tract: assessment and management in people aged 16 or over") covers diagnosis, staging, treatment, rehabilitation and follow-up of cancers of the larynx, oropharynx, hypopharynx and oral cavity, and also includes recommendations for less common tumours such as nasopharyngeal and paranasal sinus carcinoma, mucosal melanoma and nodal metastasis of unknown primary. Its staging is based on TNM 7th edition; readers should remember that the current TNM 8th edition stages HPV-associated oropharyngeal cancer separately.

NICE signals certainty through wording: "offer" is used where there is clear and strong evidence of benefit, and "consider" where the benefit is less certain. The summary below keeps this distinction.

Investigation and staging

• For a neck lump suspected to be upper aerodigestive tract cancer, adding ultrasound guidance to fine-needle aspiration cytology or core biopsy should be considered, as should on-site assessment of sample adequacy.
• In metastatic nodal squamous cell carcinoma of unknown primary, FDG PET-CT should be considered as the first investigation to find the primary; if it does not identify a site, narrow-band imaging endoscopy may be considered and surgical diagnostic assessment—which may include guided biopsies, tonsillectomy and tongue base mucosectomy—should be offered.
• Systemic staging is offered to everyone except those with T1N0 or T2N0 disease: FDG PET-CT for T4 hypopharyngeal or nasopharyngeal cancer and for N3 disease, and conventional imaging (for example chest CT) for the others.

Early-stage disease

• Transoral laser microsurgery is offered for newly diagnosed T1a glottic squamous cell carcinoma; for T1b–T2 glottic and supraglottic tumours, a choice of transoral surgery or radiotherapy is offered.
• In T1–T2 N0 oral cavity cancer the neck should be managed surgically; sentinel lymph node biopsy is offered instead of elective neck dissection unless cervical access is needed at the same time, for example for free-flap reconstruction.
• For T1–T2 N0 oropharyngeal tumours, a choice of transoral surgical resection or primary radiotherapy is offered; postoperative radiotherapy with or without chemotherapy is considered if adverse pathological risk factors are found.

Advanced disease, response assessment and HPV

• For T3 laryngeal cancer, a choice of concomitant chemoradiotherapy or surgery with adjuvant (chemo)radiotherapy is offered; the advantages of laryngeal preservation, the risk of salvage laryngectomy, existing swallowing and airway function and likely voice and swallowing outcomes should be discussed. For T4a laryngeal cancer, surgery with adjuvant (chemo)radiotherapy is considered.
• For response assessment after curative chemoradiotherapy, FDG PET-CT should be done 3 to 6 months after treatment ends; neck dissection is not offered if there is no abnormal FDG uptake or residual soft tissue mass (2018 recommendations).
• In oropharyngeal carcinoma, p16 is regarded as positive only with strong nuclear and cytoplasmic staining in more than 70% of tumour cells; high-risk HPV DNA or RNA in situ hybridisation may be considered to confirm HPV status in p16-positive cancers.
• Systemic therapy recommendations link to NICE technology appraisals (for example pembrolizumab, nivolumab, cetuximab) and are the most frequently changing part of the guideline.

Rehabilitation, support and follow-up

• The need for enteral nutrition, including prophylactic tube placement, should be assessed by the multidisciplinary team at diagnosis; help to stop smoking should be offered.
• Swallowing-exercise programmes for people having radiotherapy, mouth-opening exercises for those at risk of trismus and voice therapy for treatment-related voice change should be considered.
• Progressive resistance training should be considered as soon as possible after neck dissection for people with impaired shoulder function.
• At the end of curative treatment, people should receive tailored information about symptoms of recurrence and late effects; structured, risk-adapted local follow-up protocols addressing quality of life, psychosocial issues and detection of recurrence or second primary cancer should be considered. For osteoradionecrosis, hyperbaric oxygen or medical management is only considered within a clinical trial.

NG12: referral criteria for head and neck cancers

NG12 ("Suspected cancer: recognition and referral") was published on 23 June 2015 and last updated on 15 April 2026. Its head and neck recommendations date from 2015 and are written for England's suspected cancer pathway referral system:

• Larynx: consider a referral in people aged 45 and over with persistent and unexplained hoarseness or an unexplained lump in the neck.
• Oral cavity: consider a referral for unexplained oral ulceration lasting more than 3 weeks or a persistent unexplained neck lump; separate recommendations cover dental assessment and dentist referral for a lump on the lip or in the mouth, or a red or red-and-white patch consistent with erythroplakia or erythroleukoplakia.
• Thyroid: consider a referral for an unexplained thyroid lump.

Implications for practice

NICE guidelines are written for England (NHS England); referral timelines, service models, access to resources such as PET-CT and sentinel lymph node biopsy, and drug reimbursement differ from Turkey. The recommendations should therefore be read as an evidence-based framework rather than a protocol, alongside national practice, other guidelines such as NCCN and multidisciplinary tumour board decisions.

When communicating with primary care and dentists, the NG12 criteria (persistent hoarseness over 45, oral ulceration beyond 3 weeks, an unexplained neck lump) work as simple, memorable warning signs.

Limitations and currency

Most NG36 recommendations rest on a 2016 evidence review and use TNM 7th edition; evidence in areas such as immunotherapy is changing quickly. This summary was prepared from the NICE pages as of November 2026; the current version should be checked before use.