DISCUSSION
In this systematic review we sought to identify if there is a subset of HNSCCUP patients that can be treated with ND as single modality therapy and provide acceptable oncological safety. Despite broad search criteria, only 294 patients were identified as eligible for inclusion across 14 studies, none of which reported exclusively on patients treated with ND alone. Patients in these studies were recruited over a protracted time frame (1969-2018) during which the oncogenesis, risk factors and diagnostic approaches have evolved considerably. In addition, the nodal status of those receiving ND alone was only reported for 44.9% patients, of which 52.2% had N2b disease or above (table 1). As such, the results need to be approached with caution, as they do not reflect treatment within the framework of current international guidelines (7–9). The lack of granularity regarding p16 status and limited diagnostic work-up compared to contemporary practice further confounds the interpretation of this review.